INSERT INTO `providers_new` (`Provider_Tax_ID`, `Provider_Suffix`, `Provider_Network_ID`, `Provider_Region`, `Provider_Name`, `Provider_Doctor_First_Name`, `Provider_Doctor_Middle_Name`, `Provider_Doctor_Last_Name`, `Provider_Doctor_Degree`, `Provider_Specialty_1`, `Provider_Specialty_2`, `Provider_Specialty_3`, `Provider_Specialty_4`, `Provider_Address_Type`, `Provider_Address`, `Provider_City`, `Provider_County`, `Provider_State`, `Provider_Zip`, `Provider_Phone`, `Provider_Fax`, `Provider_Mailing_Address`, `Provider_Mailing_City`, `Provider_Mailing_County`, `Provider_Mailing_State`, `Provider_Mailing_Zip`, `Provider_Mailing_Phone`, `Provider_Mailing_Fax`, `Provider_Primary_Schedule`, `Provider_Secondary_Schedule`, `Provider_Rate_Sheet`, `Provider_Anes_Rate`, `Provider_Default_Rate`, `Provider_Max_DOS`, `Provider_Min_Match_Value`, `Provider_Effective_Date`, `Provider_Term_Date`, `Provider_Pend`, `Provider_Anes_Minutes`, `Provider_PPO`, `Provider_Hospital_1`, `Provider_Hospital_2`, `Provider_Hospital_3`, `Provider_Hospital_4`, `Provider_Type`, `Provider_NPI`, `Provider_Check_Override`, `Exclude_Dir`, `Audit_Status`, `Last_Change_Date`, `Medicare_ID`, `Provider_Lang`, `Provider_Latitude`, `Provider_Longitude`, `Provider_school`, `Provider_cert`) VALUES
('850327237', 'W12038718', 'W12038718', 'NM01', 'LHS Pro Billing', 'Kristen', '', 'Bushnell', 'PA-C', 'General Surgery', '', '', NULL, 'B', '4411 The 25 Way Ste 100', 'Albuquerque', 'Bernalillo', 'NM', '87109', '0000000000', NULL, '4411 The 25 Way Ste 100', 'Albuquerque', 'Bernalillo', 'NM', '87109', '0000000000', '          ', '', '', '', '0.00', '55.00', '0.00', 3, '2013-10-01', NULL, 0, 0, 0, 'Lovelace Westside Hospital', NULL, NULL, NULL, 'HCFA|UB|', '1982818860', 0, 'N', 0, '2013-10-03', NULL, NULL, 0, 0, NULL, NULL),
('850327237', 'W12038719', 'W12038719', 'NM01', 'Lovelace Womens Breast Care Center', 'Kristen', '', 'Bushnell', 'PA-C', 'General Surgery', '', '', NULL, 'O', '4701 Montgomery NE', 'Albuquerque', 'Bernalillo', 'NM', '87109', '5057276900', NULL, '4701 Montgomery NE', 'Albuquerque', 'Bernalillo', 'NM', '87109', '5057276900', '          ', '', '', '', '0.00', '55.00', '0.00', 3, '2013-10-01', NULL, 0, 0, 0, 'Lovelace Westside Hospital', NULL, NULL, NULL, 'HCFA|UB|', '1982818860', 0, 'N', 0, '2013-10-03', NULL, NULL, 35.131, -106.591, NULL, NULL),
('850327237', 'W12038724', 'W12038724', 'NM01', 'LHS Pro Billing', 'Darcy', '', 'Cooke', 'PA-C', 'General Surgery', '', '', NULL, 'B', '4411 The 25 Way Ste 100', 'Albuquerque', 'Bernalillo', 'NM', '87109', '0000000000', NULL, '4411 The 25 Way Ste 100', 'Albuquerque', 'Bernalillo', 'NM', '87109', '0000000000', '          ', '', '', '', '0.00', '55.00', '0.00', 3, '2013-10-01', NULL, 0, 0, 0, 'Lovelace Womens Hospital', NULL, NULL, NULL, 'HCFA|UB|', '1790870970', 0, 'N', 0, '2013-10-03', NULL, NULL, 0, 0, NULL, NULL),
('850327237', 'W12038723', 'W12038723', 'NM01', 'Lovelace Womens Breast Care Center', 'Darcy', '', 'Cooke', 'PA-C', 'General Surgery', '', '', NULL, 'O', '4701 Montgomery NE', 'Albuquerque', 'Bernalillo', 'NM', '87109', '5057276900', NULL, '4701 Montgomery NE', 'Albuquerque', 'Bernalillo', 'NM', '87109', '5057276900', '          ', '', '', '', '0.00', '55.00', '0.00', 3, '2013-10-01', NULL, 0, 0, 0, 'Lovelace Womens Hospital', NULL, NULL, NULL, 'HCFA|UB|', '1790870970', 0, 'N', 0, '2013-10-03', NULL, NULL, 35.131, -106.591, NULL, NULL),
('462548275', 'W12038734', 'W12038734', 'ILCHIGSTD', 'Concentra Immediate Care', '', '', 'Concentra Immediate Care', '', 'Urgent Care', '', '', NULL, 'B', 'PO Box 2547', 'Addison', 'Dallas', 'TX', '75001', '8774278801', '9723851759', 'PO Box 2547', 'Addison', 'Dallas', 'TX', '75001', '8774278801', '9723851759', '', '', '', '0.00', '0.00', '110.00', 3, '2013-08-01', NULL, 0, 0, 0, '', '', '', '', 'HCFA|UB|', '1093833139', 0, 'N', 0, '2013-11-27', NULL, NULL, 0, 0, NULL, NULL),
('462548275', 'W12038736', 'W12038736', 'ILCHIGSTD', 'Concentra Immediate Care', '', '', 'Concentra Immediate Care', '', 'Urgent Care', '', '', NULL, 'B', 'PO Box 2547', 'Addison', 'Dallas', 'TX', '75001', '8774278801', '9723851759', 'PO Box 2547', 'Addison', 'Dallas', 'TX', '75001', '8774278801', '9723851759', '', '', '', '0.00', '0.00', '110.00', 3, '2013-08-01', NULL, 0, 0, 0, '', '', '', '', 'HCFA|UB|', '1104015726', 0, 'N', 0, '2013-11-27', NULL, NULL, 0, 0, NULL, NULL),
('462548275', 'W12038737', 'W12038737', 'ILCHIGSTD', 'Concentra Immediate Care', '', '', 'Concentra Immediate Care', '', 'Urgent Care', '', '', NULL, 'B', 'PO Box 2547', 'Addison', 'Dallas', 'TX', '75001', '8774278801', '9723851759', 'PO Box 2547', 'Addison', 'Dallas', 'TX', '75001', '8774278801', '9723851759', '', '', '', '0.00', '0.00', '110.00', 3, '2013-08-01', NULL, 0, 0, 0, '', '', '', '', 'HCFA|UB|', '1205015781', 0, 'N', 0, '2013-11-27', NULL, NULL, 0, 0, NULL, NULL),
('462548275', 'W12038738', 'W12038738', 'ILCHIGSTD', 'Concentra Immediate Care', '', '', 'Concentra Immediate Care', '', 'Urgent Care', '', '', NULL, 'B', 'PO Box 2547', 'Addison', 'Dallas', 'TX', '75001', '8774278801', '9723851759', 'PO Box 2547', 'Addison', 'Dallas', 'TX', '75001', '8774278801', '9723851759', '', '', '', '0.00', '0.00', '110.00', 3, '2013-08-01', NULL, 0, 0, 0, '', '', '', '', 'HCFA|UB|', '1215126842', 0, 'N', 0, '2013-11-27', NULL, NULL, 0, 0, NULL, NULL),
('462548275', 'W12038739', 'W12038739', 'ILCHIGSTD', 'Concentra Immediate Care', '', '', 'Concentra Immediate Care', '', 'Urgent Care', '', '', NULL, 'B', 'PO Box 2547', 'Addison', 'Dallas', 'TX', '75001', '8774278801', '9723851759', 'PO Box 2547', 'Addison', 'Dallas', 'TX', '75001', '8774278801', '9723851759', '', '', '', '0.00', '0.00', '110.00', 3, '2013-08-01', NULL, 0, 0, 0, '', '', '', '', 'HCFA|UB|', '1316136955', 0, 'N', 0, '2013-11-27', NULL, NULL, 0, 0, NULL, NULL),
('462548275', 'W12038740', 'W12038740', 'ILCHIGSTD', 'Concentra Immediate Care', '', '', 'Concentra Immediate Care', '', 'Urgent Care', '', '', NULL, 'B', 'PO Box 2547', 'Addison', 'Dallas', 'TX', '75001', '8774278801', '9723851759', 'PO Box 2547', 'Addison', 'Dallas', 'TX', '75001', '8774278801', '9723851759', '', '', '', '0.00', '0.00', '110.00', 3, '2013-08-01', NULL, 0, 0, 0, '', '', '', '', 'HCFA|UB|', '1659560282', 0, 'N', 0, '2013-11-27', NULL, NULL, 0, 0, NULL, NULL),
('462548275', 'W12038741', 'W12038741', 'ILCHIGSTD', 'Concentra Immediate Care', '', '', 'Concentra Immediate Care', '', 'Urgent Care', '', '', NULL, 'B', 'PO Box 2547', 'Addison', 'Dallas', 'TX', '75001', '8774278801', '9723851759', 'PO Box 2547', 'Addison', 'Dallas', 'TX', '75001', '8774278801', '9723851759', '', '', '', '0.00', '0.00', '110.00', 3, '2013-08-01', NULL, 0, 0, 0, '', '', '', '', 'HCFA|UB|', '1790974368', 0, 'N', 0, '2013-11-27', NULL, NULL, 0, 0, NULL, NULL),
('462548275', 'W12038742', 'W12038742', 'ILCHIGSTD', 'Concentra Immediate Care', '', '', 'Concentra Immediate Care', '', 'Urgent Care', '', '', NULL, 'B', 'PO Box 2547', 'Addison', 'Dallas', 'TX', '75001', '8774278801', '9723851759', 'PO Box 2547', 'Addison', 'Dallas', 'TX', '75001', '8774278801', '9723851759', '', '', '', '0.00', '0.00', '110.00', 3, '2013-08-01', NULL, 0, 0, 0, '', '', '', '', 'HCFA|UB|', '1831388404', 0, 'N', 0, '2013-11-27', NULL, NULL, 0, 0, NULL, NULL),
('462548275', 'W12038743', 'W12038743', 'ILCHIGSTD', 'Concentra Immediate Care', '', '', 'Concentra Immediate Care', '', 'Urgent Care', '', '', NULL, 'B', 'PO Box 2547', 'Addison', 'Dallas', 'TX', '75001', '8774278801', '9723851759', 'PO Box 2547', 'Addison', 'Dallas', 'TX', '75001', '8774278801', '9723851759', '', '', '', '0.00', '0.00', '110.00', 3, '2013-08-01', NULL, 0, 0, 0, '', '', '', '', 'HCFA|UB|', '1093996480', 0, 'N', 0, '2013-11-27', NULL, NULL, 0, 0, NULL, NULL),
('462548275', 'W12038744', 'W12038744', 'ILCHIGSTD', 'Concentra Immediate Care', '', '', 'Concentra Immediate Care', '', 'Urgent Care', '', '', NULL, 'B', 'PO Box 2547', 'Addison', 'Dallas', 'TX', '75001', '8774278801', '9723851759', 'PO Box 2547', 'Addison', 'Dallas', 'TX', '75001', '8774278801', '9723851759', '', '', '', '0.00', '0.00', '110.00', 3, '2013-08-01', NULL, 0, 0, 0, '', '', '', '', 'HCFA|UB|', '1942489422', 0, 'N', 0, '2013-11-27', NULL, NULL, 0, 0, NULL, NULL),
('462548275', 'W12038745', 'W12038745', 'ILCHIGSTD', 'Concentra Immediate Care', '', '', 'Concentra Immediate Care', '', 'Urgent Care', '', '', NULL, 'B', 'PO Box 2547', 'Addison', 'Dallas', 'TX', '75001', '8774278801', '9723851759', 'PO Box 2547', 'Addison', 'Dallas', 'TX', '75001', '8774278801', '9723851759', '', '', '', '0.00', '0.00', '110.00', 3, '2013-08-01', NULL, 0, 0, 0, '', '', '', '', 'HCFA|UB|', '1902098742', 0, 'N', 0, '2013-11-27', NULL, NULL, 0, 0, NULL, NULL),
('462548275', 'W12038746', 'W12038746', 'ILCHIGSTD', 'Concentra Immediate Care', '', '', 'Concentra Immediate Care', '', 'Urgent Care', '', '', NULL, 'B', 'PO Box 2547', 'Addison', 'Dallas', 'TX', '75001', '8774278801', '9723851759', 'PO Box 2547', 'Addison', 'Dallas', 'TX', '75001', '8774278801', '9723851759', 'WISESTD', 'WUSTDHCPC5', '', '0.00', '35.00', '0.00', 3, '2013-08-01', '2013-08-26', 0, 0, 0, '', '', '', '', 'HCFA|UB|', '1912196536', 0, 'Y', 0, '2013-10-02', NULL, NULL, 0, 0, NULL, NULL),
('870281028', 'W12038748', 'W12038748', 'UT01', 'Central Utah Clinic', 'Brannick', 'B', 'Riggs', 'MD', 'Family Practice', '', '', NULL, 'B', 'PO Box 30079', 'Salt Lake City', 'Salt Lake', 'UT', '84130', '8013758858', '8014298180', 'PO Box 30079', 'Salt Lake City', 'Salt Lake', 'UT', '84130', '8013758858', '8014298180', 'WCUC', 'WUSTDHCPC5', '', '0.00', '35.00', '0.00', 6, '2011-03-01', NULL, 0, 0, 0, 'Ogden Regional Medical Center', NULL, NULL, NULL, 'HCFA|UB|', '1255324984', 0, 'N', 0, '2013-12-03', NULL, NULL, 0, 0, NULL, NULL),
('870281028', 'W12038749', 'W12038749', 'UT01', 'Central Utah Clinic', 'Brannick', 'B', 'Riggs', 'MD', 'Family Practice', '', '', NULL, 'M', '1055 N 500 W', 'Provo', 'Utah', 'UT', '84604', '8018124673', '8014180941', '1055 N 500 W', 'Provo', 'Utah', 'UT', '84604', '8018124673', '8014180941', 'WCUC', 'WUSTDHCPC5', '', '0.00', '35.00', '0.00', 6, '2011-03-01', NULL, 0, 0, 0, 'Ogden Regional Medical Center', NULL, NULL, NULL, 'HCFA|UB|', '1255324984', 0, 'N', 0, '2013-12-03', NULL, NULL, 0, 0, NULL, NULL),
('870281028', 'W12038747', 'W12038747', 'UT01', 'Central Utah Clinic', 'Brannick', 'B', 'Riggs', 'MD', 'Family Practice', '', '', NULL, 'O', '5991 S 3500 W Ste 400', 'Roy', 'Weber', 'UT', '84067', '8017732838', '8017732838', '5991 S 3500 W Ste 400', 'Roy', 'Weber', 'UT', '84067', '8017732838', '8017732838', 'WCUC', 'WUSTDHCPC5', '', '0.00', '35.00', '0.00', 6, '2011-03-01', NULL, 0, 0, 0, 'Ogden Regional Medical Center', NULL, NULL, NULL, 'HCFA|UB|', '1255324984', 0, 'N', 0, '2013-12-03', NULL, NULL, 41.1545, -112.064, NULL, NULL),
('850327237', 'W12038751', 'W12038751', 'NM01', 'Lovelace Westside Hospital', 'Patricia', '', 'Costales', 'CNP', 'Family Practice', '', '', NULL, 'O', '10501 Golf Course Rd NW', 'Albuquerque', 'Bernalillo', 'NM', '87114', '5057272300', NULL, '10501 Golf Course Rd NW', 'Albuquerque', 'Bernalillo', 'NM', '87114', '5057272300', '          ', '', '', '', '0.00', '55.00', '0.00', 3, '2013-10-01', NULL, 0, 0, 0, 'Lovelace Westside Hospital', NULL, NULL, NULL, 'HCFA|UB|', '1619131455', 0, 'N', 0, '2013-10-03', NULL, NULL, 35.206, -106.675, NULL, NULL),
('850327237', 'W12038752', 'W12038752', 'NM01', 'LHS Pro Billing', 'Patricia', '', 'Costales', 'CNP', 'Family Practice', '', '', NULL, 'B', '4411 The 25 Way Ste 100', 'Albuquerque', 'Bernalillo', 'NM', '87109', '0000000000', NULL, '4411 The 25 Way Ste 100', 'Albuquerque', 'Bernalillo', 'NM', '87109', '0000000000', '          ', '', '', '', '0.00', '55.00', '0.00', 3, '2013-10-01', NULL, 0, 0, 0, 'Lovelace Westside Hospital', NULL, NULL, NULL, 'HCFA|UB|', '1619131455', 0, 'N', 0, '2013-10-03', NULL, NULL, 0, 0, NULL, NULL),
('850327237', 'W12038755', 'W12038755', 'NM01', 'Lovelace Womens Hospital General Surgery', 'Eldie', '', 'Cruz', 'MD', 'General Surgery', '', '', NULL, 'O', '101 Hospital Loop NE Ste 111', 'Albuquerque', 'Bernalillo', 'NM', '87109', '5057277050', NULL, '101 Hospital Loop NE Ste 111', 'Albuquerque', 'Bernalillo', 'NM', '87109', '5057277050', '          ', '', '', '', '0.00', '55.00', '0.00', 3, '2013-10-01', NULL, 0, 0, 0, 'Lovelace Medical Center', '', '', '', 'HCFA|UB|', '1851430870', 0, 'N', 0, '2013-10-02', NULL, NULL, 35.1328, -106.593, NULL, NULL),
('850327237', 'W12038754', 'W12038754', 'NM01', 'LHS Pro Billing', 'Eldie', '', 'Cruz', 'MD', 'General Surgery', '', '', NULL, 'B', '4411 The 25 Way Ste 100', 'Albuquerque', 'Bernalillo', 'NM', '87109', '0000000000', NULL, '4411 The 25 Way Ste 100', 'Albuquerque', 'Bernalillo', 'NM', '87109', '0000000000', '          ', '', '', '', '0.00', '55.00', '0.00', 3, '2013-10-01', NULL, 0, 0, 0, 'Lovelace Medical Center', '', '', '', 'HCFA|UB|', '1851430870', 0, 'N', 0, '2013-10-02', NULL, NULL, 0, 0, NULL, NULL),
('850327237', 'W12038757', 'W12038757', 'NM01', 'Lovelace Womens Hospital', 'Elaine', '', 'DiFederico', 'MD', 'Obstetrics and Gynecology', '', '', NULL, 'O', '4701 Montgomery Blvd NE', 'Albuquerque', 'Bernalillo', 'NM', '87109', '5057276853', NULL, '4701 Montgomery Blvd NE', 'Albuquerque', 'Bernalillo', 'NM', '87109', '5057276853', '          ', '', '', '0', '0.00', '55.00', '0.00', 3, '2013-10-01', NULL, 0, 0, 0, 'Lovelace Medical Center', '', '', '', 'HCFA|UB|', '1508072752', 0, 'N', 0, '2013-10-10', NULL, NULL, 35.131, -106.591, NULL, NULL),
('850327237', 'W12038758', 'W12038758', 'NM01', 'LHS Pro Billing', 'Elaine', '', 'DiFederico', 'MD', 'Obstetrics and Gynecology', '', '', NULL, 'B', '4411 The 25 Way Ste 100', 'Albuquerque', 'Bernalillo', 'NM', '87109', '0000000000', NULL, '4411 The 25 Way Ste 100', 'Albuquerque', 'Bernalillo', 'NM', '87109', '0000000000', '          ', '', '', '', '0.00', '55.00', '0.00', 3, '2013-10-01', NULL, 0, 0, 0, 'Lovelace Medical Center', '', '', '', 'HCFA|UB|', '1508072752', 0, 'N', 0, '2013-10-10', NULL, NULL, 0, 0, NULL, NULL),
('850327237', 'W12038760', 'W12038760', 'NM01', 'Lovelace Womens Hospital General Surgery', 'Mario', '', 'Leyba', 'MD', 'General Surgery', '', '', NULL, 'O', '101 Hospital Loop NE Ste 111', 'Albuquerque', 'Bernalillo', 'NM', '87109', '5057277050', NULL, '101 Hospital Loop NE Ste 111', 'Albuquerque', 'Bernalillo', 'NM', '87109', '5057277050', '          ', '', '', '', '0.00', '55.00', '0.00', 3, '2013-10-01', NULL, 0, 0, 0, 'Lovelace Womens Hospital', NULL, NULL, NULL, 'HCFA|UB|', '1689876013', 0, 'N', 0, '2013-11-12', NULL, NULL, 35.1328, -106.593, NULL, NULL),
('850327237', 'W12038761', 'W12038761', 'NM01', 'LHS Pro Billing', 'Mario', '', 'Leyba', 'MD', 'General Surgery', '', '', NULL, 'B', '4411 The 25 Way Ste 100', 'Albuquerque', 'Bernalillo', 'NM', '87109', '0000000000', NULL, '4411 The 25 Way Ste 100', 'Albuquerque', 'Bernalillo', 'NM', '87109', '0000000000', '          ', '', '', '', '0.00', '55.00', '0.00', 3, '2013-10-01', NULL, 0, 0, 0, 'Lovelace Womens Hospital', NULL, NULL, NULL, 'HCFA|UB|', '1689876013', 0, 'N', 0, '2013-11-12', NULL, NULL, 0, 0, NULL, NULL),
('850327237', 'W12038763', 'W12038763', 'NM01', 'LHS Pro Billing', 'James', 'E', 'Martinez', 'MD', 'Gastroenterology', '', '', NULL, 'B', '4411 The 25 Way Ste 100', 'Albuquerque', 'Bernalillo', 'NM', '87109', '0000000000', NULL, '4411 The 25 Way Ste 100', 'Albuquerque', 'Bernalillo', 'NM', '87109', '0000000000', '          ', '', '', '', '0.00', '55.00', '0.00', 3, '2013-10-01', NULL, 0, 0, 0, 'Lovelace Womens Hospital', NULL, NULL, NULL, 'HCFA|UB|', '1649279944', 0, 'N', 0, '2013-10-09', NULL, NULL, 0, 0, NULL, NULL),
('850327237', 'W12038764', 'W12038764', 'NM01', 'Lovelace Womens Hospital Pavilion', 'James', 'E', 'Martinez', 'MD', 'Gastroenterology', '', '', NULL, 'O', '4705 Montgomery NE Ste 102', 'Albuquerque', 'Bernalillo', 'NM', '87109', '5057277833', NULL, '4705 Montgomery NE Ste 102', 'Albuquerque', 'Bernalillo', 'NM', '87109', '5057277833', '          ', '', '', '', '0.00', '55.00', '0.00', 3, '2013-10-01', NULL, 0, 0, 0, 'Lovelace Womens Hospital', NULL, NULL, NULL, 'HCFA|UB|', '1649279944', 0, 'N', 0, '2013-10-09', NULL, NULL, 35.131, -106.591, NULL, NULL),
('850327237', 'W12038766', 'W12038766', 'NM01', 'Lovelace Womens Hospital Pavilion', 'Leslie', '', 'Monagle', 'NP', 'Gastroenterology', '', '', NULL, 'O', '4705 Montgomery NE Ste 102', 'Albuquerque', 'Bernalillo', 'NM', '87109', '5057277833', NULL, '4705 Montgomery NE Ste 102', 'Albuquerque', 'Bernalillo', 'NM', '87109', '5057277833', '          ', '', '', '', '0.00', '55.00', '0.00', 3, '2013-10-01', NULL, 0, 0, 0, 'Lovelace Womens Hospital', NULL, NULL, NULL, 'HCFA|UB|', '1841299062', 0, 'N', 0, '2013-10-09', NULL, NULL, 35.131, -106.591, NULL, NULL),
('850327237', 'W12038767', 'W12038767', 'NM01', 'LHS Pro Billing', 'Leslie', '', 'Monagle', 'NP', 'Gastroenterology', '', '', NULL, 'B', '4411 The 25 Way Ste 100', 'Albuquerque', 'Bernalillo', 'NM', '87109', '0000000000', NULL, '4411 The 25 Way Ste 100', 'Albuquerque', 'Bernalillo', 'NM', '87109', '0000000000', '          ', '', '', '', '0.00', '55.00', '0.00', 3, '2013-10-01', NULL, 0, 0, 0, 'Lovelace Womens Hospital', NULL, NULL, NULL, 'HCFA|UB|', '1841299062', 0, 'N', 0, '2013-10-09', NULL, NULL, 0, 0, NULL, NULL),
('850327237', 'W12038769', 'W12038769', 'NM01', 'Lovelace Womens Hospital', 'Lisa', 'E', 'Moore', 'MD', 'Obstetrics and Gynecology', '', '', NULL, 'O', '4701 Montgomery Blvd NE', 'Albuquerque', 'Bernalillo', 'NM', '87109', '5057276853', NULL, '4701 Montgomery Blvd NE', 'Albuquerque', 'Bernalillo', 'NM', '87109', '5057276853', '          ', '', '', '', '0.00', '55.00', '0.00', 3, '2013-10-01', NULL, 0, 0, 0, 'Lovelace Medical Center', '', '', '', 'HCFA|UB|', '1053328013', 0, 'N', 0, '2013-10-08', NULL, NULL, 35.131, -106.591, NULL, NULL),
('850327237', 'W12038770', 'W12038770', 'NM01', 'LHS Pro Billing', 'Lisa', 'E', 'Moore', 'MD', 'Obstetrics and Gynecology', '', '', NULL, 'B', '4411 The 25 Way Ste 100', 'Albuquerque', 'Bernalillo', 'NM', '87109', '0000000000', NULL, '4411 The 25 Way Ste 100', 'Albuquerque', 'Bernalillo', 'NM', '87109', '0000000000', '          ', '', '', '', '0.00', '55.00', '0.00', 3, '2013-10-01', NULL, 0, 0, 0, 'Lovelace Medical Center', '', '', '', 'HCFA|UB|', '1053328013', 0, 'N', 0, '2013-10-08', NULL, NULL, 0, 0, NULL, NULL),
('850327237', 'W12038772', 'W12038772', 'NM01', 'Lovelace Womens Hospital', 'Kathy', '', 'Morris', '', 'Certified Genetic Counselor', '', '', NULL, 'O', '4701 Montgomery Blvd NE', 'Albuquerque', 'Bernalillo', 'NM', '87109', '5057276853', NULL, '4701 Montgomery Blvd NE', 'Albuquerque', 'Bernalillo', 'NM', '87109', '5057276853', '          ', '', '', '', '0.00', '55.00', '0.00', 3, '2013-10-01', NULL, 0, 0, 0, '', '', '', '', 'HCFA|UB|', '1366576019', 0, 'N', 0, '2013-10-24', NULL, NULL, 35.131, -106.591, NULL, NULL),
('850327237', 'W12038773', 'W12038773', 'NM01', 'LHS Pro Billing', 'Kathy', '', 'Morris', '', 'Certified Genetic Counselor', '', '', NULL, 'B', '4411 The 25 Way Ste 100', 'Albuquerque', 'Bernalillo', 'NM', '87109', '0000000000', NULL, '4411 The 25 Way Ste 100', 'Albuquerque', 'Bernalillo', 'NM', '87109', '0000000000', '          ', '', '', '', '0.00', '55.00', '0.00', 3, '2013-10-01', NULL, 0, 0, 0, '', '', '', '', 'HCFA|UB|', '1366576019', 0, 'N', 0, '2013-10-24', NULL, NULL, 0, 0, NULL, NULL),
('850327237', 'W12038775', 'W12038775', 'NM01', 'Lovelace Womens Hospital', 'Lisa', '', 'Moss', '', 'Certified Genetic Counselor', '', '', NULL, 'O', '4701 Montgomery Blvd NE', 'Albuquerque', 'Bernalillo', 'NM', '87109', '5057276853', NULL, '4701 Montgomery Blvd NE', 'Albuquerque', 'Bernalillo', 'NM', '87109', '5057276853', '          ', '', '', '', '0.00', '55.00', '0.00', 3, '2013-10-01', NULL, 0, 0, 0, '', '', '', '', 'HCFA|UB|', '1629211156', 0, 'N', 0, '2013-10-24', NULL, NULL, 35.131, -106.591, NULL, NULL),
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('850327237', 'W12038781', 'W12038781', 'NM01', 'Lovelace Womens Hospital', 'Ellen', '', 'Mozurkewich', 'MD', 'Obstetrics and Gynecology', '', '', NULL, 'O', '4701 Montgomery Blvd NE', 'Albuquerque', 'Bernalillo', 'NM', '87109', '5057276853', NULL, '4701 Montgomery Blvd NE', 'Albuquerque', 'Bernalillo', 'NM', '87109', '5057276853', '          ', '', '', '', '0.00', '55.00', '0.00', 3, '2013-10-01', NULL, 0, 0, 0, 'Lovelace Medical Center', '', '', '', 'HCFA|UB|', '1780771535', 0, 'N', 0, '2013-10-08', NULL, NULL, 35.131, -106.591, NULL, NULL),
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('850327237', 'W12038789', 'W12038789', 'NM01', 'LHS Pro Billing', 'Calvin', '', 'Ridgeway', 'MD', 'Oncology', '', '', NULL, 'B', '4411 The 25 Way Ste 100', 'Albuquerque', 'Bernalillo', 'NM', '87109', '0000000000', NULL, '4411 The 25 Way Ste 100', 'Albuquerque', 'Bernalillo', 'NM', '87109', '0000000000', '          ', '', '', '', '0.00', '55.00', '0.00', 3, '2013-10-01', NULL, 0, 0, 0, 'Lovelace Womens Hospital', NULL, NULL, NULL, 'HCFA|UB|', '1184718579', 0, 'N', 0, '2013-10-09', NULL, NULL, 0, 0, NULL, NULL),
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('850327237', 'W12038793', 'W12038793', 'NM01', 'Lovelace Rehabilitation Hospital', 'Rhonda', 'M', 'Ross', 'PSYD', 'Neurology', 'Psychology', '', NULL, 'O', '505 Elm St NE', 'Albuquerque', 'Bernalillo', 'NM', '87102', '5057274725', NULL, '505 Elm St NE', 'Albuquerque', 'Bernalillo', 'NM', '87102', '5057274725', '          ', '', '', '', '0.00', '55.00', '0.00', 3, '2013-10-01', NULL, 0, 0, 0, 'Lovelace Medical Center', '', '', '', 'HCFA|UB|', '1548441678', 0, 'N', 0, '2013-10-09', NULL, NULL, 35.0865, -106.638, NULL, NULL),
