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
('820425454', 'W12024495', 'W12024495', 'ID01', 'Boise Anesthesia, PA', 'Marilyn', 'S', 'Armayor', 'CRNA', 'Nurse Anesthetist', '', '', NULL, 'B', 'PO Box 4008', 'Portland', 'Multnomah', 'OR', '97208', '8002758752', NULL, 'PO Box 4008    ', 'Portland', 'Multnomah', 'OR', '97208', '8002758752', '0         ', 'IDSAMG3', '', '', '55.81', '10.00', '0.00', 3, '2008-07-01', '2010-01-30', 0, 15, 0, '', '', '', '', 'HCFA|UB|', '1124079785', 0, 'N', 0, '2012-10-29', NULL, NULL, 0, 0, NULL, NULL),
('742592013', 'W12024566', 'W12024566', 'TXSATSTD', 'Dermatology Associates of San Antonio', '', '', 'Dermatology Associates of San Antonio', '', 'Dermatology', '', '', NULL, 'O', '7832 Pat Booker Rd', 'San Antonio', 'Bexar', 'TX', '78233', '2106579338', NULL, '7832 Pat Booker Rd  ', 'San Antonio', 'Bexar', 'TX', '78233', '2106579338', '          ', 'TXSTD', 'TXHCPCS', '', '0.00', '50.00', '0.00', 3, '2012-08-20', NULL, 0, 0, 0, '', '', '', '', 'HCFA|UB|', '0000009777', 0, 'Y', 0, '2012-10-30', NULL, NULL, 29.5632, -98.3343, NULL, NULL),
('820425454', 'W12024507', 'W12024507', 'ID01', 'Boise Anesthesia, PA', 'Gary', 'D', 'Bevan', 'CRNA', 'Nurse Anesthetist', '', '', NULL, 'B', 'PO Box 4268', 'Portland', 'Multnomah', 'OR', '97208', '2084594641', NULL, 'PO Box 4268    ', 'Portland', 'Multnomah', 'OR', '97208', '2084594641', '0         ', 'IDSAMG3', '', '', '62.80', '10.00', '0.00', 3, '2012-07-01', NULL, 1, 15, 0, '', '', '', '', 'HCFA|UB|', '1174579742', 0, 'N', 0, '2013-04-19', NULL, NULL, 0, 0, NULL, NULL),
('820425454', 'W12024502', 'W12024502', 'ID01', 'Boise Anesthesia, PA', 'Gary', 'D', 'Bevan', 'CRNA', 'Nurse Anesthetist', '', '', NULL, 'B', 'PO Box 4008', 'Portland', 'Multnomah', 'OR', '97208', '2084594641', NULL, 'PO Box 4008    ', 'Portland', 'Multnomah', 'OR', '97208', '2084594641', '0         ', 'IDSAMG3', '', '', '55.81', '10.00', '0.00', 3, '2008-07-01', '2010-01-30', 0, 15, 0, '', '', '', '', 'HCFA|UB|', '1174579742', 0, 'N', 0, '2013-04-19', NULL, NULL, 0, 0, NULL, NULL),
('870281028', 'W12019488', 'W12019488', 'UT01', 'Central Utah Clinic PC', 'S', 'Bret', 'Chipman', '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, '2012-06-01', NULL, 0, 0, 0, 'Mountain View Hospital', '', '', '', 'HCFA|UB|', '1992734057', 0, 'N', 0, '2014-06-16', NULL, NULL, 0, 0, NULL, NULL),
('800458890', 'W12024559', 'W12024559', 'TXHOUSTD', '', 'Pachie', '', 'Chan', 'MD', 'Family Practice', '', '', NULL, 'O', '19073 I-45 S Ste 115', 'The Woodlands', 'Montgomery', 'TX', '77385', '9362712227', '9362712229', '19073 I-45 S Ste 115', 'The Woodlands', 'Montgomery', 'TX', '77385', '9362712227', '9362712229', 'HOUSTON1', 'TXHCPC13', '', '0.00', '45.00', '0.00', 3, '2013-08-01', NULL, 0, 0, 0, '', '', '', '', 'HCFA|UB|', '1013149392', 0, 'N', 0, '2013-06-20', NULL, NULL, 30.1835, -95.4519, NULL, NULL),
('364417968', 'W12024558', 'W12024558', 'ILCHIGSTD', 'Marni Goldberg MD', 'Marni', 'Hope', 'Goldberg', 'MD', 'Internal Medicine', '', '', NULL, 'O', '4555 Oakton St', 'Skokie', 'Cook', 'IL', '60076', '8476742251', '8476742253', '4555 Oakton St  ', 'Skokie', 'Cook', 'IL', '60076', '8476742251', '8476742253', 'CHIG11', 'CHIHCPCS13', '', '0.00', '40.00', '0.00', 3, '2013-01-01', NULL, 0, 0, 0, '', '', '', '', 'HCFA|UB|', '1063459741', 0, 'N', 0, '2013-05-31', NULL, NULL, 42.0262, -87.7419, NULL, NULL),
('820425454', 'W12024508', 'W12024508', 'ID01', 'Boise Anesthesia, PA', 'Terry', '', 'Black', 'CRNA', 'Nurse Anesthetist', '', '', NULL, 'B', 'PO Box 4008', 'Portland', 'Multnomah', 'OR', '97208', '8002758752', NULL, 'PO Box 4008    ', 'Portland', 'Multnomah', 'OR', '97208', '8002758752', '          ', 'IDSAMG3', '', '', '55.81', '10.00', '0.00', 3, '2008-07-01', '2010-01-30', 0, 15, 0, '', '', '', '', 'HCFA|UB|', '1902843584', 0, 'N', 0, '2012-10-29', NULL, NULL, 0, 0, NULL, NULL),
('561593887', 'W12024557', 'W12024557', 'TXHOUSTD', '', 'Syed', 'H', 'Reza', 'MD', 'Neurology', '', '', NULL, 'O', '7333 N Fwy Ste 210', 'Houston', 'Harris', 'TX', '77076', '7136948888', '7136941818', '7333 N Fwy Ste 210', 'Houston', 'Harris', 'TX', '77076', '7136948888', '7136941818', '', '', '', '0.00', '1000.00', '0.00', 3, '2030-01-01', '2030-01-01', 0, 0, 0, '', '', '', '', 'HCFA|UB', '1134168958', 0, 'N', 1, '2012-12-27', NULL, NULL, 29.8568, -95.4008, NULL, NULL),
('621801973', 'W12024554', 'W12024554', 'UT01', 'Davis Urgent Care ', 'Kimberly', 'Elyce', 'Simpson', 'NP', 'Family Practice', '', '', NULL, 'O', '124 S Fairfield Rd', 'Layton', 'Davis', 'UT', '84041', '8019273099', '8019273088', '124 S Fairfield Rd  ', 'Layton', 'Davis', 'UT', '84041', '8019273099', '8019273088', 'WUSTDINT5', 'WUSTDHCPC5', '', '0.00', '35.00', '0.00', 6, '2012-09-04', '2014-04-30', 0, 0, 0, '', '', '', '', 'HCFA|UB|', '1235488917', 0, 'N', 0, '2013-07-25', NULL, NULL, 41.0604, -111.945, NULL, NULL),
('820425454', 'W12024517', 'W12024517', 'ID01', 'Boise Anesthesia, PA', 'Jeffery', '', 'Borders', 'CRNA', 'Nurse Anesthetist', '', '', NULL, 'B', 'PO Box 4268', 'Portland', 'Multnomah', 'OR', '97208', '8002758752', NULL, 'PO Box 4268       ', 'Portland', 'Multnomah', 'OR', '97208', '8002758752', '0         ', 'IDSAMG3', '', '', '62.80', '10.00', '0.00', 3, '2012-07-01', NULL, 1, 15, 0, '', '', '', '', 'HCFA|UB|', '1942288964', 0, 'N', 0, '2012-10-29', NULL, NULL, 0, 0, NULL, NULL),
('820425454', 'W12024513', 'W12024513', 'ID01', 'Boise Anesthesia, PA', 'Jeffery', '', 'Borders', 'CRNA', 'Nurse Anesthetist', '', '', NULL, 'B', 'PO Box 4008', 'Portland', 'Multnomah', 'OR', '97208', '8002758752', NULL, 'PO Box 4008    ', 'Portland', 'Multnomah', 'OR', '97208', '8002758752', '0         ', 'IDSAMG3', '', '', '55.81', '10.00', '0.00', 3, '2008-07-01', '2010-01-30', 1, 15, 0, '', '', '', '', 'HCFA|UB|', '1942288964', 0, 'N', 0, '2012-10-29', NULL, NULL, 0, 0, NULL, NULL),
('820425454', 'W12024484', 'W12024484', 'ID01', 'Boise Anesthesia, PA', 'Jeffery', '', 'Borders', 'CRNA', 'Nurse Anesthetist', '', '', NULL, 'O', '1717 Arlington Ave', 'Caldwell', 'Canyon', 'ID', '83605', '2084594641', NULL, '1717 Arlington Ave   ', 'Caldwell', 'Canyon', 'ID', '83605', '2084594641', '0         ', 'IDSAMG3', '', '', '62.80', '10.00', '0.00', 3, '2012-07-01', NULL, 1, 15, 0, '', '', '', '', 'HCFA|UB|', '1942288964', 0, 'N', 0, '2012-10-29', NULL, NULL, 43.6542, -116.696, NULL, NULL),
('820425454', 'W12024485', 'W12024485', 'ID01', 'Boise Anesthesia, PA', 'Lara', 'A', 'Burke', 'CRNA', 'Nurse Anesthetist', '', '', NULL, 'B', 'PO Box 4268', 'Portland', 'Multnomah', 'OR', '97208', '8002758752', NULL, 'PO Box 4268  ', 'Portland', 'Multnomah', 'OR', '97208', '8002758752', '0         ', 'IDSAMG3', '', '', '60.97', '10.00', '0.00', 3, '2011-07-01', '2012-06-30', 1, 15, 0, 'Saint Alphonsus Regional Medical Center', '', '', '', 'HCFA|UB|', '1467757203', 0, 'N', 0, '2012-10-29', NULL, NULL, 0, 0, NULL, NULL),
('820425454', 'W12024486', 'W12024486', 'ID01', 'Boise Anesthesia, PA', 'Lara', 'A', 'Burke', 'CRNA', 'Nurse Anesthetist', '', '', NULL, 'B', 'PO Box 4268', 'Portland', 'Multnomah', 'OR', '97208', '8002758752', NULL, 'PO Box 4268   ', 'Portland', 'Multnomah', 'OR', '97208', '8002758752', '0         ', 'IDSAMG3', '', '', '62.80', '10.00', '0.00', 3, '2012-07-01', NULL, 1, 15, 0, 'Saint Alphonsus Regional Medical Center', '', '', '', 'HCFA|UB|', '1467757203', 0, 'N', 0, '2012-10-29', NULL, NULL, 0, 0, NULL, NULL),
('770701557', 'W12024487', 'W12024487', 'UT01', 'Jordan Family Health', 'Wesley', 'R', 'Brown', 'MD', 'General Practice', '', '', NULL, 'O', '8846 S Redwood Rd', 'West Jordan', 'Salt Lake', 'UT', '84088', '8015691999', '8015692001', '8846 S Redwood Rd  ', 'West Jordan', 'Salt Lake', 'UT', '84088', '8015691999', '8015692001', 'UTHCAPS', 'WUSTDHCPC5', '', '0.00', '35.00', '0.00', 3, '2012-10-01', NULL, 0, 0, 0, 'St Marks Hospital', '', '', '', 'HCFA|UB|', '1932229416', 0, 'N', 0, '2014-06-04', NULL, NULL, 40.5911, -111.939, NULL, NULL),
('770701557', 'W12024488', 'W12024488', 'UT01', 'MountainStar Medical Group-St Marks Hospital', 'Wesley', 'R', 'Brown', 'MD', 'General Practice', '', '', NULL, 'B', 'PO Box 198560', 'Atlanta', 'Fulton', 'GA', '30384', '6153737600', '0000000000', 'PO Box 198560   ', 'Atlanta', 'Fulton', 'GA', '30384', '6153737600', '0000000000', 'UTHCAPS', 'WUSTDHCPC5', '', '0.00', '35.00', '0.00', 3, '2012-10-01', '2013-12-20', 0, 0, 0, 'St Marks Hospital', '', '', '', 'HCFA|UB|', '1932229416', 0, 'N', 0, '2014-06-04', NULL, NULL, 0, 0, NULL, NULL),
('954893928', 'W12024489', 'W12024489', 'UT01', 'Exodus Healthcare Network', 'Jennifer', '', 'Fox', 'NP', 'Family Practice', '', '', NULL, 'O', '3665 S 8400 W', 'Magna', 'Salt Lake', 'UT', '84044', '8012509368', '8012503204', '3665 S 8400 W  ', 'Magna', 'Salt Lake', 'UT', '84044', '8012509368', '8012503204', 'WISESTD', 'WUSTDHCPC5', '', '0.00', '35.00', '0.00', 3, '2013-01-01', NULL, 0, 0, 0, '', '', '', '', 'HCFA|UB|', '1780948976', 0, 'N', 0, '2012-12-19', NULL, NULL, 40.6928, -112.092, NULL, NULL),
('820425454', 'W12024581', 'W12024581', 'ID01', 'Boise Anesthesia PA', 'Michael', 'P', 'Garrett', 'CRNA', 'Nurse Anesthetist', '', '', NULL, 'B', 'PO Box 4268', 'Portland', 'Multnomah', 'OR', '97208', '8002758752', NULL, 'PO Box 4268   ', 'Portland', 'Multnomah', 'OR', '97208', '8002758752', '          ', 'IDSAMG3', '', '', '60.97', '10.00', '0.00', 3, '2011-07-01', '2012-06-30', 1, 15, 0, '', '', '', '', 'HCFA|UB|', '1083651665', 0, 'N', 0, '2013-04-02', NULL, NULL, 0, 0, NULL, NULL),
('820425454', 'W12024582', 'W12024582', 'ID01', 'Boise Anesthesia PA', 'Michael', 'P', 'Garrett', 'CRNA', 'Nurse Anesthetist', '', '', NULL, 'B', 'PO Box 4268', 'Portland', 'Multnomah', 'OR', '97208', '8002758752', NULL, 'PO Box 4268    ', 'Portland', 'Multnomah', 'OR', '97208', '8002758752', '          ', 'IDSAMG3', '', '', '62.80', '10.00', '0.00', 3, '2012-07-01', NULL, 1, 15, 0, '', '', '', '', 'HCFA|UB|', '1083651665', 0, 'N', 0, '2013-04-02', NULL, NULL, 0, 0, NULL, NULL),
('820425454', 'W12024583', 'W12024583', 'ID01', 'Boise Anesthesia PA', 'Patricia', '', 'Gibbons', 'CRNA', 'Anesthesiology', '', '', NULL, 'B', 'PO Box 4268', 'Portland', 'Multnomah', 'OR', '97208', '8002758752', NULL, 'PO Box 4268   ', 'Portland', 'Multnomah', 'OR', '97208', '8002758752', '          ', 'IDSAMG3', '', '', '60.97', '10.00', '0.00', 3, '2011-07-01', '2012-06-30', 1, 15, 0, '', '', '', '', 'HCFA|UB|', '1184863227', 0, 'N', 0, '2012-10-30', NULL, NULL, 0, 0, NULL, NULL),
('820425454', 'W12024584', 'W12024584', 'ID01', 'Boise Anesthesia PA', 'Patricia', '', 'Gibbons', 'CRNA', 'Anesthesiology', '', '', NULL, 'B', 'PO Box 4268', 'Portland', 'Multnomah', 'OR', '97208', '8002758752', NULL, 'PO Box 4268    ', 'Portland', 'Multnomah', 'OR', '97208', '8002758752', '          ', 'IDSAMG3', '', '', '62.80', '10.00', '0.00', 3, '2012-07-01', NULL, 1, 15, 0, '', '', '', '', 'HCFA|UB|', '1184863227', 0, 'N', 0, '2012-10-30', NULL, NULL, 0, 0, NULL, NULL),
('820425454', 'W12024585', 'W12024585', 'ID01', 'Boise Anesthesia PA', 'Michael', 'D', 'Gold', 'MD', 'Anesthesiology', '', '', NULL, 'B', 'PO Box 4268', 'Portland', 'Multnomah', 'OR', '97208', '8002758752', NULL, 'PO Box 4268   ', 'Portland', 'Multnomah', 'OR', '97208', '8002758752', '          ', 'IDSAMG3', '', '', '60.97', '10.00', '0.00', 3, '2011-07-01', '2012-06-30', 1, 15, 0, 'Saint Alphonsus Regional Medical Center', NULL, NULL, NULL, 'HCFA|UB|', '1720030166', 0, 'N', 0, '2012-10-30', NULL, NULL, 0, 0, NULL, NULL),
('820425454', 'W12024586', 'W12024586', 'ID01', 'Boise Anesthesia PA', 'Michael', 'D', 'Gold', 'MD', 'Anesthesiology', '', '', NULL, 'B', 'PO Box 4268', 'Portland', 'Multnomah', 'OR', '97208', '8002758752', NULL, 'PO Box 4268    ', 'Portland', 'Multnomah', 'OR', '97208', '8002758752', '          ', 'IDSAMG3', '', '', '62.80', '10.00', '0.00', 3, '2012-07-01', NULL, 1, 15, 0, 'Saint Alphonsus Regional Medical Center', NULL, NULL, NULL, 'HCFA|UB|', '1720030166', 0, 'N', 0, '2012-10-30', NULL, NULL, 0, 0, NULL, NULL),
