Appendix A - Clinic Physician File

Appendix A - Clinic Physician File

College Clinic
Address:
4567 Broad Avenue
Woodland Hills, XY 12345-0001
Telephone Number:
(555) 486-9002
Fax:
(555) 487-8976
Practice Number:
366401CC (group employer tax identification number)
Medicaid:
HSC 12345F (clinic’s Medicaid provider number)


College Hospital

Address:
4500 Broad Avenue
Woodland Hills, XY 12345-0001
Telephone:
(555) 487-6789
Fax:
(555) 486-8900
Practice Number:
95-0731067 (hospital provider number)
Medicaid:
HSP43700F (Medicaid hospital provider number)
Medicare:
HSP43700F (Medicare hospital provider number)








Dr. No.
Name and Specialty
State License #
Fed. Tax
ID #
UPIN/PIN/
NPI #
1
Antrum, Concha, MD
Otolarynoloogist
C016020
74-1064000
1245897700
2
Atrics, Pedro, MD
Pediatrician
D060120
71-3206100
3764001700
3
Ceasar, Bertha, MD
Obstetrician/Gynecologist
A018170
72-5713000
4305675700
4
Cardi, Perry, MD
Internist/Cardiologist
C021400
70-6421700
6780502700
5
Coccidioides, Brady, MD
Internist/Pulmonologist
C048210
75-6732100
6421106700
6
Cutis, Vera, MD
Dermatologist
C060020
71-8056100
7056871700
7
Cutler, Clarence, MD
General Surgeon
B076000
71-5737200
4305004700
8
Practon, Gerald, MD
General Practitioner
C014020
70-3459700
4627889700
9
Skeleton, Raymond, MD
Orthopedist
C045610
74-6541200
1267854700
10
Ulibarri, Gene MD
Urologist
C064300
77-8653100
2567883100