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('850327237', 'W12038799', 'W12038799', 'NM01', 'Lovelace Westside Hospital', 'Cynthia "Janie"', '', 'Shumway', 'LCSW', 'Mental Health', 'Social Worker', '', NULL, 'O', '10501 Golf Course Rd NW', 'Albuquerque', 'Bernalillo', 'NM', '87114', '5057272300', NULL, '10501 Golf Course Rd NW', 'Albuquerque', 'Bernalillo', 'NM', '87114', '5057272300', '          ', '', '', '', '0.00', '55.00', '0.00', 3, '2013-10-01', NULL, 0, 0, 0, 'Lovelace Medical Center', '', '', '', 'HCFA|UB|', '1356670285', 0, 'N', 0, '2013-10-09', NULL, NULL, 35.206, -106.675, NULL, NULL),
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('850327237', 'W12038802', 'W12038802', 'NM01', 'Lovelace Womens Breast Care Center', 'Marguarite', 'J', 'Thomas', 'MD', 'General Surgery', '', '', NULL, 'O', '4701 Montgomery NE', 'Albuquerque', 'Bernalillo', 'NM', '87109', '5057276900', NULL, '4701 Montgomery NE', 'Albuquerque', 'Bernalillo', 'NM', '87109', '5057276900', '          ', '', '', '', '0.00', '55.00', '0.00', 3, '2013-10-01', NULL, 0, 0, 0, 'Lovelace Womens Hospital', NULL, NULL, NULL, 'HCFA|UB|', '1396854196', 0, 'N', 0, '2013-10-10', NULL, NULL, 35.131, -106.591, NULL, NULL),
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('850327237', 'W12038805', 'W12038805', 'NM01', 'Lovelace Womens Hospital Pavilion', 'Hala', 'A', 'Toubbeh', 'MD', 'Gastroenterology', '', '', NULL, 'O', '4705 Montgomery NE Ste 102', 'Albuquerque', 'Bernalillo', 'NM', '87109', '5057277833', NULL, '4705 Montgomery NE Ste 102', 'Albuquerque', 'Bernalillo', 'NM', '87109', '5057277833', '          ', '', '', '', '0.00', '55.00', '0.00', 3, '2013-10-01', NULL, 0, 0, 0, 'Lovelace Womens Hospital', NULL, NULL, NULL, 'HCFA|UB|', '1477513075', 0, 'N', 0, '2013-10-10', NULL, NULL, 35.131, -106.591, NULL, NULL),
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('850327237', 'W12038811', 'W12038811', 'NM01', 'LHS Pro Billing', 'Salim', '', 'Walji', 'MD', 'Thoracic Surgery', '', '', NULL, 'B', '4411 The 25 Way Ste 100', 'Albuquerque', 'Bernalillo', 'NM', '87109', '0000000000', NULL, '4411 The 25 Way Ste 100', 'Albuquerque', 'Bernalillo', 'NM', '87109', '0000000000', '          ', '', '', '', '0.00', '55.00', '0.00', 3, '2013-10-01', NULL, 0, 0, 0, 'Lovelace Medical Center', '', '', '', 'HCFA|UB|', '1992709794', 0, 'N', 0, '2013-10-10', NULL, NULL, 0, 0, NULL, NULL),
('850327237', 'W12038812', 'W12038812', 'NM01', 'Lovelace Pulmonary Clinic', 'Salim', '', 'Walji', 'MD', 'Thoracic Surgery', '', '', NULL, 'O', '500 Walter NE Ste 308', 'Albuquerque', 'Bernalillo', 'NM', '87102', '5057277450', NULL, '500 Walter NE Ste 308', 'Albuquerque', 'Bernalillo', 'NM', '87102', '5057277450', '          ', '', '', '', '0.00', '55.00', '0.00', 3, '2013-10-01', NULL, 0, 0, 0, 'Lovelace Medical Center', '', '', '', 'HCFA|UB|', '1992709794', 0, 'N', 0, '2013-10-10', NULL, NULL, 35.0863, -106.64, NULL, NULL),
('850327237', 'W12038814', 'W12038814', 'NM01', 'LHS Pro Billing', 'Jennifer', 'C', 'Wichman', 'MD', 'Pulmonary', '', '', NULL, 'B', '4411 The 25 Way Ste 100', 'Albuquerque', 'Bernalillo', 'NM', '87109', '0000000000', NULL, '4411 The 25 Way Ste 100', 'Albuquerque', 'Bernalillo', 'NM', '87109', '0000000000', '          ', '', '', '', '0.00', '55.00', '0.00', 3, '2013-10-01', NULL, 0, 0, 0, '', '', '', '', 'HCFA|UB|', '1952749764', 0, 'N', 0, '2013-11-01', NULL, NULL, 0, 0, NULL, NULL),
('850327237', 'W12038815', 'W12038815', 'NM01', 'Lovelace Medical Center', 'Jennifer', 'C', 'Wichman', 'MD', 'Pulmonary', '', '', NULL, 'O', '601 Dr Martin Luther King Jr Ave NE', 'Albuquerque', 'Bernalillo', 'NM', '87102', '5057278000', NULL, '601 Dr Martin Luther King Jr Ave NE', 'Albuquerque', 'Bernalillo', 'NM', '87102', '5057278000', '          ', '', '', '', '0.00', '55.00', '0.00', 3, '2013-10-01', NULL, 0, 0, 0, '', '', '', '', 'HCFA|UB|', '1952749764', 0, 'N', 0, '2013-11-01', NULL, NULL, 35.0857, -106.64, NULL, NULL),
('942854057', 'W12038820', 'W12038820', 'UTIHCPHY', 'Fillmore Clinic', 'Ronald', 'H', 'Crouch', 'MD', 'Urology', '', '', NULL, 'O', '700 S Hwy 99 Ste 3', 'Fillmore', 'Millard', 'UT', '84631', '4357435555', '4357435764', '700 S Hwy 99 Ste 3', 'Fillmore', 'Millard', 'UT', '84631', '4357435555', '4357435764', 'USTDMULT', 'WUSTDHCPC5', '', '0.00', '35.00', '0.00', 8, '2013-09-20', NULL, 0, 0, 0, 'Valley View Medical Center', 'Dixie Regional Medical Center', '', '', 'HCFA|UB|', '1952342248', 0, 'N', 0, '2013-10-03', NULL, NULL, 38.953, -112.341, NULL, NULL),
('942854057', 'W12038821', 'W12038821', 'UTIHCPHY', 'White Sage Family Medicine Clinic', 'Ronald', 'H', 'Crouch', 'MD', 'Urology', '', '', NULL, 'O', '130 White Sage Ave', 'Delta', 'Millard', 'UT', '84624', '4358642708', '4358642855', '130 White Sage Ave', 'Delta', 'Millard', 'UT', '84624', '4358642708', '4358642855', 'USTDMULT', 'WUSTDHCPC5', '', '0.00', '35.00', '0.00', 8, '2013-09-20', NULL, 0, 0, 0, 'Valley View Medical Center', 'Dixie Regional Medical Center', '', '', 'HCFA|UB|', '1952342248', 0, 'N', 0, '2013-10-03', NULL, NULL, 39.3505, -112.56, NULL, NULL),
('942854057', 'W12038822', 'W12038822', 'UTIHCPHY', 'Sevier Valley Clinic', 'Ronald', 'H', 'Crouch', 'MD', 'Urology', '', '', NULL, 'O', '70 E 1000 N', 'Richfield', 'Sevier', 'UT', '84701', '4358930580', '4358968420', '70 E 1000 N', 'Richfield', 'Sevier', 'UT', '84701', '4358930580', '4358968420', 'USTDMULT', 'WUSTDHCPC5', '', '0.00', '35.00', '0.00', 8, '2013-09-20', NULL, 0, 0, 0, 'Valley View Medical Center', 'Dixie Regional Medical Center', '', '', 'HCFA|UB|', '1952342248', 0, 'N', 0, '2013-10-03', NULL, NULL, 38.8608, -111.967, NULL, NULL),
('942854057', 'W12038824', 'W12038824', 'UTIHCPHY', 'Southern Utah Neurosciences Institute', 'Brian', 'D', 'Davenport', 'NP', 'Family Practice', '', '', NULL, 'O', '652 S Medical Ctr Dr Ste 420', 'St George', 'Washington', 'UT', '84790', '4352516800', '4352513701', '652 S Medical Ctr Dr Ste 420', 'St George', 'Washington', 'UT', '84790', '4352516800', '4352513701', 'USTDMULT', 'WUSTDHCPC5', '', '0.00', '35.00', '0.00', 8, '2013-08-28', NULL, 0, 0, 0, 'Dixie Regional Medical Center', NULL, NULL, NULL, 'HCFA|UB|', '1558703306', 0, 'Y', 0, '2013-10-03', NULL, NULL, 37.0498, -113.574, NULL, NULL),
('942854057', 'W12038826', 'W12038826', 'UTIHCPHY', 'Bountiful KidsCare', 'James', 'B', 'Davis', 'MD', 'Pediatrics', '', '', NULL, 'O', '390 N Main St', 'Bountiful', 'Davis', 'UT', '84010', '8012949933', '8012941183', '390 N Main St', 'Bountiful', 'Davis', 'UT', '84010', '8012949933', '8012941183', 'USTDMULT', 'WUSTDHCPC5', '', '0.00', '35.00', '0.00', 8, '2013-07-29', NULL, 0, 0, 0, '', '', '', '', 'HCFA|UB|', '1780905083', 0, 'Y', 0, '2013-10-03', NULL, NULL, 40.8935, -111.881, NULL, NULL),
('942854057', 'W12038828', 'W12038828', 'UTIHCPHY', 'Moroni Clinic', 'David', 'L', 'Deaton', 'PA-C', 'Family Practice', '', '', NULL, 'O', '51 E Main St', 'Moroni', 'Sanpete', 'UT', '84646', '4354365250', '4354365265', '51 E Main St', 'Moroni', 'Sanpete', 'UT', '84646', '4354365250', '4354365265', 'USTDMULT', 'WUSTDHCPC5', '', '0.00', '35.00', '0.00', 8, '2013-09-03', NULL, 0, 0, 0, '', '', '', '', 'HCFA|UB|', '1104844224', 0, 'Y', 0, '2013-10-03', NULL, NULL, 39.5249, -111.584, NULL, NULL),
('942854057', 'W12038830', 'W12038830', 'UTIHCPHY', 'Mt Pleasant Clinic', 'David', 'L', 'Deaton', 'PA-C', 'Family Practice', '', '', NULL, 'O', '1100 S Medical Dr', 'Mount Pleasant', 'Sanpete', 'UT', '84647', '4354623471', '4354623354', '1100 S Medical Dr', 'Mount Pleasant', 'Sanpete', 'UT', '84647', '4354623471', '4354623354', 'USTDMULT', 'WUSTDHCPC5', '', '0.00', '35.00', '0.00', 8, '2013-09-03', NULL, 0, 0, 0, '', '', '', '', 'HCFA|UB|', '1104844224', 0, 'Y', 0, '2013-10-03', NULL, NULL, 39.5318, -111.461, NULL, NULL),
('942854057', 'W12038829', 'W12038829', 'UTIHCPHY', 'Ephraim Clinic', 'David', 'L', 'Deaton', 'PA-C', 'Family Practice', '', '', NULL, 'O', '525 N Main St', 'Ephraim', 'Sanpete', 'UT', '84627', '4352834076', '4352834078', '525 N Main St', 'Ephraim', 'Sanpete', 'UT', '84627', '4352834076', '4352834078', 'USTDMULT', 'WUSTDHCPC5', '', '0.00', '35.00', '0.00', 8, '2013-09-03', NULL, 0, 0, 0, '', '', '', '', 'HCFA|UB|', '1104844224', 0, 'Y', 0, '2013-10-03', NULL, NULL, 39.371, -111.587, NULL, NULL),
('942854057', 'W12038832', 'W12038832', 'UTIHCPHY', 'Cedar City Clinic', 'Todd', 'M', 'Garrett', 'MD', 'Internal Medicine', '', '', NULL, 'O', '1303 N Main St Ste 3C', 'Cedar City', 'Iron', 'UT', '84720', '4358685500', '4358685504', '1303 N Main St Ste 3C', 'Cedar City', 'Iron', 'UT', '84720', '4358685500', '4358685504', 'USTDMULT', 'WUSTDHCPC5', '', '0.00', '35.00', '0.00', 8, '2013-09-23', NULL, 0, 0, 0, '', '', '', '', 'HCFA|UB|', '1255537429', 0, 'N', 0, '2013-10-03', NULL, NULL, 37.7003, -113.064, NULL, NULL),
('942854057', 'W12038834', 'W12038834', 'UTIHCPHY', 'Dixie Hospitalists', 'Mark', 'P', 'Hoth', 'MD', 'Hospitalist', '', '', NULL, 'O', '1380 E Medical Ctr Dr', 'St George', 'Washington', 'UT', '84790', '4352512992', '4356886222', '1380 E Medical Ctr Dr', 'St George', 'Washington', 'UT', '84790', '4352512992', '4356886222', 'USTDMULT', 'WUSTDHCPC5', '', '0.00', '35.00', '0.00', 8, '2013-08-28', NULL, 0, 0, 0, '', '', '', '', 'HCFA|UB|', '1083925606', 0, 'Y', 0, '2013-10-03', NULL, NULL, 37.0998, -113.554, NULL, NULL),
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('861148310', 'W12038867', 'W12038867', 'TXHOUSTD', 'W Marie LeBas', 'W Marie', '', 'LeBas', 'MD', 'Neurology', '', '', NULL, 'O', '380 E Medical Ctr Blvd', 'Webster', 'Harris', 'TX', '77598', '2813326949', '2813326965', '380 E Medical Ctr Blvd', 'Webster', 'Harris', 'TX', '77598', '2813326949', '2813326965', 'HOUSTON5', 'TXHCPC13', '', '0.00', '45.00', '0.00', 3, '2013-11-15', NULL, 0, 0, 0, 'Clear Lake Regional Medical Center', NULL, '', '', 'HCFA|UB|', '1144215815', 0, 'N', 0, '2013-10-15', NULL, NULL, 29.5453, -95.121, NULL, NULL);
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('271045478', 'W12038871', 'W12038871', 'TXHOUSTD', 'Houston Northwest Medical Center', 'Norman', 'J', 'Torres', 'MD', 'Neurosurgery', '', '', NULL, 'O', '710 FM 1960 W', 'Houston', 'Harris', 'TX', '77090', '2814401000', NULL, '710 FM 1960 W', 'Houston', 'Harris', 'TX', '77090', '2814401000', '          ', 'HOUSTON5', 'TXHCPC13', '', '0.00', '45.00', '0.00', 3, '2013-11-15', NULL, 0, 0, 0, '', '', '', '', 'HCFA|UB|', '1033183033', 0, 'N', 0, '2013-10-15', NULL, NULL, 30.0078, -95.4426, NULL, NULL),
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('364088232', 'W12038892', 'W12038892', 'ILCHIGSTD', 'Dreyer Medical Clinic', 'Peter', 'T', 'Rasmussen', 'PT', 'Physical Therapy', '', '', NULL, 'O', '1221 N Highland Ave', 'Aurora', 'Kane', 'IL', '60506', '6308598700', '6302648639', '1221 N Highland Ave', 'Aurora', 'Kane', 'IL', '60506', '6308598700', '6302648639', 'CHIG17', 'CHIHCPCSMA', '', '0.00', '35.00', '0.00', 3, '2013-09-23', NULL, 0, 0, 0, '', '', '', '', 'HCFA|UB|', '1194150763', 0, 'N', 0, '2014-04-04', NULL, NULL, 41.7821, -88.3293, NULL, NULL),
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('364088232', 'W12038893', 'W12038893', 'ILCHIGSTD', 'Dreyer Medical Clinic', 'Peter', 'T', 'Rasmussen', 'PT', 'Physical Therapy', '', '', NULL, 'O', '2500 W Fabyan Pkwy', 'Batavia', 'Kane', 'IL', '60510', '6308792110', '6307624779', '2500 W Fabyan Pkwy', 'Batavia', 'Kane', 'IL', '60510', '6308792110', '6307624779', 'CHIG17', 'CHIHCPCSMA', '', '0.00', '35.00', '0.00', 3, '2013-09-23', NULL, 0, 0, 0, '', '', '', '', 'HCFA|UB|', '1194150763', 0, 'N', 0, '2014-04-04', NULL, NULL, 41.8633, -88.269, NULL, NULL),
('364088232', 'W12038895', 'W12038895', 'ILCHIGSTD', 'Dreyer Medical Clinic', 'Peter', 'T', 'Rasmussen', 'PT', 'Physical Therapy', '', '', NULL, 'O', '4100 Healthway Dr', 'Aurora', 'Dupage', 'IL', '60504', '6308513105', '6309786694', '4100 Healthway Dr', 'Aurora', 'Dupage', 'IL', '60504', '6308513105', '6309786694', 'CHIG17', 'CHIHCPCSMA', '', '0.00', '35.00', '0.00', 3, '2013-09-23', NULL, 0, 0, 0, '', '', '', '', 'HCFA|UB|', '1194150763', 0, 'N', 0, '2014-04-04', NULL, NULL, 41.7522, -88.2131, NULL, NULL),
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('364088232', 'W12038890', 'W12038890', 'ILCHIGSTD', 'Dreyer Medical Clinic', 'Peter', 'T', 'Rasmussen', 'PT', 'Physical Therapy', '', '', NULL, 'O', '80 Templeton Dr', 'Oswego', 'Kendall', 'IL', '60543', '6305543456', '6305512933', '80 Templeton Dr', 'Oswego', 'Kendall', 'IL', '60543', '6305543456', '6305512933', 'CHIG17', 'CHIHCPCSMA', '', '0.00', '35.00', '0.00', 3, '2013-09-23', NULL, 0, 0, 0, '', '', '', '', 'HCFA|UB|', '1194150763', 0, 'N', 0, '2014-04-04', NULL, NULL, 41.6724, -88.3381, NULL, NULL),
('364037473', 'W12038896', 'W12038896', 'ILCHIGSTD', 'Elmhurst Memorial Professional Services', 'Ghassan', '', 'Aldurra', 'MD', 'Psychiatry', '', '', NULL, 'O', '1200 S York Rd', 'Elmhurst', 'Dupage', 'IL', '60126', '3312214400', '3312213969', '1200 S York Rd', 'Elmhurst', 'Dupage', 'IL', '60126', '3312214400', '3312213969', 'CHIG13', 'CHIHCPCS02', '', '0.00', '40.00', '0.00', 3, '2013-06-04', NULL, 0, 0, 0, 'Elmhurst Memorial Hospital', '', '', '', 'HCFA|UB|', '1699781310', 0, 'Y', 0, '2014-04-01', NULL, NULL, 41.865, -87.9322, NULL, NULL),
('364037473', 'W12038897', 'W12038897', 'ILCHIGSTD', 'Elmhurst Memorial Professional Services Billing', 'Ghassan', '', 'Aldurra', 'MD', 'Psychiatry', '', '', NULL, 'B', 'PO Box 4585', 'Carol Stream', 'Dupage', 'IL', '60122', '3312219099', '6309935681', 'PO Box 4585', 'Carol Stream', 'Dupage', 'IL', '60122', '3312219099', '6309935681', 'CHIG13', 'CHIHCPCS02', '', '0.00', '40.00', '0.00', 3, '2013-06-04', NULL, 0, 0, 0, 'Elmhurst Memorial Hospital', '', '', '', 'HCFA|UB|', '1699781310', 0, 'N', 0, '2013-10-04', NULL, NULL, 0, 0, NULL, NULL),
('260745445', 'W12038898', 'W12038898', 'NM01', '', 'Jessica', '', 'Kingsley', 'LCSW', 'Mental Health', '', '', NULL, 'O', '901 Rio Grande Blvd NW Ste F244', 'Albuquerque', 'Bernalillo', 'NM', '87105', '5053793703', '5055037280', '901 Rio Grande Blvd NW Ste F244', 'Albuquerque', 'Bernalillo', 'NM', '87105', '5053793703', '5055037280', '', '', '', '0.00', '0.00', '0.00', 3, '2013-09-26', NULL, 0, 0, 1, '', '', '', '', 'HCFA|UB|', '1528372166', 0, 'N', 0, '2013-10-04', NULL, NULL, 35.1026, -106.671, NULL, NULL),
('820470661', 'W12038903', 'W12038903', 'ID01', 'Lifeline Chiropractic', 'Lynne', 'A', 'Jellum', 'DC', 'Chiropractic', '', '', NULL, 'O', '5440 W Franklin Rd Ste 107', 'Boise', 'Ada', 'ID', '83705', '2083367900', NULL, '5440 W Franklin Rd Ste 107', 'Boise', 'Ada', 'ID', '83705', '2083367900', '          ', 'IDCHIRO1', '', '', '0.00', '35.00', '0.00', 3, '2013-09-30', NULL, 0, 0, 0, '', '', '', '', 'HCFA|UB|', '1144347048', 0, 'N', 0, '2013-10-31', NULL, NULL, 43.603, -116.249, NULL, NULL),
('820470661', 'W12038904', 'W12038904', 'SACN', 'Lifeline Chiropractic', 'Lynne', 'A', 'Jellum', 'DC', 'Chiropractic', '', '', NULL, 'O', '5440 W Franklin Rd Ste 107', 'Boise', 'Ada', 'ID', '83705', '2083367900', NULL, '5440 W Franklin Rd Ste 107', 'Boise', 'Ada', 'ID', '83705', '2083367900', '          ', 'IDSINCLAIRM', '', '', '0.00', '10.00', '0.00', 3, '2013-09-30', NULL, 0, 0, 0, '', '', '', '', 'HCFA|UB|', '1144347048', 0, 'N', 0, '2013-10-31', NULL, NULL, 0, 0, NULL, NULL),
('363330928', 'W12038905', 'W12038905', 'ILCHIGSTD', 'Presence Healthcare Services', 'Jonette', 'P', 'Belicena', 'MD', 'Pediatrics', '', '', NULL, 'O', '301 N Madison St Ste 120', 'Joliet', 'Will', 'IL', '60435', '8157737469', '8157737470', '301 N Madison St Ste 120', 'Joliet', 'Will', 'IL', '60435', '8157737469', '8157737470', 'CHIGP1', 'CHIHCPCS13', '', '0.00', '40.00', '0.00', 3, '2013-10-01', NULL, 0, 0, 0, 'Presence Saint Joseph Hospital Elgin', NULL, NULL, NULL, 'HCFA|UB|', '1134117344', 0, 'N', 0, '2013-10-04', NULL, NULL, 41.5273, -88.1346, NULL, NULL),
('363330928', 'W12038906', 'W12038906', 'ILCHIGSTD', 'Presence Healthcare Services', 'Jonette', 'P', 'Belicena', 'MD', 'Pediatrics', '', '', NULL, 'B', '62311 Collection Ctr Dr', 'Chicago', 'Cook', 'IL', '60693', '8557647687', '6309142469', '62311 Collection Ctr Dr', 'Chicago', 'Cook', 'IL', '60693', '8557647687', '6309142469', 'CHIGP1', 'CHIHCPCS13', '', '0.00', '40.00', '0.00', 3, '2013-10-01', NULL, 0, 0, 0, 'Presence Saint Joseph Hospital Elgin', NULL, NULL, NULL, 'HCFA|UB|', '1134117344', 0, 'N', 0, '2013-10-04', NULL, NULL, 0, 0, NULL, NULL),
('363330928', 'W12038907', 'W12038907', 'ILCHIGSTD', 'Presence Healthcare Services', 'Tiffany', 'C', 'Wilson', 'MD', 'Obstetrics and Gynecology', '', '', NULL, 'O', '301 N Madison St Ste 120', 'Joliet', 'Will', 'IL', '60435', '8157737469', '8157737470', '301 N Madison St Ste 120', 'Joliet', 'Will', 'IL', '60435', '8157737469', '8157737470', 'CHIGP1', 'CHIHCPCS13', '', '0.00', '40.00', '0.00', 3, '2013-08-01', NULL, 0, 0, 0, NULL, '', '', '', 'HCFA|UB|', '1609193077', 0, 'N', 0, '2013-10-04', NULL, NULL, 41.5273, -88.1346, NULL, NULL),
('363330928', 'W12038908', 'W12038908', 'ILCHIGSTD', 'Presence Healthcare Services', 'Tiffany', 'C', 'Wilson', 'MD', 'Obstetrics and Gynecology', '', '', NULL, 'B', '62311 Collection Ctr Dr', 'Chicago', 'Cook', 'IL', '60693', '8557647687', '6309142469', '62311 Collection Ctr Dr', 'Chicago', 'Cook', 'IL', '60693', '8557647687', '6309142469', 'CHIGP1', 'CHIHCPCS13', '', '0.00', '40.00', '0.00', 3, '2013-08-01', NULL, 0, 0, 0, NULL, '', '', '', 'HCFA|UB|', '1609193077', 0, 'N', 0, '2013-10-04', NULL, NULL, 0, 0, NULL, NULL),
('363330928', 'W12038909', 'W12038909', 'ILCHIGSTD', 'Presence Healthcare Services', 'Gilda', '', 'Alcala', 'MD', 'Pediatrics', '', '', NULL, 'B', '62311 Collection Ctr Dr', 'Chicago', 'Cook', 'IL', '60693', '8557647687', '6309142469', '62311 Collection Ctr Dr', 'Chicago', 'Cook', 'IL', '60693', '8557647687', '6309142469', 'CHIGP1', 'CHIHCPCS13', '', '0.00', '40.00', '0.00', 3, '2013-10-01', NULL, 0, 0, 0, 'Presence Saint Joseph Hospital Elgin', NULL, NULL, NULL, 'HCFA|UB|', '1972591188', 0, 'N', 0, '2013-10-04', NULL, NULL, 0, 0, NULL, NULL),
('363330928', 'W12038910', 'W12038910', 'ILCHIGSTD', 'Presence Healthcare Services', 'Gilda', '', 'Alcala', 'MD', 'Pediatrics', '', '', NULL, 'O', '301 N Madison St Ste 120', 'Joliet', 'Will', 'IL', '60435', '8157737469', '8157737470', '301 N Madison St Ste 120', 'Joliet', 'Will', 'IL', '60435', '8157737469', '8157737470', 'CHIGP1', 'CHIHCPCS13', '', '0.00', '40.00', '0.00', 3, '2013-10-01', NULL, 0, 0, 0, 'Presence Saint Joseph Hospital Elgin', NULL, NULL, NULL, 'HCFA|UB|', '1972591188', 0, 'N', 0, '2013-10-04', NULL, NULL, 41.5273, -88.1346, NULL, NULL),
('363330928', 'W12038911', 'W12038911', 'ILCHIGSTD', 'Presence Healthcare Services', 'Jennifer', '', 'Centore Lober', 'PA-C', 'Physician Assistant', '', '', NULL, 'O', '1535 Lake Cook Rd Ste 512', 'Northbrook', 'Cook', 'IL', '60062', '8474320300', '8474321203', '1535 Lake Cook Rd Ste 512', 'Northbrook', 'Cook', 'IL', '60062', '8474320300', '8474321203', 'CHIGP1', 'CHIHCPCS13', '', '0.00', '40.00', '0.00', 3, '2013-10-01', NULL, 0, 0, 0, 'Northwestern Lake Forest Hospital', NULL, NULL, NULL, 'HCFA|UB|', '1932198322', 0, 'Y', 0, '2013-10-04', NULL, NULL, 42.1524, -87.8039, NULL, NULL),
('363330928', 'W12038912', 'W12038912', 'ILCHIGSTD', 'Presence Healthcare Services', 'Jennifer', '', 'Centore Lober', 'PA-C', 'Physician Assistant', '', '', NULL, 'B', '62311 Collection Ctr Dr', 'Chicago', 'Cook', 'IL', '60693', '8557647687', '6309142469', '62311 Collection Ctr Dr', 'Chicago', 'Cook', 'IL', '60693', '8557647687', '6309142469', 'CHIGP1', 'CHIHCPCS13', '', '0.00', '40.00', '0.00', 3, '2013-10-01', NULL, 0, 0, 0, 'Northwestern Lake Forest Hospital', NULL, NULL, NULL, 'HCFA|UB|', '1932198322', 0, 'Y', 0, '2013-10-04', NULL, NULL, 0, 0, NULL, NULL),
('363330928', 'W12038915', 'W12038915', 'ILCHIGSTD', 'Presence Healthcare Services', 'Ira', '', 'Oliff', 'MD', 'Internal Medicine', '', '', NULL, 'O', '1535 Lake Cook Rd Ste 512', 'Northbrook', 'Cook', 'IL', '60062', '8474320300', '8474321203', '1535 Lake Cook Rd Ste 512', 'Northbrook', 'Cook', 'IL', '60062', '8474320300', '8474321203', 'CHIGP1', 'CHIHCPCS13', '', '0.00', '40.00', '0.00', 3, '2013-10-01', NULL, 0, 0, 0, 'Northwestern Lake Forest Hospital', NULL, NULL, NULL, 'HCFA|UB|', '1336138726', 0, 'Y', 0, '2013-10-04', NULL, NULL, 42.1524, -87.8039, NULL, NULL),
('363330928', 'W12038914', 'W12038914', 'ILCHIGSTD', 'Presence Healthcare Services', 'Adi', '', 'Gidron', 'MD', 'Internal Medicine', '', '', NULL, 'O', '1535 Lake Cook Rd Ste 512', 'Northbrook', 'Cook', 'IL', '60062', '8474320300', '8474321203', '1535 Lake Cook Rd Ste 512', 'Northbrook', 'Cook', 'IL', '60062', '8474320300', '8474321203', 'CHIGP1', 'CHIHCPCS13', '', '0.00', '40.00', '0.00', 3, '2013-10-01', NULL, 0, 0, 0, 'Northwestern Lake Forest Hospital', NULL, NULL, NULL, 'HCFA|UB|', '1184767444', 0, 'Y', 0, '2013-10-04', NULL, NULL, 42.1524, -87.8039, NULL, NULL),
('820302317', 'W12038916', 'W12038916', 'Sinclair', 'St Lukes Elks Rehab (Wood River)', 'Kerri', '', 'Everett', 'CCC-SLP', 'Speech Therapy', '', '', NULL, 'O', '100 Hospital Dr Ste 104', 'Ketchum', 'Blaine', 'ID', '83340', '2087278253', '2087278258', '100 Hospital Dr Ste 104', 'Ketchum', 'Blaine', 'ID', '83340', '2087278253', '2087278258', 'IDSINCLAIRA', '', '', '0.00', '35.00', '0.00', 3, '2013-12-01', NULL, 0, 0, 0, '', '', '', '', 'HCFA|UB|', '1538593512', 0, 'N', 0, '2014-04-28', NULL, NULL, 43.6485, -114.35, NULL, NULL),
('260553931', 'W12038925', 'W12038925', 'IDBOISTD', 'Saint Alphonsus Medical Group Maternal Fetal Medicine Boise', 'James', 'S', 'Betoni', 'DO', 'Obstetrics and Gynecology', '', '', NULL, 'O', '900 N Liberty Ste 206', 'Boise', 'Ada', 'ID', '83706', '2083675544', '2083675543', '900 N Liberty Ste 206', 'Boise', 'Ada', 'ID', '83706', '2083675544', '2083675543', 'IDSAMG2', '', '', '0.00', '10.00', '0.00', 6, '2013-09-09', NULL, 0, 0, 0, 'Saint Alphonsus Regional Medical Center', 'Saint Alphonsus Medical Center Nampa', '', '', 'HCFA|UB|', '1477530715', 0, 'N', 0, '2014-06-13', NULL, NULL, 43.6124, -116.261, NULL, NULL),
