EXAMPLE - PA SUPERVISED W600000 Carrier ZYZ 2000 Hydra ... · Charles Zavier, MD XMen Billing...

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W600000Carrier ZYZ2000 Hydra RoadNew York, NY 10001

Wolverine, Hugo 10 17 1960

2619 Avenue North

Brooklyn NY NY

11235 555 5555555 111 1111111

G3000000

Wolverine^^^Hugo Y4 9900V13972

Carrier ZYZ

Signature on File

01 02 2020 431 454 01 03 2020 01 03 2020 01 20 20200B 272222

DQ Charles Xavier, MD 1666699999

REFX5PA016182-8^^^G2PHYAS^^^PWK09EAC00985621^^^NTEADD20200302

0M5020

0B 944444

01 20 20 01 20 20 11 99213 A 70 24 1 9877777777

211111110 WH002345 70 24222 2222222

Charles Zavier, MD XMen Billing Services490 Western Ave 200 Shore Drive

Jean, Gray PA Brooklyn NY 11235 Great Neck NY 1234501/20/2020 1666699999 1666699997

987-65-4321

XFactor Tactical Support

94 Jamaica Drive

Jamaica

11422

EXAMPLE - PA SUPERVISED

X

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