Original
Original
*210728*2105*^*00501*100000166*1*P*:
GS*HC*8431*Zermid*20210728*215*100000166*X*005010X222A1
ST*837*0001*005010X222A1
BHT*0019*00*0001*20210728*215*CH
NM1*41*2*Chicago Therapy*****46*8431
PER*IC*Alexo Demofo*TE*5432345678*FX*5432345678
NM1*40*2*Zermid*****46*Zermid
HL*1**20*1
PRV*BI*PXC*103K00000X
NM1*85*2*Chicago Therapy*****XX*1386274488
N3*3937 Kenwood Place
N4*Los Angeles*CA*90002
REF*EI*843583002
NM1*87*2
N3*3937 Kenwood Place
N4*Los Angeles*CA*90002
HL*2*1*22*0
SBR*S*18**MCR12*****MB
NM1*IL*1*Bunte*Allan****MI*9Q21Y71GG23
N3*606 TIMBERTRAIL
N4*DUNCANVILLE*TX*75137
DMG*D8*19490815*M
NM1*PR*2*Medicare*****PI*887700
N3*Po Box 4344
N4*Dallas*TX*75266
CLM*C580*218.68***11:B:1*Y*A*Y*Y
HI*ABK:F84.8
NM1*82*1*Elliot*Jim****XX*1154627966
NM1*77*2*NY Office*****XX*1386274488
N3*5081 Tellus. Avenue*668-2204 Non Rd.
N4*Los Angeles*CA*90002
LX*1
SV1*HC:99214*218.68*UN*1.00*11**1
DTP*472*RD8*20210222-20210222
REF*6R*LN-3282
HL*3**20*1
PRV*BI*PXC*103K00000X
NM1*85*2*Chicago Therapy*****XX*1386274488
N3*3937 Kenwood Place
N4*Los Angeles*CA*90002
REF*EI*843583002
NM1*87*2
N3*3937 Kenwood Place
N4*Los Angeles*CA*90002
HL*4*3*22*0
SBR*S*18**MCR12*****MB
NM1*IL*1*Bunte*Allan****MI*9Q21Y71GG23
N3*606 TIMBERTRAIL
N4*DUNCANVILLE*TX*75137
DMG*D8*19490815*M
NM1*PR*2*Medicare*****PI*887700
N3*Po Box 4344
N4*Dallas*TX*75266
CLM*C581*467.58***11:B:1*Y*A*Y*Y
HI*ABK:F84.8
NM1*82*1*Elliot*Jim****XX*1154627966
NM1*77*2*NY Office*****XX*1386274488
N3*5081 Tellus. Avenue*668-2204 Non Rd.
N4*Los Angeles*CA*90002
LX*1
SV1*HC:93306*467.58*UN*1.00*11**1
DTP*472*RD8*20210222-20210222
REF*6R*LN-3284
SE*62*0001
GE*1*100000166
IEA*1*100000166