('260553931', 'W12038926', 'W12038926', 'IDBOISTD', 'Saint Alphonsus Medical Group Maternal Fetal Medicine Iowa', 'James', 'S', 'Betoni', 'DO', 'Obstetrics and Gynecology', '', '', NULL, 'O', '211 W Iowa Ave', 'Nampa', 'Canyon', 'ID', '83686', '2084657377', '2084657397', '211 W Iowa Ave', 'Nampa', 'Canyon', 'ID', '83686', '2084657377', '2084657397', 'IDSAMG2', '', '', '0.00', '10.00', '0.00', 6, '2013-09-09', NULL, 0, 0, 0, 'Saint Alphonsus Regional Medical Center', 'Saint Alphonsus Medical Center Nampa', '', '', 'HCFA|UB|', '1477530715', 0, 'N', 0, '2014-06-13', NULL, NULL, 43.5543, -116.574, NULL, NULL),
('260553931', 'W12038927', 'W12038927', 'IDBOISTD', 'Saint Alphonsus Medical Group Hip & Knee Reconstruction', 'Mark', 'C', 'Meier', 'MD: Joint', 'Orthopedic Surgery', '', '', NULL, 'O', '901 N Curtis Rd Ste 501', 'Meridian', 'Ada', 'ID', '83642', '2083675080', '2083672877', '901 N Curtis Rd Ste 501', 'Meridian', 'Ada', 'ID', '83642', '2083675080', '2083672877', 'IDSAMG1', '', '', '0.00', '10.00', '0.00', 6, '2013-10-01', NULL, 0, 0, 0, 'Saint Alphonsus Medical Center Nampa', '', '', '', 'HCFA|UB|', '1528017209', 0, 'N', 0, '2013-10-07', NULL, NULL, 43.6121, -116.392, NULL, NULL),
('260553931', 'W12038928', 'W12038928', 'IDBOISTD', 'Saint Alphonsus Medical Group Heart Care', 'Michael', 'A', 'Codina', 'MD', 'Cardiology', '', '', NULL, 'O', '1906 Fairview Ave Ste 430', 'Caldwell', 'Canyon', 'ID', '83605', '2083677272', '2083677111', '1906 Fairview Ave Ste 430', 'Caldwell', 'Canyon', 'ID', '83605', '2083677272', '2083677111', 'IDSAMG1', '', '', '0.00', '10.00', '0.00', 6, '2013-10-01', NULL, 0, 0, 0, 'Saint Alphonsus Medical Center Nampa', 'Saint Alphonsus Regional Medical Center', '', '', 'HCFA|UB|', '1871540708', 0, 'N', 0, '2014-07-09', NULL, NULL, 43.6588, -116.677, NULL, NULL),
('260553931', 'W12038929', 'W12038929', 'IDBOISTD', 'Saint Alphonsus Medical Group Heart Care', 'Beth', '', 'Malasky', 'MD', 'Cardiology', '', '', NULL, 'O', '1906 Fairview Ave Ste 430', 'Caldwell', 'Canyon', 'ID', '83605', '2083677272', '2083677111', '1906 Fairview Ave Ste 430', 'Caldwell', 'Canyon', 'ID', '83605', '2083677272', '2083677111', 'IDSAMG1', '', '', '0.00', '10.00', '0.00', 6, '2013-10-01', NULL, 0, 0, 0, 'Saint Alphonsus Regional Medical Center', NULL, NULL, NULL, 'HCFA|UB|', '1730285719', 0, 'N', 0, '2013-10-07', NULL, NULL, 43.6588, -116.677, NULL, NULL),
('460500210', 'W12038931', 'W12038931', 'IDBOISTD', 'Saint Alphonsus Pathology Physician Services', 'Christopher', '', 'Hager', 'MD', 'Pathology', '', '', NULL, 'O', '1055 N Curtis Rd', 'Boise', 'Ada', 'ID', '83706', '2083672153', '2083673991', '1055 N Curtis Rd', 'Boise', 'Ada', 'ID', '83706', '2083672153', '2083673991', 'IDSAMG1', '', '', '0.00', '10.00', '0.00', 6, '2013-09-09', NULL, 0, 0, 0, '', '', '', '', 'HCFA|UB|', '1306828462', 0, 'Y', 0, '2014-06-13', NULL, NULL, 43.6145, -116.254, NULL, NULL),
('820200895', 'W12038933', 'W12038933', 'IDBOISTD', 'Saint Alphonsus Medical Group Kuna Family Medicine', 'Denise', 'R', 'Bahadar', 'NP', 'Family Practice', '', '', NULL, 'O', '757 E Wythe Creek Ct', 'Kuna', 'Ada', 'ID', '83634', '2083673366', '2083672070', '757 E Wythe Creek Ct', 'Kuna', 'Ada', 'ID', '83634', '2083673366', '2083672070', 'IDSAMG2', '', '', '0.00', '10.00', '0.00', 6, '2013-09-09', NULL, 0, 0, 0, 'Saint Alphonsus Regional Medical Center', NULL, '', '', 'HCFA|', '1376899278', 0, 'N', 0, '2014-02-06', NULL, NULL, 43.4877, -116.404, NULL, NULL),
('820200895', 'W12038934', 'W12038934', 'IDBOISTD', 'Saint Alphonsus Medical Group Overland Family Medicine', 'Denise', 'R', 'Bahadar', 'NP', 'Family Practice', '', '', NULL, 'O', '10255 W Overland Rd', 'Boise', 'Ada', 'ID', '83709', '2083677205', '2083677204', '10255 W Overland Rd', 'Boise', 'Ada', 'ID', '83709', '2083677205', '2083677204', 'IDSAMG2', '', '', '0.00', '10.00', '0.00', 6, '2013-09-09', NULL, 0, 0, 0, 'Saint Alphonsus Regional Medical Center', NULL, '', '', 'HCFA|', '1376899278', 0, 'N', 0, '2014-02-06', NULL, NULL, 43.5903, -116.31, NULL, NULL),
('820200895', 'W12038935', 'W12038935', 'IDBOISTD', 'Saint Alphonsus Medical Group Garrity Family Medicine', 'Denise', 'R', 'Bahadar', 'NP', 'Family Practice', '', '', NULL, 'O', '1200 Garrity Blvd', 'Nampa', 'Canyon', 'ID', '83687', '2084669092', '2083672968', '1200 Garrity Blvd', 'Nampa', 'Canyon', 'ID', '83687', '2084669092', '2083672968', 'IDSAMG2', '', '', '0.00', '10.00', '0.00', 6, '2013-09-09', NULL, 0, 0, 0, 'Saint Alphonsus Regional Medical Center', NULL, '', '', 'HCFA|', '1376899278', 0, 'N', 0, '2014-02-06', NULL, NULL, 43.5867, -116.549, NULL, NULL),
('820200895', 'W12038936', 'W12038936', 'IDBOISTD', 'Saint Alphonsus Medical Group McMillan Family Medicine', 'Denise', 'R', 'Bahadar', 'NP', 'Family Practice', '', '', NULL, 'O', '12273 W McMillan Rd', 'Boise', 'Ada', 'ID', '83713', '2083676330', '2083674765', '12273 W McMillan Rd', 'Boise', 'Ada', 'ID', '83713', '2083676330', '2083674765', 'IDSAMG2', '', '', '0.00', '10.00', '0.00', 6, '2013-09-09', NULL, 0, 0, 0, 'Saint Alphonsus Regional Medical Center', NULL, '', '', 'HCFA|', '1376899278', 0, 'N', 0, '2014-02-06', NULL, NULL, 43.6484, -116.337, NULL, NULL),
('820200895', 'W12038937', 'W12038937', 'IDBOISTD', 'Saint Alphonsus Medical Group Express Clinics', 'Denise', 'R', 'Bahadar', 'NP', 'Family Practice', '', '', NULL, 'O', '1515 W State St', 'Boise', 'Ada', 'ID', '83702', '2083456768', NULL, '1515 W State St', 'Boise', 'Ada', 'ID', '83702', '2083456768', '          ', 'IDSAMG2', '', '', '0.00', '10.00', '0.00', 6, '2013-09-09', NULL, 0, 0, 0, 'Saint Alphonsus Regional Medical Center', NULL, '', '', 'HCFA|', '1376899278', 0, 'N', 0, '2014-02-06', NULL, NULL, 43.6229, -116.209, NULL, NULL),
('820200895', 'W12038938', 'W12038938', 'IDBOISTD', 'Saint Alphonsus Medical Group Shoreline Family Medicine', 'Denise', 'R', 'Bahadar', 'NP', 'Family Practice', '', '', NULL, 'O', '1673 W Shoreline Dr Ste 120', 'Boise', 'Ada', 'ID', '83702', '2084298311', '2083676170', '1673 W Shoreline Dr Ste 120', 'Boise', 'Ada', 'ID', '83702', '2084298311', '2083676170', 'IDSAMG2', '', '', '0.00', '10.00', '0.00', 6, '2013-09-09', NULL, 0, 0, 0, 'Saint Alphonsus Regional Medical Center', NULL, '', '', 'HCFA|', '1376899278', 0, 'N', 0, '2014-02-06', NULL, NULL, 43.6174, -116.221, NULL, NULL),
('820200895', 'W12038939', 'W12038939', 'IDBOISTD', 'Saint Alphonsus Medical Group Federal Way Family Medicine', 'Denise', 'R', 'Bahadar', 'NP', 'Family Practice', '', '', NULL, 'O', '1880 W Judith Ln', 'Boise', 'Ada', 'ID', '83705', '2083676910', '2083676170', '1880 W Judith Ln', 'Boise', 'Ada', 'ID', '83705', '2083676910', '2083676170', 'IDSAMG2', '', '', '0.00', '10.00', '0.00', 6, '2013-09-09', NULL, 0, 0, 0, 'Saint Alphonsus Regional Medical Center', NULL, '', '', 'HCFA|', '1376899278', 0, 'N', 0, '2014-02-06', NULL, NULL, 43.5913, -116.204, NULL, NULL),
('820200895', 'W12038940', 'W12038940', 'IDBOISTD', 'Saint Alphonsus Medical Group Iowa Family Medicine', 'Denise', 'R', 'Bahadar', 'NP', 'Family Practice', '', '', NULL, 'O', '211 W Iowa Ave', 'Nampa', 'Canyon', 'ID', '83686', '2084657377', '2084657397', '211 W Iowa Ave', 'Nampa', 'Canyon', 'ID', '83686', '2084657377', '2084657397', 'IDSAMG2', '', '', '0.00', '10.00', '0.00', 6, '2013-09-09', NULL, 0, 0, 0, 'Saint Alphonsus Regional Medical Center', NULL, '', '', 'HCFA|', '1376899278', 0, 'N', 0, '2014-02-06', NULL, NULL, 43.5543, -116.574, NULL, NULL),
('820200895', 'W12038941', 'W12038941', 'IDBOISTD', 'Saint Alphonsus Medical Group Dallan Woods Family Medicine', 'Denise', 'R', 'Bahadar', 'NP', 'Family Practice', '', '', NULL, 'O', '214 S Midland Blvd', 'Nampa', 'Canyon', 'ID', '83686', '2084656900', '2084656911', '214 S Midland Blvd', 'Nampa', 'Canyon', 'ID', '83686', '2084656900', '2084656911', 'IDSAMG2', '', '', '0.00', '10.00', '0.00', 6, '2013-09-09', NULL, 0, 0, 0, 'Saint Alphonsus Regional Medical Center', NULL, '', '', 'HCFA|', '1376899278', 0, 'Y', 0, '2014-02-06', NULL, NULL, 43.5706, -116.593, NULL, NULL),
('820200895', 'W12038942', 'W12038942', 'IDBOISTD', 'Saint Alphonsus Medical Group MHP Family Medicine', 'Denise', 'R', 'Bahadar', 'NP', 'Family Practice', '', '', NULL, 'O', '3025 W Cherry Ln Ste B', 'Meridian', 'Ada', 'ID', '83642', '2083678550', '2083678555', '3025 W Cherry Ln Ste B', 'Meridian', 'Ada', 'ID', '83642', '2083678550', '2083678555', 'IDSAMG2', '', '', '0.00', '10.00', '0.00', 6, '2013-09-09', NULL, 0, 0, 0, 'Saint Alphonsus Regional Medical Center', NULL, '', '', 'HCFA|', '1376899278', 0, 'N', 0, '2014-02-06', NULL, NULL, 43.6193, -116.431, NULL, NULL),
('820200895', 'W12038943', 'W12038943', 'IDBOISTD', 'Saint Alphonsus Medical Group Elm Family Medicine', 'Denise', 'R', 'Bahadar', 'NP', 'Family Practice', '', '', NULL, 'O', '315 E Elm St Ste 100', 'Caldwell', 'Canyon', 'ID', '83605', '2084597415', '2084533307', '315 E Elm St Ste 100', 'Caldwell', 'Canyon', 'ID', '83605', '2084597415', '2084533307', 'IDSAMG2', '', '', '0.00', '10.00', '0.00', 6, '2013-09-09', NULL, 0, 0, 0, 'Saint Alphonsus Regional Medical Center', NULL, '', '', 'HCFA|', '1376899278', 0, 'N', 0, '2014-02-06', NULL, NULL, 43.6534, -116.695, NULL, NULL),
('820200895', 'W12038944', 'W12038944', 'IDBOISTD', 'Saint Alphonsus Medical Group EHP Family Medicine', 'Denise', 'R', 'Bahadar', 'NP', 'Family Practice', '', '', NULL, 'O', '323 E Riverside Dr Ste 224', 'Eagle', 'Ada', 'ID', '83616', '2083675750', '2083675765', '323 E Riverside Dr Ste 224', 'Eagle', 'Ada', 'ID', '83616', '2083675750', '2083675765', 'IDSAMG2', '', '', '0.00', '10.00', '0.00', 6, '2013-09-09', NULL, 0, 0, 0, 'Saint Alphonsus Regional Medical Center', NULL, '', '', 'HCFA|', '1376899278', 0, 'N', 0, '2014-02-06', NULL, NULL, 43.6896, -116.35, NULL, NULL),
('820200895', 'W12038945', 'W12038945', 'IDBOISTD', 'Saint Alphonsus Medical Group NHP Family Medicine  ', 'Denise', 'R', 'Bahadar', 'NP', 'Family Practice', '', '', NULL, 'O', '4400 E Flamingo Ave', 'Nampa', 'Canyon', 'ID', '83687', '2084656900', '2084656910', '4400 E Flamingo Ave', 'Nampa', 'Canyon', 'ID', '83687', '2084656900', '2084656910', 'IDSAMG2', '', '', '0.00', '10.00', '0.00', 6, '2013-09-09', NULL, 0, 0, 0, 'Saint Alphonsus Regional Medical Center', NULL, '', '', 'HCFA|', '1376899278', 0, 'N', 0, '2014-02-06', NULL, NULL, 43.5966, -116.519, NULL, NULL),
('820200895', 'W12038946', 'W12038946', 'IDBOISTD', 'Saint Alphonsus Medical Group Occupational Med NHP', 'Denise', 'R', 'Bahadar', 'NP', 'Family Practice', '', '', NULL, 'O', '4400 E Flamingo Ave', 'Nampa', 'Canyon', 'ID', '83687', '2084668912', '2084663403', '4400 E Flamingo Ave', 'Nampa', 'Canyon', 'ID', '83687', '2084668912', '2084663403', 'IDSAMG2', '', '', '0.00', '10.00', '0.00', 6, '2013-09-10', NULL, 0, 0, 0, 'Saint Alphonsus Regional Medical Center', NULL, '', '', 'HCFA|', '1376899278', 0, 'N', 0, '2014-02-06', NULL, NULL, 43.5966, -116.519, NULL, NULL),
('820200895', 'W12038948', 'W12038948', 'IDBOISTD', 'Saint Alphonsus Medical Group Express Care Clinics', 'Denise', 'R', 'Bahadar', 'NP', 'Family Practice', '', '', NULL, 'O', '4700 N Eagle Rd', 'Boise', 'Ada', 'ID', '83713', '2089384797', '0000000000', '4700 N Eagle Rd', 'Boise', 'Ada', 'ID', '83713', '2089384797', '0000000000', 'IDSAMG2', '', '', '0.00', '10.00', '0.00', 6, '2013-09-09', NULL, 0, 0, 0, 'Saint Alphonsus Regional Medical Center', NULL, '', '', 'HCFA|', '1376899278', 0, 'N', 0, '2014-02-06', NULL, NULL, 43.6474, -116.354, NULL, NULL),
('820200895', 'W12038949', 'W12038949', 'IDBOISTD', 'Saint Alphonsus Medical Group Curtisian Internal Medicine (Moreau Bldg) ', 'Denise', 'R', 'Bahadar', 'NP', 'Family Practice', '', '', NULL, 'O', '6140 W Curtisian Ste 300', 'Boise', 'Ada', 'ID', '83704', '2083676575', '2083676597', '6140 W Curtisian Ste 300', 'Boise', 'Ada', 'ID', '83704', '2083676575', '2083676597', 'IDSAMG2', '', '', '0.00', '10.00', '0.00', 6, '2013-09-09', NULL, 0, 0, 0, 'Saint Alphonsus Regional Medical Center', NULL, '', '', 'HCFA|', '1376899278', 0, 'N', 0, '2014-02-06', NULL, NULL, 43.6146, -116.258, NULL, NULL),
('820200895', 'W12038950', 'W12038950', 'IDBOISTD', 'Saint Alphonsus Medical Group Emerald Family Medicine', 'Denise', 'R', 'Bahadar', 'NP', 'Family Practice', '', '', NULL, 'O', '6533 Emerald', 'Boise', 'Ada', 'ID', '83704', '2083674170', '2083678135', '6533 Emerald', 'Boise', 'Ada', 'ID', '83704', '2083674170', '2083678135', 'IDSAMG2', '', '', '0.00', '10.00', '0.00', 6, '2013-09-09', NULL, 0, 0, 0, 'Saint Alphonsus Regional Medical Center', NULL, '', '', 'HCFA|', '1376899278', 0, 'N', 0, '2014-02-06', NULL, NULL, 43.6119, -116.263, NULL, NULL),
('820200895', 'W12038951', 'W12038951', 'IDBOISTD', 'Saint Alphonsus Medical Group Occupational Med Emerald ', 'Denise', 'R', 'Bahadar', 'NP', 'Family Practice', '', '', NULL, 'O', '6533 Emerald St', 'Boise', 'Ada', 'ID', '83704', '2083674179', '2083678136', '6533 Emerald St', 'Boise', 'Ada', 'ID', '83704', '2083674179', '2083678136', 'IDSAMG2', '', '', '0.00', '10.00', '0.00', 6, '2013-09-09', NULL, 0, 0, 0, 'Saint Alphonsus Regional Medical Center', NULL, '', '', 'HCFA|', '1376899278', 0, 'N', 0, '2014-02-06', NULL, NULL, 43.6119, -116.263, NULL, NULL),
('820200895', 'W12038952', 'W12038952', 'ID01', 'Saint Alphonsus Behavioral Health', 'Abhilash', 'K', 'Desai', 'MD', 'Mental Health', 'Psychiatry', '', NULL, 'O', '131 N Allumbaugh', 'Boise', 'Ada', 'ID', '83704', '2083672175', '2083760285', '131 N Allumbaugh', 'Boise', 'Ada', 'ID', '83704', '2083672175', '2083760285', 'IDSAMG1', '', '', '0.00', '10.00', '0.00', 6, '2013-09-09', NULL, 0, 0, 0, 'Saint Alphonsus Medical Center Nampa', '', '', '', 'HCFA|', '1366519084', 0, 'N', 0, '2014-06-20', NULL, NULL, 43.6062, -116.266, NULL, NULL),
('820200895', 'W12038953', 'W12038953', 'IDBOISTD', 'Saint Alphonsus Medical Group Sleep Medicine Caldwell', 'Jennifer', '', 'Hale', 'DO', 'Sleep Medicine', '', '', NULL, 'O', '1906 Fairview Ave Ste 430', 'Caldwell', 'Canyon', 'ID', '83605', '2083677272', '2083677111', '1906 Fairview Ave Ste 430', 'Caldwell', 'Canyon', 'ID', '83605', '2083677272', '2083677111', 'IDSAMG2', '', '', '0.00', '10.00', '0.00', 6, '2013-10-01', NULL, 0, 0, 0, 'Saint Alphonsus Regional Medical Center', '', '', '', 'HCFA|', '1831143338', 0, 'N', 0, '2014-05-06', NULL, NULL, 43.6588, -116.677, NULL, NULL),
('820200895', 'W12038954', 'W12038954', 'IDBOISTD', 'Saint Alphonsus Medical Group Pulmonary Caldwell', 'Dan', 'J', 'Hendrickson', 'MD', 'Pulmonary', '', '', NULL, 'O', '1906 Fairview Ave Ste 430', 'Caldwell', 'Canyon', 'ID', '83605', '2083677272', '2083677111', '1906 Fairview Ave Ste 430', 'Caldwell', 'Canyon', 'ID', '83605', '2083677272', '2083677111', 'IDSAMG2', '', '', '0.00', '10.00', '0.00', 6, '2013-10-01', NULL, 0, 0, 0, 'Saint Alphonsus Medical Center Nampa', NULL, NULL, NULL, 'HCFA|', '1467525949', 0, 'N', 0, '2013-10-07', NULL, NULL, 43.6588, -116.677, NULL, NULL),
('820200895', 'W12038955', 'W12038955', 'IDBOISTD', 'Saint Alphonsus Medical Group Pulmonary Caldwell', 'Cary', '', 'Jackson', 'MD', 'Pulmonary', 'Sleep Medicine', 'Sleep Disorders', NULL, 'O', '1906 Fairview Ave Ste 430', 'Caldwell', 'Canyon', 'ID', '83605', '2083677272', '2083677111', '1906 Fairview Ave Ste 430', 'Caldwell', 'Canyon', 'ID', '83605', '2083677272', '2083677111', 'IDSAMG2', '', '', '0.00', '10.00', '0.00', 6, '2013-10-01', NULL, 0, 0, 0, 'Saint Alphonsus Medical Center Nampa', '', '', '', 'HCFA|', '1932169042', 0, 'N', 0, '2014-06-20', NULL, NULL, 43.6588, -116.677, NULL, NULL),
('200055625', 'W12038960', 'W12038960', 'ID02', 'Saint Alphonsus Medical Center-Ontario  (Apogee)', 'Tejesh', 'S', 'Reddy', 'MD', 'Hospitalist', '', '', NULL, 'O', '351 SW 9th St', 'Ontario', 'Malheur', 'OR', '97914', '5418817000', '6023242249', '351 SW 9th St', 'Ontario', 'Malheur', 'OR', '97914', '5418817000', '6023242249', 'IDACN', '', '', '0.00', '15.00', '0.00', 3, '2013-09-09', NULL, 0, 0, 1, '', '', '', '', 'HCFA|UB|', '1922312636', 0, 'N', 0, '2013-10-11', NULL, NULL, 44.0252, -116.976, NULL, NULL),
('200055625', 'W12038961', 'W12038961', 'ID02', 'Saint Alphonsus Medical Center-Ontario  (Apogee)', 'Tejesh', 'S', 'Reddy', 'MD', 'Hospitalist', '', '', NULL, 'B', 'PO Box 708850', 'Sandy', 'Salt Lake', 'UT', '84070', '8013529500', '0000000000', 'PO Box 708850', 'Sandy', 'Salt Lake', 'UT', '84070', '8013529500', '0000000000', 'IDACN', '', '', '0.00', '15.00', '0.00', 3, '2013-09-09', NULL, 0, 0, 1, '', '', '', '', 'HCFA|UB|', '1922312636', 0, 'N', 0, '2013-10-11', NULL, NULL, 0, 0, NULL, NULL),
('452716222', 'W12038962', 'W12038962', 'ID02', 'St Lukes Clinic Pediatric Cardiology', 'Eloisa', 'S', 'Walker', '(accepting newborn pediatric patients only)', 'Pediatric Cardiology', '', '', NULL, 'O', '315 E Elm St Ste 100', 'Caldwell', 'Canyon', 'ID', '83605', '2085878401', '2085809807', '315 E Elm St Ste 100', 'Caldwell', 'Canyon', 'ID', '83605', '2085878401', '2085809807', 'IDACN', '', '', '0.00', '15.00', '0.00', 8, '2013-02-05', NULL, 0, 0, 1, '', '', '', '', 'HCFA|UB|', '1760433601', 0, 'N', 0, '2014-06-20', NULL, NULL, 43.6539, -116.695, NULL, NULL),
('452716222', 'W12038963', 'W12038963', 'ID02', 'St Lukes Clinic Pediatric Cardiology', 'Eloisa', 'S', 'Walker', '(accepting newborn pediatric patients only)', 'Pediatric Cardiology', '', '', NULL, 'O', '890 N 6th E', 'Mountain Home', 'Elmore', 'ID', '83647', '2085878401', '2085809807', '890 N 6th E', 'Mountain Home', 'Elmore', 'ID', '83647', '2085878401', '2085809807', 'IDACN', '', '', '0.00', '15.00', '0.00', 8, '2013-02-05', NULL, 0, 0, 1, '', '', '', '', 'HCFA|UB|', '1760433601', 0, 'N', 0, '2014-06-20', NULL, NULL, 43.1392, -115.692, NULL, NULL),
('452716222', 'W12038964', 'W12038964', 'ID02', 'St Lukes Clinic Pediatric Cardiology', 'Eloisa', 'S', 'Walker', '(accepting newborn pediatric patients only)', 'Pediatric Cardiology', '', '', NULL, 'O', '1200 Garrity Blvd', 'Nampa', 'Canyon', 'ID', '83687', '2085878401', '2085809807', '1200 Garrity Blvd', 'Nampa', 'Canyon', 'ID', '83687', '2085878401', '2085809807', 'IDACN', '', '', '0.00', '15.00', '0.00', 8, '2013-02-05', NULL, 0, 0, 1, '', '', '', '', 'HCFA|UB|', '1760433601', 0, 'N', 0, '2014-06-20', NULL, NULL, 43.587, -116.549, NULL, NULL),
('820309671', 'W12038965', 'W12038965', 'ID02', 'OB/GYN Associates PA', 'Karen', 'E', 'Carloy', 'NPC', 'Nurse Practitioner', '', '', NULL, 'B', '3080 W Gentry Way', 'Meridian', 'Ada', 'ID', '83642', '2089550350', '2084541065', '3080 W Gentry Way', 'Meridian', 'Ada', 'ID', '83642', '2089550350', '2084541065', 'IDACN', '', '', '0.00', '15.00', '0.00', 8, '2013-09-05', '2014-07-14', 0, 0, 1, '', '', '', '', 'HCFA|UB|', '1700949260', 0, 'N', 0, '2014-07-09', NULL, NULL, 0, 0, NULL, NULL),
('820309671', 'W12038966', 'W12038966', 'ID02', 'OB/GYN Associates PA', 'Theodore', '', 'Colwell', 'MD', 'Obstetrics and Gynecology', '', '', NULL, 'B', '3080 W Gentry Way', 'Meridian', 'Ada', 'ID', '83642', '2089550350', '2084541065', '3080 W Gentry Way', 'Meridian', 'Ada', 'ID', '83642', '2089550350', '2084541065', 'IDACN', '', '', '0.00', '15.00', '0.00', 8, '2013-09-05', '2014-07-14', 0, 0, 1, 'West Valley Medical Center', '', '', '', 'HCFA|UB|', '1598735391', 0, 'N', 0, '2014-07-10', NULL, NULL, 0, 0, NULL, NULL),
('820309671', 'W12038967', 'W12038967', 'ID02', 'OB/GYN Associates PA', 'Jessica', '', 'Fu', 'MD', 'Obstetrics and Gynecology', '', '', NULL, 'B', '3080 W Gentry Way', 'Meridian', 'Ada', 'ID', '83642', '2089550350', '2084541065', '3080 W Gentry Way', 'Meridian', 'Ada', 'ID', '83642', '2089550350', '2084541065', 'IDACN', '', '', '0.00', '15.00', '0.00', 8, '2013-09-05', '2014-07-14', 0, 0, 1, 'West Valley Medical Center', '', '', '', 'HCFA|UB|', '1710185111', 0, 'N', 0, '2014-07-09', NULL, NULL, 0, 0, NULL, NULL),
('820309671', 'W12038968', 'W12038968', 'ID02', 'OB/GYN Associates PA', 'Bryan', '', 'Palmer', 'MD', 'Obstetrics and Gynecology', '', '', NULL, 'B', '3080 W Gentry Way', 'Meridian', 'Ada', 'ID', '83642', '2089550350', '2084541065', '3080 W Gentry Way', 'Meridian', 'Ada', 'ID', '83642', '2089550350', '2084541065', 'IDACN', '', '', '0.00', '15.00', '0.00', 8, '2013-09-05', '2014-07-11', 0, 0, 1, 'West Valley Medical Center', '', '', '', 'HCFA|UB|', '1730338161', 0, 'N', 0, '2014-07-14', NULL, NULL, 0, 0, NULL, NULL),
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('203768194', 'W12038997', 'W12038997', 'TXHOUSTD', 'Healing Hearts Clinic', 'Paul', 'Y', 'Cunningham', 'MD', 'Cardiovascular Disease', 'Cardiology', '', NULL, 'O', '920 Medical Plaza Dr Ste 330', 'The Woodlands', 'Montgomery', 'TX', '77380', '9364419680', '9365399685', '920 Medical Plaza Dr Ste 330', 'The Woodlands', 'Montgomery', 'TX', '77380', '9364419680', '9365399685', 'HOUSTON2', 'TXONCHCPC13', '', '0.00', '45.00', '0.00', 3, '2013-11-15', NULL, 0, 0, 0, 'Conroe Regional Medical Center', NULL, NULL, NULL, 'HCFA|UB|', '1356582886', 0, 'N', 0, '2013-10-10', NULL, NULL, 30.1728, -95.452, NULL, NULL),
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('203768194', 'W12039000', 'W12039000', 'TXHOUSTD', 'Healing Hearts Clinic', 'Arindam', '', 'Banerjee', 'MD', 'Cardiovascular Disease', 'Cardiology', '', NULL, 'O', '920 Medical Plaza Dr Ste 330', 'The Woodlands', 'Montgomery', 'TX', '77380', '9364419680', '9365399685', '920 Medical Plaza Dr Ste 330', 'The Woodlands', 'Montgomery', 'TX', '77380', '9364419680', '9365399685', 'HOUSTON2', 'TXONCHCPC13', '', '0.00', '45.00', '0.00', 3, '2013-11-15', NULL, 0, 0, 0, 'Conroe Regional Medical Center', NULL, NULL, NULL, 'HCFA|UB|', '1861402810', 0, 'N', 0, '2013-10-10', NULL, NULL, 30.1728, -95.452, NULL, NULL),
