Case File
efta-02693550DOJ Data Set 11OtherEFTA02693550
Date
Unknown
Source
DOJ Data Set 11
Reference
efta-02693550
Pages
1
Persons
0
Integrity
Extracted Text (OCR)
Text extracted via OCR from the original document. May contain errors from the scanning process.
BILL TO/PATIENT.
STATEMENT PERIOD:
July 1. 2011 - July 31, 2011
For professional services:
Date
Description
Amount
07/01/2011 Previous balance
$
400.00
07/05/2011
400.00
07/12/2011
400.00
07/19/2011
400.00
07/28/2011
400.00
Balance due
$
2000.00
Provider Tax ID 132698221
Diagnosis: 309.24
Provider NPI 1508083437
Please remit your payment within 30 days, pay
ost major credit cards accepted. II you
have any questions, please call Renee Sibrizzi
Thank you.
E FTA_R 1_02038084
EFTA02693550
Technical Artifacts (3)
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Phone
2693550Phone
2698221Phone
8083437Forum Discussions
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