('820425454', 'W12024587', 'W12024587', 'ID01', 'Boise Anesthesia PA', 'Daniel', 'L', 'Grange', 'DO', 'Anesthesiology', '', '', NULL, 'B', 'PO Box 4268', 'Portland', 'Multnomah', 'OR', '97208', '8002758752', NULL, 'PO Box 4268   ', 'Portland', 'Multnomah', 'OR', '97208', '8002758752', '          ', 'IDSAMG3', '', '', '60.97', '10.00', '0.00', 3, '2011-07-01', '2012-06-30', 1, 15, 0, 'Saint Alphonsus Regional Medical Center', NULL, NULL, NULL, 'HCFA|UB|', '1710977509', 0, 'Y', 0, '2012-10-30', NULL, NULL, 0, 0, NULL, NULL),
('820425454', 'W12024588', 'W12024588', 'ID01', 'Boise Anesthesia PA', 'Daniel', 'L', 'Grange', 'DO', 'Anesthesiology', '', '', NULL, 'B', 'PO Box 4268', 'Portland', 'Multnomah', 'OR', '97208', '8002758752', NULL, 'PO Box 4268    ', 'Portland', 'Multnomah', 'OR', '97208', '8002758752', '          ', 'IDSAMG3', '', '', '62.80', '10.00', '0.00', 3, '2012-07-01', NULL, 1, 15, 0, 'Saint Alphonsus Regional Medical Center', NULL, NULL, NULL, 'HCFA|UB|', '1710977509', 0, 'Y', 0, '2012-10-30', NULL, NULL, 0, 0, NULL, NULL),
('820425454', 'W12024589', 'W12024589', 'ID01', 'Boise Anesthesia PA', 'Jeremy', 'P', 'Greenwood', 'CRNA', 'Nurse Anesthetist', '', '', NULL, 'B', 'PO Box 4268', 'Portland', 'Multnomah', 'OR', '97208', '8002758752', NULL, 'PO Box 4268   ', 'Portland', 'Multnomah', 'OR', '97208', '8002758752', '          ', 'IDSAMG3', '', '', '60.97', '10.00', '0.00', 3, '2011-07-01', '2012-06-30', 1, 15, 0, 'Saint Alphonsus Regional Medical Center', '', '', '', 'HCFA|UB|', '1629390018', 0, 'Y', 0, '2012-10-30', NULL, NULL, 0, 0, NULL, NULL),
('820425454', 'W12024590', 'W12024590', 'ID01', 'Boise Anesthesia PA', 'Jeremy', 'P', 'Greenwood', 'CRNA', 'Nurse Anesthetist', '', '', NULL, 'B', 'PO Box 4268', 'Portland', 'Multnomah', 'OR', '97208', '8002758752', NULL, 'PO Box 4268    ', 'Portland', 'Multnomah', 'OR', '97208', '8002758752', '          ', 'IDSAMG3', '', '', '62.80', '10.00', '0.00', 3, '2012-07-01', NULL, 1, 15, 0, 'Saint Alphonsus Regional Medical Center', '', '', '', 'HCFA|UB|', '1629390018', 0, 'Y', 0, '2012-10-30', NULL, NULL, 0, 0, NULL, NULL),
('820425454', 'W12024591', 'W12024591', 'ID01', 'Boise Anesthesia PA', 'David', 'R', 'Haymore', 'CRNA', 'Nurse Anesthetist', '', '', NULL, 'B', 'PO Box 4268', 'Portland', 'Multnomah', 'OR', '97208', '8002758752', NULL, 'PO Box 4268   ', 'Portland', 'Multnomah', 'OR', '97208', '8002758752', '          ', 'IDSAMG3', '', '', '60.97', '10.00', '0.00', 3, '2011-07-01', '2012-06-30', 1, 15, 0, '', '', '', '', 'HCFA|UB|', '1790968634', 0, 'N', 0, '2012-10-30', NULL, NULL, 0, 0, NULL, NULL),
('820425454', 'W12024592', 'W12024592', 'ID01', 'Boise Anesthesia PA', 'David', 'R', 'Haymore', 'CRNA', 'Nurse Anesthetist', '', '', NULL, 'B', 'PO Box 4268', 'Portland', 'Multnomah', 'OR', '97208', '8002758752', NULL, 'PO Box 4268    ', 'Portland', 'Multnomah', 'OR', '97208', '8002758752', '          ', 'IDSAMG3', '', '', '62.80', '10.00', '0.00', 3, '2012-07-01', NULL, 1, 15, 0, '', '', '', '', 'HCFA|UB|', '1790968634', 0, 'N', 0, '2012-10-30', NULL, NULL, 0, 0, NULL, NULL),
('820425454', 'W12024593', 'W12024593', 'ID01', 'Boise Anesthesia PA', 'Sheri', 'L', 'Hirai', 'CRNA', 'Nurse Anesthetist', '', '', NULL, 'B', 'PO Box 4268', 'Portland', 'Multnomah', 'OR', '97208', '8002758752', NULL, 'PO Box 4268   ', 'Portland', 'Multnomah', 'OR', '97208', '8002758752', '          ', 'IDSAMG3', '', '', '60.97', '10.00', '0.00', 3, '2011-07-01', '2012-06-30', 1, 15, 0, '', '', '', '', 'HCFA|UB|', '1609821099', 0, 'N', 0, '2012-10-30', NULL, NULL, 0, 0, NULL, NULL),
('820425454', 'W12024594', 'W12024594', 'ID01', 'Boise Anesthesia PA', 'Sheri', 'L', 'Hirai', 'CRNA', 'Nurse Anesthetist', '', '', NULL, 'B', 'PO Box 4268', 'Portland', 'Multnomah', 'OR', '97208', '8002758752', NULL, 'PO Box 4268    ', 'Portland', 'Multnomah', 'OR', '97208', '8002758752', '          ', 'IDSAMG3', '', '', '62.80', '10.00', '0.00', 3, '2012-07-01', '2013-06-25', 1, 15, 0, '', '', '', '', 'HCFA|UB|', '1609821099', 0, 'N', 0, '2013-07-12', NULL, NULL, 0, 0, NULL, NULL),
('363768937', 'W12024596', 'W12024596', 'ILCHIGSTD', 'Childrens Health Care', 'Boris', '', 'Lelchuk', 'MD', 'Pediatrics', '', '', NULL, 'O', '201 E Strong St Ste 6', 'Wheeling', 'Cook', 'IL', '60090', '8472155222', '8472155142', '201 E Strong St Ste 6', 'Wheeling', 'Cook', 'IL', '60090', '8472155222', '8472155142', 'CHIG1', 'CHIHCPCS13', '', '0.00', '35.00', '0.00', 3, '2013-01-01', NULL, 0, 0, 0, NULL, NULL, '', '', 'HCFA|UB|', '1932132123', 0, 'N', 0, '2012-12-19', NULL, NULL, 42.144, -87.9114, NULL, NULL),
('363768937', 'W12024600', 'W12024600', 'ILCHIGSTD', 'Childrens Health Care', 'Veronika', 'V', 'Kroin', 'MD', 'Pediatrics', '', '', NULL, 'O', '201 E Strong St Ste 6', 'Wheeling', 'Cook', 'IL', '60090', '8472155222', '8472155142', '201 E Strong St Ste 6', 'Wheeling', 'Cook', 'IL', '60090', '8472155222', '8472155142', 'CHIG1', 'CHIHCPCS13', '', '0.00', '35.00', '0.00', 3, '2013-01-01', NULL, 0, 0, 0, NULL, NULL, '', '', 'HCFA|UB|', '1740213925', 0, 'N', 0, '2013-04-03', NULL, NULL, 42.144, -87.9114, NULL, NULL),
('363198234', 'W12024598', 'W12024598', 'ILCHIGSTD', 'P Patel MD', 'Prasuna', '', 'Toomganti', 'MD', 'Internal Medicine', '', '', NULL, 'O', '7447 W Talcott Ave Ste 216', 'Chicago', 'Cook', 'IL', '60631', '7736310566', '7736314436', '7447 W Talcott Ave Ste 216', 'Chicago', 'Cook', 'IL', '60631', '7736310566', '7736314436', 'CHIG11', 'CHIHCPCS13', '', '0.00', '40.00', '0.00', 3, '2013-01-01', NULL, 0, 0, 0, 'Presence Resurrection Medical Center', 'Presence Our Lady Of The Resurrection Medical Center', '', '', 'HCFA|UB|', '1811061567', 0, 'N', 0, '2013-05-24', NULL, NULL, 41.9887, -87.8131, NULL, NULL),
('363198234', 'W12024599', 'W12024599', 'ILCHIGSTD', 'P Patel  MD', 'Pramod', '', 'Patel', 'MD', 'Family Practice', '', '', NULL, 'O', '7447 W Talcott Ave Ste 216', 'Chicago', 'Cook', 'IL', '60631', '7736310566', '7736314436', '7447 W Talcott Ave Ste 216', 'Chicago', 'Cook', 'IL', '60631', '7736310566', '7736314436', 'CHIG11', 'CHIHCPCS13', '', '0.00', '40.00', '0.00', 3, '2013-01-01', NULL, 0, 0, 0, 'Presence Resurrection Medical Center', NULL, NULL, NULL, 'HCFA|UB|', '1841298205', 0, 'N', 0, '2013-05-24', NULL, NULL, 41.9887, -87.8131, NULL, NULL),
('363768937', 'W12024601', 'W12024601', 'ILCHIGSTD', 'Childrens Health Care', 'Tatiana', '', 'Scolin', 'MD', 'Pediatrics', '', '', NULL, 'O', '201 E Strong St Ste 6', 'Wheeling', 'Cook', 'IL', '60090', '8472155222', '8472155142', '201 E Strong St Ste 6', 'Wheeling', 'Cook', 'IL', '60090', '8472155222', '8472155142', 'CHIG1', 'CHIHCPCS13', '', '0.00', '35.00', '0.00', 3, '2013-01-01', NULL, 0, 0, 0, NULL, NULL, '', '', 'HCFA|UB|', '1265447676', 0, 'N', 0, '2012-12-20', NULL, NULL, 42.144, -87.9114, NULL, NULL),
('363198234', 'W12024602', 'W12024602', 'ILCHIGSTD', 'P Patel MD', 'Mehul', '', 'Shah', 'MD', 'Internal Medicine', '', '', NULL, 'O', '7447 W Talcott Ave Ste 216', 'Chicago', 'Cook', 'IL', '60631', '7736310566', '7736314436', '7447 W Talcott Ave Ste 216', 'Chicago', 'Cook', 'IL', '60631', '7736310566', '7736314436', 'CHIG11', 'CHIHCPCS13', '', '0.00', '40.00', '0.00', 3, '2013-01-01', NULL, 0, 0, 0, 'Presence Resurrection Medical Center', NULL, NULL, NULL, 'HCFA|UB|', '1538196043', 0, 'N', 0, '2013-05-24', NULL, NULL, 41.9887, -87.8131, NULL, NULL),
('271632335', 'W12024603', 'W12024603', 'TXHOUSTD', 'Advanced Womens Healthcare', 'Kris', 'Ellen', 'Barnsfather', 'MD', 'Obstetrics and Gynecology', '', '', NULL, 'O', '22999 Hwy 59 N Ste 250', 'Kingwood', 'Harris', 'TX', '77339', '2813124425', '2813124435', '22999 Hwy 59 N Ste 250', 'Kingwood', 'Harris', 'TX', '77339', '2813124425', '2813124435', 'HOUSTON3', 'TXHCPC13', '', '0.00', '45.00', '0.00', 3, '2013-01-01', '2013-11-30', 0, 0, 0, 'Kingwood Medical Center', NULL, NULL, NULL, 'HCFA|UB|', '1407951940', 0, 'N', 0, '2013-12-03', NULL, NULL, 30.0528, -95.256, NULL, NULL),
('363092972', 'W12026054', 'W12026054', 'ILCHIGSTD', 'Phillip Oncology & Hematology', '', '', 'Phillip Oncology & Hematology', '', 'Oncology', '', '', NULL, 'O', '800 Austin St West Tower Ste 607', 'Evanston', 'Cook', 'IL', '60202', '8474756063', '8474756065', '800 Austin St West Tower Ste 607', 'Evanston', 'Cook', 'IL', '60202', '8474756063', '8474756065', 'CHIG7', 'CHIHCPCS13', '', '0.00', '35.00', '0.00', 3, '2013-01-01', NULL, 0, 0, 0, '', '', '', '', 'HCFA|UB|', '1407961923', 0, 'Y', 0, '2013-05-10', NULL, NULL, 42.0255, -87.6819, NULL, NULL),
('454981858', 'W12024604', 'W12024604', 'ID01', 'Haase Consulting & Counseling', 'Travis', '', 'Haase', 'LCPC', 'Mental Health', 'Counseling', '', NULL, 'O', '413 N Allumbaugh Ste 101', 'Boise', 'Ada', 'ID', '83704', '2083231125', '2083239604', '413 N Allumbaugh Ste 101', 'Boise', 'Ada', 'ID', '83704', '2083231125', '2083239604', 'IDMA', '', '', '0.00', '35.00', '0.00', 3, '2013-03-01', NULL, 0, 0, 0, '', '', '', '', 'HCFA|UB|', '1649536418', 0, 'N', 0, '2013-03-05', NULL, NULL, 43.6087, -116.266, NULL, NULL),
('010885716', 'W12024605', 'W12024605', 'UTMH1', 'Riley Individual Family and Marriage Counseling', 'Faith', 'R', 'Torres', 'LMFT', 'Mental Health', 'Counseling', '', NULL, 'O', '873 Baxter Dr', 'South Jordan', 'Salt Lake', 'UT', '84095', '8016570163', '8015687856', '873 Baxter Dr  ', 'South Jordan', 'Salt Lake', 'UT', '84095', '8016570163', '8015687856', 'UTMA', '', '', '0.00', '35.00', '0.00', 3, '2013-01-01', '2013-01-01', 0, 0, 0, '', '', '', '', 'HCFA|UB|', '1629345236', 0, 'N', 0, '2013-01-21', NULL, NULL, 0, 0, NULL, NULL),
('010885716', 'W12024606', 'W12024606', 'UTMH1', 'Riley Individual Family and Marriage Counseling', 'Faith', 'R', 'Torres', 'LMFT', 'Mental Health', 'Counseling', '', NULL, 'B', 'PO Box 708458', 'Sandy', 'Salt Lake', 'UT', '84070', '8016570163', '8015687856', 'PO Box 708458   ', 'Sandy', 'Salt Lake', 'UT', '84070', '8016570163', '8015687856', 'UTMA', '', '', '0.00', '35.00', '0.00', 3, '2013-01-01', '2013-01-01', 0, 0, 0, '', '', '', '', 'HCFA|UB|', '1629345236', 0, 'N', 0, '2013-01-21', NULL, NULL, 0, 0, NULL, NULL),
('454981859', 'W12024607', 'W12024607', 'ID01', 'KB Connseling', 'Katie', 'L', 'Brown', 'LCSW', 'Mental Health', 'Social Worker', '', NULL, 'O', '413 N Allumbaugh St Ste 101', 'Boise', 'Ada', 'ID', '83704', '2083231125', '2082329604', '413 N Allumbaugh St Ste 101', 'Boise', 'Ada', 'ID', '83704', '2083231125', '2082329604', 'IDMA', '', '', '0.00', '35.00', '0.00', 3, '2013-01-01', '2013-02-14', 0, 0, 0, '', '', '', '', 'HCFA|UB|', '1619204898', 0, 'N', 0, '2012-12-28', NULL, NULL, 43.6086, -116.268, NULL, NULL),
('010885716', 'W12024610', 'W12024610', 'UTMH1', 'Riley Individual Family and Marriage Counseling', 'David', 'W', 'Jensen', 'LPC', 'Mental Health', 'Counseling', '', NULL, 'O', '873 Baxter Dr', 'South Jordan', 'Salt Lake', 'UT', '84095', '8016570163', '8015687856', '873 Baxter Dr   ', 'South Jordan', 'Salt Lake', 'UT', '84095', '8016570163', '8015687856', 'UTMA', '', '', '0.00', '35.00', '0.00', 3, '2013-01-01', '2013-02-14', 0, 0, 0, '', '', '', '', 'HCFA|UB|', '1417225012', 0, 'N', 0, '2013-02-27', NULL, NULL, 0, 0, NULL, NULL),
('010885716', 'W12024611', 'W12024611', 'UTMH1', 'Riley Individual Family and Marriage Counseling', 'David', 'W', 'Jensen', 'LPC', 'Mental Health', 'Counseling', '', NULL, 'B', 'PO Box 708458', 'Sandy', 'Salt Lake', 'UT', '84070', '8016570163', '8015687856', 'PO Box 708458    ', 'Sandy', 'Salt Lake', 'UT', '84070', '8016570163', '8015687856', 'UTMA', '', '', '0.00', '35.00', '0.00', 3, '2013-01-01', '2013-02-14', 0, 0, 0, '', '', '', '', 'HCFA|UB|', '1417225012', 0, 'N', 0, '2013-02-27', NULL, NULL, 0, 0, NULL, NULL),
('454027358', 'W12024612', 'W12024612', 'UTMH1', 'Psychiatric & Behavioral Solutions', 'Crystal', 'N', 'Garduno', 'LPC', 'Mental Health', 'Counseling', '', NULL, 'O', '1522 S 1100 E', 'Salt Lake City', 'Salt Lake', 'UT', '84105', '8014671200', '8014671210', '1522 S 1100 E  ', 'Salt Lake City', 'Salt Lake', 'UT', '84105', '8014671200', '8014671210', 'UTMA', '', '', '0.00', '35.00', '0.00', 3, '2013-01-01', '2013-02-14', 0, 0, 0, '', '', '', '', 'HCFA|UB|', '1144527243', 0, 'N', 0, '2013-02-27', NULL, NULL, 0, 0, NULL, NULL),