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('752780597', 'W12039007', 'W12039007', 'UTDT01', 'Snow Country Dental Care', 'Joshua', '', 'Bateman', 'DDS', 'Dentist', '', '', NULL, 'O', '1729 Sidewinder Dr Ste 102', 'Park City', 'Summit', 'UT', '84060', '4356499492', NULL, '1729 Sidewinder Dr Ste 102', 'Park City', 'Summit', 'UT', '84060', '4356499492', '          ', 'UT000A', '', '', '0.00', '20.00', '0.00', 8, '2013-05-01', NULL, 0, 0, 0, '', '', '', '', 'DEN|', '1255377578', 0, 'N', 0, '2013-12-30', NULL, NULL, 0, 0, NULL, NULL),
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('454297916', 'W12039013', 'W12039013', 'UTDT01', 'Platinum Care Dental', 'Graydon', '', 'Briggs', 'DDS', 'Dentist', 'Endondontist', '', NULL, 'O', '279 E 5900 S Ste 200', 'Murray', 'Salt Lake', 'UT', '84107', '8012931234', NULL, '279 E 5900 S Ste 200', 'Murray', 'Salt Lake', 'UT', '84107', '8012931234', '          ', 'UT000A', '', '', '0.00', '20.00', '0.00', 8, '2013-06-01', NULL, 0, 0, 0, '', '', '', '', 'DEN|', '0000004160', 0, 'N', 0, '2013-10-08', NULL, NULL, 0, 0, NULL, NULL),
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('527255124', 'W12039021', 'W12039021', 'UTDT01', 'Center Creek Dental', 'Densley', '', 'David', 'DDS', 'Dentist', '', '', NULL, 'O', '10 E State St', 'Lehi', 'Utah', 'UT', '84043', '8017663700', NULL, '10 E State St', 'Lehi', 'Utah', 'UT', '84043', '8017663700', '          ', 'UT000A', '', '', '0.00', '20.00', '0.00', 8, '2013-06-01', NULL, 0, 0, 0, '', '', '', '', 'HCFA|UB|', '0000010145', 0, 'N', 0, '2013-10-08', NULL, NULL, 0, 0, NULL, NULL),
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('030520538', 'W12039025', 'W12039025', 'UTDT01', 'Willden Family Dental', 'Lisa', '', 'Romney', 'DMD', 'Dentist', '', '', NULL, 'O', '3632 W S Jordan Pkwy Ste 202', 'South Jordan', 'Salt Lake', 'UT', '84095', '8014464668', NULL, '3632 W S Jordan Pkwy Ste 202', 'South Jordan', 'Salt Lake', 'UT', '84095', '8014464668', '          ', 'UT000A', '', '', '0.00', '20.00', '0.00', 8, '2013-06-01', NULL, 0, 0, 0, '', '', '', '', 'DEN|', '0000010147', 0, 'N', 0, '2013-10-08', NULL, NULL, 0, 0, NULL, NULL),
('870635819', 'W12039028', 'W12039028', 'UTDT01', 'Lexington Heights Dental', 'James', '', 'Standring', 'DDS', 'Dentist', '', '', NULL, 'O', '4587 Cedar Hills Dr Ste 100', 'Pleasant Grove', 'Utah', 'UT', '84062', '8017562006', NULL, '4587 Cedar Hills Dr Ste 100', 'Pleasant Grove', 'Utah', 'UT', '84062', '8017562006', '          ', 'UT000A', '', '', '0.00', '20.00', '0.00', 8, '2013-06-01', NULL, 0, 0, 0, '', '', '', '', 'DEN', '1326483512', 0, 'N', 0, '2013-12-06', NULL, NULL, 0, 0, NULL, NULL),
('870500544', 'W12039030', 'W12039030', 'UTDT01', 'Dental Care 4 Kids', 'Colleen', '', 'Taylor', 'DMD', 'Pedodontist', '', '', NULL, 'O', '535 E Medical Dr', 'Bountiful', 'Davis', 'UT', '84010', '8012922828', NULL, '535 E Medical Dr', 'Bountiful', 'Davis', 'UT', '84010', '8012922828', '          ', 'UT0SPA', '', '', '0.00', '20.00', '0.00', 3, '2013-06-01', NULL, 0, 0, 0, '', '', '', '', 'DEN', '0000010149', 0, 'N', 0, '2013-10-08', NULL, NULL, 0, 0, NULL, NULL),
('364712022', 'W12039032', 'W12039032', 'UTDT01', 'West Jordan Modern Dentistry', 'James', '', 'Willardsen', 'DDS', 'Dentist', '', '', NULL, 'O', '7632 S Campus View Dr', 'West Jordan', 'Salt Lake', 'UT', '84084', '8012824142', NULL, '7632 S Campus View Dr', 'West Jordan', 'Salt Lake', 'UT', '84084', '8012824142', '          ', 'UT000A', '', '', '0.00', '20.00', '0.00', 8, '2013-06-01', NULL, 0, 0, 0, '', '', '', '', 'DEN|', '0000010150', 0, 'N', 0, '2013-10-08', NULL, NULL, 0, 0, NULL, NULL),
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('911947573', 'W12039038', 'W12039038', 'TXDALSTD', 'Health Texas Provider Network', 'Terry', 'P', 'Taylor', 'MD', 'Internal Medicine', '', '', NULL, 'B', 'PO Box 842001', 'Dallas', 'Dallas', 'TX', '75284', '2148203000', '2148203022', 'PO Box 842001', 'Dallas', 'Dallas', 'TX', '75284', '2148203000', '2148203022', 'HTPN', 'TXHCPCHTPN', '', '0.00', '45.00', '0.00', 3, '2013-10-15', NULL, 0, 0, 0, 'Baylor University Medical Center', NULL, '', '', 'HCFA|UB|', '1669791109', 0, 'N', 0, '2013-10-08', NULL, NULL, 0, 0, NULL, NULL),
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('911947573', 'W12039046', 'W12039046', 'TXDALSTD', '', 'Santosh', 'N', 'Hakkapakki', 'MD', 'Internal Medicine', '', '', NULL, 'O', '1405 W Jefferson St', 'Waxahachie', 'Ellis', 'TX', '75165', '9729237144', '9729237145', '1405 W Jefferson St', 'Waxahachie', 'Ellis', 'TX', '75165', '9729237144', '9729237145', 'HTPN', 'TXHCPCHTPN', '', '0.00', '45.00', '0.00', 3, '2013-10-15', '2014-04-12', 0, 0, 0, '', '', '', '', 'HCFA|UB|', '1568641371', 0, 'N', 0, '2014-04-17', NULL, NULL, 32.3968, -96.865, NULL, NULL),
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('752536818', 'W12039049', 'W12039049', 'TXDALSTD', 'Health Texas Provider Network', 'Subhra', 'Jit', 'Mookerjee', 'MD', 'Physical Medicine and Rehabilitation', '', '', NULL, 'B', 'PO Box 844128', 'Dallas', 'Dallas', 'TX', '75284', '8663771650', '4694675905', 'PO Box 844128', 'Dallas', 'Dallas', 'TX', '75284', '8663771650', '4694675905', 'HTPN', 'TXHCPCHTPN', '', '0.00', '45.00', '0.00', 3, '2013-10-15', NULL, 0, 0, 0, 'Baylor University Medical Center', NULL, '', '', 'HCFA|UB', '1578739249', 0, 'N', 0, '2013-10-08', NULL, NULL, 0, 0, NULL, NULL),
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('911947573', 'W12039061', 'W12039061', 'TXDALSTD', '', 'Fawad', 'Aslam', 'Tufail', 'MD', 'Internal Medicine', '', '', NULL, 'O', '1405 W Jefferson St', 'Waxahachie', 'Ellis', 'TX', '75165', '9729237144', '9729237145', '1405 W Jefferson St', 'Waxahachie', 'Ellis', 'TX', '75165', '9729237144', '9729237145', 'HTPN', 'TXHCPCHTPN', '', '0.00', '45.00', '0.00', 3, '2013-10-15', NULL, 0, 0, 0, 'Baylor Medical Center at Waxahachie', NULL, '', '', 'HCFA|UB|', '1558371682', 0, 'N', 0, '2014-01-24', NULL, NULL, 32.3968, -96.865, NULL, NULL),
('911947573', 'W12039062', 'W12039062', 'TXDALSTD', 'Health Texas Provider Network', 'Fawad', 'Aslam', 'Tufail', 'MD', 'Internal Medicine', '', '', NULL, 'B', 'PO Box 842001', 'Dallas', 'Dallas', 'TX', '75284', '2148203000', '2148203022', 'PO Box 842001', 'Dallas', 'Dallas', 'TX', '75284', '2148203000', '2148203022', 'HTPN', 'TXHCPCHTPN', '', '0.00', '45.00', '0.00', 3, '2013-10-15', NULL, 0, 0, 0, 'Baylor Medical Center at Waxahachie', NULL, '', '', 'HCFA|UB|', '1558371682', 0, 'N', 0, '2013-10-08', NULL, NULL, 0, 0, NULL, NULL),
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('752536818', 'W12039066', 'W12039066', 'TXDALSTD', 'SPORT of McKinney', 'Lance', 'Richard', 'Winter', 'MD', 'Orthopedic Surgery', '', '', NULL, 'O', '5236 W University Dr Ste 2000', 'Mckinney', 'Collin', 'TX', '75071', '8774477678', '4698006079', '5236 W University Dr Ste 2000', 'Mckinney', 'Collin', 'TX', '75071', '8774477678', '4698006079', 'HTPN', 'TXHCPCHTPN', '', '0.00', '45.00', '0.00', 3, '2013-10-15', NULL, 0, 0, 0, 'Baylor Regional Medical Center at Plano', NULL, NULL, NULL, 'HCFA|UB|', '1386693976', 0, 'N', 0, '2014-01-08', NULL, NULL, 33.2183, -96.684, NULL, NULL),
('760077790', 'W12039067', 'W12039067', 'TXHOUSTD', 'Houston Pulmonary Medicine Associates', 'Raziuddin', '', 'Ahmed', 'MD', 'Pulmonary', '', '', NULL, 'O', '11920 Astria Blvd Ste 320', 'Houston', 'Harris', 'TX', '77089', '2814849369', '2814841843', '11920 Astria Blvd Ste 320', 'Houston', 'Harris', 'TX', '77089', '2814849369', '2814841843', 'HOUSTON4', 'TXHCPC13', '', '0.00', '45.00', '0.00', 3, '2013-11-01', NULL, 0, 0, 0, 'Clear Lake Regional Medical Center', 'Bayshore Medical Center', '', '', 'HCFA|UB|', '1952562407', 0, 'N', 0, '2013-11-21', NULL, NULL, 29.5853, -95.2069, NULL, NULL),
('264333033', 'W12039070', 'W12039070', 'TXSATSTD', '', 'Sarah', 'A', 'Stafford', 'MD', 'Pediatrics', '', '', NULL, 'B', '1210 Arion Pkwy', 'San Antonio', 'Bexar', 'TX', '78216', '2106563040', NULL, '1210 Arion Pkwy         ', 'San Antonio', 'Bexar', 'TX', '78216', '2106563040', '          ', 'TXOBG', 'TXHCPCS', '', '0.00', '50.00', '0.00', 3, '2014-01-01', NULL, 0, 0, 0, 'Baptist Medical Center', '', '', '', 'HCFA|UB|', '1801116496', 0, 'N', 0, '2014-01-06', NULL, NULL, 0, 0, NULL, NULL),
('264333033', 'W12039068', 'W12039068', 'TXSATSTD', '', 'Sarah', 'A', 'Stafford', 'MD', 'Pediatrics', '', '', NULL, 'O', '5000 Schertz Pkwy Ste 200', 'Schertz', 'Guadalupe', 'TX', '78154', '2106590220', '2106510483', '5000 Schertz Pkwy Ste 200', 'Schertz', 'Guadalupe', 'TX', '78154', '2106590220', '2106510483', 'TXOBG', 'TXHCPCS', '', '0.00', '50.00', '0.00', 3, '2014-01-01', NULL, 0, 0, 0, 'Baptist Medical Center', '', '', '', 'HCFA|UB|', '1801116496', 0, 'N', 0, '2014-01-06', NULL, NULL, 29.5641, -98.2617, NULL, NULL),
('014521730', 'W12039071', 'W12039071', 'UTMH1', 'Andrew Briefer LMFT', 'Andrew', 'A', 'Briefer', 'LMFT', 'Mental Health', 'Marriage & Family Therapy', '', NULL, 'O', '160 S 1000 E Ste 210', 'Salt Lake City', 'Salt Lake', 'UT', '84102', '8017128768', '          ', '160 S 1000 E Ste 210', 'Salt Lake City', 'Salt Lake', 'UT', '84102', '8017128768', '          ', 'UTMA', '', '', '0.00', '40.00', '0.00', 6, '2013-08-01', '2014-08-28', 0, 0, 0, '', '', '', '', 'HCFA|UB|', '1487745410', 0, 'N', 0, '2014-05-29', NULL, NULL, 40.7659, -111.862, NULL, NULL),
('364037473', 'W12039072', 'W12039072', 'ILCHIGSTD', 'Elmhurst Clinic', 'Michelle', '', 'Jackowski', 'CNM', 'Certified Nurse Midwife', '', '', NULL, 'O', '1200 S York Rd Ste 4120', 'Elmhurst', 'Dupage', 'IL', '60126', '3312219009', '3312213977', '1200 S York Rd Ste 4120', 'Elmhurst', 'Dupage', 'IL', '60126', '3312219009', '3312213977', 'CHIG13', 'CHIHCPCS02', '', '0.00', '40.00', '0.00', 3, '2013-09-24', NULL, 0, 0, 0, 'Elmhurst Memorial Hospital', '', '', '', 'HCFA|UB|', '1194039669', 0, 'N', 0, '2014-06-10', NULL, NULL, 41.865, -87.9322, NULL, NULL),
('364037473', 'W12039073', 'W12039073', 'ILCHIGSTD', 'Elmhurst Clinic', 'Michelle', '', 'Jackowski', 'CNM', 'Certified Nurse Midwife', '', '', NULL, 'B', 'Dept 4585', 'Carol Stream', 'Dupage', 'IL', '60122', '6309412616', '6309935681', 'Dept 4585', 'Carol Stream', 'Dupage', 'IL', '60122', '6309412616', '6309935681', 'CHIG13', 'CHIHCPCS02', '', '0.00', '40.00', '0.00', 3, '2013-09-24', NULL, 0, 0, 0, 'Elmhurst Memorial Hospital', '', '', '', 'HCFA|UB|', '1194039669', 0, 'N', 0, '2014-06-10', NULL, NULL, 0, 0, NULL, NULL),
('364037473', 'W12039074', 'W12039074', 'ILCHIGSTD', 'Elmhurst Clinic', 'Michelle', '', 'Jackowski', 'CNM', 'Certified Nurse Midwife', '', '', NULL, 'M', '172 Schiller', 'Elmhurst', 'Dupage', 'IL', '60126', '6303567600', '6307589940', '172 Schiller', 'Elmhurst', 'Dupage', 'IL', '60126', '6303567600', '6307589940', 'CHIG13', 'CHIHCPCS02', '', '0.00', '40.00', '0.00', 3, '2013-09-24', NULL, 0, 0, 0, 'Elmhurst Memorial Hospital', '', '', '', 'HCFA|UB|', '1194039669', 0, 'N', 0, '2014-06-10', NULL, NULL, 41.9011, -87.9365, NULL, NULL),
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('460906063', 'W12039120', 'W12039120', 'UTMH1', 'The Counseling Center', 'Matthew', 'J', 'Seelos', 'LCSW', 'Mental Health', 'Social Worker', '', NULL, 'O', '386 N Main St', 'Centerville', 'Davis', 'UT', '84014', '8012982000', '8019511490', '386 N Main St', 'Centerville', 'Davis', 'UT', '84014', '8012982000', '8019511490', 'ma', '', '', '0.00', '40.00', '0.00', 3, '2013-12-01', NULL, 0, 0, 0, '', '', '', '', 'HCFA|', '1346676640', 0, 'N', 0, '2013-11-26', NULL, NULL, 40.9214, -111.879, NULL, NULL);
INSERT INTO `providers_new` (`Provider_Tax_ID`, `Provider_Suffix`, `Provider_Network_ID`, `Provider_Region`, `Provider_Name`, `Provider_Doctor_First_Name`, `Provider_Doctor_Middle_Name`, `Provider_Doctor_Last_Name`, `Provider_Doctor_Degree`, `Provider_Specialty_1`, `Provider_Specialty_2`, `Provider_Specialty_3`, `Provider_Specialty_4`, `Provider_Address_Type`, `Provider_Address`, `Provider_City`, `Provider_County`, `Provider_State`, `Provider_Zip`, `Provider_Phone`, `Provider_Fax`, `Provider_Mailing_Address`, `Provider_Mailing_City`, `Provider_Mailing_County`, `Provider_Mailing_State`, `Provider_Mailing_Zip`, `Provider_Mailing_Phone`, `Provider_Mailing_Fax`, `Provider_Primary_Schedule`, `Provider_Secondary_Schedule`, `Provider_Rate_Sheet`, `Provider_Anes_Rate`, `Provider_Default_Rate`, `Provider_Max_DOS`, `Provider_Min_Match_Value`, `Provider_Effective_Date`, `Provider_Term_Date`, `Provider_Pend`, `Provider_Anes_Minutes`, `Provider_PPO`, `Provider_Hospital_1`, `Provider_Hospital_2`, `Provider_Hospital_3`, `Provider_Hospital_4`, `Provider_Type`, `Provider_NPI`, `Provider_Check_Override`, `Exclude_Dir`, `Audit_Status`, `Last_Change_Date`, `Medicare_ID`, `Provider_Lang`, `Provider_Latitude`, `Provider_Longitude`, `Provider_school`, `Provider_cert`) VALUES
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('752356557', 'W12039122', 'W12039122', 'TXDALSTD', 'Las Colinas Obstetrics Gynecology Infertility Association PA', '', '', 'Las Colinas Obstetrics Gynecology Infertility Association PA', '', 'Obstetrics and Gynecology', '', '', NULL, 'O', '3501 N MacArthur Blvd Ste 350', 'Irving', 'Dallas', 'TX', '75062', '9722575300', '9722575322', '3501 N MacArthur Blvd Ste 350', 'Irving', 'Dallas', 'TX', '75062', '9722575300', '9722575322', 'DALLAS3', 'TXHCPC13', '', '0.00', '50.00', '0.00', 3, '2013-11-01', NULL, 0, 0, 0, 'Irving-Coppell Surgical Hospital', NULL, '', '', 'HCFA|UB|', '1275550360', 0, 'N', 0, '2013-10-18', NULL, NULL, 32.8525, -96.9591, NULL, NULL),
('752356557', 'W12039124', 'W12039124', 'TXDALSTD', 'Las Colinas Obstetrics Gynecology Infertility Association PA', 'John', 'J', 'Zavaleta', 'MD', 'Obstetrics and Gynecology', '', '', NULL, 'O', '3501 N MacArthur Blvd Ste 350', 'Irving', 'Dallas', 'TX', '75062', '9722575300', '9722575322', '3501 N MacArthur Blvd Ste 350', 'Irving', 'Dallas', 'TX', '75062', '9722575300', '9722575322', 'DALLAS3', 'TXHCPC13', '', '0.00', '50.00', '0.00', 3, '2013-11-23', NULL, 0, 0, 0, 'Irving-Coppell Surgical Hospital', NULL, '', '', 'HCFA|UB|', '1023038155', 0, 'N', 0, '2013-10-25', NULL, NULL, 32.8525, -96.9591, NULL, NULL),
('752356557', 'W12039126', 'W12039126', 'TXDALSTD', 'Las Colinas Obstetrics Gynecology Infertility Association PA', 'John', 'R', 'Hanson', 'MD', 'Obstetrics and Gynecology', '', '', NULL, 'O', '3501 N MacArthur Blvd Ste 350', 'Irving', 'Dallas', 'TX', '75062', '9722575300', '9722575322', '3501 N MacArthur Blvd Ste 350', 'Irving', 'Dallas', 'TX', '75062', '9722575300', '9722575322', 'DALLAS3', 'TXHCPC13', '', '0.00', '50.00', '0.00', 3, '2013-11-23', NULL, 0, 0, 0, 'Irving-Coppell Surgical Hospital', NULL, '', '', 'HCFA|UB|', '1174636070', 0, 'N', 0, '2013-10-25', NULL, NULL, 32.8525, -96.9591, NULL, NULL),
('752356557', 'W12039128', 'W12039128', 'TXDALSTD', 'Las Colinas Obstetrics Gynecology Infertility Association PA', 'Gonzalo', 'H', 'Garcia', 'MD', 'Obstetrics and Gynecology', '', '', NULL, 'O', '3501 N MacArthur Blvd Ste 350', 'Irving', 'Dallas', 'TX', '75062', '9722575300', '9722575322', '3501 N MacArthur Blvd Ste 350', 'Irving', 'Dallas', 'TX', '75062', '9722575300', '9722575322', 'DALLAS3', 'TXHCPC13', '', '0.00', '50.00', '0.00', 3, '2013-11-23', NULL, 0, 0, 0, 'Irving-Coppell Surgical Hospital', NULL, '', '', 'HCFA|UB|', '1477660884', 0, 'N', 0, '2013-10-25', NULL, NULL, 32.8525, -96.9591, NULL, NULL),
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('760406602', 'W12039142', 'W12039142', 'TXHOUSTD', 'Southwest Surgical Associates', 'Joey', 'M', 'Bluhm', 'MD', 'General Surgery', '', '', NULL, 'O', '915 Gessner Rd Ste 301', 'Houston', 'Harris', 'TX', '77024', '7137721200', '2816933522', '915 Gessner Rd Ste 301', 'Houston', 'Harris', 'TX', '77024', '7137721200', '2816933522', 'HOUSTON4', 'TXHCPC13', '', '0.00', '45.00', '0.00', 3, '2013-11-15', NULL, 0, 0, 0, 'Houston Methodist Sugar Land Hospital', NULL, NULL, NULL, 'HCFA|', '1356534663', 0, 'N', 0, '2013-10-15', NULL, NULL, 29.7804, -95.5445, NULL, NULL),
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('760406602', 'W12039145', 'W12039145', 'TXHOUSTD', 'Southwest Surgical Associates', 'Kelly', '', 'Dempsey', 'MD', 'General Surgery', '', '', NULL, 'B', 'PO Box 2967', 'Sugar Land', 'Fort Bend', 'TX', '77487', '7137721200', '7137720258', 'PO Box 2967', 'Sugar Land', 'Fort Bend', 'TX', '77487', '7137721200', '7137720258', 'HOUSTON4', 'TXHCPC13', '', '0.00', '45.00', '0.00', 3, '2013-11-15', NULL, 0, 0, 0, 'Houston Methodist Sugar Land Hospital', NULL, NULL, NULL, 'HCFA|', '1891888400', 0, 'N', 0, '2013-10-15', NULL, NULL, 0, 0, NULL, NULL),
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('760406602', 'W12039154', 'W12039154', 'TXHOUSTD', 'Southwest Surgical Associates', 'John', 'D', 'Fisher', 'MD', 'General Surgery', '', '', NULL, 'O', '17510 W Grand Pkwy S Ste 490', 'Sugar Land', 'Fort Bend', 'TX', '77479', '7137721200', '2813423957', '17510 W Grand Pkwy S Ste 490', 'Sugar Land', 'Fort Bend', 'TX', '77479', '7137721200', '2813423957', 'HOUSTON4', 'TXHCPC13', '', '0.00', '45.00', '0.00', 3, '2013-11-15', NULL, 0, 0, 0, 'Houston Methodist Sugar Land Hospital', NULL, NULL, NULL, 'HCFA|', '1093800732', 0, 'N', 0, '2013-10-15', NULL, NULL, 29.5639, -95.688, NULL, NULL),
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('452469842', 'W12039242', 'W12039242', 'TXHOUSTD', 'Texas Regional Urology PLLC', 'Liliana', '', 'Woo', 'MD', 'Urology', '', '', NULL, 'O', '22999 US Hwy 59 Ste 276', 'Kingwood', 'Harris', 'TX', '77339', '2815701391', '2815701398', '22999 US Hwy 59 Ste 276', 'Kingwood', 'Harris', 'TX', '77339', '2815701391', '2815701398', 'HOUSTON4', 'TXHCPC13', '', '0.00', '45.00', '0.00', 3, '2013-11-01', NULL, 0, 0, 0, 'Kingwood Medical Center', NULL, NULL, NULL, 'HCFA|UB|', '1497715171', 0, 'N', 0, '2013-10-25', NULL, NULL, 30.048, -95.2535, NULL, NULL),
('202695346', 'NVA000062', 'NVA000062', 'UT01', 'North Valley Anesthesia', 'Erin', '', 'Welker', 'CRNA', 'Anesthesiology', '', '', NULL, 'B', 'PO Box 3810', 'SLC', 'Salt Lake', 'UT', '84110', '8014322609', '          ', 'PO Box 3810', 'SLC', 'Salt Lake', 'UT', '84110', '8014322609', '          ', '', '', '', '47.00', '25.00', '0.00', 6, '2015-07-01', NULL, 0, 12, 0, '', '', '', '', 'HCFA|UB|', '1285952622', 0, 'Y', 0, '2014-06-23', NULL, NULL, 0, 0, NULL, NULL),
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('463164660', 'W12039249', 'W12039249', 'UT01', 'Sandman Physician Services', 'Richard', '', 'Glines', '', 'Anesthesiology', '', '', NULL, 'O', 'PO Box 160354', 'Clearfield', 'Davis', 'UT', '84016', '          ', NULL, 'PO Box 160354', 'Clearfield', 'Davis', 'UT', '84016', '          ', '          ', '', '', '', '54.00', '35.00', '0.00', 3, '2013-09-01', NULL, 0, 12, 0, '', '', '', '', 'HCFA|UB|', '1760814834', 0, 'N', 0, '2013-10-11', NULL, NULL, 41.1054, -112.031, NULL, NULL),
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('942854057', 'W12039256', 'W12039256', 'UTIHC04', 'Primary Childrens Medical Center', 'Tyson', '', 'Christensen', 'LCSW', 'Social Worker', '', '', NULL, 'O', '5770 S 1500 W', 'Salt Lake City', 'Salt Lake', 'UT', '84123', '8013137770', NULL, '5770 S 1500 W', 'Salt Lake City', 'Salt Lake', 'UT', '84123', '8013137770', '          ', '', '', '', '0.00', '10.00', '0.00', 8, '2013-09-16', '2014-01-24', 0, 0, 0, '', '', '', '', 'HCFA|UB|', '1558675223', 0, 'N', 0, '2014-03-03', NULL, NULL, 40.6462, -111.934, NULL, NULL),
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('942854057', 'W12039263', 'W12039263', 'UTIHC04', 'Dixie Regional Medical Center', 'Terrin', 'M', 'Parker', 'PT', 'Physical Therapy', '', '', NULL, 'O', '1380 E Medical Ctr Dr', 'St George', 'Washington', 'UT', '84790', '4352511000', NULL, '1380 E Medical Ctr Dr', 'St George', 'Washington', 'UT', '84790', '4352511000', '          ', '', '', '', '0.00', '15.00', '0.00', 8, '2013-01-01', NULL, 0, 0, 0, '', '', '', '', 'HCFA|UB|', '1316189749', 0, 'Y', 0, '2013-10-14', NULL, NULL, 37.0998, -113.554, NULL, NULL),
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('942854057', 'W12039267', 'W12039267', 'UTIHC04', 'Primary Childrens Medical Center', 'Michelle', '', 'Taggart', 'OT', 'Occupational Therapy', '', '', NULL, 'O', '3845 W 4700 S', 'Taylorsville', 'Salt Lake', 'UT', '84118', '8018404360', NULL, '3845 W 4700 S', 'Taylorsville', 'Salt Lake', 'UT', '84118', '8018404360', '          ', '', '', '', '0.00', '10.00', '0.00', 8, '2013-08-01', NULL, 0, 0, 0, '', '', '', '', 'HCFA|UB|', '1467885962', 0, 'N', 0, '2013-10-14', NULL, NULL, 40.6675, -111.983, NULL, NULL),
('742927135', 'W12039444', 'W12039444', 'ID01', 'Mountain States Neonatology', 'Oluyemisi', 'M', 'Oyafemi', 'MD', 'Neonatology', '', '', NULL, 'O', '4400 E Flamingo Ave', 'Nampa', 'Canyon', 'ID', '83687', '2083678063', '2083678067', '4400 E Flamingo Ave', 'Nampa', 'Canyon', 'ID', '83687', '2083678063', '2083678067', 'IDNEONATE', 'WUSTDHCPC5', '', '0.00', '25.00', '0.00', 3, '2013-11-01', NULL, 0, 0, 0, 'Saint Alphonsus Medical Center Nampa', '', '', '', 'HCFA|UB|', '1366400343', 0, 'N', 0, '2013-10-31', NULL, NULL, 43.5966, -116.519, NULL, NULL),
('462252776', 'W12039270', 'W12039270', 'UT01', 'Premier Family Medical', 'Thad', 'J', 'Barkdull', 'MD', 'Family Practice', '', '', NULL, 'O', '275 W 200 N', 'Lindon', 'Utah', 'UT', '84042', '8017961333', '8017960625', '275 W 200 N', 'Lindon', 'Utah', 'UT', '84042', '8017961333', '8017960625', 'WUUVPN11', 'WUSTDHCPC5', '', '0.00', '35.00', '0.00', 3, '2013-07-01', NULL, 0, 0, 0, 'Timpanogos Regional Hospital', '', '', '', 'HCFA|UB|', '1871524421', 0, 'N', 0, '2013-10-14', NULL, NULL, 40.3419, -111.722, NULL, NULL),
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('462252776', 'W12039273', 'W12039273', 'UT01', 'Premier Family Medical', 'Steven', 'B', 'Cherrington', 'DO', 'Family Practice', NULL, NULL, NULL, 'O', '275 W 200 N', 'Lindon', 'Utah', 'UT', '84042', '8017961333', '8017561705', '275 W 200 N', 'Lindon', 'Utah', 'UT', '84042', '8017961333', '8017561705', 'WUUVPN11', 'WUSTDHCPC5', '', '0.00', '35.00', '0.00', 3, '2013-07-01', NULL, 0, 0, 0, 'Timpanogos Regional Hospital', '', '', '', 'HCFA|UB|', '1871608893', 0, 'N', 0, '2013-10-14', NULL, NULL, 40.3419, -111.722, NULL, NULL),
('462252776', 'W12039274', 'W12039274', 'UT01', 'Premier Family Medical', 'Elwood', 'J', 'Corry', 'MD', 'Family Practice', '', '', NULL, 'O', '275 W 200 N', 'Lindon', 'Utah', 'UT', '84042', '8017961333', NULL, '275 W 200 N', 'Lindon', 'Utah', 'UT', '84042', '8017961333', '          ', 'WUUVPN11', 'WUSTDHCPC5', '', '0.00', '35.00', '0.00', 3, '2013-07-01', NULL, 0, 0, 0, 'Timpanogos Regional Hospital', 'Mountain View Hospital', '', '', 'HCFA|UB|', '1609984988', 0, 'N', 0, '2014-03-07', NULL, NULL, 40.3419, -111.722, NULL, NULL),
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('462252776', 'W12039277', 'W12039277', 'UT01', 'Premier Family Medical', 'Glen', 'R', 'Fuller', 'MD', 'Family Practice', NULL, NULL, NULL, 'O', '830 N 2000 W', 'Pleasant Grove', 'Utah', 'UT', '84062', '8017563511', NULL, '830 N 2000 W', 'Pleasant Grove', 'Utah', 'UT', '84062', '8017563511', '          ', 'WUUVPN11', 'WUSTDHCPC5', '', '0.00', '35.00', '0.00', 3, '2013-07-01', NULL, 0, 0, 0, 'Timpanogos Regional Hospital', '', '', '', 'HCFA|UB|', '1467557330', 0, 'N', 0, '2013-10-14', NULL, NULL, 40.3705, -111.769, NULL, NULL),
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('462252776', 'W12039281', 'W12039281', 'UT01', 'Premier Family Medical', 'Scott', 'L', 'Smith', 'MD', 'Family Practice', NULL, NULL, NULL, 'O', '830 N 2000 W', 'Pleasant Grove', 'Utah', 'UT', '84062', '8017563511', NULL, '830 N 2000 W', 'Pleasant Grove', 'Utah', 'UT', '84062', '8017563511', '          ', 'WUUVPN11', 'WUSTDHCPC5', '', '0.00', '35.00', '0.00', 3, '2013-07-01', NULL, 0, 0, 0, 'Timpanogos Regional Hospital', '', '', '', 'HCFA|UB|', '1336257617', 0, 'N', 0, '2013-11-25', NULL, NULL, 40.3705, -111.769, NULL, NULL),
('462252776', 'W12039282', 'W12039282', 'UT01', 'Premier Family Medical', 'Marshall', 'F', 'Willis', 'MD', 'Family Practice', '', '', NULL, 'O', '830 N 2000 W', 'Pleasant Grove', 'Utah', 'UT', '84062', '8017563511', NULL, '830 N 2000 W', 'Pleasant Grove', 'Utah', 'UT', '84062', '8017563511', '', 'WUUVPN11', 'WUSTDHCPC5', '', '0.00', '35.00', '0.00', 3, '2013-07-01', NULL, 0, 0, 0, 'Timpanogos Regional Hospital', '', '', '', 'HCFA|UB|', '1194833475', 0, 'N', 0, '2014-05-19', NULL, NULL, 40.3705, -111.769, NULL, NULL),
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('800223062', 'W12035939', 'W12035939', 'UT01', 'MountainStar Canyon Surgical Clinic', 'Lance', 'R', 'Bryce', 'MD', 'General Surgery', '', '', NULL, 'O', '984 S Medical Dr Ste 2', 'Brigham City', 'Box Elder', 'UT', '84302', '4357230329', '4357230429', '984 S Medical Dr Ste 2', 'Brigham City', 'Box Elder', 'UT', '84302', '4357230329', '4357230429', 'UTHCAPS', 'WUSTDHCPC5', '', '0.00', '35.00', '0.00', 3, '2013-01-01', NULL, 0, 0, 0, 'Ogden Regional Medical Center', NULL, NULL, NULL, 'HCFA|UB|', '1639372840', 0, 'N', 0, '2013-10-15', NULL, NULL, 41.4888, -112.026, NULL, NULL),
('800223062', 'W12035940', 'W12035940', 'UT01', 'MountainStar Canyon Surgical Clinic', 'Lance', 'R', 'Bryce', 'MD', 'General Surgery', '', '', NULL, 'B', 'Po Box 268', 'Bountiful', 'Davis', 'UT', '84011', '4357230329', '4357230429', 'Po Box 268', 'Bountiful', 'Davis', 'UT', '84011', '4357230329', '4357230429', 'UTHCAPS', 'WUSTDHCPC5', '', '0.00', '35.00', '0.00', 3, '2013-01-01', NULL, 0, 0, 0, 'Ogden Regional Medical Center', NULL, NULL, NULL, 'HCFA|UB|', '1639372840', 0, 'N', 0, '2013-10-15', NULL, NULL, 0, 0, NULL, NULL);
INSERT INTO `providers_new` (`Provider_Tax_ID`, `Provider_Suffix`, `Provider_Network_ID`, `Provider_Region`, `Provider_Name`, `Provider_Doctor_First_Name`, `Provider_Doctor_Middle_Name`, `Provider_Doctor_Last_Name`, `Provider_Doctor_Degree`, `Provider_Specialty_1`, `Provider_Specialty_2`, `Provider_Specialty_3`, `Provider_Specialty_4`, `Provider_Address_Type`, `Provider_Address`, `Provider_City`, `Provider_County`, `Provider_State`, `Provider_Zip`, `Provider_Phone`, `Provider_Fax`, `Provider_Mailing_Address`, `Provider_Mailing_City`, `Provider_Mailing_County`, `Provider_Mailing_State`, `Provider_Mailing_Zip`, `Provider_Mailing_Phone`, `Provider_Mailing_Fax`, `Provider_Primary_Schedule`, `Provider_Secondary_Schedule`, `Provider_Rate_Sheet`, `Provider_Anes_Rate`, `Provider_Default_Rate`, `Provider_Max_DOS`, `Provider_Min_Match_Value`, `Provider_Effective_Date`, `Provider_Term_Date`, `Provider_Pend`, `Provider_Anes_Minutes`, `Provider_PPO`, `Provider_Hospital_1`, `Provider_Hospital_2`, `Provider_Hospital_3`, `Provider_Hospital_4`, `Provider_Type`, `Provider_NPI`, `Provider_Check_Override`, `Exclude_Dir`, `Audit_Status`, `Last_Change_Date`, `Medicare_ID`, `Provider_Lang`, `Provider_Latitude`, `Provider_Longitude`, `Provider_school`, `Provider_cert`) VALUES
('205958022', 'W12039385', 'W12039385', 'UT01', 'Mountain Land Ivins', 'Steven', 'Clark', 'Bennett', 'PT', 'Physical Therapy', '', '', NULL, 'O', '272 E Center St Ste 103', 'Ivins', 'Washington', 'UT', '84738', '4356742115', '4356737711', '272 E Center St Ste 103', 'Ivins', 'Washington', 'UT', '84738', '4356742115', '4356737711', 'WESTREHAB', 'WUSTDHCPC5', '', '0.00', '0.00', '73.00', 3, '2013-09-12', NULL, 0, 0, 0, '', '', '', '', 'HCFA|', '1205911872', 0, 'N', 0, '2013-10-16', NULL, NULL, 37.1684, -113.673, NULL, NULL),
('261529574', 'W12039383', 'W12039383', 'UT01', 'Rocky Mountain Therapy Services LLC', 'Mitchell', '', 'Felix', 'PT', 'Physical Therapy', '', '', NULL, 'B', 'PO Box 540640', 'North Salt Lake', 'Davis', 'UT', '84054', '8019751403', '8019730391', 'PO Box 540640', 'North Salt Lake', 'Davis', 'UT', '84054', '8019751403', '8019730391', 'WESTREHAB', 'WUSTDHCPC5', '', '0.00', '0.00', '73.00', 3, '2013-09-24', NULL, 0, 0, 0, '', '', '', '', 'HCFA|', '1144213216', 0, 'N', 0, '2013-12-04', NULL, NULL, 0, 0, NULL, NULL),
('261529574', 'W12039384', 'W12039384', 'UT01', 'Rocky Mountain Therapy Services LLC', 'James', 'M', 'Wortley', 'PT', 'Physical Therapy', '', '', NULL, 'B', 'PO Box 540640', 'North Salt Lake', 'Davis', 'UT', '84054', '8019751403', '8019730391', 'PO Box 540640', 'North Salt Lake', 'Davis', 'UT', '84054', '8019751403', '8019730391', 'WESTREHAB', 'WUSTDHCPC5', '', '0.00', '0.00', '73.00', 3, '2013-09-24', NULL, 0, 0, 0, '', '', '', '', 'HCFA|', '1326031493', 0, 'Y', 0, '2013-12-06', NULL, NULL, 0, 0, NULL, NULL),
('261529574', 'W12039382', 'W12039382', 'UT01', 'Rocky Mountain Therapy Services LLC', 'Mitchell', '', 'Felix', 'PT', 'Physical Therapy', '', '', NULL, 'O', '441 S Redwood Rd', 'Salt Lake City', 'Salt Lake', 'UT', '84104', '8019751403', '8019730391', '441 S Redwood Rd', 'Salt Lake City', 'Salt Lake', 'UT', '84104', '8019751403', '8019730391', 'WESTREHAB', 'WUSTDHCPC5', '', '0.00', '0.00', '73.00', 3, '2013-09-24', NULL, 0, 0, 0, '', '', '', '', 'HCFA|', '1144213216', 0, 'N', 0, '2013-12-04', NULL, NULL, 40.7598, -111.939, NULL, NULL),
('261529574', 'W12039381', 'W12039381', 'UT01', 'Rocky Mountain Therapy Services LLC', 'B', 'Jay', 'Ludwig', 'PT', 'Physical Therapy', '', '', NULL, 'B', 'PO Box 540640', 'North Salt Lake', 'Davis', 'UT', '84054', '8019751403', '8019730391', 'PO Box 540640', 'North Salt Lake', 'Davis', 'UT', '84054', '8019751403', '8019730391', 'WESTREHAB', 'WUSTDHCPC5', '', '0.00', '0.00', '73.00', 3, '2013-09-24', NULL, 0, 0, 0, '', '', '', '', 'HCFA|', '1245251800', 0, 'N', 0, '2013-12-06', NULL, NULL, 0, 0, NULL, NULL),
('452716222', 'W12039379', 'W12039379', 'ID02', 'St Lukes Clinic Urology', 'Donald', 'K', 'Stritzke', 'MD', 'Urology', '', '', NULL, 'O', '3950 17th St', 'Baker City', 'Baker', 'OR', '97814', '2084549181', '2084546338', '3950 17th St', 'Baker City', 'Baker', 'OR', '97814', '2084549181', '2084546338', 'IDACN', '', '', '0.00', '15.00', '0.00', 8, '2013-10-16', NULL, 0, 0, 1, '', '', 'West Valley Medical Center', 'Saint Alphonsus Medical Center Nampa', 'HCFA|UB|', '1457331019', 0, 'N', 0, '2013-10-16', NULL, NULL, 0, 0, NULL, NULL),
('452716222', 'W12039396', 'W12039396', 'ID02', 'St Lukes Idaho Family Physicians', 'Gregory', 'W', 'Johnson', 'MD', 'Family Practice', '', '', NULL, 'B', 'PO Box 640', 'Boise', 'Ada', 'ID', '83701', '2087065000', '0000000000', 'PO Box 640', 'Boise', 'Ada', 'ID', '83701', '2087065000', '0000000000', 'IDACN', '', '', '0.00', '15.00', '0.00', 8, '2013-02-05', NULL, 0, 0, 1, '', '', '', '', 'HCFA|UB|', '1508969973', 0, 'N', 0, '2014-05-22', NULL, NULL, 0, 0, NULL, NULL),
('870546052', 'W12039399', 'W12039399', 'UT01', 'Professional Physical Therapy & Sports Medicine', 'Amber', 'Lynne', 'Ivie', 'PT', 'Physical Therapy', '', '', NULL, 'B', '1325 S 800 E Ste 215', 'Orem', 'Utah', 'UT', '84097', '8017682723', '8017682725', '1325 S 800 E Ste 215', 'Orem', 'Utah', 'UT', '84097', '8017682723', '8017682725', 'WESTREHAB', 'WUSTDHCPC5', '', '0.00', '0.00', '73.00', 3, '2013-10-01', NULL, 0, 0, 0, '', '', '', '', 'HCFA|', '1467614339', 0, 'N', 0, '2013-10-16', NULL, NULL, 0, 0, NULL, NULL),
('810231784', 'W12039376', 'W12039376', 'WYBILLINGS', 'Billings Clinic', 'Holly', 'A', 'Silvers', 'APRN', 'Neurosurgery', '', '', NULL, 'B', 'PO Box 31315', 'Billings', 'Yellowstone', 'MT', '59107', '4062382617', '0000000000', 'PO Box 31315', 'Billings', 'Yellowstone', 'MT', '59107', '4062382617', '0000000000', '', '', '', '0.00', '17.00', '0.00', 3, '2013-09-10', NULL, 0, 0, 0, '', '', '', '', 'HCFA|UB|', '1588099881', 0, 'N', 0, '2013-10-21', NULL, NULL, 0, 0, NULL, NULL),
('810231784', 'W12039375', 'W12039375', 'WYBILLINGS', 'Billings Clinic - Neurosurgery', 'Holly', 'A', 'Silvers', 'APRN', 'Neurosurgery', '', '', NULL, 'O', '801 N 29th St', 'Billings', 'Yellowstone', 'MT', '59101', '4062382501', '4062385809', '801 N 29th St', 'Billings', 'Yellowstone', 'MT', '59101', '4062382501', '4062385809', '', '', '', '0.00', '17.00', '0.00', 3, '2013-09-10', NULL, 0, 0, 0, '', '', '', '', 'HCFA|UB|', '1588099881', 0, 'N', 0, '2013-10-21', NULL, NULL, 0, 0, NULL, NULL),
('810231784', 'W12039373', 'W12039373', 'WYBILLINGS', 'Billings Clinic', 'Daen', 'E', 'Scott', 'APRN', 'Endocrinology', '', '', NULL, 'B', 'PO Box 31315', 'Billings', 'Yellowstone', 'MT', '59107', '4062382617', '0000000000', 'PO Box 31315', 'Billings', 'Yellowstone', 'MT', '59107', '4062382617', '0000000000', '', '', '', '0.00', '17.00', '0.00', 3, '2013-09-10', NULL, 0, 0, 0, '', '', '', '', 'HCFA|UB|', '1790049674', 0, 'N', 0, '2013-10-21', NULL, NULL, 0, 0, NULL, NULL),
('810231784', 'W12039372', 'W12039372', 'WYBILLINGS', 'Billings Clinic - Endocrinology', 'Daen', 'E', 'Scott', 'APRN', 'Endocrinology', '', '', NULL, 'O', '1045 N 30th St', 'Billings', 'Yellowstone', 'MT', '59101', '4062382501', '4062382413', '1045 N 30th St', 'Billings', 'Yellowstone', 'MT', '59101', '4062382501', '4062382413', '', '', '', '0.00', '17.00', '0.00', 3, '2013-09-10', NULL, 0, 0, 0, '', '', '', '', 'HCFA|UB|', '1790049674', 0, 'N', 0, '2013-10-21', NULL, NULL, 0, 0, NULL, NULL),
('205934739', 'W12039370', 'W12039370', 'ID02', 'Family Medicine Health Center', 'Martha', 'Clinton', 'Wilson', 'MD', 'Family Practice', '', '', NULL, 'O', '777 N Raymond St', 'Boise', 'Ada', 'ID', '83704', '2085142500', '2083752217', '777 N Raymond St', 'Boise', 'Ada', 'ID', '83704', '2085142500', '2083752217', 'IDPPO', 'WUSTDHCPC5', '', '0.00', '30.00', '0.00', 3, '2013-11-01', NULL, 0, 0, 1, '', '', '', '', 'HCFA|UB|', '1417268574', 0, 'N', 0, '2014-06-05', NULL, NULL, 0, 0, NULL, NULL),
('205934739', 'W12039369', 'W12039369', 'ID02', 'Family Medicine Health Center', 'Martha', 'Clinton', 'Wilson', 'MD', 'Family Practice', '', '', NULL, 'O', '6094 W Emerald St', 'Boise', 'Ada', 'ID', '83704', '2085142510', '2085142511', '6094 W Emerald St', 'Boise', 'Ada', 'ID', '83704', '2085142510', '2085142511', 'IDPPO', 'WUSTDHCPC5', '', '0.00', '30.00', '0.00', 3, '2013-11-01', NULL, 0, 0, 1, '', '', '', '', 'HCFA|UB|', '1417268574', 0, 'N', 0, '2014-06-05', NULL, NULL, 0, 0, NULL, NULL),
('205934739', 'W12039367', 'W12039367', 'ID02', 'Family Medicine Health Center', 'Kathleen', 'M', 'Romito', 'MD', 'Family Practice', '', '', NULL, 'O', '6094 W Emerald St', 'Boise', 'Ada', 'ID', '83704', '2085142510', '2085142511', '6094 W Emerald St', 'Boise', 'Ada', 'ID', '83704', '2085142510', '2085142511', 'IDPPO', 'WUSTDHCPC5', '', '0.00', '30.00', '0.00', 3, '2013-11-01', NULL, 0, 0, 1, 'Saint Alphonsus Medical Center Nampa', NULL, '', '', 'HCFA|UB|', '1619919933', 0, 'N', 0, '2014-06-05', NULL, NULL, 0, 0, NULL, NULL),
('205934739', 'W12039366', 'W12039366', 'ID02', 'Family Medicine Health Center', 'Kathleen', 'M', 'Romito', 'MD', 'Family Practice', '', '', NULL, 'O', '777 N Raymond St', 'Boise', 'Ada', 'ID', '83704', '2085142500', '2083752217', '777 N Raymond St', 'Boise', 'Ada', 'ID', '83704', '2085142500', '2083752217', 'IDPPO', 'WUSTDHCPC5', '', '0.00', '30.00', '0.00', 3, '2013-11-01', NULL, 0, 0, 1, 'Saint Alphonsus Medical Center Nampa', NULL, '', '', 'HCFA|UB|', '1619919933', 0, 'N', 0, '2014-06-05', NULL, NULL, 0, 0, NULL, NULL),
('452716222', 'W12039365', 'W12039365', 'ID02', 'St Lukes Physician Services', 'Amy', 'M', 'Ambrosier', 'PA-C', 'Family Practice', '', '', NULL, 'B', 'PO Box 640', 'Boise', 'Ada', 'ID', '83701', '2087065000', '0000000000', 'PO Box 640', 'Boise', 'Ada', 'ID', '83701', '2087065000', '0000000000', 'IDACN', '', '', '0.00', '15.00', '0.00', 8, '2013-02-05', NULL, 0, 0, 1, '', '', '', '', 'HCFA|UB|', '1073898821', 0, 'N', 0, '2013-10-16', NULL, NULL, 0, 0, NULL, NULL),
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('942854057', 'W12043998', 'W12043998', 'UTIHCPHY', 'Southern Utah Neuro-Cedar', 'Jon', 'B', 'Obray', 'MD', 'Pain Management', 'Anesthesiology', '', NULL, 'O', '1303 N Main', 'Cedar City', 'Iron', 'UT', '84721', '4356562424', '4356562828', '1303 N Main', 'Cedar City', 'Iron', 'UT', '84721', '4356562424', '4356562828', 'USTDMULT', 'WUSTDHCPC5', '', '0.00', '35.00', '0.00', 8, '2014-01-01', '2013-12-31', 0, 0, 0, 'Dixie Regional Medical Center', '', '', '', 'HCFA|UB|', '1205814803', 0, 'Y', 0, '2014-06-27', NULL, NULL, 37.7003, -113.064, NULL, NULL),
('820200895', 'W12043997', 'W12043997', 'IDBOISTD', 'Saint Alphonsus Medical Group Glycemic Cherry Lane', 'Andrea', 'L', 'Bockenstette', 'NP', 'Family Practice', '', '', NULL, 'O', '3250 W Cherry Ln', 'Meridian', 'Ada', 'ID', '83642', '2083676127', '2083677316', '3250 W Cherry Ln', 'Meridian', 'Ada', 'ID', '83642', '2083676127', '2083677316', 'IDSAMG2', '', '', '0.00', '10.00', '0.00', 6, '2014-01-20', NULL, 0, 0, 0, 'Saint Alphonsus Regional Medical Center', NULL, '', '', 'HCFA|', '1437583408', 0, 'N', 0, '2014-02-06', NULL, NULL, 43.6193, -116.434, NULL, NULL),
('820200895', 'W12043996', 'W12043996', 'IDBOISTD', 'Saint Alphonsus Medical Group Glycemic SARMC', 'Andrea', 'L', 'Bockenstette', 'NP', 'Family Practice', '', '', NULL, 'O', '1055 N Curtis Rd', 'Boise', 'Ada', 'ID', '83706', '2083676130', '2083677316', '1055 N Curtis Rd', 'Boise', 'Ada', 'ID', '83706', '2083676130', '2083677316', 'IDSAMG2', '', '', '0.00', '10.00', '0.00', 6, '2014-01-20', NULL, 0, 0, 0, 'Saint Alphonsus Regional Medical Center', NULL, '', '', 'HCFA|', '1437583408', 0, 'Y', 0, '2014-02-06', NULL, NULL, 43.6145, -116.254, NULL, NULL),
('820200895', 'W12043995', 'W12043995', 'IDBOISTD', 'Saint Alphonsus Medical Group Glycemic Nampa', 'Andrea', 'L', 'Bockenstette', 'NP', 'Family Practice', '', '', NULL, 'O', '4400 E Flamingo Ave', 'Nampa', 'Canyon', 'ID', '83687', '2084656900', '2084656910', '4400 E Flamingo Ave', 'Nampa', 'Canyon', 'ID', '83687', '2084656900', '2084656910', 'IDSAMG2', '', '', '0.00', '10.00', '0.00', 6, '2014-01-20', NULL, 0, 0, 0, 'Saint Alphonsus Regional Medical Center', NULL, '', '', 'HCFA|', '1437583408', 0, 'Y', 0, '2014-02-06', NULL, NULL, 43.5966, -116.519, NULL, NULL),
('820200895', 'W12043994', 'W12043994', 'IDBOISTD', 'Saint Alphonsus Medical Group Glycemic Boise', 'Andrea', 'L', 'Bockenstette', 'NP', 'Family Practice', '', '', NULL, 'O', '1000 N Curtis Rd Ste 305', 'Boise', 'Ada', 'ID', '83706', '2083676130', '2083677316', '1000 N Curtis Rd Ste 305', 'Boise', 'Ada', 'ID', '83706', '2083676130', '2083677316', 'IDSAMG2', '', '', '0.00', '10.00', '0.00', 6, '2014-01-20', NULL, 0, 0, 0, 'Saint Alphonsus Regional Medical Center', NULL, '', '', 'HCFA|', '1437583408', 0, 'Y', 0, '2014-02-06', NULL, NULL, 43.6134, -116.254, NULL, NULL),
('260553931', 'W12043992', 'W12043992', 'IDBOISTD', 'Saint Alphonsus Medical Group Heart Care Boise', 'Nancy', 'N', 'Taylor', 'NP-C', 'Cardiology', '', '', NULL, 'O', '6140 W Curtisian Ave Ste 100', 'Boise', 'Ada', 'ID', '83704', '2083678880', '2083677030', '6140 W Curtisian Ave Ste 100', 'Boise', 'Ada', 'ID', '83704', '2083678880', '2083677030', 'IDSAMG1', '', '', '0.00', '10.00', '0.00', 6, '2014-01-13', NULL, 0, 0, 0, 'Saint Alphonsus Medical Center Nampa', '', '', '', 'HCFA|UB|', '1609808328', 0, 'N', 0, '2014-06-13', NULL, NULL, 43.6146, -116.258, NULL, NULL),
('260553931', 'W12043991', 'W12043991', 'IDBOISTD', 'Saint Alphonsus Medical Group Heart Care Boise Moreau Bldg', 'Nancy', 'N', 'Taylor', 'NP-C', 'Cardiology', '', '', NULL, 'O', '6140 W Curtisian Ste 200', 'Boise', 'Ada', 'ID', '83704', '2083674278', '2083675200', '6140 W Curtisian Ste 200', 'Boise', 'Ada', 'ID', '83704', '2083674278', '2083675200', 'IDSAMG1', '', '', '0.00', '10.00', '0.00', 6, '2014-01-13', NULL, 0, 0, 0, 'Saint Alphonsus Medical Center Nampa', '', '', '', 'HCFA|UB|', '1609808328', 0, 'Y', 0, '2014-06-13', NULL, NULL, 43.6146, -116.258, NULL, NULL),
('260553931', 'W12043990', 'W12043990', 'IDBOISTD', 'Saint Alphonsus Medical Group Gynecology/Oncology Nampa', 'Gerard', 'P', 'Connor', 'MD', 'Gynecologic Oncology', '', '', NULL, 'O', '1603 E 12th Ave Ste B', 'Nampa', 'Canyon', 'ID', '83686', '2083675227', '2083675225', '1603 E 12th Ave Ste B', 'Nampa', 'Canyon', 'ID', '83686', '2083675227', '2083675225', 'IDSAMG1', '', '', '0.00', '10.00', '0.00', 6, '2014-02-07', NULL, 0, 0, 0, 'Saint Alphonsus Regional Medical Center', '', '', '', 'HCFA|UB|', '1669470274', 0, 'N', 0, '2014-03-17', NULL, NULL, 43.5531, -116.573, NULL, NULL),
('611696015', 'W12043989', 'W12043989', 'UT01', 'Lone Peak General Surgery', '', '', 'HCA', '', 'Clinics', '', '', NULL, 'B', 'PO Box 741648', 'Atlanta', 'Fulton', 'GA', '30384', '8015663062', '8015018219', 'PO Box 741648', 'Atlanta', 'Fulton', 'GA', '30384', '8015663062', '8015018219', 'UTHCAPS', 'WUSTDHCPC5', '', '0.00', '35.00', '0.00', 3, '2013-09-01', NULL, 0, 0, 0, '', '', '', '', 'HCFA|UB', '0000009770', 0, 'Y', 0, '2014-05-15', NULL, NULL, 0, 0, NULL, NULL),
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('800864010', 'W12043981', 'W12043981', 'UT01', 'St Marks Senior Health Center', 'Rebecca', 'H', 'Moore', 'MD', 'Nephrology', '', '', NULL, 'O', '1275 E Ft Union Blvd Ste 150', 'Sandy', 'Salt Lake', 'UT', '84070', '8012687766', '8012703395', '1275 E Ft Union Blvd Ste 150', 'Sandy', 'Salt Lake', 'UT', '84070', '8012687766', '8012703395', 'UTHCAPS', 'WUSTDHCPC5', '', '0.00', '35.00', '0.00', 3, '2013-08-01', NULL, 0, 0, 0, 'St Marks Hospital', '', '', '', 'HCFA|UB', '1477609089', 0, 'N', 0, '2014-04-16', NULL, NULL, 0, 0, NULL, NULL),
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('800864010', 'W12043980', 'W12043980', 'UT01', 'St Marks Senior Health Center', 'Cynthia', '', 'Lawlor', 'MD', 'Internal Medicine', '', '', NULL, 'O', '1275 E Ft Union Blvd Ste 150', 'Sandy', 'Salt Lake', 'UT', '84070', '8012687766', '8012703395', '1275 E Ft Union Blvd Ste 150', 'Sandy', 'Salt Lake', 'UT', '84070', '8012687766', '8012703395', 'UTHCAPS', 'WUSTDHCPC5', '', '0.00', '35.00', '0.00', 3, '2013-08-01', NULL, 0, 0, 0, 'St Marks Hospital', NULL, NULL, NULL, 'HCFA|UB', '1396999868', 0, 'N', 0, '2014-02-06', NULL, NULL, 0, 0, NULL, NULL),
('800864010', 'W12043979', 'W12043979', 'UT01', 'St Marks Senior Health Center', 'Laurene', '', 'Joseph', 'MD', 'Geriatrics', 'Internal Medicine', '', NULL, 'O', '1275 E Ft Union Blvd Ste 150', 'Sandy', 'Salt Lake', 'UT', '84070', '8012687766', '8012703395', '1275 E Ft Union Blvd Ste 150', 'Sandy', 'Salt Lake', 'UT', '84070', '8012687766', '8012703395', 'UTHCAPS', 'WUSTDHCPC5', '', '0.00', '35.00', '0.00', 3, '2013-08-01', NULL, 0, 0, 0, 'St Marks Hospital', NULL, NULL, NULL, 'HCFA|UB', '1629145123', 0, 'N', 0, '2014-02-06', NULL, NULL, 0, 0, NULL, NULL),
('800864010', 'W12043977', 'W12043977', 'UT01', 'St Marks Senior Health Center', 'Danesh', '', 'Rahimi', 'MD', 'Geriatrics', 'Internal Medicine', '', NULL, 'O', '1275 E Ft Union Blvd Ste 150', 'Sandy', 'Salt Lake', 'UT', '84070', '8012687766', '8012703395', '1275 E Ft Union Blvd Ste 150', 'Sandy', 'Salt Lake', 'UT', '84070', '8012687766', '8012703395', 'UTHCAPS', 'WUSTDHCPC5', '', '0.00', '35.00', '0.00', 3, '2013-08-01', NULL, 0, 0, 0, 'St Marks Hospital', NULL, NULL, NULL, 'HCFA|UB', '1487744553', 0, 'N', 0, '2014-02-06', NULL, NULL, 0, 0, NULL, NULL),
('800864010', 'W12043978', 'W12043978', 'UT01', 'St Marks Senior Health Center', 'Alexander', '', 'Del Castillo', 'MD', 'Geriatrics', 'Internal Medicine', '', NULL, 'O', '1275 E Ft Union Blvd Ste 150', 'Sandy', 'Salt Lake', 'UT', '84070', '8012687766', '8012703395', '1275 E Ft Union Blvd Ste 150', 'Sandy', 'Salt Lake', 'UT', '84070', '8012687766', '8012703395', 'UTHCAPS', 'WUSTDHCPC5', '', '0.00', '35.00', '0.00', 3, '2013-08-01', NULL, 0, 0, 0, 'St Marks Hospital', NULL, NULL, NULL, 'HCFA|UB', '1881705168', 0, 'N', 0, '2014-02-06', NULL, NULL, 0, 0, NULL, NULL),