('810608733', 'W12024614', 'W12024614', 'UT01', 'Nexus Pain Care', 'Shawn ', 'R', 'Furst ', 'DO', 'Physical Medicine and Rehabilitation', '', '', NULL, 'O', '3585 N University Ave Ste 150', 'Provo', 'Utah', 'UT', '84604', '8013566100', '8013562113', '3585 N University Ave Ste 150', 'Provo', 'Utah', 'UT', '84604', '8013566100', '8013562113', 'WUSTDPAIN5', 'WUSTDHCPC5', '', '0.00', '35.00', '0.00', 3, '2013-01-01', '2014-01-27', 0, 0, 0, 'Timpanogos Regional Hospital', '', '', '', 'HCFA|UB|', '1154578565', 0, 'N', 0, '2014-01-31', NULL, NULL, 0, 0, NULL, NULL),
('810608733', 'W12024615', 'W12024615', 'UT01', 'Nexus Pain Care', 'Shawn ', 'R', 'Furst ', 'DO', 'Physical Medicine and Rehabilitation', '', '', NULL, 'B', 'PO Box 15109', 'Springfield', 'Hampden', 'MA', '01115', '8013566100', NULL, 'PO Box 15109  ', 'Springfield', 'Hampden', 'MA', '01115', '8013566100', '          ', 'WUSTDPAIN5', 'WUSTDHCPC5', '', '0.00', '35.00', '0.00', 3, '2013-01-01', '2014-01-27', 0, 0, 0, 'Timpanogos Regional Hospital', '', '', '', 'HCFA|UB|', '1154578565', 0, 'N', 0, '2014-01-31', NULL, NULL, 0, 0, NULL, NULL),
('820425454', 'W12024617', 'W12024617', 'ID01', 'Boise Anesthesia, PA', 'Shelley', 'M', 'Jacks', 'MD', 'Anesthesiology', '', '', NULL, 'B', 'PO Box 4268', 'Portland', 'Multnomah', 'OR', '97208', '8002758752', NULL, 'PO Box 4268      ', 'Portland', 'Multnomah', 'OR', '97208', '8002758752', '0         ', 'IDSAMG3', '', '', '60.97', '10.00', '0.00', 3, '2011-07-01', '2012-06-30', 1, 15, 0, 'Saint Alphonsus Regional Medical Center', NULL, NULL, NULL, 'HCFA|UB|', '1679524920', 0, 'N', 0, '2012-11-01', NULL, NULL, 0, 0, NULL, NULL),
('820425454', 'W12024618', 'W12024618', 'ID01', 'Boise Anesthesia, PA', 'Shelley', 'M', 'Jacks', 'MD', 'Anesthesiology', '', '', NULL, 'B', 'PO Box 4268', 'Portland', 'Multnomah', 'OR', '97208', '8002758752', NULL, 'PO Box 4268       ', 'Portland', 'Multnomah', 'OR', '97208', '8002758752', '0         ', 'IDSAMG3', '', '', '62.80', '10.00', '0.00', 3, '2012-07-01', NULL, 1, 15, 0, 'Saint Alphonsus Regional Medical Center', NULL, NULL, NULL, 'HCFA|UB|', '1679524920', 0, 'N', 0, '2012-11-01', NULL, NULL, 0, 0, NULL, NULL),
('820425454', 'W12024619', 'W12024619', 'ID01', 'Boise Anesthesia PA', 'Denise', 'L', 'Janicek', 'CRNA', 'Nurse Anesthetist', '', '', NULL, 'B', 'PO Box 4268', 'Portland', 'Multnomah', 'OR', '97208', '8002758752', NULL, 'PO Box 4268   ', 'Portland', 'Multnomah', 'OR', '97208', '8002758752', '          ', 'IDSAMG3', '', '', '60.97', '10.00', '0.00', 3, '2011-07-01', '2012-06-30', 1, 15, 0, '', '', '', '', 'HCFA|UB|', '1477509057', 0, 'N', 0, '2012-11-01', NULL, NULL, 0, 0, NULL, NULL),
('820425454', 'W12024620', 'W12024620', 'ID01', 'Boise Anesthesia PA', 'Denise', 'L', 'Janicek', 'CRNA', 'Nurse Anesthetist', '', '', NULL, 'B', 'PO Box 4268', 'Portland', 'Multnomah', 'OR', '97208', '8002758752', NULL, 'PO Box 4268    ', 'Portland', 'Multnomah', 'OR', '97208', '8002758752', '          ', 'IDSAMG3', '', '', '62.80', '10.00', '0.00', 3, '2012-07-01', NULL, 1, 15, 0, '', '', '', '', 'HCFA|UB|', '1477509057', 0, 'N', 0, '2012-11-01', NULL, NULL, 0, 0, NULL, NULL),
('820425454', 'W12024621', 'W12024621', 'ID01', 'Boise Anesthesia PA', 'Jason', 'P', 'Jenkins', 'MD', 'Anesthesiology', '', '', NULL, 'B', 'PO Box 4268', 'Portland', 'Multnomah', 'OR', '97208', '8002758752', NULL, 'PO Box 4268   ', 'Portland', 'Multnomah', 'OR', '97208', '8002758752', '          ', 'IDSAMG3', '', '', '60.97', '10.00', '0.00', 3, '2011-07-01', '2012-06-30', 0, 15, 0, 'Saint Alphonsus Regional Medical Center', NULL, NULL, NULL, 'HCFA|UB|', '1942252390', 0, 'N', 1, '2012-11-01', NULL, NULL, 0, 0, NULL, NULL),
('820425454', 'W12024622', 'W12024622', 'ID01', 'Boise Anesthesia PA', 'Jason', 'P', 'Jenkins', 'MD', 'Anesthesiology', '', '', NULL, 'B', 'PO Box 4268', 'Portland', 'Multnomah', 'OR', '97208', '8002758752', NULL, 'PO Box 4268    ', 'Portland', 'Multnomah', 'OR', '97208', '8002758752', '          ', 'IDSAMG3', '', '', '62.80', '10.00', '0.00', 3, '2012-07-01', NULL, 1, 15, 0, 'Saint Alphonsus Regional Medical Center', NULL, NULL, NULL, 'HCFA|UB|', '1942252390', 0, 'N', 0, '2012-11-01', NULL, NULL, 0, 0, NULL, NULL),
('820425454', 'W12024623', 'W12024623', 'ID01', 'Boise Anesthesia PA', 'Kevin', 'E', 'Kartchner', 'MD', 'Anesthesiology', '', '', NULL, 'B', 'PO Box 4268', 'Portland', 'Multnomah', 'OR', '97208', '8002758752', NULL, 'PO Box 4268   ', 'Portland', 'Multnomah', 'OR', '97208', '8002758752', '          ', 'IDSAMG3', '', '', '60.97', '10.00', '0.00', 3, '2011-07-01', '2012-06-30', 1, 15, 0, 'Saint Alphonsus Regional Medical Center', NULL, NULL, NULL, 'HCFA|UB|', '1831141282', 0, 'N', 0, '2012-11-01', NULL, NULL, 0, 0, NULL, NULL),
('820425454', 'W12024624', 'W12024624', 'ID01', 'Boise Anesthesia PA', 'Kevin', 'E', 'Kartchner', 'MD', 'Anesthesiology', '', '', NULL, 'B', 'PO Box 4268', 'Portland', 'Multnomah', 'OR', '97208', '8002758752', NULL, 'PO Box 4268    ', 'Portland', 'Multnomah', 'OR', '97208', '8002758752', '          ', 'IDSAMG3', '', '', '62.80', '10.00', '0.00', 3, '2012-07-01', NULL, 1, 15, 0, 'Saint Alphonsus Regional Medical Center', NULL, NULL, NULL, 'HCFA|UB|', '1831141282', 0, 'N', 0, '2012-11-01', NULL, NULL, 0, 0, NULL, NULL),
('820425454', 'W12024625', 'W12024625', 'ID01', 'Boise Anesthesia PA', 'Darin', '', 'Lee', 'CRNA', 'Nurse Anesthetist', '', '', NULL, 'B', 'PO Box 4268', 'Portland', 'Multnomah', 'OR', '97208', '8002758752', NULL, 'PO Box 4268   ', 'Portland', 'Multnomah', 'OR', '97208', '8002758752', '          ', 'IDSAMG3', '', '', '60.97', '10.00', '0.00', 3, '2011-07-01', '2012-06-30', 1, 15, 0, '', '', '', '', 'HCFA|UB|', '1578519542', 0, 'N', 0, '2012-11-01', NULL, NULL, 0, 0, NULL, NULL),
('820425454', 'W12024626', 'W12024626', 'ID01', 'Boise Anesthesia PA', 'Darin', '', 'Lee', 'CRNA', 'Nurse Anesthetist', '', '', NULL, 'B', 'PO Box 4268', 'Portland', 'Multnomah', 'OR', '97208', '8002758752', NULL, 'PO Box 4268    ', 'Portland', 'Multnomah', 'OR', '97208', '8002758752', '          ', 'IDSAMG3', '', '', '62.80', '10.00', '0.00', 3, '2012-07-01', NULL, 1, 15, 0, '', '', '', '', 'HCFA|UB|', '1578519542', 0, 'N', 0, '2012-11-01', NULL, NULL, 0, 0, NULL, NULL),
('820425454', 'W12024627', 'W12024627', 'ID01', 'Boise Anesthesia PA', 'Derek', '', 'Lish', 'CRNA', 'Anesthesiology', '', '', NULL, 'B', 'PO Box 4268', 'Portland', 'Multnomah', 'OR', '97208', '8002758752', NULL, 'PO Box 4268   ', 'Portland', 'Multnomah', 'OR', '97208', '8002758752', '          ', 'IDSAMG3', '', '', '60.97', '10.00', '0.00', 3, '2011-07-01', '2012-06-30', 1, 15, 0, '', '', '', '', 'HCFA|UB|', '1699914044', 0, 'N', 0, '2013-06-24', NULL, NULL, 0, 0, NULL, NULL),
('820425454', 'W12024628', 'W12024628', 'ID01', 'Boise Anesthesia PA', 'Derek', '', 'Lish', 'CRNA', 'Anesthesiology', '', '', NULL, 'B', 'PO Box 4268', 'Portland', 'Multnomah', 'OR', '97208', '8002758752', NULL, 'PO Box 4268    ', 'Portland', 'Multnomah', 'OR', '97208', '8002758752', '          ', 'IDSAMG3', '', '', '62.80', '10.00', '0.00', 3, '2012-07-01', '2013-05-31', 1, 15, 0, '', '', '', '', 'HCFA|UB|', '1699914044', 0, 'N', 0, '2013-06-24', NULL, NULL, 0, 0, NULL, NULL),
('820425454', 'W12024629', 'W12024629', 'ID01', 'Boise Anesthesia PA', 'C Paul', '', 'Mansfield', 'CRNA', 'Nurse Anesthetist', '', '', NULL, 'B', 'PO Box 4268', 'Portland', 'Multnomah', 'OR', '97208', '8002758752', NULL, 'PO Box 4268   ', 'Portland', 'Multnomah', 'OR', '97208', '8002758752', '          ', 'IDSAMG3', '', '', '60.97', '10.00', '0.00', 3, '2011-07-01', '2012-06-30', 1, 15, 0, '', '', '', '', 'HCFA|UB|', '1972558393', 0, 'N', 0, '2012-11-01', NULL, NULL, 0, 0, NULL, NULL),
('820425454', 'W12024630', 'W12024630', 'ID01', 'Boise Anesthesia PA', 'C Paul', '', 'Mansfield', 'CRNA', 'Nurse Anesthetist', '', '', NULL, 'B', 'PO Box 4268', 'Portland', 'Multnomah', 'OR', '97208', '8002758752', NULL, 'PO Box 4268    ', 'Portland', 'Multnomah', 'OR', '97208', '8002758752', '          ', 'IDSAMG3', '', '', '62.80', '10.00', '0.00', 3, '2012-07-01', NULL, 1, 15, 0, '', '', '', '', 'HCFA|UB|', '1972558393', 0, 'N', 0, '2012-11-01', NULL, NULL, 0, 0, NULL, NULL),
('820425454', 'W12024631', 'W12024631', 'ID01', 'Boise Anesthesia PA', 'John', 'T', 'Martin', 'MD', 'Anesthesiology', '', '', NULL, 'B', 'PO Box 4268', 'Portland', 'Multnomah', 'OR', '97208', '8002758752', NULL, 'PO Box 4268   ', 'Portland', 'Multnomah', 'OR', '97208', '8002758752', '          ', 'IDSAMG3', '', '', '60.97', '10.00', '0.00', 3, '2011-07-01', '2012-06-30', 1, 15, 0, 'Saint Alphonsus Regional Medical Center', NULL, NULL, NULL, 'HCFA|UB|', '1720031479', 0, 'N', 0, '2012-11-01', NULL, NULL, 0, 0, NULL, NULL),
('820425454', 'W12024632', 'W12024632', 'ID01', 'Boise Anesthesia PA', 'John', 'T', 'Martin', 'MD', 'Anesthesiology', '', '', NULL, 'B', 'PO Box 4268', 'Portland', 'Multnomah', 'OR', '97208', '8002758752', NULL, 'PO Box 4268    ', 'Portland', 'Multnomah', 'OR', '97208', '8002758752', '          ', 'IDSAMG3', '', '', '62.80', '10.00', '0.00', 3, '2012-07-01', NULL, 1, 15, 0, 'Saint Alphonsus Regional Medical Center', NULL, NULL, NULL, 'HCFA|UB|', '1720031479', 0, 'N', 0, '2012-11-01', NULL, NULL, 0, 0, NULL, NULL),
('820425454', 'W12024633', 'W12024633', 'ID01', 'Boise Anesthesia PA', 'Dorothy', 'L', 'Mattise', 'CRNA', 'Nurse Anesthetist', '', '', NULL, 'B', 'PO Box 4268', 'Portland', 'Multnomah', 'OR', '97208', '8002758752', NULL, 'PO Box 4268   ', 'Portland', 'Multnomah', 'OR', '97208', '8002758752', '          ', 'IDSAMG3', '', '', '60.97', '10.00', '0.00', 3, '2011-07-01', '2012-06-30', 1, 15, 0, '', '', '', '', 'HCFA|UB|', '1457306870', 0, 'N', 0, '2013-06-24', NULL, NULL, 0, 0, NULL, NULL),
('820425454', 'W12024634', 'W12024634', 'ID01', 'Boise Anesthesia PA', 'Dorothy', 'L', 'Mattise', 'CRNA', 'Nurse Anesthetist', '', '', NULL, 'B', 'PO Box 4268', 'Portland', 'Multnomah', 'OR', '97208', '8002758752', NULL, 'PO Box 4268    ', 'Portland', 'Multnomah', 'OR', '97208', '8002758752', '          ', 'IDSAMG3', '', '', '62.80', '10.00', '0.00', 3, '2012-07-01', '2013-04-04', 1, 15, 0, '', '', '', '', 'HCFA|UB|', '1457306870', 0, 'N', 0, '2013-06-24', NULL, NULL, 0, 0, NULL, NULL),
('820425454', 'W12024635', 'W12024635', 'ID01', 'Boise Anesthesia PA', 'Lisa', 'A', 'Bootsma', 'CRNA', 'Nurse Anesthetist', '', '', NULL, 'B', 'PO Box 4268', 'Portland', 'Multnomah', 'OR', '97208', '8002758752', NULL, 'PO Box 4268   ', 'Portland', 'Multnomah', 'OR', '97208', '8002758752', '          ', 'IDSAMG3', '', '', '60.97', '10.00', '0.00', 3, '2011-07-01', '2012-06-30', 1, 15, 0, '', '', '', '', 'HCFA|UB|', '1891732475', 0, 'N', 0, '2013-06-10', NULL, NULL, 0, 0, NULL, NULL),
('820425454', 'W12024636', 'W12024636', 'ID01', 'Boise Anesthesia PA', 'Lisa', 'A', 'Bootsma', 'CRNA', 'Nurse Anesthetist', '', '', NULL, 'B', 'PO Box 4268', 'Portland', 'Multnomah', 'OR', '97208', '8002758752', NULL, 'PO Box 4268    ', 'Portland', 'Multnomah', 'OR', '97208', '8002758752', '          ', 'IDSAMG3', '', '', '62.80', '10.00', '0.00', 3, '2012-07-01', NULL, 1, 15, 0, '', '', '', '', 'HCFA|UB|', '1891732475', 0, 'N', 0, '2013-06-10', NULL, NULL, 0, 0, NULL, NULL),
('820425454', 'W12024639', 'W12024639', 'ID01', 'Boise Anesthesia PA', 'Eric', 'J', 'Melbihess', 'MD', 'Anesthesiology', '', '', NULL, 'B', 'PO Box 4268', 'Portland', 'Multnomah', 'OR', '97208', '8002758752', NULL, 'PO Box 4268   ', 'Portland', 'Multnomah', 'OR', '97208', '8002758752', '          ', 'IDSAMG3', '', '', '60.97', '10.00', '0.00', 3, '2011-07-01', '2012-06-30', 1, 15, 0, 'Saint Alphonsus Medical Center Nampa', '', 'West Valley Medical Center', '', 'HCFA|UB|', '1699782656', 0, 'N', 0, '2012-11-01', NULL, NULL, 0, 0, NULL, NULL),
('820425454', 'W12024638', 'W12024638', 'ID01', 'Boise Anesthesia PA', 'Sean', '', 'MCGarry', 'MD', 'Anesthesia', '', '', NULL, 'B', 'PO Box 4268', 'Portland', 'Multnomah', 'OR', '97208', '8002758752', NULL, 'PO Box 4268    ', 'Portland', 'Multnomah', 'OR', '97208', '8002758752', '          ', 'IDSAMG3', '', '', '62.80', '10.00', '0.00', 3, '2012-08-03', NULL, 1, 15, 0, 'Saint Alphonsus Regional Medical Center', '', '', '', 'HCFA|UB|', '1154513596', 0, 'N', 0, '2012-11-01', NULL, NULL, 0, 0, NULL, NULL),