('800864010', 'W12043976', 'W12043976', 'UT01', 'St Marks Senior Health Center', 'Florentino', '', 'Abueg', 'MD', 'Geriatrics', 'Internal Medicine', '', NULL, 'O', '1275 E Ft Union Blvd Ste 150', 'Sandy', 'Salt Lake', 'UT', '84070', '8012687766', '8012703395', '1275 E Ft Union Blvd Ste 150', 'Sandy', 'Salt Lake', 'UT', '84070', '8012687766', '8012703395', 'UTHCAPS', 'WUSTDHCPC5', '', '0.00', '35.00', '0.00', 3, '2013-08-01', NULL, 0, 0, 0, 'St Marks Hospital', NULL, NULL, NULL, 'HCFA|UB', '1649372558', 0, 'N', 0, '2014-02-06', NULL, NULL, 0, 0, NULL, NULL),
('363330928', 'W12043983', 'W12043983', 'ILCHIGSTD', 'Presence Medical Group', 'Paulette', 'C', 'Wilson', 'MD', 'Internal Medicine', '', '', NULL, 'O', '1150 W Fullerton Ave', 'Chicago', 'Cook', 'IL', '60614', '7735497757', '7735491221', '1150 W Fullerton Ave', 'Chicago', 'Cook', 'IL', '60614', '7735497757', '7735491221', 'CHIGP1', 'CHIHCPCS13', '', '0.00', '40.00', '0.00', 3, '2014-02-01', NULL, 0, 0, 0, 'Presence Saint Joseph Hospital Chicago', NULL, '', '', 'HCFA|UB|', '1326068487', 0, 'N', 0, '2014-02-06', NULL, NULL, 41.9253, -87.6576, NULL, NULL),
('363330928', 'W12043984', 'W12043984', 'ILCHIGSTD', 'Presence Medical Group', 'Paulette', 'C', 'Wilson', 'MD', 'Internal Medicine', '', '', NULL, 'O', '5425 W Lawrence Ave', 'Chicago', 'Cook', 'IL', '60630', '7737257557', '7737940138', '5425 W Lawrence Ave', 'Chicago', 'Cook', 'IL', '60630', '7737257557', '7737940138', 'CHIGP1', 'CHIHCPCS13', '', '0.00', '40.00', '0.00', 3, '2014-02-01', NULL, 0, 0, 0, 'Presence Saint Joseph Hospital Chicago', NULL, '', '', 'HCFA|UB|', '1326068487', 0, 'N', 0, '2014-02-06', NULL, NULL, 41.9677, -87.7636, NULL, NULL),
('205967125', 'W12043973', 'W12043973', 'ID02', 'Vein Center of Idaho', '', '', 'Imaging Center of Idaho LLC', 'GROUP', 'Imaging Center', 'Radiology', '', NULL, 'O', '2512 N Stokesberry Pl Ste 102', 'Meridian', 'Ada', 'ID', '83646', '2084024467', '2083218626', '2512 N Stokesberry Pl Ste 102', 'Meridian', 'Ada', 'ID', '83646', '2084024467', '2083218626', 'IDPPO', 'WUSTDHCPC5', '', '0.00', '30.00', '0.00', 3, '2014-02-03', NULL, 0, 0, 1, '', '', '', '', 'HCFA|UB|', '0000006851', 0, 'N', 0, '2014-02-06', NULL, NULL, 0, 0, NULL, NULL),
('841367175', 'W12044100', 'W12044100', 'UT01', 'Canyon View Medical Group', 'David ', 'J', 'Beckstead', 'MD', 'Family Practice', '', '', NULL, 'O', '336 W 100 S', 'Spanish Fork', 'Utah', 'UT', '84660', '8017987301', NULL, '336 W 100 S', 'Spanish Fork', 'Utah', 'UT', '84660', '8017987301', '', 'WUUVPN11', 'WUSTDHCPC5', '', '0.00', '35.00', '0.00', 3, '2030-01-01', NULL, 0, 0, 0, 'Mountain View Hospital', '', '', '', 'HCFA|UB|', '1003107558', 0, 'N', 1, '2014-07-01', NULL, NULL, 0, 0, NULL, NULL),
('518784710', 'W12043972', 'W12043972', 'Sinclair', '(Sinclair Health Services\rProvider) ', 'Melissa', 'A', 'Boley', 'LCPC', 'Mental Health', 'Counseling', '', NULL, 'B', 'PO Box 5865', 'Ketchum', 'Blaine', 'ID', '83340', '2087267584', NULL, 'PO Box 5865', 'Ketchum', 'Blaine', 'ID', '83340', '2087267584', '          ', 'MD-2', '', '', '0.00', '40.00', '0.00', 3, '2013-10-01', NULL, 0, 0, 0, '', '', '', '', 'HCFA|UB|', '1578732293', 0, 'N', 0, '2014-02-06', NULL, NULL, 0, 0, NULL, NULL),
('300038860', 'W12045994', 'W12045994', 'TXHOUSTD', 'Lone Star Family Health Center', 'Christina', '', 'Ho', 'DO', 'Family Practice', '', '', NULL, 'O', '440 Rayford Rd Ste 150', 'Spring', 'Montgomery', 'TX', '77386', '8322468700', '2814191395', '440 Rayford Rd Ste 150', 'Spring', 'Montgomery', 'TX', '77386', '8322468700', '2814191395', 'HOUSTON1', 'TXHCPC13', '', '0.00', '45.00', '0.00', 3, '2014-03-24', NULL, 0, 0, 0, NULL, NULL, '', '', 'HCFA|UB', '1508136227', 0, 'N', 0, '2014-04-04', NULL, NULL, 0, 0, NULL, NULL),
('870373083', 'W12043966', 'W12043966', 'UT01', 'Heart and Lung Institute', 'Clinton', '', 'Anderson', 'PAC', 'Pulmonary', '', '', NULL, 'B', 'PO Box 847112', 'Dallas', 'Dallas', 'TX', '75284', '8012632370', '8012651200', 'PO Box 847112', 'Dallas', 'Dallas', 'TX', '75284', '8012632370', '8012651200', 'WUSTDCARD5', 'WUSTDHCPC5', '', '0.00', '35.00', '0.00', 3, '2014-04-01', '2014-04-30', 0, 0, 0, 'St Marks Hospital', '', '', '', 'HCFA|UB|', '1003922790', 0, 'N', 0, '2014-06-16', NULL, NULL, 0, 0, NULL, NULL),
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('870373083', 'W12043964', 'W12043964', 'UT01', 'Heart and Lung Institute', 'Clinton', '', 'Anderson', 'PAC', 'Pulmonary', '', '', NULL, 'O', '5979 S Fashion Blvd', 'Murray', 'Salt Lake', 'UT', '84107', '8012632370', '8012651200', '5979 S Fashion Blvd', 'Murray', 'Salt Lake', 'UT', '84107', '8012632370', '8012651200', 'WUSTDCARD5', 'WUSTDHCPC5', '', '0.00', '35.00', '0.00', 3, '2014-04-01', '2014-04-30', 0, 0, 0, 'St Marks Hospital', '', '', '', 'HCFA|UB|', '1003922790', 0, 'N', 0, '2014-06-16', NULL, NULL, 0, 0, NULL, NULL),
('203847246', 'W12043963', 'W12043963', 'UT01', 'Mt Nebo Anesthesia Associates', '', '', 'Mt Nebo Anesthesia Associates', 'GROUP', 'Anesthesiology', '', '', NULL, 'B', 'PO Box 3810', 'Salt Lake City', 'Salt Lake', 'UT', '84110', '8018254700', NULL, 'PO Box 3810', 'Salt Lake City', 'Salt Lake', 'UT', '84110', '8018254700', '          ', '', '', '1000', '40.90', '0.00', '0.00', 3, '2014-02-01', NULL, 0, 12, 0, '', '', '', '', 'HCFA|UB|', '0000955173', 0, 'Y', 0, '2014-02-05', NULL, NULL, 0, 0, NULL, NULL);
INSERT INTO `providers_new` (`Provider_Tax_ID`, `Provider_Suffix`, `Provider_Network_ID`, `Provider_Region`, `Provider_Name`, `Provider_Doctor_First_Name`, `Provider_Doctor_Middle_Name`, `Provider_Doctor_Last_Name`, `Provider_Doctor_Degree`, `Provider_Specialty_1`, `Provider_Specialty_2`, `Provider_Specialty_3`, `Provider_Specialty_4`, `Provider_Address_Type`, `Provider_Address`, `Provider_City`, `Provider_County`, `Provider_State`, `Provider_Zip`, `Provider_Phone`, `Provider_Fax`, `Provider_Mailing_Address`, `Provider_Mailing_City`, `Provider_Mailing_County`, `Provider_Mailing_State`, `Provider_Mailing_Zip`, `Provider_Mailing_Phone`, `Provider_Mailing_Fax`, `Provider_Primary_Schedule`, `Provider_Secondary_Schedule`, `Provider_Rate_Sheet`, `Provider_Anes_Rate`, `Provider_Default_Rate`, `Provider_Max_DOS`, `Provider_Min_Match_Value`, `Provider_Effective_Date`, `Provider_Term_Date`, `Provider_Pend`, `Provider_Anes_Minutes`, `Provider_PPO`, `Provider_Hospital_1`, `Provider_Hospital_2`, `Provider_Hospital_3`, `Provider_Hospital_4`, `Provider_Type`, `Provider_NPI`, `Provider_Check_Override`, `Exclude_Dir`, `Audit_Status`, `Last_Change_Date`, `Medicare_ID`, `Provider_Lang`, `Provider_Latitude`, `Provider_Longitude`, `Provider_school`, `Provider_cert`) VALUES
('830199236', 'W12043961', 'W12043961', 'WY01', 'Yellowstone Behavioral Health Center', 'Kristen', 'P', 'Hendershot', 'LPC', 'Mental Health', 'Counseling', '', NULL, 'O', '2538 Big Horn Ave', 'Cody', 'Park', 'WY', '82414', '3075872197', NULL, '2538 Big Horn Ave', 'Cody', 'Park', 'WY', '82414', '3075872197', '          ', 'MA', '', '', '0.00', '40.00', '0.00', 6, '2013-11-01', NULL, 0, 0, 0, '', '', '', '', 'HCFA|UB|', '1659326528', 0, 'N', 0, '2014-02-20', NULL, NULL, 44.5334, -109.04, NULL, NULL),
('760681988', 'W12043960', 'W12043960', 'TXHOUSTD', 'C Funsho Fagbohun MD', 'Sabina', '', 'Cherian', 'MD', 'Obstetrics and Gynecology', '', '', NULL, 'M', '324 Dulles Dr', 'Lafayette', 'Lafayette', 'LA', '70506', '0000000000', '0000000000', '324 Dulles Dr', 'Lafayette', 'Lafayette', 'LA', '70506', '0000000000', '0000000000', 'HOUSTON3', 'TXHCPC13', '', '0.00', '45.00', '0.00', 3, '2014-01-10', NULL, 0, 0, 0, '', '', '', '', 'HCFA', '1245467042', 0, 'N', 0, '2014-02-05', NULL, NULL, 0, 0, NULL, NULL),
('364195126', 'W12043958', 'W12043958', 'ILCHIGSTD', 'Provena Immediate Care Plainfield Imaging', 'Lubna', 'S', 'Madani', 'MD', 'Family Practice', '', '', NULL, 'B', '2668 Momentum Pl', 'Chicago', 'Cook', 'IL', '60689', '6309142087', '0000000000', '2668 Momentum Pl', 'Chicago', 'Cook', 'IL', '60689', '6309142087', '0000000000', 'CHIGP1', 'CHIHCPCS13', '', '0.00', '40.00', '0.00', 6, '2013-07-01', NULL, 0, 0, 0, 'Presence Saint Joseph Hospital Chicago', NULL, '', '', 'HCFA|UB|', '1124349006', 0, 'N', 0, '2014-02-05', NULL, NULL, 0, 0, NULL, NULL),
('760681988', 'W12043959', 'W12043959', 'TXHOUSTD', 'C Funsho Fagbohun MD', 'Sabina', '', 'Cherian', 'MD', 'Obstetrics and Gynecology', '', '', NULL, 'O', '1601 Main St Ste A', 'Richmond', 'Fort Bend', 'TX', '77469', '2813426962', '2813426963', '1601 Main St Ste A', 'Richmond', 'Fort Bend', 'TX', '77469', '2813426962', '2813426963', 'HOUSTON3', 'TXHCPC13', '', '0.00', '45.00', '0.00', 3, '2014-01-10', NULL, 0, 0, 0, '', '', '', '', 'HCFA', '1245467042', 0, 'N', 0, '2014-02-25', NULL, NULL, 29.5772, -95.7691, NULL, NULL),
('364195126', 'W12043956', 'W12043956', 'ILCHIGSTD', 'Provena Immediate Care Plainfield Imaging', 'Lubna', 'S', 'Madani', 'MD', 'Family Practice', '', '', NULL, 'O', '7000 Caton Farm Rd', 'Plainfield', 'Will', 'IL', '60586', '8156095501', '6309142499', '7000 Caton Farm Rd', 'Plainfield', 'Will', 'IL', '60586', '8156095501', '6309142499', 'CHIGP1', 'CHIHCPCS13', '', '0.00', '40.00', '0.00', 6, '2013-07-01', NULL, 0, 0, 0, 'Presence Saint Joseph Hospital Chicago', NULL, '', '', 'HCFA|UB|', '1124349006', 0, 'N', 0, '2014-02-05', NULL, NULL, 41.5651, -88.2088, NULL, NULL),
('364195126', 'W12043957', 'W12043957', 'ILCHIGSTD', 'Neuroscience Institute at Provena', 'Lubna', 'S', 'Madani', 'MD', 'Family Practice', '', '', NULL, 'O', '410 E Lincoln Hwy', 'New Lenox', 'Will', 'IL', '60451', '8154625566', '6309142499', '410 E Lincoln Hwy', 'New Lenox', 'Will', 'IL', '60451', '8154625566', '6309142499', 'CHIGP1', 'CHIHCPCS13', '', '0.00', '40.00', '0.00', 6, '2013-07-01', NULL, 0, 0, 0, 'Presence Saint Joseph Hospital Chicago', NULL, '', '', 'HCFA|UB|', '1124349006', 0, 'N', 0, '2014-02-05', NULL, NULL, 41.5123, -87.957, NULL, NULL),
('463397455', 'W12043955', 'W12043955', 'ILCHIGSTD', 'Center for Brain and Nerve Disorders', 'Sreepathy', '', 'Kannan', 'MD', 'Neurology', '', '', NULL, 'B', '8s323 Hampton Ct', 'Naperville', 'Dupage', 'IL', '60540', '8157682210', '7086757110', '8s323 Hampton Ct', 'Naperville', 'Dupage', 'IL', '60540', '8157682210', '7086757110', 'CHIGP1', 'CHIHCPCS13', '', '0.00', '40.00', '0.00', 3, '2014-01-13', NULL, 0, 0, 0, 'Presence Saint Joseph Medical Center', NULL, NULL, NULL, 'HCFA|UB|', '1295793529', 0, 'N', 0, '2014-02-05', NULL, NULL, 0, 0, NULL, NULL),
('942854057', 'W12043954', 'W12043954', 'UTIHCPHY', 'Southern Utah Ortho Sports Med', '', '', 'Southern Utah Ortho Sports Med', '', 'Sports Medicine', '', '', NULL, 'O', '166 W 1325 N Ste 150', 'Cedar City', 'Iron', 'UT', '84721', '4355866962', '4358671663', '166 W 1325 N Ste 150', 'Cedar City', 'Iron', 'UT', '84721', '4355866962', '4358671663', 'USTDMULT', 'WUSTDHCPC5', '', '0.00', '35.00', '0.00', 8, '2014-01-01', NULL, 0, 0, 0, '', '', '', '', 'HCFA|UB|', '1982035531', 0, 'N', 0, '2014-02-05', NULL, NULL, 37.7011, -113.065, NULL, NULL),
('621801973', 'W12043945', 'W12043945', 'UT01', 'Jordan Valley Neurology Associates', 'Zoe', '', 'Robbins', 'APRN', 'Neurology', '', '', NULL, 'O', '3590 W 9000 S Ste 120', 'West Jordan', 'Salt Lake', 'UT', '84088', '8013528373', '8013528459', '3590 W 9000 S Ste 120', 'West Jordan', 'Salt Lake', 'UT', '84088', '8013528373', '8013528459', 'WUSTDINT5', 'WUSTDHCPC5', '', '0.00', '35.00', '0.00', 6, '2014-02-01', '2014-04-30', 0, 0, 0, '', '', '', '', 'HCFA|UB|', '1134321508', 0, 'N', 0, '2014-02-04', NULL, NULL, 40.5879, -111.976, NULL, NULL),
('621801973', 'W12043943', 'W12043943', 'UT01', 'Jordan Valley Neurology Associates', 'Nancy', '', 'Lieu', 'LCSW', 'Mental Health', 'Social Worker', '', NULL, 'O', '3590 W 9000 S Ste 120', 'West Jordan', 'Salt Lake', 'UT', '84088', '8013528373', '8013528459', '3590 W 9000 S Ste 120', 'West Jordan', 'Salt Lake', 'UT', '84088', '8013528373', '8013528459', 'WUSTDINT5', 'WUSTDHCPC5', '', '0.00', '35.00', '0.00', 6, '2014-02-01', '2014-04-30', 0, 0, 0, '', '', '', '', 'HCFA|UB|', '1205124021', 0, 'N', 0, '2014-02-04', NULL, NULL, 40.5879, -111.976, NULL, NULL),
('830300467', 'W12043939', 'W12043939', 'WYT1', 'Powell Valley Healthcare', 'Lisa', 'A', 'Smith', 'PA-C', 'Family Practice', '', '', NULL, 'O', '450 Mountain View St', 'Powell', 'Park', 'WY', '82435', '3077547257', NULL, '450 Mountain View St', 'Powell', 'Park', 'WY', '82435', '3077547257', '          ', '', '', '', '0.00', '12.00', '0.00', 3, '2014-01-27', NULL, 0, 0, 0, '', '', '', '', 'HCFA|UB|', '1780777169', 0, 'N', 0, '2014-02-04', NULL, NULL, 0, 0, NULL, NULL),
('621801973', 'W12043942', 'W12043942', 'UT01', 'Jordan Valley Neurology Associates', 'Phuong', '', 'Le', 'LCSW', 'Mental Health', 'Counseling', '', NULL, 'O', '3590 W 9000 S Ste 120', 'West Jordan', 'Salt Lake', 'UT', '84088', '8013528373', '8013528459', '3590 W 9000 S Ste 120', 'West Jordan', 'Salt Lake', 'UT', '84088', '8013528373', '8013528459', 'WUSTDINT5', 'WUSTDHCPC5', '', '0.00', '35.00', '0.00', 6, '2014-02-01', '2014-04-30', 0, 0, 0, '', '', '', '', 'HCFA|UB|', '1831169341', 0, 'N', 0, '2014-02-04', NULL, NULL, 40.5879, -111.976, NULL, NULL),
('830300467', 'W12043941', 'W12043941', 'WYT1', 'Powell Valley Healthcare', 'Lisa', 'A', 'Smith', 'PA-C', 'Family Practice', '', '', NULL, 'B', '777 Ave H', 'Powell', 'Park', 'WY', '82435', '3077542267', NULL, '777 Ave H', 'Powell', 'Park', 'WY', '82435', '3077542267', '          ', '', '', '', '0.00', '12.00', '0.00', 3, '2014-01-27', NULL, 0, 0, 0, '', '', '', '', 'HCFA|UB|', '1780777169', 0, 'N', 0, '2014-02-04', NULL, NULL, 0, 0, NULL, NULL),
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('363330928', 'W12043865', 'W12043865', 'ILCHIGSTD', 'Presence Healthcare Services', 'Owais', '', 'Lodhi', 'MD', 'Internal Medicine', '', '', NULL, 'O', '3002 N Ashland Ave', 'Chicago', 'Cook', 'IL', '60657', '7732440441', '7732440906', '3002 N Ashland Ave', 'Chicago', 'Cook', 'IL', '60657', '7732440441', '7732440906', 'CHIGP1', 'CHIHCPCS13', '', '0.00', '40.00', '0.00', 3, '2014-02-01', NULL, 0, 0, 0, 'Presence Saint Joseph Hospital Chicago', NULL, '', '', 'HCFA|UB|', '1427212638', 0, 'N', 0, '2014-01-31', NULL, NULL, 41.9366, -87.6686, NULL, NULL),
('363330928', 'W12043864', 'W12043864', 'ILCHIGSTD', 'Presence Healthcare Services', 'King', '', 'Leong', 'MD', 'Internal Medicine', '', '', NULL, 'O', '3002 N Ashland Ave', 'Chicago', 'Cook', 'IL', '60657', '7732440441', '7732440906', '3002 N Ashland Ave', 'Chicago', 'Cook', 'IL', '60657', '7732440441', '7732440906', 'CHIGP1', 'CHIHCPCS13', '', '0.00', '40.00', '0.00', 3, '2014-02-01', NULL, 0, 0, 0, 'Presence Our Lady Of The Resurrection Medical Center', NULL, NULL, NULL, 'HCFA|UB|', '1356521314', 0, 'N', 0, '2014-01-31', NULL, NULL, 41.9366, -87.6686, NULL, NULL),
('363330928', 'W12043863', 'W12043863', 'ILCHIGSTD', 'Presence Healthcare Services', 'Erin', '', 'Malone', 'MD', 'Endocrinology', 'Internal Medicine', 'Pediatrics', NULL, 'O', '3002 N Ashland Ave', 'Chicago', 'Cook', 'IL', '60657', '7732440441', '7732440906', '3002 N Ashland Ave', 'Chicago', 'Cook', 'IL', '60657', '7732440441', '7732440906', 'CHIGP1', 'CHIHCPCS13', '', '0.00', '40.00', '0.00', 3, '2014-02-01', NULL, 0, 0, 0, 'Presence Saints Mary and Elizabeth Medical Center Saint Mary Campus', NULL, NULL, NULL, 'HCFA|UB|', '1013173376', 0, 'N', 0, '2014-01-31', NULL, NULL, 41.9366, -87.6686, NULL, NULL),
('202630141', 'W12043861', 'W12043861', 'IDBOISTD', 'Primary Health Medical Group', 'Jenna', 'L', 'Maffey', 'PA', 'Family Practice', '', '', NULL, 'O', '8971 W Overland', 'Boise', 'Ada', 'ID', '83709', '2083784288', '2083784297', '8971 W Overland', 'Boise', 'Ada', 'ID', '83709', '2083784288', '2083784297', 'IDPRIMARY', 'WUSTDHCPC5', '', '0.00', '30.00', '0.00', 3, '2014-01-19', NULL, 0, 0, 0, '', '', '', '', 'HCFA|UB|', '1467787598', 0, 'Y', 0, '2014-04-29', NULL, NULL, 43.5903, -116.294, NULL, NULL),
('202630141', 'W12043860', 'W12043860', 'IDBOISTD', 'Primary Health Medical Group', 'Jenna', 'L', 'Maffey', 'PA', 'Family Practice', '', '', NULL, 'O', '6052 W State St', 'Boise', 'Ada', 'ID', '83703', '2089471947', '2089471945', '6052 W State St', 'Boise', 'Ada', 'ID', '83703', '2089471947', '2089471945', 'IDPRIMARY', 'WUSTDHCPC5', '', '0.00', '30.00', '0.00', 3, '2014-01-19', NULL, 0, 0, 0, '', '', '', '', 'HCFA|UB|', '1467787598', 0, 'Y', 0, '2014-04-29', NULL, NULL, 43.6592, -116.264, NULL, NULL),
('202630141', 'W12043859', 'W12043859', 'IDBOISTD', 'Primary Health Medical Group', 'Jenna', 'L', 'Maffey', 'PA', 'Family Practice', '', '', NULL, 'O', '5108 E Cleveland Blvd', 'Caldwell', 'Canyon', 'ID', '83607', '2089556500', '2084549690', '5108 E Cleveland Blvd', 'Caldwell', 'Canyon', 'ID', '83607', '2089556500', '2084549690', 'IDPRIMARY', 'WUSTDHCPC5', '', '0.00', '30.00', '0.00', 3, '2014-01-19', NULL, 0, 0, 0, '', '', '', '', 'HCFA|UB|', '1467787598', 0, 'Y', 0, '2014-04-29', NULL, NULL, 43.6327, -116.643, NULL, NULL),
('202630141', 'W12043858', 'W12043858', 'IDBOISTD', 'Primary Health Medical Group', 'Jenna', 'L', 'Maffey', 'PA', 'Family Practice', '', '', NULL, 'O', '4815 Cleveland Blvd', 'Caldwell', 'Canyon', 'ID', '83605', '2084553545', '2084549690', '4815 Cleveland Blvd', 'Caldwell', 'Canyon', 'ID', '83605', '2084553545', '2084549690', 'IDPRIMARY', 'WUSTDHCPC5', '', '0.00', '30.00', '0.00', 3, '2014-01-19', NULL, 0, 0, 0, '', '', '', '', 'HCFA|UB|', '1467787598', 0, 'Y', 0, '2014-04-29', NULL, NULL, 43.6351, -116.647, NULL, NULL),
('202630141', 'W12043857', 'W12043857', 'IDBOISTD', 'Primary Health Medical Group', 'Jenna', 'L', 'Maffey', 'PA', 'Family Practice', '', '', NULL, 'O', '435 S Eagle Rd', 'Eagle', 'Ada', 'ID', '83616', '2089398200', '2089398222', '435 S Eagle Rd', 'Eagle', 'Ada', 'ID', '83616', '2089398200', '2089398222', 'IDPRIMARY', 'WUSTDHCPC5', '', '0.00', '30.00', '0.00', 3, '2014-01-19', NULL, 0, 0, 0, '', '', '', '', 'HCFA|UB|', '1467787598', 0, 'Y', 0, '2014-04-29', NULL, NULL, 43.6918, -116.354, NULL, NULL),
('202630141', 'W12043856', 'W12043856', 'IDBOISTD', 'Primary Health Medical Group', 'Jenna', 'L', 'Maffey', 'PA', 'Family Practice', '', '', NULL, 'O', '3115 E Florence', 'Meridian', 'Ada', 'ID', '83642', '2088958670', '2089550494', '3115 E Florence', 'Meridian', 'Ada', 'ID', '83642', '2088958670', '2089550494', 'IDPRIMARY', 'WUSTDHCPC5', '', '0.00', '30.00', '0.00', 3, '2014-01-19', NULL, 0, 0, 0, '', '', '', '', 'HCFA|UB|', '1467787598', 0, 'Y', 0, '2014-04-29', NULL, NULL, 43.6166, -116.356, NULL, NULL),
('202630141', 'W12043855', 'W12043855', 'IDBOISTD', 'Primary Health Medical Group', 'Jenna', 'L', 'Maffey', 'PA', 'Family Practice', '', '', NULL, 'O', '300 W Myrtle St Ste 100', 'Boise', 'Ada', 'ID', '83702', '2084729082', '2084729083', '300 W Myrtle St Ste 100', 'Boise', 'Ada', 'ID', '83702', '2084729082', '2084729083', 'IDPRIMARY', 'WUSTDHCPC5', '', '0.00', '30.00', '0.00', 3, '2014-01-19', NULL, 0, 0, 0, '', '', '', '', 'HCFA|UB|', '1467787598', 0, 'Y', 0, '2014-04-29', NULL, NULL, 43.6096, -116.201, NULL, NULL),
('202630141', 'W12043854', 'W12043854', 'IDBOISTD', 'Primary Health Medical Group', 'Jenna', 'L', 'Maffey', 'PA', 'Family Practice', '', '', NULL, 'O', '1907 S Broadway Ave Ste 101', 'Boise', 'Ada', 'ID', '83706', '2083451222', '2083451261', '1907 S Broadway Ave Ste 101', 'Boise', 'Ada', 'ID', '83706', '2083451222', '2083451261', 'IDPRIMARY', 'WUSTDHCPC5', '', '0.00', '30.00', '0.00', 3, '2014-01-19', NULL, 0, 0, 0, '', '', '', '', 'HCFA|UB|', '1467787598', 0, 'Y', 0, '2014-04-29', NULL, NULL, 43.5897, -116.194, NULL, NULL),
('202630141', 'W12043853', 'W12043853', 'IDBOISTD', 'Primary Health Medical Group', 'Jenna', 'L', 'Maffey', 'PA', 'Family Practice', '', '', NULL, 'O', '1825 Kimball Ave', 'Caldwell', 'Canyon', 'ID', '83605', '2084553545', '2084549690', '1825 Kimball Ave', 'Caldwell', 'Canyon', 'ID', '83605', '2084553545', '2084549690', 'IDPRIMARY', 'WUSTDHCPC5', '', '0.00', '30.00', '0.00', 3, '2014-01-19', NULL, 0, 0, 0, '', '', '', '', 'HCFA|UB|', '1467787598', 0, 'Y', 0, '2014-04-29', NULL, NULL, 43.6541, -116.698, NULL, NULL),
('202630141', 'W12043852', 'W12043852', 'IDBOISTD', 'Primary Health Medical Group', 'Jenna', 'L', 'Maffey', 'PA', 'Family Practice', '', '', NULL, 'O', '125 E Idaho St Ste 201', 'Boise', 'Ada', 'ID', '83712', '2083859330', '2083810607', '125 E Idaho St Ste 201', 'Boise', 'Ada', 'ID', '83712', '2083859330', '2083810607', 'IDPRIMARY', 'WUSTDHCPC5', '', '0.00', '30.00', '0.00', 3, '2014-01-19', NULL, 0, 0, 0, '', '', '', '', 'HCFA|UB|', '1467787598', 0, 'Y', 0, '2014-04-29', NULL, NULL, 43.6121, -116.194, NULL, NULL),
('202630141', 'W12043851', 'W12043851', 'IDBOISTD', 'Primary Health Medical Group', 'Jenna', 'L', 'Maffey', 'PA', 'Family Practice', '', '', NULL, 'O', '1130 E Fairview', 'Meridian', 'Ada', 'ID', '83642', '2088889393', '2088889525', '1130 E Fairview', 'Meridian', 'Ada', 'ID', '83642', '2088889393', '2088889525', 'IDPRIMARY', 'WUSTDHCPC5', '', '0.00', '30.00', '0.00', 3, '2014-01-19', NULL, 0, 0, 0, '', '', '', '', 'HCFA|UB|', '1467787598', 0, 'Y', 0, '2014-04-29', NULL, NULL, 43.6195, -116.38, NULL, NULL),
('202630141', 'W12043850', 'W12043850', 'IDBOISTD', 'Primary Health Medical Group', 'Jenna', 'L', 'Maffey', 'PA', 'Family Practice', '', '', NULL, 'O', '11197 W Fairview Ave', 'Boise', 'Ada', 'ID', '83713', '2083788011', '2083228095', '11197 W Fairview Ave', 'Boise', 'Ada', 'ID', '83713', '2083788011', '2083228095', 'IDPRIMARY', 'WUSTDHCPC5', '', '0.00', '30.00', '0.00', 3, '2014-01-19', NULL, 0, 0, 0, '', '', '', '', 'HCFA|UB|', '1467787598', 0, 'N', 0, '2014-04-29', NULL, NULL, 43.6195, -116.322, NULL, NULL),