('820425454', 'W12024640', 'W12024640', 'ID01', 'Boise Anesthesia PA', 'Eric', 'J', 'Melbihess', 'MD', 'Anesthesiology', '', '', NULL, 'B', 'PO Box 4268', 'Portland', 'Multnomah', 'OR', '97208', '8002758752', NULL, 'PO Box 4268    ', 'Portland', 'Multnomah', 'OR', '97208', '8002758752', '          ', 'IDSAMG3', '', '', '62.80', '10.00', '0.00', 3, '2012-07-01', NULL, 1, 15, 0, 'Saint Alphonsus Medical Center Nampa', '', 'West Valley Medical Center', '', 'HCFA|UB|', '1699782656', 0, 'N', 0, '2012-11-01', NULL, NULL, 0, 0, NULL, NULL),
('820425454', 'W12024641', 'W12024641', 'ID01', 'Boise Anesthesia PA', 'Stephen', 'B', 'Packer', 'MD', 'Anesthesiology', '', '', NULL, 'B', 'PO Box 4268', 'Portland', 'Multnomah', 'OR', '97208', '8002758752', NULL, 'PO Box 4268   ', 'Portland', 'Multnomah', 'OR', '97208', '8002758752', '          ', 'IDSAMG3', '', '', '60.97', '10.00', '0.00', 3, '2011-07-01', '2012-06-30', 1, 15, 0, 'Saint Alphonsus Medical Center Nampa', '', 'West Valley Medical Center', '', 'HCFA|UB|', '1598713349', 0, 'N', 0, '2012-11-01', NULL, NULL, 0, 0, NULL, NULL),
('820425454', 'W12024642', 'W12024642', 'ID01', 'Boise Anesthesia PA', 'Stephen', 'B', 'Packer', 'MD', 'Anesthesiology', '', '', NULL, 'B', 'PO Box 4268', 'Portland', 'Multnomah', 'OR', '97208', '8002758752', NULL, 'PO Box 4268    ', 'Portland', 'Multnomah', 'OR', '97208', '8002758752', '          ', 'IDSAMG3', '', '', '62.80', '10.00', '0.00', 3, '2012-07-01', NULL, 1, 15, 0, 'Saint Alphonsus Medical Center Nampa', '', 'West Valley Medical Center', '', 'HCFA|UB|', '1598713349', 0, 'N', 0, '2012-11-01', NULL, NULL, 0, 0, NULL, NULL),
('820425454', 'W12024643', 'W12024643', 'ID01', 'Boise Anesthesia PA', 'Bryant', 'L', 'Peterson', 'CRNA', 'Nurse Anesthetist', '', '', NULL, 'B', 'PO Box 4268', 'Portland', 'Multnomah', 'OR', '97208', '8002758752', NULL, 'PO Box 4268   ', 'Portland', 'Multnomah', 'OR', '97208', '8002758752', '          ', 'IDSAMG3', '', '', '60.97', '10.00', '0.00', 3, '2011-07-01', '2012-06-30', 1, 15, 0, '', '', '', '', 'HCFA|UB|', '1174794127', 0, 'N', 0, '2013-06-24', NULL, NULL, 0, 0, NULL, NULL),
('820425454', 'W12024644', 'W12024644', 'ID01', 'Boise Anesthesia PA', 'Bryant', 'L', 'Peterson', 'CRNA', 'Nurse Anesthetist', '', '', NULL, 'B', 'PO Box 4268', 'Portland', 'Multnomah', 'OR', '97208', '8002758752', NULL, 'PO Box 4268    ', 'Portland', 'Multnomah', 'OR', '97208', '8002758752', '          ', 'IDSAMG3', '', '', '62.80', '10.00', '0.00', 3, '2012-07-01', '2013-05-31', 1, 15, 0, '', '', '', '', 'HCFA|UB|', '1174794127', 0, 'N', 0, '2013-06-24', NULL, NULL, 0, 0, NULL, NULL),
('820425454', 'W12024645', 'W12024645', 'ID01', 'Boise Anesthesia PA', 'Nathan', 'A', 'Poulson', 'MD', 'Anesthesia', '', '', NULL, 'B', 'PO Box 4268', 'Portland', 'Multnomah', 'OR', '97208', '8002758752', '2083759530', 'PO Box 4268  ', 'Portland', 'Multnomah', 'OR', '97208', '8002758752', '2083759530', 'IDSAMG3', '', '', '60.97', '10.00', '0.00', 3, '2011-07-22', '2012-06-30', 1, 15, 0, 'Saint Alphonsus Regional Medical Center', '', '', '', 'HCFA|UB|', '1992903173', 0, 'N', 0, '2012-11-01', NULL, NULL, 0, 0, NULL, NULL),
('820425454', 'W12024646', 'W12024646', 'ID01', 'Boise Anesthesia PA', 'Nathan', 'A', 'Poulson', 'MD', 'Anesthesia', '', '', NULL, 'B', 'PO Box 4268', 'Portland', 'Multnomah', 'OR', '97208', '8002758752', '2083759530', 'PO Box 4268   ', 'Portland', 'Multnomah', 'OR', '97208', '8002758752', '2083759530', 'IDSAMG3', '', '', '62.80', '10.00', '0.00', 3, '2012-07-01', NULL, 1, 15, 0, 'Saint Alphonsus Regional Medical Center', '', '', '', 'HCFA|UB|', '1992903173', 0, 'N', 0, '2012-11-01', NULL, NULL, 0, 0, NULL, NULL),
('820425454', 'W12024647', 'W12024647', 'ID01', 'Boise Anesthesia PA', 'Emily', '', 'Price', 'CRNA', 'Nurse Anesthetist', '', '', NULL, 'B', 'PO Box 4268', 'Portland', 'Multnomah', 'OR', '97208', '8002758752', NULL, 'PO Box 4268   ', 'Portland', 'Multnomah', 'OR', '97208', '8002758752', '          ', 'IDSAMG3', '', '', '60.97', '10.00', '0.00', 3, '2011-07-01', '2012-06-30', 1, 15, 0, '', '', '', '', 'HCFA|UB|', '1508803255', 0, 'N', 0, '2012-12-27', NULL, NULL, 0, 0, NULL, NULL),
('820425454', 'W12024648', 'W12024648', 'ID01', 'Boise Anesthesia PA', 'Emily', '', 'Price', 'CRNA', 'Nurse Anesthetist', '', '', NULL, 'B', 'PO Box 4268', 'Portland', 'Multnomah', 'OR', '97208', '8002758752', NULL, 'PO Box 4268    ', 'Portland', 'Multnomah', 'OR', '97208', '8002758752', '          ', 'IDSAMG3', '', '', '62.80', '10.00', '0.00', 3, '2012-07-01', NULL, 1, 15, 0, '', '', '', '', 'HCFA|UB|', '1508803255', 0, 'N', 0, '2012-12-27', NULL, NULL, 0, 0, NULL, NULL),
('820425454', 'W12024649', 'W12024649', 'ID01', 'Boise Anesthesia PA', 'MaryBeth', '', 'Puzio', 'CRNA', 'Nurse Anesthetist', '', '', NULL, 'B', 'PO Box 4268', 'Portland', 'Multnomah', 'OR', '97208', '8002758752', NULL, 'PO Box 4268   ', 'Portland', 'Multnomah', 'OR', '97208', '8002758752', '          ', 'IDSAMG3', '', '', '60.97', '10.00', '0.00', 3, '2011-07-01', '2012-06-30', 1, 15, 0, '', '', '', '', 'HCFA|UB|', '1912948464', 0, 'N', 0, '2012-11-01', NULL, NULL, 0, 0, NULL, NULL),
('820425454', 'W12024650', 'W12024650', 'ID01', 'Boise Anesthesia PA', 'MaryBeth', '', 'Puzio', 'CRNA', 'Nurse Anesthetist', '', '', NULL, 'B', 'PO Box 4268', 'Portland', 'Multnomah', 'OR', '97208', '8002758752', NULL, 'PO Box 4268    ', 'Portland', 'Multnomah', 'OR', '97208', '8002758752', '          ', 'IDSAMG3', '', '', '62.80', '10.00', '0.00', 3, '2012-07-01', NULL, 1, 15, 0, '', '', '', '', 'HCFA|UB|', '1912948464', 0, 'N', 0, '2012-11-01', NULL, NULL, 0, 0, NULL, NULL),
('820425454', 'W12024651', 'W12024651', 'ID01', 'Boise Anesthesia PA', 'Steven', 'D', 'Reid', 'MD', 'Anesthesiology', '', '', NULL, 'B', 'PO Box 4268', 'Portland', 'Multnomah', 'OR', '97208', '8002758752', NULL, 'PO Box 4268   ', 'Portland', 'Multnomah', 'OR', '97208', '8002758752', '          ', 'IDSAMG3', '', '', '60.97', '10.00', '0.00', 3, '2011-07-01', '2012-06-30', 1, 15, 0, 'Saint Alphonsus Regional Medical Center', NULL, NULL, NULL, 'HCFA|UB|', '1639122385', 0, 'N', 0, '2012-11-01', NULL, NULL, 0, 0, NULL, NULL),
('820425454', 'W12024652', 'W12024652', 'ID01', 'Boise Anesthesia PA', 'Steven', 'D', 'Reid', 'MD', 'Anesthesiology', '', '', NULL, 'B', 'PO Box 4268', 'Portland', 'Multnomah', 'OR', '97208', '8002758752', NULL, 'PO Box 4268    ', 'Portland', 'Multnomah', 'OR', '97208', '8002758752', '          ', 'IDSAMG3', '', '', '62.80', '10.00', '0.00', 3, '2012-07-01', NULL, 1, 15, 0, 'Saint Alphonsus Regional Medical Center', NULL, NULL, NULL, 'HCFA|UB|', '1639122385', 0, 'N', 0, '2012-11-01', NULL, NULL, 0, 0, NULL, NULL),
('820425454', 'W12024653', 'W12024653', 'ID01', 'Boise Anesthesia PA', 'Lisa', '', 'Rogien', 'CRNA', 'Nurse Anesthetist', '', '', NULL, 'B', 'PO Box 4268', 'Portland', 'Multnomah', 'OR', '97208', '8002758752', NULL, 'PO Box 4268   ', 'Portland', 'Multnomah', 'OR', '97208', '8002758752', '          ', 'IDSAMG3', '', '', '60.97', '10.00', '0.00', 3, '2011-07-01', '2012-06-30', 1, 15, 0, '', '', '', '', 'HCFA|UB|', '1871752782', 0, 'N', 0, '2012-11-01', NULL, NULL, 0, 0, NULL, NULL),
('820425454', 'W12024654', 'W12024654', 'ID01', 'Boise Anesthesia PA', 'Lisa', '', 'Rogien', 'CRNA', 'Nurse Anesthetist', '', '', NULL, 'B', 'PO Box 4268', 'Portland', 'Multnomah', 'OR', '97208', '8002758752', NULL, 'PO Box 4268    ', 'Portland', 'Multnomah', 'OR', '97208', '8002758752', '          ', 'IDSAMG3', '', '', '62.80', '10.00', '0.00', 3, '2012-07-01', NULL, 1, 15, 0, '', '', '', '', 'HCFA|UB|', '1871752782', 0, 'N', 0, '2012-11-01', NULL, NULL, 0, 0, NULL, NULL),
('820425454', 'W12024655', 'W12024655', 'ID01', 'Boise Anesthesia PA', 'Phillip', '', 'Roylance', 'CRNA', 'Nurse Anesthetist', '', '', NULL, 'B', 'PO Box 4268', 'Portland', 'Multnomah', 'OR', '97208', '8002758752', '2083759530', 'PO Box 4268  ', 'Portland', 'Multnomah', 'OR', '97208', '8002758752', '2083759530', 'IDSAMG3', '', '', '60.97', '10.00', '0.00', 3, '2011-12-02', '2012-06-30', 1, 15, 0, '', '', '', '', 'HCFA|UB|', '1306170907', 0, 'N', 0, '2012-11-01', NULL, NULL, 0, 0, NULL, NULL),
('820425454', 'W12024656', 'W12024656', 'ID01', 'Boise Anesthesia PA', 'Phillip', '', 'Roylance', 'CRNA', 'Nurse Anesthetist', '', '', NULL, 'B', 'PO Box 4268', 'Portland', 'Multnomah', 'OR', '97208', '8002758752', NULL, 'PO Box 4268    ', 'Portland', 'Multnomah', 'OR', '97208', '8002758752', '          ', 'IDSAMG3', '', '', '62.80', '10.00', '0.00', 3, '2012-07-01', NULL, 1, 15, 0, '', '', '', '', 'HCFA|UB|', '1306170907', 0, 'N', 0, '2012-11-01', NULL, NULL, 0, 0, NULL, NULL),
('820425454', 'W12024657', 'W12024657', 'ID01', 'Boise Anesthesia PA', 'Robert', 'T', 'Sargeant', 'CRNA', 'Nurse Anesthetist', '', '', NULL, 'B', 'PO Box 4268', 'Portland', 'Multnomah', 'OR', '97208', '8002758752', NULL, 'PO Box 4268    ', 'Portland', 'Multnomah', 'OR', '97208', '8002758752', '          ', 'IDSAMG3', '', '', '60.97', '10.00', '0.00', 3, '2011-07-01', '2012-06-30', 1, 15, 0, '', '', '', '', 'HCFA|UB|', '1346431012', 0, 'N', 0, '2012-11-01', NULL, NULL, 0, 0, NULL, NULL),
('820425454', 'W12024658', 'W12024658', 'ID01', 'Boise Anesthesia PA', 'Robert', 'T', 'Sargeant', 'CRNA', 'Nurse Anesthetist', '', '', NULL, 'B', 'PO Box 4268', 'Portland', 'Multnomah', 'OR', '97208', '8002758752', NULL, 'PO Box 4268    ', 'Portland', 'Multnomah', 'OR', '97208', '8002758752', '          ', 'IDSAMG3', '', '', '62.80', '10.00', '0.00', 3, '2012-07-01', NULL, 1, 15, 0, '', '', '', '', 'HCFA|UB|', '1346431012', 0, 'N', 0, '2012-11-01', NULL, NULL, 0, 0, NULL, NULL),
('820425454', 'W12024659', 'W12024659', 'ID01', 'Boise Anesthesia PA', 'Cassandra', 'L', 'Schnell', 'CRNA', 'Nurse Anesthetist', '', '', NULL, 'B', 'PO Box 4268', 'Portland', 'Multnomah', 'OR', '97208', '8002758752', NULL, 'PO Box 4268   ', 'Portland', 'Multnomah', 'OR', '97208', '8002758752', '          ', 'IDSAMG3', '', '', '60.97', '10.00', '0.00', 3, '2011-07-01', '2012-06-30', 1, 15, 0, '', '', '', '', 'HCFA|UB|', '1669419313', 0, 'N', 0, '2012-11-01', NULL, NULL, 0, 0, NULL, NULL),
('820425454', 'W12024661', 'W12024661', 'ID01', 'Boise Anesthesia PA', 'Cassandra', 'L', 'Schnell', 'CRNA', 'Nurse Anesthetist', '', '', NULL, 'B', 'PO Box 4268', 'Portland', 'Multnomah', 'OR', '97208', '8002758752', NULL, 'PO Box 4268    ', 'Portland', 'Multnomah', 'OR', '97208', '8002758752', '          ', 'IDSAMG3', '', '', '62.80', '10.00', '0.00', 3, '2012-07-01', NULL, 1, 15, 0, '', '', '', '', 'HCFA|UB|', '1669419313', 0, 'N', 0, '2012-11-01', NULL, NULL, 0, 0, NULL, NULL),
('820425454', 'W12024662', 'W12024662', 'ID01', 'Boise Anesthesia PA', 'LeslieAnn', '', 'Schweiger', 'CRNA', 'Nurse Anesthetist', '', '', NULL, 'B', 'PO Box 4268', 'Portland', 'Multnomah', 'OR', '97208', '8002758752', NULL, 'PO Box 4268   ', 'Portland', 'Multnomah', 'OR', '97208', '8002758752', '          ', 'IDSAMG3', '', '', '60.97', '10.00', '0.00', 3, '2011-07-01', '2012-06-30', 1, 15, 0, '', '', '', '', 'HCFA|UB|', '1306892807', 0, 'N', 0, '2013-02-19', NULL, NULL, 0, 0, NULL, NULL),
('820425454', 'W12024663', 'W12024663', 'ID01', 'Boise Anesthesia PA', 'LeslieAnn', '', 'Schweiger', 'CRNA', 'Nurse Anesthetist', '', '', NULL, 'B', 'PO Box 4268', 'Portland', 'Multnomah', 'OR', '97208', '8002758752', NULL, 'PO Box 4268    ', 'Portland', 'Multnomah', 'OR', '97208', '8002758752', '          ', 'IDSAMG3', '', '', '62.80', '10.00', '0.00', 3, '2012-07-01', '2014-01-30', 1, 15, 0, '', '', '', '', 'HCFA|UB|', '1306892807', 0, 'N', 0, '2014-02-20', NULL, NULL, 0, 0, NULL, NULL),
('820425454', 'W12024664', 'W12024664', 'ID01', 'Boise Anesthesia PA', 'James', 'I', 'Shippers', 'CRNA', 'Nurse Anesthetist', '', '', NULL, 'B', 'PO Box 4268', 'Portland', 'Multnomah', 'OR', '97208', '8002758752', NULL, 'PO Box 4268   ', 'Portland', 'Multnomah', 'OR', '97208', '8002758752', '          ', 'IDSAMG3', '', '', '60.97', '10.00', '0.00', 3, '2011-07-01', '2012-06-30', 1, 15, 0, '', '', '', '', 'HCFA|UB|', '1801841820', 0, 'N', 0, '2012-11-01', 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
('820425454', 'W12024665', 'W12024665', 'ID01', 'Boise Anesthesia PA', 'James', 'I', 'Shippers', 'CRNA', 'Nurse Anesthetist', '', '', NULL, 'B', 'PO Box 4268', 'Portland', 'Multnomah', 'OR', '97208', '8002758752', NULL, 'PO Box 4268    ', 'Portland', 'Multnomah', 'OR', '97208', '8002758752', '          ', 'IDSAMG3', '', '', '62.80', '10.00', '0.00', 3, '2012-07-01', NULL, 1, 15, 0, '', '', '', '', 'HCFA|UB|', '1801841820', 0, 'N', 0, '2012-11-01', NULL, NULL, 0, 0, NULL, NULL),
('820425454', 'W12024666', 'W12024666', 'ID01', 'Boise Anesthesia PA', 'Carl', 'M', 'Smagula', 'MD', 'Anesthesiology', '', '', NULL, 'B', 'PO Box 4268', 'Portland', 'Multnomah', 'OR', '97208', '8002758752', NULL, 'PO Box 4268   ', 'Portland', 'Multnomah', 'OR', '97208', '8002758752', '          ', 'IDSAMG3', '', '', '60.97', '10.00', '0.00', 3, '2011-07-01', '2012-06-30', 1, 15, 0, 'Saint Alphonsus Medical Center Nampa', '', 'West Valley Medical Center', '', 'HCFA|UB|', '1568414100', 0, 'N', 0, '2012-11-01', NULL, NULL, 0, 0, NULL, NULL),
('820425454', 'W12024667', 'W12024667', 'ID01', 'Boise Anesthesia PA', 'Carl', 'M', 'Smagula', 'MD', 'Anesthesiology', '', '', NULL, 'B', 'PO Box 4268', 'Portland', 'Multnomah', 'OR', '97208', '8002758752', NULL, 'PO Box 4268    ', 'Portland', 'Multnomah', 'OR', '97208', '8002758752', '          ', 'IDSAMG3', '', '', '62.80', '10.00', '0.00', 3, '2012-07-01', NULL, 1, 15, 0, 'Saint Alphonsus Medical Center Nampa', '', 'West Valley Medical Center', '', 'HCFA|UB|', '1568414100', 0, 'N', 0, '2012-11-01', NULL, NULL, 0, 0, NULL, NULL),
('820425454', 'W12024668', 'W12024668', 'ID01', 'Boise Anesthesia PA', 'Nathan', '', 'Steenblik', 'CRNA', 'Nurse Anesthetist', '', '', NULL, 'B', 'PO Box 4268', 'Portland', 'Multnomah', 'OR', '97208', '8002758752', NULL, 'PO Box 4268   ', 'Portland', 'Multnomah', 'OR', '97208', '8002758752', '          ', 'IDSAMG3', '', '', '60.97', '10.00', '0.00', 3, '2011-07-01', '2012-06-30', 1, 15, 0, '', '', '', '', 'HCFA|UB|', '1306143185', 0, 'N', 0, '2012-11-01', NULL, NULL, 0, 0, NULL, NULL),
('820425454', 'W12024669', 'W12024669', 'ID01', 'Boise Anesthesia PA', 'Nathan', '', 'Steenblik', 'CRNA', 'Nurse Anesthetist', '', '', NULL, 'B', 'PO Box 4268', 'Portland', 'Multnomah', 'OR', '97208', '8002758752', NULL, 'PO Box 4268    ', 'Portland', 'Multnomah', 'OR', '97208', '8002758752', '          ', 'IDSAMG3', '', '', '62.80', '10.00', '0.00', 3, '2012-07-01', NULL, 1, 15, 0, '', '', '', '', 'HCFA|UB|', '1306143185', 0, 'N', 0, '2012-11-01', NULL, NULL, 0, 0, NULL, NULL),
('820425454', 'W12024670', 'W12024670', 'ID01', 'Boise Anesthesia PA', 'Joseph', '', 'Stover', 'CRNA', 'Nurse Anesthetist', '', '', NULL, 'B', 'PO Box 4268', 'Portland', 'Multnomah', 'OR', '97208', '8002758752', NULL, 'PO Box 4268   ', 'Portland', 'Multnomah', 'OR', '97208', '8002758752', '          ', 'IDSAMG3', '', '', '60.97', '10.00', '0.00', 3, '2012-01-24', '2012-06-30', 1, 15, 0, 'Saint Alphonsus Regional Medical Center', '', '', '', 'HCFA|UB|', '1720064306', 0, 'N', 0, '2012-11-01', NULL, NULL, 0, 0, NULL, NULL),
('820425454', 'W12024671', 'W12024671', 'ID01', 'Boise Anesthesia PA', 'Joseph', '', 'Stover', 'CRNA', 'Nurse Anesthetist', '', '', NULL, 'B', 'PO Box 4268', 'Portland', 'Multnomah', 'OR', '97208', '8002758752', NULL, 'PO Box 4268    ', 'Portland', 'Multnomah', 'OR', '97208', '8002758752', '          ', 'IDSAMG3', '', '', '62.80', '10.00', '0.00', 3, '2012-07-01', NULL, 1, 15, 0, 'Saint Alphonsus Regional Medical Center', '', '', '', 'HCFA|UB|', '1720064306', 0, 'N', 0, '2012-11-01', NULL, NULL, 0, 0, NULL, NULL),
('820425454', 'W12024672', 'W12024672', 'ID01', 'Boise Anesthesia PA', 'Michael', 'J', 'Suida', 'CRNA', 'Nurse Anesthetist', '', '', NULL, 'B', 'PO Box 4268', 'Portland', 'Multnomah', 'OR', '97208', '8002758752', NULL, 'PO Box 4268   ', 'Portland', 'Multnomah', 'OR', '97208', '8002758752', '          ', 'IDSAMG3', '', '', '60.97', '10.00', '0.00', 3, '2011-07-01', '2012-06-30', 1, 15, 0, '', '', '', '', 'HCFA|UB|', '1407802127', 0, 'N', 0, '2012-11-01', NULL, NULL, 0, 0, NULL, NULL),
('820425454', 'W12024673', 'W12024673', 'ID01', 'Boise Anesthesia PA', 'Michael', 'J', 'Suida', 'CRNA', 'Nurse Anesthetist', '', '', NULL, 'B', 'PO Box 4268', 'Portland', 'Multnomah', 'OR', '97208', '8002758752', NULL, 'PO Box 4268    ', 'Portland', 'Multnomah', 'OR', '97208', '8002758752', '          ', 'IDSAMG3', '', '', '62.80', '10.00', '0.00', 3, '2012-07-01', NULL, 1, 15, 0, '', '', '', '', 'HCFA|UB|', '1407802127', 0, 'N', 0, '2012-11-01', NULL, NULL, 0, 0, NULL, NULL),
('820425454', 'W12024674', 'W12024674', 'ID01', 'Boise Anesthesia PA', 'Jeffrey', '', 'Varga', 'CRNA', 'Nurse Anesthetist', '', '', NULL, 'B', 'PO Box 4268', 'Portland', 'Multnomah', 'OR', '97208', '8002758752', NULL, 'PO Box 4268   ', 'Portland', 'Multnomah', 'OR', '97208', '8002758752', '          ', 'IDSAMG3', '', '', '60.97', '10.00', '0.00', 3, '2012-04-13', '2012-06-30', 1, 15, 0, 'Saint Alphonsus Regional Medical Center', '', '', '', 'HCFA|UB|', '1306173026', 0, 'N', 0, '2012-11-01', NULL, NULL, 0, 0, NULL, NULL),
('820425454', 'W12024676', 'W12024676', 'ID01', 'Boise Anesthesia PA', 'Jeffrey', '', 'Varga', 'CRNA', 'Nurse Anesthetist', '', '', NULL, 'B', 'PO Box 4268', 'Portland', 'Multnomah', 'OR', '97208', '8002758752', NULL, 'PO Box 4268    ', 'Portland', 'Multnomah', 'OR', '97208', '8002758752', '          ', 'IDSAMG3', '', '', '62.80', '10.00', '0.00', 3, '2012-07-01', NULL, 1, 15, 0, 'Saint Alphonsus Regional Medical Center', '', '', '', 'HCFA|UB|', '1306173026', 0, 'N', 0, '2012-11-01', NULL, NULL, 0, 0, NULL, NULL),
('820425454', 'W12024677', 'W12024677', 'ID01', 'Boise Anesthesia PA', 'James', 'L', 'Ward', 'MD', 'Anesthesiology', '', '', NULL, 'B', 'PO Box 4268', 'Portland', 'Multnomah', 'OR', '97208', '8002758752', NULL, 'PO Box 4268   ', 'Portland', 'Multnomah', 'OR', '97208', '8002758752', '          ', 'IDSAMG3', '', '', '60.97', '10.00', '0.00', 3, '2001-07-01', '2012-06-30', 1, 15, 0, '', '', 'West Valley Medical Center', '', 'HCFA|UB|', '1720133085', 0, 'N', 0, '2013-07-18', NULL, NULL, 0, 0, NULL, NULL),
('820425454', 'W12024678', 'W12024678', 'ID01', 'Boise Anesthesia PA', 'James', 'L', 'Ward', 'MD', 'Anesthesiology', '', '', NULL, 'B', 'PO Box 4268', 'Portland', 'Multnomah', 'OR', '97208', '8002758752', NULL, 'PO Box 4268    ', 'Portland', 'Multnomah', 'OR', '97208', '8002758752', '          ', 'IDSAMG3', '', '', '62.80', '10.00', '0.00', 3, '2012-07-01', NULL, 1, 15, 0, '', '', 'West Valley Medical Center', '', 'HCFA|UB|', '1720133085', 0, 'N', 0, '2013-07-18', NULL, NULL, 0, 0, NULL, NULL),
('820425454', 'W12024679', 'W12024679', 'ID01', 'Boise Anesthesia PA', 'Gary', 'L', 'Weber', 'CRNA', 'Nurse Anesthetist', '', '', NULL, 'B', 'PO Box 4268', 'Portland', 'Multnomah', 'OR', '97208', '8002758752', NULL, 'PO Box 4268   ', 'Portland', 'Multnomah', 'OR', '97208', '8002758752', '          ', 'IDSAMG3', '', '', '60.97', '10.00', '0.00', 3, '2011-07-01', '2012-06-30', 1, 15, 0, '', '', '', '', 'HCFA|UB|', '1578510236', 0, 'N', 0, '2012-11-01', NULL, NULL, 0, 0, NULL, NULL),
('820425454', 'W12024680', 'W12024680', 'ID01', 'Boise Anesthesia PA', 'Gary', 'L', 'Weber', 'CRNA', 'Nurse Anesthetist', '', '', NULL, 'B', 'PO Box 4268', 'Portland', 'Multnomah', 'OR', '97208', '8002758752', NULL, 'PO Box 4268    ', 'Portland', 'Multnomah', 'OR', '97208', '8002758752', '          ', 'IDSAMG3', '', '', '62.80', '10.00', '0.00', 3, '2012-07-01', NULL, 1, 15, 0, '', '', '', '', 'HCFA|UB|', '1578510236', 0, 'N', 0, '2012-11-01', NULL, NULL, 0, 0, NULL, NULL),
('820425454', 'W12024681', 'W12024681', 'ID01', 'Boise Anesthesia PA', 'Scott', 'D', 'Westerlund', 'CRNA', 'Nurse Anesthetist', '', '', NULL, 'B', 'PO Box 4268', 'Portland', 'Multnomah', 'OR', '97208', '8002758752', NULL, 'PO Box 4268   ', 'Portland', 'Multnomah', 'OR', '97208', '8002758752', '          ', 'IDSAMG3', '', '', '60.97', '10.00', '0.00', 3, '2011-07-01', '2012-06-30', 1, 15, 0, '', '', '', '', 'HCFA|UB|', '1568403186', 0, 'N', 0, '2012-11-01', NULL, NULL, 0, 0, NULL, NULL),
('820425454', 'W12024682', 'W12024682', 'ID01', 'Boise Anesthesia PA', 'Scott', 'D', 'Westerlund', 'CRNA', 'Nurse Anesthetist', '', '', NULL, 'B', 'PO Box 4268', 'Portland', 'Multnomah', 'OR', '97208', '8002758752', NULL, 'PO Box 4268    ', 'Portland', 'Multnomah', 'OR', '97208', '8002758752', '          ', 'IDSAMG3', '', '', '62.80', '10.00', '0.00', 3, '2012-07-01', NULL, 1, 15, 0, '', '', '', '', 'HCFA|UB|', '1568403186', 0, 'N', 0, '2012-11-01', NULL, NULL, 0, 0, NULL, NULL),
('820425454', 'W12024683', 'W12024683', 'ID01', 'Boise Anesthesia PA', 'Ryan', 'E', 'White', 'CRNA', 'Nurse Anesthetist', '', '', NULL, 'B', 'PO Box 4268', 'Portland', 'Multnomah', 'OR', '97208', '8002758752', NULL, 'PO Box 4268   ', 'Portland', 'Multnomah', 'OR', '97208', '8002758752', '          ', 'IDSAMG3', '', '', '60.97', '10.00', '0.00', 3, '2011-07-01', '2012-06-30', 1, 15, 0, '', '', '', '', 'HCFA|UB|', '1346449956', 0, 'N', 0, '2012-11-01', NULL, NULL, 0, 0, NULL, NULL),
('820425454', 'W12024684', 'W12024684', 'ID01', 'Boise Anesthesia PA', 'Ryan', 'E', 'White', 'CRNA', 'Nurse Anesthetist', '', '', NULL, 'B', 'PO Box 4268', 'Portland', 'Multnomah', 'OR', '97208', '8002758752', NULL, 'PO Box 4268    ', 'Portland', 'Multnomah', 'OR', '97208', '8002758752', '          ', 'IDSAMG3', '', '', '62.80', '10.00', '0.00', 3, '2012-07-01', NULL, 1, 15, 0, '', '', '', '', 'HCFA|UB|', '1346449956', 0, 'N', 0, '2012-11-01', NULL, NULL, 0, 0, NULL, NULL),
('362659620', 'W12024719', 'W12024719', 'ILCHIGSTD', 'Anointed Heallth Partners', 'Wanda', '', 'Elliott-Pearson', 'MD', 'Family Practice', '', '', NULL, 'O', '2315 E 93rd St Ste 440', 'Chicago', 'Cook', 'IL', '60617', '7737682535', '7733744079', '2315 E 93rd St Ste 440', 'Chicago', 'Cook', 'IL', '60617', '7737682535', '7733744079', 'CHIG1', 'CHIHCPCS13', '', '0.00', '35.00', '0.00', 3, '2013-01-01', NULL, 0, 0, 0, NULL, 'Little Company of Mary Hospital', '', '', 'HCFA|UB|', '1669538641', 0, 'N', 0, '2013-10-22', NULL, NULL, 41.7262, -87.5678, NULL, NULL),
('362659620', 'W12024720', 'W12024720', 'ILCHIGSTD', 'Anointed Heallth Partners', 'Diane', '', 'Schaar', 'MD', 'Pediatrics', '', '', NULL, 'O', '2315 E 93rd St Ste 440', 'Chicago', 'Cook', 'IL', '60617', '7737682535', '7733744079', '2315 E 93rd St Ste 440', 'Chicago', 'Cook', 'IL', '60617', '7737682535', '7733744079', 'CHIG1', 'CHIHCPCS13', '', '0.00', '35.00', '0.00', 3, '2013-01-01', NULL, 0, 0, 0, NULL, 'Little Company of Mary Hospital', '', '', 'HCFA|UB|', '1164436275', 0, 'N', 0, '2012-12-20', NULL, NULL, 41.7262, -87.5678, NULL, NULL),
('362659620', 'W12024721', 'W12024721', 'ILCHIGSTD', 'Anointed Health Partners', 'Patricia', 'D', 'Damper', 'MD', 'Internal Medicine', '', '', NULL, 'O', '2315 E 93rd St Ste 440', 'Chicago', 'Cook', 'IL', '60617', '7737682535', '7733744079', '2315 E 93rd St Ste 440', 'Chicago', 'Cook', 'IL', '60617', '7737682535', '7733744079', 'CHIG1', 'CHIHCPCS13', '', '0.00', '35.00', '0.00', 3, '2013-01-01', NULL, 0, 0, 0, NULL, 'Little Company of Mary Hospital', '', '', 'HCFA|UB|', '1023174943', 0, 'N', 0, '2014-03-11', NULL, NULL, 41.7262, -87.5678, NULL, NULL),
('760053696', 'W12024722', 'W12024722', 'TXHOUSTD', 'North Houston Nephrology', '', '', 'North Houston Nephrology', '', 'Nephrology', '', '', NULL, 'O', '607 Timberdale Ln Ste 201', 'Houston', 'Harris', 'TX', '77090', '2814403005', '2814449070', '607 Timberdale Ln Ste 201', 'Houston', 'Harris', 'TX', '77090', '2814403005', '2814449070', 'HOUSTON4', 'TXHCPC13', '', '0.00', '45.00', '0.00', 3, '2013-01-01', NULL, 0, 0, 0, '', '', '', '', 'HCFA|UB|', '0000009959', 0, 'Y', 0, '2013-03-30', NULL, NULL, 30.0213, -95.4381, NULL, NULL),
('208670470', 'W12024723', 'W12024723', 'UT01', 'Heart of Dixie Cardiology', 'Gregory', 'D', 'Price', 'MD', 'Cardiovascular Disease', '', '', NULL, 'B', 'PO Box 540610', 'North Salt Lake', 'Davis', 'UT', '84054', '8014516060', NULL, 'PO Box 540610  ', 'North Salt Lake', 'Davis', 'UT', '84054', '8014516060', '', 'WUSTDCARD5', 'WUSTDHCPC5', '', '0.00', '35.00', '0.00', 3, '2012-11-26', NULL, 0, 0, 0, 'Dixie Regional Medical Center', '', '', '', 'HCFA|UB|', '1699761106', 0, 'N', 0, '2014-04-16', NULL, NULL, 0, 0, NULL, NULL),