('202630141', 'W12043849', 'W12043849', 'IDBOISTD', 'Primary Health Medical Group', 'Jenna', 'L', 'Maffey', 'PA', 'Family Practice', '', '', NULL, 'O', '10787 W Ustick', 'Boise', 'Ada', 'ID', '83713', '2084666567', '2084667922', '10787 W Ustick', 'Boise', 'Ada', 'ID', '83713', '2084666567', '2084667922', 'IDPRIMARY', 'WUSTDHCPC5', '', '0.00', '30.00', '0.00', 3, '2014-01-19', NULL, 0, 0, 0, '', '', '', '', 'HCFA|UB|', '1467787598', 0, 'Y', 0, '2014-04-29', NULL, NULL, 43.6339, -116.317, NULL, NULL),
('202630141', 'W12043847', 'W12043847', 'IDBOISTD', 'Primary Health Medical Group', 'Ramon', 'A', 'Relyea', 'PA', 'Family Practice', '', '', NULL, 'B', 'PO Box 191050', 'Boise', 'Ada', 'ID', '83719', '2088958670', NULL, 'PO Box 191050', 'Boise', 'Ada', 'ID', '83719', '2088958670', '          ', 'IDPRIMARY', 'WUSTDHCPC5', '', '0.00', '30.00', '0.00', 3, '2014-01-19', NULL, 0, 0, 0, '', '', '', '', 'HCFA|UB|', '1972805943', 0, 'N', 0, '2014-01-30', NULL, NULL, 0, 0, NULL, NULL),
('202630141', 'W12043846', 'W12043846', 'IDBOISTD', 'Primary Health Medical Group', 'Ramon', 'A', 'Relyea', 'PA', 'Family Practice', '', '', NULL, 'O', '8971 W Overland', 'Boise', 'Ada', 'ID', '83709', '2083784288', '2083784297', '8971 W Overland', 'Boise', 'Ada', 'ID', '83709', '2083784288', '2083784297', 'IDPRIMARY', 'WUSTDHCPC5', '', '0.00', '30.00', '0.00', 3, '2014-01-19', NULL, 0, 0, 0, '', '', '', '', 'HCFA|UB|', '1972805943', 0, 'Y', 0, '2014-01-31', NULL, NULL, 43.5903, -116.294, NULL, NULL),
('202630141', 'W12043845', 'W12043845', 'IDBOISTD', 'Primary Health Medical Group', 'Ramon', 'A', 'Relyea', 'PA', 'Family Practice', '', '', NULL, 'O', '700 Caldwell Blvd', 'Nampa', 'Canyon', 'ID', '83651', '2083451222', '2083451261', '700 Caldwell Blvd', 'Nampa', 'Canyon', 'ID', '83651', '2083451222', '2083451261', 'IDPRIMARY', 'WUSTDHCPC5', '', '0.00', '30.00', '0.00', 3, '2014-01-19', NULL, 0, 0, 0, '', '', '', '', 'HCFA|UB|', '1972805943', 0, 'N', 0, '2014-01-30', NULL, NULL, 43.5963, -116.59, NULL, NULL),
('202630141', 'W12043843', 'W12043843', 'IDBOISTD', 'Primary Health Medical Group', 'Ramon', 'A', 'Relyea', 'PA', 'Family Practice', '', '', NULL, 'O', '4815 Cleveland Blvd', 'Caldwell', 'Canyon', 'ID', '83605', '2084553545', '2084549690', '4815 Cleveland Blvd', 'Caldwell', 'Canyon', 'ID', '83605', '2084553545', '2084549690', 'IDPRIMARY', 'WUSTDHCPC5', '', '0.00', '30.00', '0.00', 3, '2014-01-19', NULL, 0, 0, 0, '', '', '', '', 'HCFA|UB|', '1972805943', 0, 'Y', 0, '2014-01-31', NULL, NULL, 43.6351, -116.647, NULL, NULL),
('202630141', 'W12043844', 'W12043844', 'IDBOISTD', 'Primary Health Medical Group', 'Ramon', 'A', 'Relyea', 'PA', 'Family Practice', '', '', NULL, 'O', '6348 Emerald St', 'Boise', 'Ada', 'ID', '83704', '2083774400', '2083774416', '6348 Emerald St', 'Boise', 'Ada', 'ID', '83704', '2083774400', '2083774416', 'IDPRIMARY', 'WUSTDHCPC5', '', '0.00', '30.00', '0.00', 3, '2014-01-19', NULL, 0, 0, 0, '', '', '', '', 'HCFA|UB|', '1972805943', 0, 'Y', 0, '2014-01-31', NULL, NULL, 43.6119, -116.261, NULL, NULL),
('202630141', 'W12043842', 'W12043842', 'IDBOISTD', 'Primary Health Medical Group', 'Ramon', 'A', 'Relyea', 'PA', 'Family Practice', '', '', NULL, 'O', '435 S Eagle Rd', 'Eagle', 'Ada', 'ID', '83616', '2089398200', '2089398222', '435 S Eagle Rd', 'Eagle', 'Ada', 'ID', '83616', '2089398200', '2089398222', 'IDPRIMARY', 'WUSTDHCPC5', '', '0.00', '30.00', '0.00', 3, '2014-01-19', NULL, 0, 0, 0, '', '', '', '', 'HCFA|UB|', '1972805943', 0, 'Y', 0, '2014-01-31', NULL, NULL, 43.6918, -116.354, NULL, NULL),
('202630141', 'W12043841', 'W12043841', 'IDBOISTD', 'Primary Health Medical Group', 'Ramon', 'A', 'Relyea', 'PA', 'Family Practice', '', '', NULL, 'O', '3115 E Florence', 'Meridian', 'Ada', 'ID', '83642', '2088958670', '2089550494', '3115 E Florence', 'Meridian', 'Ada', 'ID', '83642', '2088958670', '2089550494', 'IDPRIMARY', 'WUSTDHCPC5', '', '0.00', '30.00', '0.00', 3, '2014-01-19', NULL, 0, 0, 0, '', '', '', '', 'HCFA|UB|', '1972805943', 0, 'Y', 0, '2014-01-31', NULL, NULL, 43.6166, -116.356, NULL, NULL),
('202630141', 'W12043840', 'W12043840', 'IDBOISTD', 'Primary Health Medical Group', 'Ramon', 'A', 'Relyea', 'PA', 'Family Practice', '', '', NULL, 'O', '1115 12th Ave Rd', 'Nampa', 'Canyon', 'ID', '83686', '2084981080', '2084981081', '1115 12th Ave Rd', 'Nampa', 'Canyon', 'ID', '83686', '2084981080', '2084981081', 'IDPRIMARY', 'WUSTDHCPC5', '', '0.00', '30.00', '0.00', 3, '2014-01-19', NULL, 0, 0, 0, '', '', '', '', 'HCFA|UB|', '1972805943', 0, 'Y', 0, '2014-01-31', NULL, NULL, 43.5577, -116.573, NULL, NULL),
('202630141', 'W12043839', 'W12043839', 'IDBOISTD', 'Primary Health Medical Group', 'Ramon', 'A', 'Relyea', 'PA', 'Family Practice', '', '', NULL, 'O', '300 W Myrtle St Ste 100', 'Boise', 'Ada', 'ID', '83702', '2084729082', '2084729083', '300 W Myrtle', 'Boise', 'Ada', 'ID', '83702', '2084729082', '2084729083', 'IDPRIMARY', 'WUSTDHCPC5', '', '0.00', '30.00', '0.00', 3, '2014-01-19', NULL, 0, 0, 0, '', '', '', '', 'HCFA|UB|', '1972805943', 0, 'Y', 0, '2014-01-31', NULL, NULL, 43.6096, -116.201, NULL, NULL),
('202630141', 'W12043838', 'W12043838', 'IDBOISTD', 'Primary Health Medical Group', 'Ramon', 'A', 'Relyea', 'PA', 'Family Practice', '', '', NULL, 'O', '1907 S Broadway Ave Ste 101', 'Boise', 'Ada', 'ID', '83706', '2083451222', '2083451261', '1907 S Broadway Ave Ste 101', 'Boise', 'Ada', 'ID', '83706', '2083451222', '2083451261', 'IDPRIMARY', 'WUSTDHCPC5', '', '0.00', '30.00', '0.00', 3, '2014-01-19', NULL, 0, 0, 0, '', '', '', '', 'HCFA|UB|', '1972805943', 0, 'Y', 0, '2014-01-31', NULL, NULL, 43.5897, -116.194, NULL, NULL),
('202630141', 'W12043837', 'W12043837', 'IDBOISTD', 'Primary Health Medical Group', 'Ramon', 'A', 'Relyea', 'PA', 'Family Practice', '', '', NULL, 'O', '125 E Idaho St Ste 201', 'Boise', 'Ada', 'ID', '83712', '2083859330', '2083810607', '125 E Idaho St Ste 201', 'Boise', 'Ada', 'ID', '83712', '2083859330', '2083810607', 'IDPRIMARY', 'WUSTDHCPC5', '', '0.00', '30.00', '0.00', 3, '2014-01-19', NULL, 0, 0, 0, '', '', '', '', 'HCFA|UB|', '1972805943', 0, 'Y', 0, '2014-01-31', NULL, NULL, 43.6121, -116.194, NULL, NULL),
('202630141', 'W12043836', 'W12043836', 'IDBOISTD', 'Primary Health Medical Group', 'Ramon', 'A', 'Relyea', 'PA', 'Family Practice', '', '', NULL, 'O', '1130 E Fairview', 'Meridian', 'Ada', 'ID', '83642', '2088889393', '2088889525', '1130 E Fairview', 'Meridian', 'Ada', 'ID', '83642', '2088889393', '2088889525', 'IDPRIMARY', 'WUSTDHCPC5', '', '0.00', '30.00', '0.00', 3, '2014-01-19', NULL, 0, 0, 0, '', '', '', '', 'HCFA|UB|', '1972805943', 0, 'Y', 0, '2014-01-31', NULL, NULL, 43.6195, -116.38, NULL, NULL),
('202630141', 'W12043835', 'W12043835', 'IDBOISTD', 'Primary Health Medical Group', 'Ramon', 'A', 'Relyea', 'PA', 'Family Practice', '', '', NULL, 'O', '11197 W Fairview Ave', 'Boise', 'Ada', 'ID', '83713', '2083788011', '2083228095', '11197 W Fairview Ave', 'Boise', 'Ada', 'ID', '83713', '2083788011', '2083228095', 'IDPRIMARY', 'WUSTDHCPC5', '', '0.00', '30.00', '0.00', 3, '2014-01-19', NULL, 0, 0, 0, '', '', '', '', 'HCFA|UB|', '1972805943', 0, 'Y', 0, '2014-01-31', NULL, NULL, 43.6195, -116.322, NULL, NULL),
('202630141', 'W12043834', 'W12043834', 'IDBOISTD', 'Primary Health Medical Group', 'Jennifer', 'R', 'Appel', 'PA', 'Family Practice', '', '', NULL, 'O', '300 W Myrtle St Ste 100', 'Boise', 'Ada', 'ID', '83702', '2084729082', '2084729083', '300 W Myrtle St Ste 100', 'Boise', 'Ada', 'ID', '83702', '2084729082', '2084729083', 'IDPRIMARY', 'WUSTDHCPC5', '', '0.00', '30.00', '0.00', 3, '2014-01-19', '2014-07-04', 0, 0, 0, '', '', '', '', 'HCFA|UB|', '1588918924', 0, 'N', 0, '2014-07-10', NULL, NULL, 43.6096, -116.201, NULL, NULL),
('202630141', 'W12043833', 'W12043833', 'IDBOISTD', 'Primary Health Medical Group', 'Jennifer', 'R', 'Appel', 'PA', 'Family Practice', '', '', NULL, 'O', '6052 W State St', 'Boise', 'Ada', 'ID', '83703', '2083447799', '2089471945', '6052 W State St', 'Boise', 'Ada', 'ID', '83703', '2083447799', '2089471945', 'IDPRIMARY', 'WUSTDHCPC5', '', '0.00', '30.00', '0.00', 3, '2014-01-19', '2014-07-04', 0, 0, 0, '', '', '', '', 'HCFA|UB|', '1588918924', 0, 'Y', 0, '2014-07-10', NULL, NULL, 43.6592, -116.264, NULL, NULL);
INSERT INTO `providers_new` (`Provider_Tax_ID`, `Provider_Suffix`, `Provider_Network_ID`, `Provider_Region`, `Provider_Name`, `Provider_Doctor_First_Name`, `Provider_Doctor_Middle_Name`, `Provider_Doctor_Last_Name`, `Provider_Doctor_Degree`, `Provider_Specialty_1`, `Provider_Specialty_2`, `Provider_Specialty_3`, `Provider_Specialty_4`, `Provider_Address_Type`, `Provider_Address`, `Provider_City`, `Provider_County`, `Provider_State`, `Provider_Zip`, `Provider_Phone`, `Provider_Fax`, `Provider_Mailing_Address`, `Provider_Mailing_City`, `Provider_Mailing_County`, `Provider_Mailing_State`, `Provider_Mailing_Zip`, `Provider_Mailing_Phone`, `Provider_Mailing_Fax`, `Provider_Primary_Schedule`, `Provider_Secondary_Schedule`, `Provider_Rate_Sheet`, `Provider_Anes_Rate`, `Provider_Default_Rate`, `Provider_Max_DOS`, `Provider_Min_Match_Value`, `Provider_Effective_Date`, `Provider_Term_Date`, `Provider_Pend`, `Provider_Anes_Minutes`, `Provider_PPO`, `Provider_Hospital_1`, `Provider_Hospital_2`, `Provider_Hospital_3`, `Provider_Hospital_4`, `Provider_Type`, `Provider_NPI`, `Provider_Check_Override`, `Exclude_Dir`, `Audit_Status`, `Last_Change_Date`, `Medicare_ID`, `Provider_Lang`, `Provider_Latitude`, `Provider_Longitude`, `Provider_school`, `Provider_cert`) VALUES
('202630141', 'W12043832', 'W12043832', 'IDBOISTD', 'Primary Health Medical Group', 'Jennifer', 'R', 'Appel', 'PA', 'Family Practice', '', '', NULL, 'O', '1907 S Broadway Ave Ste 101', 'Boise', 'Ada', 'ID', '83706', '2083451222', '2083451261', '1907 S Broadway Ave Ste 101', 'Boise', 'Ada', 'ID', '83706', '2083451222', '2083451261', 'IDPRIMARY', 'WUSTDHCPC5', '', '0.00', '30.00', '0.00', 3, '2014-01-19', '2014-07-04', 0, 0, 0, '', '', '', '', 'HCFA|UB|', '1588918924', 0, 'Y', 0, '2014-07-10', NULL, NULL, 43.5897, -116.194, NULL, NULL),
('202630141', 'W12043831', 'W12043831', 'IDBOISTD', 'Primary Health Medical Group', 'Jennifer', 'R', 'Appel', 'PA', 'Family Practice', '', '', NULL, 'O', '8971 W Overland', 'Boise', 'Ada', 'ID', '83709', '2083784288', '2083784297', '8971 W Overland', 'Boise', 'Ada', 'ID', '83709', '2083784288', '2083784297', 'IDPRIMARY', 'WUSTDHCPC5', '', '0.00', '30.00', '0.00', 3, '2014-01-19', '2014-07-04', 0, 0, 0, '', '', '', '', 'HCFA|UB|', '1588918924', 0, 'N', 0, '2014-07-10', NULL, NULL, 43.5903, -116.294, NULL, NULL),
('202630141', 'W12043830', 'W12043830', 'IDBOISTD', 'Primary Health Medical Group', 'Jennifer', 'R', 'Appel', 'PA', 'Family Practice', '', '', NULL, 'O', '1115 12th Ave Rd', 'Nampa', 'Canyon', 'ID', '83686', '2084981080', '2084981081', '1115 12th Ave Rd', 'Nampa', 'Canyon', 'ID', '83686', '2084981080', '2084981081', 'IDPRIMARY', 'WUSTDHCPC5', '', '0.00', '30.00', '0.00', 3, '2014-01-19', '2014-07-04', 0, 0, 0, '', '', '', '', 'HCFA|UB|', '1588918924', 0, 'Y', 0, '2014-07-10', NULL, NULL, 43.5577, -116.573, NULL, NULL),
('202630141', 'W12043829', 'W12043829', 'IDBOISTD', 'Primary Health Medical Group', 'Jennifer', 'R', 'Appel', 'PA', 'Family Practice', '', '', NULL, 'O', '700 Caldwell Blvd', 'Nampa', 'Canyon', 'ID', '83651', '2083451222', '2083451261', '700 Caldwell Blvd', 'Nampa', 'Canyon', 'ID', '83651', '2083451222', '2083451261', 'IDPRIMARY', 'WUSTDHCPC5', '', '0.00', '30.00', '0.00', 3, '2014-01-19', '2014-07-04', 0, 0, 0, '', '', '', '', 'HCFA|UB|', '1588918924', 0, 'Y', 0, '2014-07-10', NULL, NULL, 43.5963, -116.59, NULL, NULL),
('202630141', 'W12043828', 'W12043828', 'IDBOISTD', 'Primary Health Medical Group', 'Jennifer', 'R', 'Appel', 'PA', 'Family Practice', '', '', NULL, 'O', '1130 E Fairview', 'Meridian', 'Ada', 'ID', '83642', '2088889393', '2088889525', '1130 E Fairview', 'Meridian', 'Ada', 'ID', '83642', '2088889393', '2088889525', 'IDPRIMARY', 'WUSTDHCPC5', '', '0.00', '30.00', '0.00', 3, '2014-01-19', '2014-07-04', 0, 0, 0, '', '', '', '', 'HCFA|UB|', '1588918924', 0, 'Y', 0, '2014-07-10', NULL, NULL, 43.6195, -116.38, NULL, NULL),
('202630141', 'W12043827', 'W12043827', 'IDBOISTD', 'Primary Health Medical Group', 'Jennifer', 'R', 'Appel', 'PA', 'Family Practice', '', '', NULL, 'O', '435 S Eagle Rd', 'Eagle', 'Ada', 'ID', '83616', '2089398200', '2089398222', '435 S Eagle Rd', 'Eagle', 'Ada', 'ID', '83616', '2089398200', '2089398222', 'IDPRIMARY', 'WUSTDHCPC5', '', '0.00', '30.00', '0.00', 3, '2014-01-19', '2014-07-04', 0, 0, 0, '', '', '', '', 'HCFA|UB|', '1588918924', 0, 'Y', 0, '2014-07-10', NULL, NULL, 43.6918, -116.354, NULL, NULL),
('202630141', 'W12043826', 'W12043826', 'IDBOISTD', 'Primary Health Medical Group', 'Jennifer', 'R', 'Appel', 'PA', 'Family Practice', '', '', NULL, 'O', '3115 E Florence', 'Meridian', 'Ada', 'ID', '83642', '2088958670', '2089550494', '3115 E Florence', 'Meridian', 'Ada', 'ID', '83642', '2088958670', '2089550494', 'IDPRIMARY', 'WUSTDHCPC5', '', '0.00', '30.00', '0.00', 3, '2014-01-19', '2014-07-04', 0, 0, 0, '', '', '', '', 'HCFA|UB|', '1588918924', 0, 'Y', 0, '2014-07-10', NULL, NULL, 43.6166, -116.356, NULL, NULL),
('202630141', 'W12043825', 'W12043825', 'IDBOISTD', 'Primary Health Medical Group', 'Jennifer', 'R', 'Appel', 'PA', 'Family Practice', '', '', NULL, 'O', '4815 Cleveland Blvd', 'Caldwell', 'Canyon', 'ID', '83605', '2084553545', '2084549690', '4815 Cleveland Blvd', 'Caldwell', 'Canyon', 'ID', '83605', '2084553545', '2084549690', 'IDPRIMARY', 'WUSTDHCPC5', '', '0.00', '30.00', '0.00', 3, '2014-01-19', '2014-07-04', 0, 0, 0, '', '', '', '', 'HCFA|UB|', '1588918924', 0, 'Y', 0, '2014-07-10', NULL, NULL, 43.6351, -116.647, NULL, NULL),
('262978009', 'W12043823', 'W12043823', 'TXDALSTD', 'Baylor Emergency Medical Center at Keller', '', '', 'Baylor Emergency Medical Center at Keller', '', 'Hospital', '', '', NULL, 'B', 'PO Box 46017', 'Houston', 'Harris', 'TX', '77210', '2142946100', NULL, 'PO Box 46017', 'Houston', 'Harris', 'TX', '77210', '2142946100', '          ', '', '', 'BAYHEALTHD', '0.00', '0.00', '0.00', 3, '2013-12-18', NULL, 0, 0, 0, '', '', '', '', 'HCFA|UB|', '1689002651', 0, 'N', 0, '2014-01-30', NULL, NULL, 0, 0, NULL, NULL),
('262978009', 'W12043824', 'W12043824', 'TXDALSTD', 'Baylor Emergency Medical Center at Keller', '', '', 'Baylor Emergency Medical Center at Keller', '', 'Hospital', '', '', NULL, 'O', '620 S Main St Ste 100', 'Keller', 'Tarrant', 'TX', '76248', '2142946100', NULL, '620 S Main St Ste 100', 'Keller', 'Tarrant', 'TX', '76248', '2142946100', '          ', '', '', 'BAYHEALTHD', '0.00', '0.00', '0.00', 3, '2013-12-18', NULL, 0, 0, 0, '', '', '', '', 'HCFA|UB|', '1689002651', 0, 'N', 0, '2014-01-30', NULL, NULL, 0, 0, NULL, NULL),
('462971399', 'W12043822', 'W12043822', 'TXDALSTD', 'Dermone Dermatology', 'Carolyn', '', 'Kim', 'MD', 'Dermatology', '', '', NULL, 'B', 'PO Box 12688', 'Belfast', 'Waldo', 'ME', '04915', '8172611626', '8172750441', 'PO Box 12688', 'Belfast', 'Waldo', 'ME', '04915', '8172611626', '8172750441', 'SPA', 'TXHCPC13', '', '0.00', '45.00', '0.00', 3, '2014-02-20', NULL, 0, 0, 0, '', '', '', '', 'HCFA|UB|', '1063594299', 0, 'N', 0, '2014-01-30', NULL, NULL, 0, 0, NULL, NULL),
('462971399', 'W12043821', 'W12043821', 'TXDALSTD', 'Dermone Dermatology', 'Carolyn', '', 'Kim', 'MD', 'Dermatology', '', '', NULL, 'O', '4927 Lake Ridge Pkwy Ste 170', 'Grand Prairie', 'Dallas', 'TX', '75052', '8174668651', '8174662503', '4927 Lake Ridge Pkwy Ste 170', 'Grand Prairie', 'Dallas', 'TX', '75052', '8174668651', '8174662503', 'SPA', 'TXHCPC13', '', '0.00', '45.00', '0.00', 3, '2014-02-20', NULL, 0, 0, 0, '', '', '', '', 'HCFA|UB|', '1063594299', 0, 'N', 0, '2014-01-30', NULL, NULL, 32.6594, -97.037, NULL, NULL),
('462971399', 'W12043820', 'W12043820', 'TXDALSTD', 'Dermone Dermatology', 'Carolyn', '', 'Kim', 'MD', 'Dermatology', '', '', NULL, 'O', '715 N Fielder Rd Ste 300', 'Arlington', 'Tarrant', 'TX', '76012', '8172611626', '8172750441', '715 N Fielder Rd Ste 300', 'Arlington', 'Tarrant', 'TX', '76012', '8172611626', '8172750441', 'SPA', 'TXHCPC13', '', '0.00', '45.00', '0.00', 3, '2014-02-20', NULL, 0, 0, 0, '', '', '', '', 'HCFA|UB|', '1063594299', 0, 'N', 0, '2014-01-30', NULL, NULL, 32.7441, -97.1318, NULL, NULL),
('752955654', 'W12043818', 'W12043818', 'TXDALSTD', 'Frisco Pediatrics', 'Lorie', 'M', 'Booth', 'MD', 'Pediatrics', '', '', NULL, 'O', '6930 Parkwood Blvd', 'Frisco', 'Denton', 'TX', '75034', '9723354444', '9723350880', '6930 Parkwood Blvd', 'Frisco', 'Denton', 'TX', '75034', '9723354444', '9723350880', 'SPA', 'TXHCPC13', '', '0.00', '45.00', '0.00', 3, '2014-02-20', NULL, 0, 0, 0, 'Baylor Medical Center at Carrollton', NULL, '', '', 'HCFA|UB|', '1891767232', 0, 'N', 0, '2014-01-30', NULL, NULL, 33.1258, -96.8055, NULL, NULL),
('463233444', 'W12043816', 'W12043816', 'TXDALSTD', 'Questcare Medical Clinics', 'Kurtt', 'R', 'Wix', 'DO', 'Family Practice', '', '', NULL, 'B', 'PO Box 678048', 'Dallas', 'Dallas', 'TX', '75267', '8172951121', '8172958170', 'PO Box 678048', 'Dallas', 'Dallas', 'TX', '75267', '8172951121', '8172958170', 'SPA', 'TXHCPC13', '', '0.00', '45.00', '0.00', 3, '2014-02-20', NULL, 0, 0, 0, '', '', '', '', 'HCFA|UB|', '1154607604', 0, 'N', 0, '2014-01-30', NULL, NULL, 0, 0, NULL, NULL),
('463233444', 'W12043814', 'W12043814', 'TXDALSTD', 'Questcare Medical Clinics', 'Kurtt', 'R', 'Wix', 'DO', 'Family Practice', '', '', NULL, 'O', '1571 SW Wilshire Blvd Ste 500', 'Burleson', 'Johnson', 'TX', '76028', '8172951121', '8172958170', '1571 SW Wilshire Blvd Ste 500', 'Burleson', 'Johnson', 'TX', '76028', '8172951121', '8172958170', 'SPA', 'TXHCPC13', '', '0.00', '45.00', '0.00', 3, '2014-02-20', NULL, 0, 0, 0, '', '', '', '', 'HCFA|UB|', '1154607604', 0, 'N', 0, '2014-01-30', NULL, NULL, 32.5184, -97.3502, NULL, NULL),
('463233444', 'W12043815', 'W12043815', 'TXDALSTD', 'Questcare Medical Clinics', 'Kurtt', 'R', 'Wix', 'DO', 'Family Practice', '', '', NULL, 'O', '900 8th Ave', 'Fort Worth', 'Tarrant', 'TX', '76104', '2142171911', '2142171912', '900 8th Ave', 'Fort Worth', 'Tarrant', 'TX', '76104', '2142171911', '2142171912', 'SPA', 'TXHCPC13', '', '0.00', '45.00', '0.00', 3, '2014-02-20', NULL, 0, 0, 0, '', '', '', '', 'HCFA|UB|', '1154607604', 0, 'N', 0, '2014-01-30', NULL, NULL, 32.7349, -97.3437, NULL, NULL),
('205308618', 'W12043812', 'W12043812', 'TXDALSTD', 'Southern Endocrinology Associates', 'Srinivas', '', 'Bontha', 'MD', 'Endocrinology', '', '', NULL, 'O', '1621 N Beltline Rd Ste A', 'Mesquite', 'Dallas', 'TX', '75149', '9726825700', '9726825703', '1621 N Beltline Rd Ste A', 'Mesquite', 'Dallas', 'TX', '75149', '9726825700', '9726825703', 'SPA', 'TXHCPC13', '', '0.00', '45.00', '0.00', 3, '2014-02-20', NULL, 0, 0, 0, '', '', '', '', 'HCFA|UB|', '1770676405', 0, 'N', 0, '2014-01-30', NULL, NULL, 32.7863, -96.5959, NULL, NULL),
('205308618', 'W12043811', 'W12043811', 'TXDALSTD', 'Southern Endocrinology Associates', 'Srinivas', '', 'Bontha', 'MD', 'Endocrinology', '', '', NULL, 'B', 'PO Box 871834 Ste A', 'Mesquite', 'Dallas', 'TX', '75187', '9726825700', '9726825703', 'PO Box 871834 Ste A', 'Mesquite', 'Dallas', 'TX', '75187', '9726825700', '9726825703', 'SPA', 'TXHCPC13', '', '0.00', '45.00', '0.00', 3, '2014-02-20', NULL, 0, 0, 0, '', '', '', '', 'HCFA|UB|', '1770676405', 0, 'N', 0, '2014-01-30', NULL, NULL, 0, 0, NULL, NULL),
('462971399', 'W12043809', 'W12043809', 'TXDALSTD', 'Dermone Dermatology', 'Howard', 'K', 'Steinman', 'MD', 'Dermatology', '', '', NULL, 'O', 'PO Box 12688', 'Belfast', 'Waldo', 'ME', '04915', '9722543118', '9722537812', 'PO Box 12688', 'Belfast', 'Waldo', 'ME', '04915', '9722543118', '9722537812', 'SPA', 'TXHCPC13', '', '0.00', '45.00', '0.00', 3, '2014-02-20', NULL, 0, 0, 0, '', '', '', '', 'HCFA|UB', '1487781357', 0, 'N', 0, '2014-01-30', NULL, NULL, 0, 0, NULL, NULL),
('462971399', 'W12043808', 'W12043808', 'TXDALSTD', 'Dermone Dermatology', 'Howard', 'K', 'Steinman', 'MD', 'Dermatology', '', '', NULL, 'O', '2021 N MacArthur Blvd Ste 300', 'Irving', 'Dallas', 'TX', '75061', '9722543118', '9722537814', '2021 N MacArthur Blvd Ste 300', 'Irving', 'Dallas', 'TX', '75061', '9722543118', '9722537814', 'SPA', 'TXHCPC13', '', '0.00', '45.00', '0.00', 3, '2014-02-20', NULL, 0, 0, 0, '', '', '', '', 'HCFA|UB', '1487781357', 0, 'N', 0, '2014-01-30', NULL, NULL, 32.835, -96.9592, NULL, NULL),
('208836373', 'W12043806', 'W12043806', 'TXDALSTD', 'WLS Surgical Associates PA', 'Joseph', 'A', 'Kuhn', 'MD', 'General Surgery', '', '', NULL, 'O', '3409 Worth St Ste 420', 'Dallas', 'Dallas', 'TX', '75246', '2148235000', '9725667590', '3409 Worth St Ste 420', 'Dallas', 'Dallas', 'TX', '75246', '2148235000', '9725667590', 'SPA', 'TXHCPC13', '', '0.00', '45.00', '0.00', 3, '2014-02-20', NULL, 0, 0, 0, 'Baylor University Medical Center', NULL, NULL, NULL, 'HCFA|UB|', '1346270261', 0, 'N', 0, '2014-01-30', NULL, NULL, 32.7886, -96.779, NULL, NULL),
('208836373', 'W12043805', 'W12043805', 'TXDALSTD', 'WLS Surgical Associates PA', 'Joseph', 'A', 'Kuhn', 'MD', 'General Surgery', '', '', NULL, 'O', '7777 Forest Ln Ste C 400', 'Dallas', 'Dallas', 'TX', '75230', '2148235000', '2148247167', '7777 Forest Ln Ste C 400', 'Dallas', 'Dallas', 'TX', '75230', '2148235000', '2148247167', 'SPA', 'TXHCPC13', '', '0.00', '45.00', '0.00', 3, '2014-02-20', NULL, 0, 0, 0, 'Baylor University Medical Center', NULL, NULL, NULL, 'HCFA|UB|', '1346270261', 0, 'N', 0, '2014-01-30', NULL, NULL, 32.9095, -96.7721, NULL, NULL),
('462971399', 'W12043801', 'W12043801', 'TXDALSTD', 'Dermone Dermatology', 'Raymond', 'L', 'Garcia', 'MD', 'Dermatology', '', '', NULL, 'O', '2021 N MacArthur Blvd Ste 300', 'Irving', 'Dallas', 'TX', '75061', '9722543118', '9722537814', '2021 N MacArthur Blvd Ste 300', 'Irving', 'Dallas', 'TX', '75061', '9722543118', '9722537814', 'SPA', 'TXHCPC13', '', '0.00', '45.00', '0.00', 3, '2014-02-20', NULL, 0, 0, 0, 'Baylor Medical Center at Irving', NULL, NULL, NULL, 'HCFA|UB', '1417957630', 0, 'N', 0, '2014-01-30', NULL, NULL, 32.835, -96.9592, NULL, NULL),