('208670470', 'W12024724', 'W12024724', 'UT01', 'Heart of Dixie Cardiology', 'David', 'C', 'Boorman', 'MD', 'Cardiovascular Disease', '', '', NULL, 'B', 'PO Box 540610', 'North Salt Lake', 'Davis', 'UT', '84054', '8014516060', NULL, 'PO Box 540610   ', 'North Salt Lake', 'Davis', 'UT', '84054', '8014516060', '          ', 'WUSTDCARD5', 'WUSTDHCPC5', '', '0.00', '35.00', '0.00', 3, '2012-11-26', NULL, 0, 0, 0, 'Dixie Regional Medical Center', NULL, NULL, NULL, 'HCFA|UB|', '1659344471', 0, 'N', 0, '2013-10-31', NULL, NULL, 0, 0, NULL, NULL),
('208670470', 'W12024725', 'W12024725', 'UT01', 'Heart of Dixie Cardiology', 'Mary', 'A', 'McDonnell', 'MD', 'Cardiovascular Disease', '', '', NULL, 'B', 'PO Box 540610', 'North Salt Lake', 'Davis', 'UT', '84054', '8014516060', NULL, 'PO Box 540610   ', 'North Salt Lake', 'Davis', 'UT', '84054', '8014516060', '          ', 'WUSTDCARD5', 'WUSTDHCPC5', '', '0.00', '35.00', '0.00', 3, '2012-11-26', NULL, 0, 0, 0, 'Dixie Regional Medical Center', NULL, NULL, NULL, 'HCFA|UB|', '1316126410', 0, 'N', 0, '2012-11-05', NULL, NULL, 0, 0, NULL, NULL),
('208670470', 'W12024726', 'W12024726', 'UT01', 'Heart of Dixie Cardiology', 'Jamison', 'C', 'Jones', 'MD', 'Cardiovascular Disease', '', '', NULL, 'B', 'PO Box 540610', 'North Salt Lake', 'Davis', 'UT', '84054', '8014516060', NULL, 'PO Box 540610   ', 'North Salt Lake', 'Davis', 'UT', '84054', '8014516060', '          ', 'WUSTDCARD5', 'WUSTDHCPC5', '', '0.00', '35.00', '0.00', 3, '2012-11-26', NULL, 0, 0, 0, 'Dixie Regional Medical Center', NULL, NULL, NULL, 'HCFA|UB|', '1205031549', 0, 'N', 0, '2013-12-06', NULL, NULL, 0, 0, NULL, NULL),
('760714523', 'W12024732', 'W12024732', 'TXSATSTD', 'Mission Trail Baptist Hospital', '', '', 'South East Baptist Hospital', '', 'Hospital', '', '', NULL, 'O', '3333 Reserach Plaza', 'San Antonio', 'Bexar', 'TX', '78235', '2102973000', NULL, '3333 Reserach Plaza  ', 'San Antonio', 'Bexar', 'TX', '78235', '2102973000', '          ', '', '', 'Baptist', '0.00', '100.00', '0.00', 3, '2012-10-29', NULL, 0, 0, 0, '', '', '', '', 'HCFA|UB|', '0000008828', 0, 'N', 0, '2012-11-06', NULL, NULL, 29.3444, -98.4362, NULL, NULL),
('202630141', 'W12024733', 'W12024733', 'ID02', 'Primary Health Medical Group-Nampa Clinic', 'Scott', '', 'Frisby', 'PA', 'Family Practice', '', '', NULL, 'O', '700 Caldwell Blvd', 'Nampa', 'Canyon', 'ID', '83651', '2084666567', NULL, '700 Caldwell Blvd  ', 'Nampa', 'Canyon', 'ID', '83651', '2084666567', '          ', 'IDSTDPPO', 'WUSTDHCPC5', '', '0.00', '30.00', '0.00', 3, '2012-10-29', '2013-02-28', 0, 0, 1, 'Saint Alphonsus Medical Center Nampa', NULL, NULL, NULL, 'HCFA|UB|', '1982857702', 0, 'N', 0, '2013-02-28', NULL, NULL, 43.5968, -116.59, NULL, NULL),
('202630141', 'W12024734', 'W12024734', 'ID02', 'Primary Health Medical Group-Nampa Clinic', 'Scott', '', 'Frisby', 'PA', 'Family Practice', '', '', NULL, 'B', 'PO Box 191050', 'Boise', 'Ada', 'ID', '83719', '2084666567', NULL, 'PO Box 191050   ', 'Boise', 'Ada', 'ID', '83719', '2084666567', '          ', 'IDSTDPPO', 'WUSTDHCPC5', '', '0.00', '30.00', '0.00', 3, '2012-10-29', '2013-02-28', 0, 0, 1, 'Saint Alphonsus Medical Center Nampa', NULL, NULL, NULL, 'HCFA|UB|', '1982857702', 0, 'N', 0, '2013-02-28', NULL, NULL, 0, 0, NULL, NULL),
('202006175', 'W12024608', 'W12024608', 'TXSATSTD', 'Nix Health Care', 'Guillermo', '', 'Rocha', 'MD', 'Internal Medicine', '', '', NULL, 'O', '3408 Roosevelt Ave', 'San Antonio', 'Bexar', 'TX', '78214', '2109225922', '2109245600', '3408 Roosevelt Ave  ', 'San Antonio', 'Bexar', 'TX', '78214', '2109225922', '2109245600', 'SANANTONIO1', 'TXHCPC13', '', '0.00', '45.00', '0.00', 3, '2030-01-01', NULL, 0, 0, 0, '', '', '', '', 'HCFA|UB|', '1508900622', 0, 'N', 1, '2012-12-03', NULL, NULL, 0, 0, NULL, NULL),
('201234588', 'W12024735', 'W12024735', 'TXHOUSTD', 'Family Tree Health Clinic', 'Alvaro', 'F', 'Zamora', 'MD', 'Family Practice', '', '', NULL, 'O', '2911 S Shore Blvd Ste 190', 'League City', 'Galveston', 'TX', '77573', '2815388188', '2815388189', '2911 S Shore Blvd Ste 190', 'League City', 'Galveston', 'TX', '77573', '2815388188', '2815388189', 'HOUSTON1', 'TXHCPC13', '', '0.00', '45.00', '0.00', 3, '2013-01-01', NULL, 0, 0, 0, 'Clear Lake Regional Medical Center', NULL, NULL, NULL, 'HCFA|UB|', '1285736900', 0, 'N', 0, '2012-12-17', NULL, NULL, 29.5407, -95.063, NULL, NULL),
('271437001', 'W12024736', 'W12024736', 'TXHOUSTD', 'Regent Family Practice ', 'Nathan', 'P', 'Nguyen', 'MD', 'Family Practice', '', '', NULL, 'O', '2022 Regional Medical Dr Ste 1315', 'Wharton', 'Wharton', 'TX', '77488', '9795322000', '9795322008', '2022 Regional Medical Dr Ste 1315', 'Wharton', 'Wharton', 'TX', '77488', '9795322000', '9795322008', 'HOUSTON1', 'TXHCPC13', '', '0.00', '45.00', '0.00', 3, '2013-05-22', NULL, 0, 0, 0, NULL, NULL, '', '', 'HCFA|UB|', '1336393156', 0, 'N', 0, '2014-04-28', NULL, NULL, 29.3601, -96.1037, NULL, NULL),
('450581588', 'W12024737', 'W12024737', 'TXHOUSTD', 'Family Dermatology & Skin Care Center', 'Isabella', 'K', 'Gyening', 'MD', 'Dermatology', '', '', NULL, 'O', '10905 Memorial Hermann', 'Pearland', 'Brazoria', 'TX', '77584', '2819021026', '7133401725', '10905 Memorial Hermann  ', 'Pearland', 'Brazoria', 'TX', '77584', '2819021026', '7133401725', 'HOUSTON4', 'TXHCPC13', '', '0.00', '45.00', '0.00', 3, '2013-01-01', NULL, 0, 0, 0, '', '', '', '', 'HCFA|UB|', '1417036799', 0, 'N', 0, '2013-05-31', NULL, NULL, 29.5603, -95.3892, NULL, NULL),
('223859094', 'W12024738', 'W12024738', 'WY01', 'Jackson Hole Womens Care ', 'Mary', '', 'Girling', 'MD', 'Obstetrics and Gynecology', '', '', NULL, 'O', '140 E Broadway', 'Jackson', 'Teton', 'WY', '83001', '3072011489', '3072011491', '140 E Broadway  ', 'Jackson', 'Teton', 'WY', '83001', '3072011489', '3072011491', 'WYSTD', 'WUSTDHCPC5', '', '0.00', '35.00', '0.00', 3, '2013-01-01', NULL, 0, 0, 0, NULL, '', '', '', 'HCFA|UB|', '1417904095', 0, 'N', 0, '2013-01-23', NULL, NULL, 43.48, -110.765, NULL, NULL),
('223859094', 'W12024739', 'W12024739', 'WY01', 'Jackson Hole Womens Care ', 'Mary', '', 'Girling', 'MD', 'Obstetrics and Gynecology', '', '', NULL, 'B', 'PO Box 12740', 'Jackson', 'Teton', 'WY', '83002', '3072011489', '3072011491', 'PO Box 12740   ', 'Jackson', 'Teton', 'WY', '83002', '3072011489', '3072011491', 'WYSTD', 'WUSTDHCPC5', '', '0.00', '35.00', '0.00', 3, '2013-01-01', NULL, 0, 0, 0, NULL, '', '', '', 'HCFA|UB|', '1417904095', 0, 'N', 0, '2013-01-23', NULL, NULL, 0, 0, NULL, NULL),
('274294367', 'W12024740', 'W12024740', 'ID01', 'Remedy Counseling Center', 'Jamie ', 'L', 'Weiszhaar', 'LPC', 'Mental Health', 'Counseling', '', NULL, 'O', '750 W Ustick Rd Ste 120', 'Meridian', 'Ada', 'ID', '83646', '2083661601', '2083661602', '750 W Ustick Rd Ste 120', 'Meridian', 'Ada', 'ID', '83646', '2083661601', '2083661602', 'IDMA', '', '', '0.00', '35.00', '0.00', 3, '2013-01-01', '2013-02-14', 0, 0, 0, '', '', '', '', 'HCFA|UB|', '1437405271', 0, 'N', 0, '2013-05-07', NULL, NULL, 0, 0, NULL, NULL),
('272432685', 'W12024609', 'W12024609', 'TXSATSTD', 'Sara Apsley Ambriz MD', 'Sara', '', 'Apsley-Ambriz', 'DO', 'Family Practice', '', '', NULL, 'O', '4435 De Zavala Rd', 'San Antonio', 'Bexar', 'TX', '78249', '2106944081', '2106968053', '4435 De Zavala Rd  ', 'San Antonio', 'Bexar', 'TX', '78249', '2106944081', '2106968053', 'SANANTONIO1', 'TXHCPC13', '', '0.00', '45.00', '0.00', 3, '2013-01-01', NULL, 0, 0, 0, 'St Lukes Baptist Hospital', NULL, NULL, NULL, 'HCFA|UB|', '1942205919', 0, 'N', 0, '2013-05-28', NULL, NULL, 29.5726, -98.5712, NULL, NULL),
('364236074', 'W12024742', 'W12024742', 'ILCHIGSTD', 'Talcott Primary Care', '', '', 'Talcott Primary Care', '', 'Clinics', '', '', NULL, 'O', '7447 W Talcott Ave Ste 409 415', 'Chicago', 'Cook', 'IL', '60631', '7737633808', '7737632885', '7447 W Talcott Ste 409-415', 'Chicago', 'Cook', 'IL', '60631', '7737633808', '7737632885', 'CHIG11', 'CHIHCPCS13', '', '0.00', '40.00', '0.00', 3, '2013-01-01', NULL, 0, 0, 0, '', '', '', '', 'HCFA|UB|', '0000009964', 0, 'Y', 0, '2012-12-04', NULL, NULL, 41.9887, -87.8131, NULL, NULL),
('364236074', 'W12024744', 'W12024744', 'ILCHIGSTD', 'Talcott Primary Care', 'Steven', 'J', 'Pearlman', 'MD', 'Family Practice', '', '', NULL, 'O', '7447 W Talcott Ave Ste 409 415', 'Chicago', 'Cook', 'IL', '60631', '7737633808', '7737632885', '7447 W Talcott Ste 409-415', 'Chicago', 'Cook', 'IL', '60631', '7737633808', '7737632885', 'CHIG11', 'CHIHCPCS13', '', '0.00', '40.00', '0.00', 3, '2013-01-01', NULL, 0, 0, 0, 'Presence Resurrection Medical Center', NULL, NULL, NULL, 'HCFA|UB|', '1518025220', 0, 'N', 0, '2012-12-04', NULL, NULL, 41.9887, -87.8131, NULL, NULL),
('364236074', 'W12024746', 'W12024746', 'ILCHIGSTD', 'Talcott Primary Care', 'Pawan', 'K', 'Sethi', 'MD', 'Family Practice', '', '', NULL, 'O', '7447 W Talcott Ave Ste 409 415', 'Chicago', 'Cook', 'IL', '60631', '7737633808', '7737632885', '7447 W Talcott Ste 409-415', 'Chicago', 'Cook', 'IL', '60631', '7737633808', '7737632885', 'CHIG11', 'CHIHCPCS13', '', '0.00', '40.00', '0.00', 3, '2013-01-01', NULL, 0, 0, 0, 'Presence Resurrection Medical Center', NULL, NULL, NULL, 'HCFA|UB|', '1235297938', 0, 'N', 0, '2012-12-04', NULL, NULL, 41.9887, -87.8131, NULL, NULL),
('364236074', 'W12024748', 'W12024748', 'ILCHIGSTD', 'Talcott Primary Care', 'Italo', 'D', 'Pieri', 'MD', 'Internal Medicine', '', '', NULL, 'O', '7447 W Talcott Ave Ste 409 415', 'Chicago', 'Cook', 'IL', '60631', '7737633808', '7737632885', '7447 W Talcott Ste 409-415', 'Chicago', 'Cook', 'IL', '60631', '7737633808', '7737632885', 'CHIG11', 'CHIHCPCS13', '', '0.00', '40.00', '0.00', 3, '2013-01-01', NULL, 0, 0, 0, 'Presence Resurrection Medical Center', NULL, NULL, NULL, 'HCFA|UB|', '1821156548', 0, 'N', 0, '2012-12-04', NULL, NULL, 41.9887, -87.8131, NULL, NULL),
('364236074', 'W12024750', 'W12024750', 'ILCHIGSTD', 'Talcott Primary Care', 'Sarwar', '', 'Husain', 'MD', 'Internal Medicine', '', '', NULL, 'O', '7447 W Talcott Ave Ste 409 415', 'Chicago', 'Cook', 'IL', '60631', '7737633808', '7737632885', '7447 W Talcott Ave Ste 409 415', 'Chicago', 'Cook', 'IL', '60631', '7737633808', '7737632885', 'CHIG11', 'CHIHCPCS13', '', '0.00', '40.00', '0.00', 3, '2013-01-01', NULL, 0, 0, 0, 'Presence Resurrection Medical Center', NULL, NULL, NULL, 'HCFA|UB|', '1215005822', 0, 'Y', 0, '2013-07-15', NULL, NULL, 41.9887, -87.8131, NULL, NULL),
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('364094373', 'W12024755', 'W12024755', 'ILCHIGSTD', 'Vadim Edelstein MD', 'Boris', '', 'Sheynin', 'MD', 'Internal Medicine', '', '', NULL, 'O', '4555 Oakton St', 'Skokie', 'Cook', 'IL', '60076', '8479829988', '8476868899', '4555 Oakton St   ', 'Skokie', 'Cook', 'IL', '60076', '8479829988', '8476868899', 'CHIG11', 'CHIHCPCS13', '', '0.00', '40.00', '0.00', 3, '2013-01-01', NULL, 0, 0, 0, 'Presence Saint Francis Hospital', NULL, '', '', 'HCFA|UB|', '1952359440', 0, 'N', 0, '2013-05-31', NULL, NULL, 42.0262, -87.7419, NULL, NULL),
('841409176', 'W12024756', 'W12024756', 'UTMH1', 'Northeastern Counseling Center', 'Rhonda', '', 'Kamai-Kekela', 'LCSW', 'Mental Health', 'Social Worker', '', NULL, 'O', '1140 W 500 S', 'Vernal', 'Uintah', 'UT', '84078', '4357896300', NULL, '1140 W 500 S  ', 'Vernal', 'Uintah', 'UT', '84078', '4357896300', '          ', 'UTMA', '', '', '0.00', '35.00', '0.00', 6, '2013-01-01', '2013-02-14', 0, 0, 0, '', '', '', '', 'HCFA|UB|', '1538315858', 0, 'N', 0, '2013-02-27', NULL, NULL, 0, 0, NULL, NULL),
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('752831584', 'W12024762', 'W12024762', 'TXDALSTD', 'Bestawrous Family Clinic', 'Reda', '', 'Bestawrous', 'MD', 'Family Practice', '', '', NULL, 'O', '1200 Keller Pkwy Ste 100', 'Keller', 'Tarrant', 'TX', '76248', '8177418011', '8177418005', '1200 Keller Pkwy Ste 100', 'Keller', 'Tarrant', 'TX', '76248', '8177418011', '8177418005', 'DALLAS1', 'TXHCPC13', '', '0.00', '50.00', '0.00', 3, '2030-01-01', '2030-01-01', 0, 0, 0, '', '', '', '', 'HCFA|UB|', '1811995723', 0, 'N', 1, '2012-12-27', NULL, NULL, 0, 0, NULL, NULL),