('462971399', 'W12043803', 'W12043803', 'TXDALSTD', 'Dermone Dermatology', 'Raymond', 'L', 'Garcia', 'MD', 'Dermatology', '', '', NULL, 'B', 'PO Box 12688', 'Belfast', 'Waldo', 'ME', '04915', '8172611626', '8172750441', 'PO Box 12688', 'Belfast', 'Waldo', 'ME', '04915', '8172611626', '8172750441', 'SPA', 'TXHCPC13', '', '0.00', '45.00', '0.00', 3, '2014-02-20', NULL, 0, 0, 0, 'Baylor Medical Center at Irving', NULL, NULL, NULL, 'HCFA|UB|', '1417957630', 0, 'N', 0, '2014-01-30', NULL, NULL, 0, 0, NULL, NULL),
('462971399', 'W12043799', 'W12043799', 'TXDALSTD', 'Dermone Dermatology', 'Lawrence', 'B', 'Meyerson', 'MD', 'Dermatology', '', '', NULL, 'O', '2021 N MacArthur Blvd Ste 300', 'Irving', 'Dallas', 'TX', '75061', '9722543118', '9722537814', '2021 N MacArthur Blvd Ste 300', 'Irving', 'Dallas', 'TX', '75061', '9722543118', '9722537814', 'SPA', 'TXHCPC13', '', '0.00', '45.00', '0.00', 3, '2014-02-20', NULL, 0, 0, 0, 'Baylor Medical Center at Irving', NULL, NULL, NULL, 'HCFA|UB', '1285634055', 0, 'N', 0, '2014-01-30', NULL, NULL, 32.835, -96.9592, NULL, NULL),
('462971399', 'W12043800', 'W12043800', 'TXDALSTD', 'Dermone Dermatology', 'Lawrence', 'B', 'Meyerson', 'MD', 'Dermatology', '', '', NULL, 'O', 'PO Box 12688', 'Belfast', 'Waldo', 'ME', '04915', '9722543118', '9722537812', 'PO Box 12688', 'Belfast', 'Waldo', 'ME', '04915', '9722543118', '9722537812', 'SPA', 'TXHCPC13', '', '0.00', '45.00', '0.00', 3, '2014-02-20', NULL, 0, 0, 0, 'Baylor Medical Center at Irving', NULL, NULL, NULL, 'HCFA|UB', '1285634055', 0, 'N', 0, '2014-01-30', NULL, NULL, 0, 0, NULL, NULL),
('462971399', 'W12043802', 'W12043802', 'TXDALSTD', 'Dermone Dermatology', 'Raymond', 'L', 'Garcia', 'MD', 'Dermatology', '', '', NULL, 'O', '2001 N MacArthur Blvd Ste 655', 'Irving', 'Dallas', 'TX', '75061', '9722534591', '9722733856', '2001 N MacArthur Blvd Ste 655', 'Irving', 'Dallas', 'TX', '75061', '9722534591', '9722733856', 'SPA', 'TXHCPC13', '', '0.00', '45.00', '0.00', 3, '2014-02-20', NULL, 0, 0, 0, 'Baylor Medical Center at Irving', NULL, NULL, NULL, 'HCFA|UB', '1417957630', 0, 'N', 0, '2014-01-30', NULL, NULL, 32.8349, -96.9592, NULL, NULL),
('462971399', 'W12043798', 'W12043798', 'TXDALSTD', 'Dermone Dermatology', 'Lawrence', 'B', 'Meyerson', 'MD', 'Dermatology', '', '', NULL, 'O', '2001 N MacArthur Blvd Ste 655', 'Irving', 'Dallas', 'TX', '75061', '9722534591', '9722733856', '2001 N MacArthur Blvd Ste 655', 'Irving', 'Dallas', 'TX', '75061', '9722534591', '9722733856', 'SPA', 'TXHCPC13', '', '0.00', '45.00', '0.00', 3, '2014-02-20', NULL, 0, 0, 0, 'Baylor Medical Center at Irving', NULL, NULL, NULL, 'HCFA|UB', '1285634055', 0, 'N', 0, '2014-01-30', NULL, NULL, 32.8349, -96.9592, NULL, NULL),
('208836373', 'W12043792', 'W12043792', 'TXDALSTD', 'WLS Surgical Associates PA', 'Jeffrey', 'W', 'Henke', 'MD', 'General Surgery', '', '', NULL, 'O', '3409 Worth St Ste 420', 'Dallas', 'Dallas', 'TX', '75246', '2148235000', '9725667590', '3409 Worth St Ste 420', 'Dallas', 'Dallas', 'TX', '75246', '2148235000', '9725667590', 'SPA', 'TXHCPC13', '', '0.00', '45.00', '0.00', 3, '2014-02-20', NULL, 0, 0, 0, 'Baylor University Medical Center', NULL, NULL, NULL, 'HCFA|UB|', '1811194384', 0, 'N', 0, '2014-01-30', NULL, NULL, 32.7886, -96.779, NULL, NULL),
('208836373', 'W12043791', 'W12043791', 'TXDALSTD', 'WLS Surgical Associates PA', 'Jeffrey', 'W', 'Henke', 'MD', 'General Surgery', '', '', NULL, 'O', '7777 Forest Ln Ste C 400', 'Dallas', 'Dallas', 'TX', '75230', '2148235000', '2148247167', '7777 Forest Ln Ste C 400', 'Dallas', 'Dallas', 'TX', '75230', '2148235000', '2148247167', 'SPA', 'TXHCPC13', '', '0.00', '45.00', '0.00', 3, '2014-02-20', NULL, 0, 0, 0, 'Baylor University Medical Center', NULL, NULL, NULL, 'HCFA|UB|', '1811194384', 0, 'N', 0, '2014-01-30', NULL, NULL, 32.9095, -96.7721, NULL, NULL),
('364088232', 'W12043789', 'W12043789', 'ILCHIGSTD', 'Dreyer Medical Clinic', 'Tammy', 'Lynn', 'Laas', 'NP', 'Pediatrics', '', '', NULL, 'B', '62199 Collection Ctr Dr', 'Chicago', 'Cook', 'IL', '60693', '6308596800', NULL, '62199 Collection Ctr Dr', 'Chicago', 'Cook', 'IL', '60693', '6308596800', '          ', 'CHIG17', 'CHIHCPCSMA', '', '0.00', '35.00', '0.00', 3, '2014-01-17', NULL, 0, 0, 0, 'Presence Mercy Medical Center', NULL, '', '', 'HCFA|UB|', '1720331473', 0, 'N', 0, '2014-01-30', NULL, NULL, 0, 0, NULL, NULL),
('364088232', 'W12043788', 'W12043788', 'ILCHIGSTD', 'Dreyer Medical Clinic', 'Tammy', 'Lynn', 'Laas', 'NP', 'Pediatrics', '', '', NULL, 'O', '4100 Healthway Dr', 'Aurora', 'Dupage', 'IL', '60504', '6308513105', '6309786605', '4100 Healthway Dr', 'Aurora', 'Dupage', 'IL', '60504', '6308513105', '6309786605', 'CHIG17', 'CHIHCPCSMA', '', '0.00', '35.00', '0.00', 3, '2014-01-17', NULL, 0, 0, 0, 'Presence Mercy Medical Center', NULL, '', '', 'HCFA|UB|', '1720331473', 0, 'N', 0, '2014-01-30', NULL, NULL, 41.7522, -88.2131, NULL, NULL),
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('271595277', 'W12043769', 'W12043769', 'TXSATSTD', 'Texas IPS', 'Ravi', '', 'Santhanam', 'MD', 'Internal Medicine', '', '', NULL, 'O', '21 Spurs Ln Ste 230B', 'San Antonio', 'Bexar', 'TX', '78240', '2106907400', '2106907405', '21 Spurs Ln Ste 230B', 'San Antonio', 'Bexar', 'TX', '78240', '2106907400', '2106907405', 'TXSTD', 'TXHCPC13', '', '0.00', '50.00', '0.00', 3, '2014-03-10', NULL, 0, 0, 0, '', '', '', '', 'HCFA|UB|', '1598856304', 0, 'N', 0, '2014-02-10', NULL, NULL, 0, 0, NULL, NULL),
('202280943', 'W12043768', 'W12043768', 'TXSATSTD', 'Jario A Melo', 'Jairo', 'A', 'Melo', 'MD', 'Pulmonary', '', '', NULL, 'O', '21 Spurs Ln Ste 230B', 'San Antonio', 'Bexar', 'TX', '78240', '2106907400', '2106907405', '21 Spurs Ln Ste 230B', 'San Antonio', 'Bexar', 'TX', '78240', '2106907400', '2106907405', 'TXSTD', 'TXHCPC13', '', '0.00', '50.00', '0.00', 3, '2014-03-10', NULL, 0, 0, 0, 'St Lukes Baptist Hospital', NULL, '', '', 'HCFA|UB|', '1073792735', 0, 'N', 0, '2014-02-10', NULL, NULL, 0, 0, NULL, NULL),
('271595277', 'W12043767', 'W12043767', 'TXSATSTD', 'Texas IPS', 'Atif', '', 'Qureshi', 'MD', 'Pulmonary', '', '', NULL, 'O', '21 Spurs Ln Ste 230B', 'San Antonio', 'Bexar', 'TX', '78240', '2106907400', '2106907405', '21 Spurs Ln Ste 230B', 'San Antonio', 'Bexar', 'TX', '78240', '2106907400', '2106907405', 'TXSTD', 'TXHCPC13', '', '0.00', '50.00', '0.00', 3, '2014-03-10', NULL, 0, 0, 0, '', '', '', '', 'HCFA|UB|', '1477614303', 0, 'N', 0, '2014-02-10', NULL, NULL, 0, 0, NULL, NULL),
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('742922021', 'W12043766', 'W12043766', 'TXSATSTD', 'Vista Eye Association', 'Hector', 'L', 'Nevarez', 'MD', 'Ophthalmology', '', '', NULL, 'O', '730 N Main Ave Ste 418', 'San Antonio', 'Bexar', 'TX', '78205', '2102246633', '2102240416', '730 N Main Ave Ste 418', 'San Antonio', 'Bexar', 'TX', '78205', '2102246633', '2102240416', 'TXSTD', 'TXHCPC13', '', '0.00', '50.00', '0.00', 3, '2014-03-10', NULL, 0, 0, 0, 'Baptist Medical Center', NULL, '', '', 'HCFA|UB|', '1316939572', 0, 'N', 0, '2014-02-10', NULL, NULL, 0, 0, NULL, NULL),
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('571049412', 'W12043745', 'W12043745', 'TXSATSTD', 'Vista Eye Associates', 'Peter', 'J', 'Speicher', 'MD', 'Ophthalmology', '', '', NULL, 'O', '2921 Pat Booker Ste 112', 'Universal City', 'Bexar', 'TX', '78148', '2102239707', '2102240416', '2921 Pat Booker Ste 112', 'Universal City', 'Bexar', 'TX', '78148', '2102239707', '2102240416', 'TXSTD', 'TXHCPC13', '', '0.00', '50.00', '0.00', 3, '2014-03-10', NULL, 0, 0, 0, 'Baptist Medical Center', NULL, '', '', 'HCFA|UB|', '1669464822', 0, 'N', 0, '2014-02-10', NULL, NULL, 0, 0, NULL, NULL),
('742429894', 'W12043747', 'W12043747', 'TXSATSTD', 'Sammy Vick', 'Sammy', '', 'Vick', 'MD', 'Urology', '', '', NULL, 'O', '8038 Wurzbach Rd 430', 'San Antonio', 'Bexar', 'TX', '78229', '2106160410', '2106151295', '8038 Wurzbach Rd 430', 'San Antonio', 'Bexar', 'TX', '78229', '2106160410', '2106151295', 'TXSTD', 'TXHCPC13', '', '0.00', '50.00', '0.00', 3, '2014-03-10', NULL, 0, 0, 0, '', '', '', '', 'HCFA|UB|', '1174528459', 0, 'Y', 0, '2014-02-10', NULL, NULL, 0, 0, NULL, NULL),
('518784710', 'W12043971', 'W12043971', 'Sinclair', '(Sinclair Health Services\rProvider) ', 'Melissa', 'A', 'Boley', 'LCPC', 'Mental Health', 'Counseling', '', NULL, 'O', '333 S Main St', 'Ketchum', 'Blaine', 'ID', '83340', '2087267584', NULL, '333 S Main St', 'Ketchum', 'Blaine', 'ID', '83340', '2087267584', '          ', 'MD-2', '', '', '0.00', '40.00', '0.00', 3, '2013-10-01', NULL, 0, 0, 0, '', '', '', '', 'HCFA|UB|', '1578732293', 0, 'N', 0, '2014-02-06', NULL, NULL, 0, 0, NULL, NULL),
('571049412', 'W12043744', 'W12043744', 'TXSATSTD', 'Peter J Speicher', 'Peter', 'J', 'Speicher', 'MD', 'Ophthalmology', '', '', NULL, 'O', '730 N Main Ave Ste 418', 'San Antonio', 'Bexar', 'TX', '78205', '2102239707', '2102240416', '730 N Main Ave Ste 418', 'San Antonio', 'Bexar', 'TX', '78205', '2102239707', '2102240416', 'TXSTD', 'TXHCPC13', '', '0.00', '50.00', '0.00', 3, '2014-03-10', NULL, 0, 0, 0, 'Baptist Medical Center', NULL, '', '', 'HCFA|UB|', '1669464822', 0, 'N', 0, '2014-02-10', NULL, NULL, 0, 0, NULL, NULL),
('820529971', 'W12043743', 'W12043743', 'ID02', 'Childrens Therapy Place', '', '', 'Childrens Therapy Place', '', 'Speech Therapy', '', '', NULL, 'O', '6855 W Fairview Ave Ste 120', 'Boise', 'Ada', 'ID', '83704', '2083238888', NULL, '6855 W Fairview Ave Ste 120', 'Boise', 'Ada', 'ID', '83704', '2083238888', '          ', 'WestRehab', '', '', '0.00', '0.00', '65.00', 3, '2009-01-01', NULL, 0, 0, 1, '', '', '', '', 'HCFA|UB|', '0000009792', 0, 'Y', 0, '2014-02-06', NULL, NULL, 0, 0, NULL, NULL),
('200830401', 'W12027221', 'W12027221', 'TXDALSTD', 'Ear Nose and Throat Associatess of Texas', 'Nicholas', 'J', 'Peiffer', 'MD', 'Ear, Nose and Throat', '', '', NULL, 'O', '6717 W Eldorado Pkwy Ste 140', 'McKinney', 'Collin', 'TX', '75070', '9727317654', '9727316226', '6717 W Eldorado Pkwy Ste 140', 'McKinney', 'Collin', 'TX', '75070', '9727317654', '9727316226', 'ENTofTX', 'TXHCPC13', '', '0.00', '50.00', '0.00', 3, '2013-01-01', NULL, 0, 0, 0, 'Baylor Regional Medical Center at Plano', NULL, '', '', 'HCFA|UB|', '1083817688', 0, 'N', 0, '2014-01-29', NULL, NULL, 33.1741, -96.7048, NULL, NULL),
('200830401', 'W12027220', 'W12027220', 'TXDALSTD', 'Ear Nose and Throat Associatess of Texas', 'Nicholas', 'J', 'Peiffer', 'MD', 'Ear, Nose and Throat', '', '', NULL, 'O', '4716 Alliance Blvd Ste 260', 'Plano', 'Collin', 'TX', '75093', '9727317654', '9727316226', '4716 Alliance Blvd Ste 260', 'Plano', 'Collin', 'TX', '75093', '9727317654', '9727316226', 'ENTofTX', 'TXHCPC13', '', '0.00', '50.00', '0.00', 3, '2013-01-01', NULL, 0, 0, 0, 'Baylor Regional Medical Center at Plano', NULL, '', '', 'HCFA|UB|', '1083817688', 0, 'N', 0, '2014-01-29', NULL, NULL, 33.0145, -96.7926, NULL, NULL),
('743003947', 'W12043737', 'W12043737', 'TXSATSTD', 'The San Antonio Orthopaedic Group', 'Robert', 'U', 'Hartzler', 'MD', 'Orthopedic Surgery', '', '', NULL, 'O', '2829 Babcock Rd Ste 700', 'San Antonio', 'Bexar', 'TX', '78229', '2108045400', '2104026257', '2829 Babcock Rd Ste 700', 'San Antonio', 'Bexar', 'TX', '78229', '2108045400', '2104026257', 'TXORTHO', 'TXHCPCS', '', '0.00', '50.00', '0.00', 3, '2014-05-01', NULL, 0, 0, 0, 'Baptist Medical Center', '', '', '', 'HCFA|UB|', '1780849372', 0, 'N', 0, '2014-04-18', NULL, NULL, 0, 0, NULL, NULL),
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('743003947', 'W12043736', 'W12043736', 'TXSATSTD', 'The San Antonio Orthopaedic Group', 'Robert', 'U', 'Hartzler', 'MD', 'Orthopedic Surgery', '', '', NULL, 'O', '3327 Research Plaza Ste 404', 'San Antonio', 'Bexar', 'TX', '78235', '2108045400', '2104026257', '3327 Research Plaza Ste 404', 'San Antonio', 'Bexar', 'TX', '78235', '2108045400', '2104026257', 'TXORTHO', 'TXHCPCS', '', '0.00', '50.00', '0.00', 3, '2014-05-01', NULL, 0, 0, 0, 'Baptist Medical Center', '', '', '', 'HCFA|UB|', '1780849372', 0, 'N', 0, '2014-04-18', NULL, NULL, 0, 0, NULL, NULL),
('743003947', 'W12043732', 'W12043732', 'TXSATSTD', 'The San Antonio Orthopaedic Group', 'Robert', 'U', 'Hartzler', 'MD', 'Orthopedic Surgery', '', '', NULL, 'O', '150 E Sonterra Blvd Ste 300', 'San Antonio', 'Bexar', 'TX', '78258', '2108045400', '2104026257', '150 E Sonterra Blvd Ste 300', 'San Antonio', 'Bexar', 'TX', '78258', '2108045400', '2104026257', 'TXORTHO', 'TXHCPCS', '', '0.00', '50.00', '0.00', 3, '2014-05-01', NULL, 0, 0, 0, 'Baptist Medical Center', '', '', '', 'HCFA|UB|', '1780849372', 0, 'N', 0, '2014-04-18', NULL, NULL, 0, 0, NULL, NULL),
('743003947', 'W12043734', 'W12043734', 'TXSATSTD', 'The San Antonio Orthopaedic Group', 'Robert', 'U', 'Hartzler', 'MD', 'Orthopedic Surgery', '', '', NULL, 'B', 'PO Box 9585', 'Belfast', 'Waldo', 'ME', '04915', '2108045400', '2108045487', 'PO Box 9585', 'Belfast', 'Waldo', 'ME', '04915', '2108045400', '2108045487', 'TXORTHO', 'TXHCPCS', '', '0.00', '50.00', '0.00', 3, '2014-05-01', NULL, 0, 0, 0, 'Baptist Medical Center', '', '', '', 'HCFA|UB|', '1780849372', 0, 'N', 0, '2014-04-18', NULL, NULL, 0, 0, NULL, NULL),
('830326307', 'W12043730', 'W12043730', 'WY01', 'Community Health Center of Central Wyoming', 'Grady', 'K', 'Snyder', 'MD', 'Family Practice', '', '', NULL, 'O', '5000 Blackmore Rd', 'Casper', 'Natrona', 'WY', '82609', '3072336000', '3072336089', '5000 Blackmore Rd', 'Casper', 'Natrona', 'WY', '82609', '3072336000', '3072336089', 'WISEWYSTD', 'WUSTDHCPC5', '', '0.00', '35.00', '0.00', 3, '2014-04-01', NULL, 0, 0, 0, 'Wyoming Medical Center', '', '', '', 'HCFA|UB|', '1851337984', 0, 'N', 0, '2014-03-10', NULL, NULL, 0, 0, NULL, NULL),
('850232628', 'W12043729', 'W12043729', 'NM01', 'Womens Specialists of NM', 'Beverly', 'A', 'Pucka', '', 'Obstetrics and Gynecology', '', '', NULL, 'O', '201 Cedar St SE Ste 5640', 'Albuquerque', 'Bernalillo', 'NM', '87106', '5058436168', '5052479743', '201 Cedar St SE Ste 5640', 'Albuquerque', 'Bernalillo', 'NM', '87106', '5058436168', '5052479743', 'NMWOMENS', 'WUSTDHCPC5', '', '0.00', '35.00', '0.00', 3, '2030-01-01', NULL, 0, 0, 0, '', '', '', '', 'HCFA|UB|', '1881701191', 0, 'N', 1, '2014-01-28', NULL, NULL, 0, 0, NULL, NULL),
('830326307', 'W12043731', 'W12043731', 'WYT1', 'Community Health Center of Central Wyoming', 'Grady', 'K', 'Snyder', 'MD', 'Family Practice', '', '', NULL, 'O', '5000 Blackmore Rd', 'Casper', 'Natrona', 'WY', '82609', '3072336000', '3072336089', '5000 Blackmore Rd', 'Casper', 'Natrona', 'WY', '82609', '3072336000', '3072336089', 'WISEWYSTD', 'WUSTDHCPC5', '', '0.00', '35.00', '0.00', 3, '2014-04-01', NULL, 0, 0, 0, 'Wyoming Medical Center', '', '', '', 'HCFA|UB|', '1851337984', 0, 'N', 0, '2014-03-10', NULL, NULL, 0, 0, NULL, NULL),
('741654878', 'W12043728', 'W12043728', 'TXSATSTD', 'Neurosurgical Associates of San Antonio', '', '', 'Neurosurgical Associates of San Antonio PA', '', 'Neurosurgery', '', '', NULL, 'O', '260 Cully', 'Kerrville', 'Kerr', 'TX', '78028', '2106142453', '2106142462', '260 Cully', 'Kerrville', 'Kerr', 'TX', '78028', '2106142453', '2106142462', 'TXNEURO', 'TXHCPCS', '', '0.00', '50.00', '0.00', 3, '2014-01-17', NULL, 0, 0, 0, '', '', '', '', 'HCFA|UB|', '0000007825', 0, 'Y', 0, '2014-01-28', NULL, NULL, 0, 0, NULL, NULL),
('741654878', 'W12043726', 'W12043726', 'TXSATSTD', 'Neurosurgical Associates of San Antonio', '', '', 'Neurosurgical Associates of San Antonio PA', '', 'Neurosurgery', '', '', NULL, 'O', '1139 E Sonterra Blvd Ste 301', 'San Antonio', 'Bexar', 'TX', '78258', '2104771956', '0000000000', '1139 E Sonterra Blvd Ste 301', 'San Antonio', 'Bexar', 'TX', '78258', '2104771956', '0000000000', 'TXNEURO', 'TXHCPCS', '', '0.00', '50.00', '0.00', 3, '2014-01-17', NULL, 0, 0, 0, '', '', '', '', 'HCFA|UB|', '0000007825', 0, 'Y', 0, '2014-01-28', NULL, NULL, 29.6148, -98.4777, NULL, NULL),
('741654878', 'W12043727', 'W12043727', 'TXSATSTD', 'Neurosurgical Associates of San Antonio', '', '', 'Neurosurgical Associates of San Antonio PA', '', 'Neurosurgery', '', '', NULL, 'O', '1303 McCullough Ave Ste 264', 'San Antonio', 'Bexar', 'TX', '78212', '2106142453', '2106142462', '1303 McCullough Ave Ste 264', 'San Antonio', 'Bexar', 'TX', '78212', '2106142453', '2106142462', 'TXNEURO', 'TXHCPCS', '', '0.00', '50.00', '0.00', 3, '2014-01-17', NULL, 0, 0, 0, '', '', '', '', 'HCFA|UB|', '0000007825', 0, 'Y', 0, '2014-01-28', NULL, NULL, 29.4407, -98.4918, NULL, NULL),
('364130066', 'W12043725', 'W12043725', 'ILCHIGSTD', 'Podiatric Management Systems', 'Pratibha', '', 'Patel', 'DPM', 'Podiatry', '', '', NULL, 'O', '5330 W Devon Ave Ste 10', 'Chicago', 'Cook', 'IL', '60646', '7737929300', '7737929302', '5330 W Devon Ave Ste 10', 'Chicago', 'Cook', 'IL', '60646', '7737929300', '7737929302', 'CHIG6', 'CHIHCPCS13', '', '0.00', '35.00', '0.00', 3, '2014-02-01', NULL, 0, 0, 0, '', '', '', '', 'HCFA|UB|', '1265693790', 0, 'N', 0, '2014-04-09', NULL, NULL, 41.9973, -87.7621, NULL, NULL),
('200830401', 'W12027219', 'W12027219', 'TXDALSTD', 'Ear Nose and Throat Associatess of Texas', 'Nicholas', 'J', 'Peiffer', 'MD', 'Ear, Nose and Throat', '', '', NULL, 'O', '4401 Coit Rd Ste 411', 'Frisco', 'Collin', 'TX', '75035', '9727317654', '9727316226', '4401 Coit Rd Ste 411', 'Frisco', 'Collin', 'TX', '75035', '9727317654', '9727316226', 'ENTofTX', 'TXHCPC13', '', '0.00', '50.00', '0.00', 3, '2013-01-01', NULL, 0, 0, 0, 'Baylor Regional Medical Center at Plano', NULL, '', '', 'HCFA|UB|', '1083817688', 0, 'N', 0, '2014-01-29', NULL, NULL, 33.1129, -96.7682, NULL, NULL),
('364130066', 'W12043724', 'W12043724', 'ILCHIGSTD', 'Podiatric Management Systems', 'Pratibha', '', 'Patel', 'DPM', 'Podiatry', '', '', NULL, 'B', '30 S Michigan Ave  Ste 503', 'Chicago', 'Cook', 'IL', '60603', '3123721100', '3123723346', '30 S Michigan Ave  Ste 503', 'Chicago', 'Cook', 'IL', '60603', '3123721100', '3123723346', 'CHIG6', 'CHIHCPCS13', '', '0.00', '35.00', '0.00', 3, '2014-02-01', NULL, 0, 0, 0, '', '', '', '', 'HCFA|UB|', '1265693790', 0, 'N', 0, '2014-04-09', NULL, NULL, 0, 0, NULL, NULL),
('320346082', 'W12043720', 'W12043720', 'Group', 'Concentra Primary Care', '', '', 'Concentra Urgent Care', '', 'Urgent Care', '', '', NULL, 'B', '8647 Wurzbach Rd', 'San Antonio', 'Bexar', 'TX', '78240', '2104487700', '2104487703', '8647 Wurzbach Rd', 'San Antonio', 'Bexar', 'TX', '78240', '2104487700', '2104487703', 'WiseSTD', 'WUSTDHCPC5', '', '0.00', '35.00', '0.00', 3, '2013-01-01', NULL, 0, 0, 0, '', '', '', '', 'HCFA|UB|', '0000010034', 0, 'Y', 0, '2014-07-15', NULL, NULL, 0, 0, NULL, NULL),
('000001004', 'W12043719', 'W12043719', 'NM01', 'Concentra Urgent Care', '', '', 'Concentra Urgent Care', '', 'Urgent Care', '', '', NULL, 'O', '15810 Midway Rd', 'Addison', 'Dallas', 'TX', '75001', '8669446046', '9724587776', '15810 Midway Rd', 'Addison', 'Dallas', 'TX', '75001', '8669446046', '9724587776', '', '', '', '0.00', '0.00', '110.00', 3, '2013-01-01', NULL, 0, 0, 0, '', '', '', '', 'HCFA|UB', '0000010034', 0, 'Y', 0, '2014-07-15', NULL, NULL, 32.9653, -96.839, NULL, NULL),
('000001004', 'W12043718', 'W12043718', 'UT01', 'Concentra Urgent Care', '', '', 'Concentra Urgent Care', '', 'Urgent Care', '', '', NULL, 'O', '15810 Midway Rd', 'Addison', 'Dallas', 'TX', '75001', '8669446046', '9724587776', '15810 Midway Rd', 'Addison', 'Dallas', 'TX', '75001', '8669446046', '9724587776', '', '', '', '0.00', '0.00', '110.00', 3, '2013-01-01', NULL, 0, 0, 0, '', '', '', '', 'HCFA|UB', '0000010034', 0, 'Y', 0, '2014-07-15', NULL, NULL, 32.9653, -96.839, NULL, NULL),
('000001004', 'W12043717', 'W12043717', 'TXHOUSTD', 'Concentra Urgent Care', '', '', 'Concentra Urgent Care', '', 'Urgent Care', '', '', NULL, 'O', '15810 Midway Rd', 'Addison', 'Dallas', 'TX', '75001', '8669446046', '9724587776', '15810 Midway Rd', 'Addison', 'Dallas', 'TX', '75001', '8669446046', '9724587776', '', '', '', '0.00', '0.00', '110.00', 3, '2013-01-01', NULL, 0, 0, 0, '', '', '', '', 'HCFA|UB', '0000010034', 0, 'Y', 0, '2014-07-15', NULL, NULL, 32.9653, -96.839, NULL, NULL),
('870524176', 'W12043714', 'W12043714', 'UTMH1', 'Comprehensive Psychological Services', '', '', 'Comprehensive Psychological', '', 'Mental Health', '', '', NULL, 'O', '1208 E 3300 S UTMA', 'Salt Lake City', 'Salt Lake', 'UT', '84106', '8014831600', '8014831610', '1208 E 3300 S UTMA', 'Salt Lake City', 'Salt Lake', 'UT', '84106', '8014831600', '8014831610', 'UTMA', '', '', '0.00', '40.00', '0.00', 6, '2030-01-01', NULL, 0, 0, 0, '', '', '', '', 'HCFA|UB|', '0000009778', 0, 'Y', 1, '2014-04-16', NULL, NULL, 0, 0, NULL, NULL),
('742698089', 'W12043722', 'W12043722', 'Group', 'Alamo City Medical Group', '', '', 'Concentra Urgent Care', '', 'Urgent Care', '', '', NULL, 'B', 'PO Box 792', 'Boerne', 'Kendall', 'TX', '78006', '2105414501', '2103080244', 'PO Box 792', 'Boerne', 'Kendall', 'TX', '78006', '2105414501', '2103080244', 'WISESTD', 'WUSTDHCPC5', '', '0.00', '35.00', '0.00', 3, '2013-01-01', NULL, 0, 0, 0, '', '', '', '', 'HCFA|UB', '0000010034', 0, 'Y', 0, '2014-07-15', NULL, NULL, 0, 0, NULL, NULL),
('870524176', 'W12043713', 'W12043713', 'UTMH1', 'Comprehensive Psychological Services', '', '', 'Comprehensive Psychological', '', 'Mental Health', '', '', NULL, 'O', '1208 E 3300 S PHD', 'Salt Lake City', 'Salt Lake', 'UT', '84106', '8014831600', '8014831610', '1208 E 3300 S PHD', 'Salt Lake City', 'Salt Lake', 'UT', '84106', '8014831600', '8014831610', 'PHD', '', '', '0.00', '40.00', '0.00', 6, '2030-01-01', NULL, 0, 0, 0, '', '', '', '', 'HCFA|UB|', '0000009778', 0, 'Y', 1, '2014-04-16', NULL, NULL, 0, 0, NULL, NULL);