('752831584', 'W12024760', 'W12024760', 'TXDALSTD', 'Rufe Snow Clinic', 'Reda', '', 'Bestawrous', 'MD', 'Family Practice', '', '', NULL, 'O', '6651 Watauga Rd Ste 104', 'Fort Worth', 'Tarrant', 'TX', '76148', '8174986944', '8175813920', '6651 Watauga Rd Ste 104', 'Fort Worth', 'Tarrant', 'TX', '76148', '8174986944', '8175813920', 'DALLAS1', 'TXHCPC13', '', '0.00', '50.00', '0.00', 3, '2030-01-01', NULL, 0, 0, 0, '', '', '', '', 'HCFA|UB|', '1811995723', 0, 'N', 1, '2012-12-27', NULL, NULL, 0, 0, NULL, NULL),
('820500162', 'W12030574', 'W12030574', 'ID01', 'Anesthesiology Consultants of ID', '', '', 'Saint Alphonsus Health Alliance PPO', '', 'Master', '', '', NULL, 'B', '104 W 5th Ave Ste 250E', 'Spokane', 'Spokane', 'WA', '99204', '2084635029', '2084635081', '104 W 5th Ave Ste 250E', 'Spokane', 'Spokane', 'WA', '99204', '2084635029', '2084635081', '', '', '', '59.62', '0.00', '0.00', 3, '2013-01-01', '2013-01-01', 0, 15, 0, '', '', '', '', 'HCFA|UB|', '0000009765', 0, 'Y', 0, '2014-01-15', NULL, NULL, 0, 0, NULL, NULL),
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('760403505', 'W12024793', 'W12024793', 'TXHOUSTD', 'Foot and Ankle Center', 'Jerry', '', 'Miles', 'DPM', 'Podiatry', '', '', NULL, 'O', '8901 FM 1960 Bypass Ste 305', 'Humble', 'Harris', 'TX', '77338', '2814467773', '2814462223', '8901 FM 1960 Bypass Ste 305', 'Humble', 'Harris', 'TX', '77338', '2814467773', '2814462223', 'HOUSTON4', 'TXHCPC13', '', '0.00', '45.00', '0.00', 3, '2013-01-01', NULL, 0, 0, 0, 'Kingwood Medical Center', NULL, NULL, NULL, 'HCFA|UB|', '1710914973', 0, 'N', 0, '2012-12-21', NULL, NULL, 30.005, -95.2895, NULL, NULL),
('751663879', 'W12024804', 'W12024804', 'TXDALSTD', 'Chiarello, Richard', 'Richard', 'A', 'Chiarello', 'MD', 'Pediatrics', '', '', NULL, 'O', '717 N Fielder Rd', 'Arlington', 'Tarrant', 'TX', '76012', '8174607911', '8174605485', '717 N Fielder Rd  ', 'Arlington', 'Tarrant', 'TX', '76012', '8174607911', '8174605485', 'DALLAS1', 'TXHCPC13', '', '0.00', '50.00', '0.00', 3, '2013-01-01', NULL, 0, 0, 0, '', '', '', '', 'HCFA|UB|', '1801843354', 0, 'N', 0, '2013-04-17', NULL, NULL, 32.7441, -97.1318, NULL, NULL),
('751639037', 'W12024805', 'W12024805', 'TXDALSTD', NULL, 'Chanramohan', '', 'Mudaliar', 'MD', 'Internal Medicine', '', '', NULL, 'O', '1220 5th Ave', 'Fort Worth', 'Tarrant', 'TX', '76104', '8173323002', '8173324320', '1220 Fifth Ave  ', 'Fort Worth', 'Tarrant', 'TX', '76104', '8173323002', '8173324320', 'DALLAS1', 'TXHCPC13', '', '0.00', '50.00', '0.00', 3, '2013-01-01', NULL, 0, 0, 0, '', '', '', '', 'HCFA|UB|', '1699749055', 0, 'N', 0, '2012-12-07', NULL, NULL, 32.7311, -97.3388, NULL, NULL),
('205984213', 'W12024807', 'W12024807', 'TXDALSTD', 'Morrill Medical Clinic', 'Thomas', 'R', 'Morrill', 'MD', 'Family Practice', '', '', NULL, 'O', '4125 Broadway Blvd Ste C120', 'Garland', 'Dallas', 'TX', '75043', '9723030861', '9723030928', '4125 Broadway Blvd Ste C-120', 'Garland', 'Dallas', 'TX', '75043', '9723030861', '9723030928', 'DALLAS1', 'TXHCPC13', '', '0.00', '50.00', '0.00', 3, '2013-01-01', NULL, 0, 0, 0, '', '', '', '', 'HCFA|UB|', '1659304327', 0, 'N', 0, '2012-12-07', NULL, NULL, 32.8638, -96.6044, NULL, NULL),
('271685543', 'W12024818', 'W12024818', 'WY01', 'All About Family Inc', '', '', 'All About Family Inc', 'GROUP', 'Home Health Agency', '', '', NULL, 'O', '195 Pronghorn', 'Casper', 'Natrona', 'WY', '82601', '3072326459', '3072338520', '195 Pronghorn  ', 'Casper', 'Natrona', 'WY', '82601', '3072326459', '3072338520', '', '', '5002', '0.00', '100.00', '0.00', 3, '2030-01-01', NULL, 0, 0, 0, '', '', '', '', 'HCFA|UB|', '1689962805', 0, 'N', 1, '2012-11-16', NULL, NULL, 0, 0, NULL, NULL),
('271685543', 'W12024820', 'W12024820', 'WY01', 'All About Family Inc', '', '', 'All About Family Inc', 'GROUP', 'Home Health Agency', '', '', NULL, 'B', 'PO Box 18', 'Evansville', 'Natrona', 'WY', '82636', '3072326459', '3072338520', 'PO Box 18   ', 'Evansville', 'Natrona', 'WY', '82636', '3072326459', '3072338520', '', '', '5002', '0.00', '100.00', '0.00', 3, '2030-01-01', NULL, 0, 0, 0, '', '', '', '', 'HCFA|UB|', '1689962805', 0, 'N', 1, '2012-11-16', NULL, NULL, 0, 0, NULL, NULL),
('271685543', 'W12024819', 'W12024819', 'WYT1', 'All About Family Inc', '', '', 'All About Family Inc', 'GROUP', 'Home Health Agency', '', '', NULL, 'O', '195 Pronghorn', 'Casper', 'Natrona', 'WY', '82601', '3072326459', '3072338520', '195 Pronghorn   ', 'Casper', 'Natrona', 'WY', '82601', '3072326459', '3072338520', '', '', '5002', '0.00', '100.00', '0.00', 3, '2030-01-01', NULL, 0, 0, 0, '', '', '', '', 'HCFA|UB|', '1689962805', 0, 'N', 1, '2012-11-16', NULL, NULL, 0, 0, NULL, NULL),
('271685543', 'W12024821', 'W12024821', 'WYT1', 'All About Family Inc', '', '', 'All About Family Inc', 'GROUP', 'Home Health Agency', '', '', NULL, 'B', 'PO Box 18', 'Evansville', 'Natrona', 'WY', '82636', '3072326459', '3072338520', 'PO Box 18    ', 'Evansville', 'Natrona', 'WY', '82636', '3072326459', '3072338520', '', '', '5002', '0.00', '100.00', '0.00', 3, '2030-01-01', NULL, 0, 0, 0, '', '', '', '', 'HCFA|UB|', '1689962805', 0, 'N', 1, '2012-11-16', NULL, NULL, 0, 0, NULL, NULL),
('870281028', 'W12024825', 'W12024825', 'UT01', 'Central Utah Clinic PC', 'Randy', '', 'Clark', 'MD', 'Orthopedic Surgery', '', '', NULL, 'O', '965 S Main St Ste A', 'Cedar City', 'Iron', 'UT', '84720', '8002399393', '4356289382', '965 S Main St Ste A', 'Cedar City', 'Iron', 'UT', '84720', '8002399393', '4356289382', 'WCUC', 'WUSTDHCPC5', '', '0.00', '35.00', '0.00', 6, '2012-10-25', NULL, 0, 0, 0, 'Dixie Regional Medical Center', NULL, NULL, NULL, 'HCFA|UB|', '1679781140', 0, 'N', 0, '2013-10-24', NULL, NULL, 37.6611, -113.07, NULL, NULL),
('870281028', 'W12024826', 'W12024826', 'UT01', 'Central Utah Clinic PC', 'David ', 'S', 'Slade', 'MD', 'Ophthalmology', '', '', NULL, 'O', '330 Falcon Ridge Pkwy Ste 400A', 'Mesquite', 'Clark', 'NV', '89027', '8002399393', '4356289382', '330 Falcon Ridge Pkwy Ste 400A', 'Mesquite', 'Clark', 'NV', '89027', '8002399393', '4356289382', 'WCUC', 'WUSTDHCPC5', '', '0.00', '35.00', '0.00', 6, '2012-11-01', NULL, 0, 0, 0, 'Dixie Regional Medical Center', NULL, NULL, NULL, 'HCFA|UB|', '1598918666', 0, 'N', 0, '2013-12-12', NULL, NULL, 36.8075, -114.113, NULL, NULL),
('870281028', 'W12024827', 'W12024827', 'UT01', 'Central Utah Clinic PC', 'Michael', '', 'Carlson', 'MD', 'Orthopedic Surgery', '', '', NULL, 'O', '1100 S Medical Dr', 'Mount Pleasant', 'Sanpete', 'UT', '84647', '8013737350', '8012245337', '1100 S Medical Dr  ', 'Mount Pleasant', 'Sanpete', 'UT', '84647', '8013737350', '8012245337', 'WCUC', 'WUSTDHCPC5', '', '0.00', '35.00', '0.00', 6, '2012-10-29', NULL, 0, 0, 0, 'Mountain View Hospital', 'Timpanogos Regional Hospital', '', '', 'HCFA|UB|', '1407076193', 0, 'N', 0, '2013-10-24', NULL, NULL, 39.5318, -111.461, NULL, NULL),
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('200364311', 'W12024829', 'W12024829', 'UT01', 'Richfield Care Center', '', '', 'Richfield Care Center', 'GROUP', 'Skilled Nursing Facility', '', '', NULL, 'O', '163 E 1000 N', 'Richfield', 'Sevier', 'UT', '84701', '4358968211', '4358968217', '163 E 1000 N  ', 'Richfield', 'Sevier', 'UT', '84701', '4358968211', '4358968217', '', '', '7', '0.00', '100.00', '0.00', 3, '2012-10-29', NULL, 0, 0, 0, '', '', '', '', 'HCFA|UB|', '0000008388', 0, 'N', 0, '2012-12-06', NULL, NULL, 0, 0, NULL, NULL),
('363741043', 'W12024833', 'W12024833', 'ILCHIGSTD', 'Allergy and Asthma Associates', '', '', 'Allergy and Asthma Associates', '', 'Allergy and Immunology', '', '', NULL, 'O', '150 W Half Day Rd Ste 200', 'Buffalo Grove', 'Lake', 'IL', '60089', '8477930777', '8477930999', '150 W Half Day Rd Ste 200', 'Buffalo Grove', 'Lake', 'IL', '60089', '8477930777', '8477930999', 'CHIG2', 'CHIHCPCS13', '', '0.00', '40.00', '0.00', 3, '2013-01-01', NULL, 0, 0, 0, '', '', '', '', 'HCFA|UB|', '1366585614', 0, 'Y', 0, '2013-05-10', NULL, NULL, 42.1959, -87.9611, NULL, NULL),
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('363741043', 'W12024834', 'W12024834', 'ILCHIGSTD', 'Allergy and Asthma Associates', '', '', 'Allergy and Asthma Associates', '', 'Allergy and Immunology', '', '', NULL, 'O', '5911 Northwest Hwy Ste 208', 'Crystal Lake', 'McHenry', 'IL', '60014', '8154557289', '8154557747', '5911 Northwest Hwy Ste 208', 'Crystal Lake', 'McHenry', 'IL', '60014', '8154557289', '8154557747', 'CHIG2', 'CHIHCPCS13', '', '0.00', '40.00', '0.00', 3, '2013-01-01', NULL, 0, 0, 0, '', '', '', '', 'HCFA|UB|', '1366585614', 0, 'Y', 0, '2013-05-10', NULL, NULL, 42.2262, -88.3145, NULL, NULL),
('870388269', 'W12025454', 'W12025454', 'UT01', 'Hand & Orthopedic Rehabilitation Specialists', 'David', 'C', 'Moss', 'PT', 'Physical Medicine and Rehabilitation', '', '', NULL, 'O', '702 E S Temple Ste 102', 'Salt Lake City', 'Salt Lake', 'UT', '84102', '8013288535', '8013641242', '702 E S Temple Ste 102', 'Salt Lake City', 'Salt Lake', 'UT', '84102', '8013288535', '8013641242', 'WestRehab', 'WUSTDHCPC5', '', '0.00', '0.00', '73.00', 3, '2012-11-01', NULL, 0, 0, 0, '', '', '', '', 'HCFA|UB|', '1982780102', 0, 'N', 0, '2012-11-20', NULL, NULL, 40.7694, -111.871, NULL, NULL),
('363741043', 'W12024839', 'W12024839', 'ILCHIGSTD', 'Allergy and Asthma Associates', 'David', '', 'Chudwin', 'MD', 'Allergy and Immunology', '', '', NULL, 'O', '5911 Northwest Hwy Ste 208', 'Crystal Lake', 'McHenry', 'IL', '60014', '8154557289', '8154557747', '5911 Northwest Hwy Ste 208', 'Crystal Lake', 'McHenry', 'IL', '60014', '8154557289', '8154557747', 'CHIG2', 'CHIHCPCS13', '', '0.00', '40.00', '0.00', 3, '2013-01-01', NULL, 0, 0, 0, 'Presence Saints Mary and Elizabeth Medical Center Saint Mary Campus', NULL, '', '', 'HCFA|UB|', '1669472262', 0, 'N', 0, '2013-04-03', NULL, NULL, 42.2262, -88.3145, NULL, NULL),
('363741043', 'W12024836', 'W12024836', 'ILCHIGSTD', 'Allergy and Asthma Associates', 'David', '', 'Chudwin', 'MD', 'Allergy and Immunology', '', '', NULL, 'O', '150 W Half Day Rd Ste 200', 'Buffalo Grove', 'Lake', 'IL', '60089', '8477930777', '8477930999', '150 W Half Day Rd Ste 200', 'Buffalo Grove', 'Lake', 'IL', '60089', '8477930777', '8477930999', 'CHIG2', 'CHIHCPCS13', '', '0.00', '40.00', '0.00', 3, '2013-01-01', NULL, 0, 0, 0, 'Presence Saints Mary and Elizabeth Medical Center Saint Mary Campus', NULL, '', '', 'HCFA|UB|', '1669472262', 0, 'N', 0, '2013-04-03', NULL, NULL, 42.1959, -87.9611, 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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('363741043', 'W12024838', 'W12024838', 'ILCHIGSTD', 'Allergy and Asthma Associates', 'David', '', 'Chudwin', 'MD', 'Allergy and Immunology', '', '', NULL, 'O', '500 Skokie Blvd Ste 140', 'Northbrook', 'Cook', 'IL', '60062', '8472724296', '8472724177', '500 Skokie Blvd Ste 140', 'Northbrook', 'Cook', 'IL', '60062', '8472724296', '8472724177', 'CHIG2', 'CHIHCPCS13', '', '0.00', '40.00', '0.00', 3, '2013-01-01', NULL, 0, 0, 0, 'Presence Saints Mary and Elizabeth Medical Center Saint Mary Campus', NULL, '', '', 'HCFA|UB|', '1669472262', 0, 'N', 0, '2013-04-03', NULL, NULL, 42.1427, -87.7948, NULL, NULL),
('202714504', 'W12025961', 'W12025961', 'TXHOUSTD', 'Dermatological Association of Texas', 'Karan', '', 'Sra', 'MD', 'Dermatology', '', '', NULL, 'O', '20320 NW Fwy Ste 700', 'Houston', 'Harris', 'TX', '77065', '7135544688', '8324785662', '20320 NW Fwy Ste 700', 'Houston', 'Harris', 'TX', '77065', '7135544688', '8324785662', 'HOUSTON1', 'TXHCPC13', '', '0.00', '45.00', '0.00', 3, '2013-01-01', NULL, 0, 0, 0, 'Houston Methodist Willowbrook Hospital', NULL, '', '', 'HCFA|UB|', '1043414634', 0, 'N', 0, '2012-12-07', NULL, NULL, 29.921, -95.6197, NULL, NULL),
('363741043', 'W12024841', 'W12024841', 'ILCHIGSTD', 'Allergy and Asthma Associates', 'Salmon', 'S', 'Goldberg', 'MD', 'Allergy and Immunology', '', '', NULL, 'O', '150 W Half Day Rd Ste 200', 'Buffalo Grove', 'Lake', 'IL', '60089', '8477930777', '8477930999', '150 W Half Day Rd Ste 200', 'Buffalo Grove', 'Lake', 'IL', '60089', '8477930777', '8477930999', 'CHIG2', 'CHIHCPCS13', '', '0.00', '40.00', '0.00', 3, '2013-01-01', NULL, 0, 0, 0, 'Presence Saints Mary and Elizabeth Medical Center Saint Mary Campus', NULL, '', '', 'HCFA|UB|', '1487674883', 0, 'N', 0, '2012-11-28', NULL, NULL, 42.1959, -87.9611, NULL, NULL),
('363741043', 'W12024842', 'W12024842', 'ILCHIGSTD', 'Allergy and Asthma Associates', 'Salmon', 'S', 'Goldberg', 'MD', 'Allergy and Immunology', '', '', NULL, 'O', '475 Brown Blvd Ste 104', 'Bourbonnais', 'Kankakee', 'IL', '60914', '8159335096', '8159335494', '475 Brown Blvd Ste 104', 'Bourbonnais', 'Kankakee', 'IL', '60914', '8159335096', '8159335494', 'CHIG2', 'CHIHCPCS13', '', '0.00', '40.00', '0.00', 3, '2013-01-01', NULL, 0, 0, 0, 'Presence Saints Mary and Elizabeth Medical Center Saint Mary Campus', NULL, '', '', 'HCFA|UB|', '1487674883', 0, 'Y', 0, '2012-11-28', NULL, NULL, 41.1618, -87.8815, NULL, NULL),
('363741043', 'W12024843', 'W12024843', 'ILCHIGSTD', 'Allergy and Asthma Associates', 'Salmon', 'S', 'Goldberg', 'MD', 'Allergy and Immunology', '', '', NULL, 'O', '500 Skokie Blvd Ste 140', 'Northbrook', 'Cook', 'IL', '60062', '8472724296', '8472724177', '500 Skokie Blvd Ste 140', 'Northbrook', 'Cook', 'IL', '60062', '8472724296', '8472724177', 'CHIG2', 'CHIHCPCS13', '', '0.00', '40.00', '0.00', 3, '2013-01-01', NULL, 0, 0, 0, 'Presence Saints Mary and Elizabeth Medical Center Saint Mary Campus', NULL, '', '', 'HCFA|UB|', '1487674883', 0, 'N', 0, '2012-11-28', NULL, NULL, 42.1427, -87.7948, NULL, NULL),
('363741043', 'W12024844', 'W12024844', 'ILCHIGSTD', 'Allergy and Asthma Associates', 'Salmon', 'S', 'Goldberg', 'MD', 'Allergy and Immunology', '', '', NULL, 'O', '5911 Northwest Hwy Ste 208', 'Crystal Lake', 'McHenry', 'IL', '60014', '8154557289', '8154557747', '5911 Northwest Hwy Ste 208', 'Crystal Lake', 'Mchenry', 'IL', '60014', '8154557289', '8154557747', 'CHIG2', 'CHIHCPCS13', '', '0.00', '40.00', '0.00', 3, '2013-01-01', NULL, 0, 0, 0, 'Presence Saints Mary and Elizabeth Medical Center Saint Mary Campus', NULL, '', '', 'HCFA|UB|', '1487674883', 0, 'N', 0, '2012-11-28', NULL, NULL, 42.2262, -88.3145, NULL, NULL),
('363741043', 'W12024849', 'W12024849', 'ILCHIGSTD', 'Allergy and Asthma Associates', 'Kathy', 'R', 'Sonenthal', 'MD', 'Allergy and Immunology', '', '', NULL, 'O', '5911 Northwest Hwy Ste 208', 'Crystal Lake', 'McHenry', 'IL', '60014', '8154557289', '8154557747', '5911 Northwest Hwy Ste 208', 'Crystal Lake', 'Mchenry', 'IL', '60014', '8154557289', '8154557747', 'CHIG2', 'CHIHCPCS13', '', '0.00', '40.00', '0.00', 3, '2013-01-01', NULL, 0, 0, 0, 'Presence Saints Mary and Elizabeth Medical Center Saint Mary Campus', NULL, '', '', 'HCFA|UB|', '1265452940', 0, 'N', 0, '2012-11-28', NULL, NULL, 42.2262, -88.3145, NULL, NULL),
('363741043', 'W12024846', 'W12024846', 'ILCHIGSTD', 'Allergy and Asthma Associates', 'Kathy', 'R', 'Sonenthal', 'MD', 'Allergy and Immunology', '', '', NULL, 'O', '150 W Half Day Rd Ste 200', 'Buffalo Grove', 'Lake', 'IL', '60089', '8477930777', '8477930999', '150 W Half Day Rd Ste 200', 'Buffalo Grove', 'Lake', 'IL', '60089', '8477930777', '8477930999', 'CHIG2', 'CHIHCPCS13', '', '0.00', '40.00', '0.00', 3, '2013-01-01', NULL, 0, 0, 0, 'Presence Saints Mary and Elizabeth Medical Center Saint Mary Campus', NULL, '', '', 'HCFA|UB|', '1265452940', 0, 'N', 0, '2012-11-28', NULL, NULL, 42.1959, -87.9611, NULL, NULL),
('363741043', 'W12024847', 'W12024847', 'ILCHIGSTD', 'Allergy and Asthma Associates', 'Kathy', 'R', 'Sonenthal', 'MD', 'Allergy and Immunology', '', '', NULL, 'O', '475 Brown Blvd Ste 104', 'Bourbonnais', 'Kankakee', 'IL', '60914', '8159335096', '8159335494', '475 Brown Blvd Ste 104', 'Bourbonnais', 'Kankakee', 'IL', '60914', '8159335096', '8159335494', 'CHIG2', 'CHIHCPCS13', '', '0.00', '40.00', '0.00', 3, '2013-01-01', NULL, 0, 0, 0, 'Presence Saints Mary and Elizabeth Medical Center Saint Mary Campus', NULL, '', '', 'HCFA|UB|', '1265452940', 0, 'Y', 0, '2012-11-28', NULL, NULL, 41.1618, -87.8815, NULL, NULL),
('363741043', 'W12024848', 'W12024848', 'ILCHIGSTD', 'Allergy and Asthma Associates', 'Kathy', 'R', 'Sonenthal', 'MD', 'Allergy and Immunology', '', '', NULL, 'O', '500 Skokie Blvd Ste 140', 'Northbrook', 'Cook', 'IL', '60062', '8472724296', '8472724177', '500 Skokie Blvd Ste 140', 'Northbrook', 'Cook', 'IL', '60062', '8472724296', '8472724177', 'CHIG2', 'CHIHCPCS13', '', '0.00', '40.00', '0.00', 3, '2013-01-01', NULL, 0, 0, 0, 'Presence Saints Mary and Elizabeth Medical Center Saint Mary Campus', NULL, '', '', 'HCFA|UB|', '1265452940', 0, 'N', 0, '2012-11-28', NULL, NULL, 42.1427, -87.7948, NULL, NULL),
('363741043', 'W12024854', 'W12024854', 'ILCHIGSTD', 'Allergy and Asthma Associates', 'John', 'K', 'Lawson', 'MD', 'Allergy and Immunology', '', '', NULL, 'O', '5911 Northwest Hwy Ste 208', 'Crystal Lake', 'McHenry', 'IL', '60014', '8154557289', '8154557747', '5911 Northwest Hwy Ste 208', 'Crystal Lake', 'McHenry', 'IL', '60014', '8154557289', '8154557747', 'CHIG2', 'CHIHCPCS13', '', '0.00', '40.00', '0.00', 3, '2013-01-01', NULL, 0, 0, 0, 'Presence Saints Mary and Elizabeth Medical Center Saint Mary Campus', NULL, '', '', 'HCFA|UB|', '1689864357', 0, 'N', 0, '2013-04-03', NULL, NULL, 42.2262, -88.3145, NULL, NULL),
('363741043', 'W12024851', 'W12024851', 'ILCHIGSTD', 'Allergy and Asthma Associates', 'John', 'K', 'Lawson', 'MD', 'Allergy and Immunology', '', '', NULL, 'O', '150 W Half Day Rd Ste 200', 'Buffalo Grove', 'Lake', 'IL', '60089', '8477930777', '8477930999', '150 W Half Day Rd Ste 200', 'Buffalo Grove', 'Lake', 'IL', '60089', '8477930777', '8477930999', 'CHIG2', 'CHIHCPCS13', '', '0.00', '40.00', '0.00', 3, '2013-01-01', NULL, 0, 0, 0, 'Presence Saints Mary and Elizabeth Medical Center Saint Mary Campus', NULL, '', '', 'HCFA|UB|', '1689864357', 0, 'N', 0, '2013-04-03', NULL, NULL, 42.1959, -87.9611, NULL, NULL),
('363741043', 'W12024852', 'W12024852', 'ILCHIGSTD', 'Allergy and Asthma Associates', 'John', 'K', 'Lawson', 'MD', 'Allergy and Immunology', '', '', NULL, 'O', '475 Brown Blvd Ste 104', 'Bourbonnais', 'Kankakee', 'IL', '60914', '8159335096', '8159335494', '475 Brown Blvd Ste 104', 'Bourbonnais', 'Kankakee', 'IL', '60914', '8159335096', '8159335494', 'CHIG2', 'CHIHCPCS13', '', '0.00', '40.00', '0.00', 3, '2013-01-01', NULL, 0, 0, 0, 'Presence Saints Mary and Elizabeth Medical Center Saint Mary Campus', NULL, '', '', 'HCFA|UB|', '1689864357', 0, 'Y', 0, '2013-04-03', NULL, NULL, 41.1618, -87.8815, NULL, NULL),
('363741043', 'W12024853', 'W12024853', 'ILCHIGSTD', 'Allergy and Asthma Associates', 'John', 'K', 'Lawson', 'MD', 'Allergy and Immunology', '', '', NULL, 'O', '500 Skokie Blvd Ste 140', 'Northbrook', 'Cook', 'IL', '60062', '8472724296', '8472724177', '500 Skokie Blvd Ste 140', 'Northbrook', 'Cook', 'IL', '60062', '8472724296', '8472724177', 'CHIG2', 'CHIHCPCS13', '', '0.00', '40.00', '0.00', 3, '2013-01-01', NULL, 0, 0, 0, 'Presence Saints Mary and Elizabeth Medical Center Saint Mary Campus', NULL, '', '', 'HCFA|UB|', '1689864357', 0, 'N', 0, '2013-04-03', NULL, NULL, 42.1427, -87.7948, NULL, NULL),
('363741043', 'W12024856', 'W12024856', 'ILCHIGSTD', 'Allergy and Asthma Associates', 'Irma', 'M', 'Oliff', 'MD', 'Allergy and Immunology', '', '', NULL, 'O', '150 W Half Day Rd Ste 200', 'Buffalo Grove', 'Lake', 'IL', '60089', '8477930777', '8477930999', '150 W Half Day Rd Ste 200', 'Buffalo Grove', 'Lake', 'IL', '60089', '8477930777', '8477930999', 'CHIG2', 'CHIHCPCS13', '', '0.00', '40.00', '0.00', 3, '2013-01-01', NULL, 0, 0, 0, 'Presence Saints Mary and Elizabeth Medical Center Saint Mary Campus', NULL, '', '', 'HCFA|UB|', '1811976475', 0, 'N', 0, '2013-03-25', NULL, NULL, 42.1959, -87.9611, NULL, NULL),
('363741043', 'W12024857', 'W12024857', 'ILCHIGSTD', 'Allergy and Asthma Associates', 'Irma', 'M', 'Oliff', 'MD', 'Allergy and Immunology', '', '', NULL, 'O', '475 Brown Blvd Ste 104', 'Bourbonnais', 'Kankakee', 'IL', '60914', '8159335096', '8159335494', '475 Brown Blvd Ste 104', 'Bourbonnais', 'Kankakee', 'IL', '60914', '8159335096', '8159335494', 'CHIG2', 'CHIHCPCS13', '', '0.00', '40.00', '0.00', 3, '2013-01-01', NULL, 0, 0, 0, 'Presence Saints Mary and Elizabeth Medical Center Saint Mary Campus', NULL, '', '', 'HCFA|UB|', '1811976475', 0, 'Y', 0, '2013-03-25', NULL, NULL, 41.1618, -87.8815, NULL, NULL),
('363741043', 'W12024858', 'W12024858', 'ILCHIGSTD', 'Allergy and Asthma Associates', 'Irma', 'M', 'Oliff', 'MD', 'Allergy and Immunology', '', '', NULL, 'O', '500 Skokie Blvd Ste 140', 'Northbrook', 'Cook', 'IL', '60062', '8472724296', '8472724177', '500 Skokie Blvd Ste 140', 'Northbrook', 'Cook', 'IL', '60062', '8472724296', '8472724177', 'CHIG2', 'CHIHCPCS13', '', '0.00', '40.00', '0.00', 3, '2013-01-01', NULL, 0, 0, 0, 'Presence Saints Mary and Elizabeth Medical Center Saint Mary Campus', NULL, '', '', 'HCFA|UB|', '1811976475', 0, 'N', 0, '2013-03-25', NULL, NULL, 42.1427, -87.7948, NULL, NULL),
('363741043', 'W12024859', 'W12024859', 'ILCHIGSTD', 'Allergy and Asthma Associates', 'Irma', 'M', 'Oliff', 'MD', 'Allergy and Immunology', '', '', NULL, 'O', '5911 Northwest Hwy Ste 208', 'Crystal Lake', 'McHenry', 'IL', '60014', '8154557289', '8154557747', '5911 Northwest Hwy Ste 208', 'Crystal Lake', 'McHenry', 'IL', '60014', '8154557289', '8154557747', 'CHIG2', 'CHIHCPCS13', '', '0.00', '40.00', '0.00', 3, '2013-01-01', NULL, 0, 0, 0, 'Presence Saints Mary and Elizabeth Medical Center Saint Mary Campus', NULL, '', '', 'HCFA|UB|', '1811976475', 0, 'N', 0, '2013-03-25', NULL, NULL, 42.2262, -88.3145, NULL, NULL),
('010885716', 'W12024860', 'W12024860', 'UTMH1', 'Riley Individual Family and Marriage Counseling', 'Noelle', 'K', 'Gardner', 'LPC', 'Mental Health', 'Counseling', '', NULL, 'O', '873 Baxter Dr', 'South Jordan', 'Salt Lake', 'UT', '84095', '8016570163', '8015687856', '873 Baxter Dr   ', 'South Jordan', 'Salt Lake', 'UT', '84095', '8016570163', '8015687856', 'UTMA', '', '', '0.00', '35.00', '0.00', 3, '2013-01-01', '2013-02-14', 0, 0, 0, '', '', '', '', 'HCFA|UB|', '1336442227', 0, 'N', 0, '2013-07-23', NULL, NULL, 0, 0, NULL, NULL),
('010885716', 'W12024861', 'W12024861', 'UTMH1', 'Riley Individual Family and Marriage Counseling', 'Noelle', 'K', 'Gardner', 'LPC', 'Mental Health', 'Counseling', '', NULL, 'B', 'PO Box 708458', 'Sandy', 'Salt Lake', 'UT', '84070', '8016570163', '8015687856', 'PO Box 708458    ', 'Sandy', 'Salt Lake', 'UT', '84070', '8016570163', '8015687856', 'UTMA', '', '', '0.00', '35.00', '0.00', 3, '2013-01-01', '2013-02-14', 0, 0, 0, '', '', '', '', 'HCFA|UB|', '1336442227', 0, 'N', 0, '2013-07-23', NULL, NULL, 0, 0, NULL, NULL),
('760585414', 'W12024862', 'W12024862', 'TXHOUSTD', 'Stephen V Day DPM', 'Stephen', '', 'Day', 'DPM', 'Podiatry', '', '', NULL, 'O', '1610 James Bowie Dr Ste A102', 'Baytown', 'Harris', 'TX', '77520', '2814271802', '2814273664', '1610 James Bowie Dr Ste A102', 'Baytown', 'Harris', 'TX', '77520', '2814271802', '2814273664', 'HOUSTON4', 'TXHCPC13', '', '0.00', '45.00', '0.00', 3, '2013-01-01', NULL, 0, 0, 0, 'Houston Methodist San Jacinto Hospital', NULL, '', '', 'HCFA|UB|', '1518063023', 0, 'N', 0, '2012-12-17', NULL, NULL, 29.7464, -94.9473, NULL, NULL),
('010953377', 'W12024863', 'W12024863', 'TXDALSTD', 'North Star Dermatology', 'Sina', '', 'Aboutalebi', 'MD', 'Dermatology', '', '', NULL, 'O', '5320 N Tarrant Pkwy Ste 200', 'Keller', 'Tarrant', 'TX', '76244', '8174273376', '8174273379', '5320 N Tarrant Pkwy Ste 200', 'Keller', 'Tarrant', 'TX', '76244', '8174273376', '8174273379', 'DALLAS4', 'TXHCPC13', '', '0.00', '50.00', '0.00', 3, '2013-01-01', NULL, 0, 0, 0, '', '', '', '', 'HCFA|UB|', '1932391232', 0, 'N', 0, '2014-07-11', NULL, NULL, 32.8948, -97.2692, NULL, NULL),
('363247253', 'W12024864', 'W12024864', 'ILCHIGSTD', 'Badowski Druzak and Jensen MDS', '', '', 'Badowski Druzak and Jensen MDS', '', 'Obstetrics and Gynecology', '', '', NULL, 'O', '10 W Martin Ste 100', 'Naperville', 'Dupage', 'IL', '60540', '6303697700', '6303697705', '10 W Martin Ste 100', 'Naperville', 'Dupage', 'IL', '60540', '6303697700', '6303697705', 'CHIG2', 'CHIHCPCS13', '', '0.00', '40.00', '0.00', 3, '2013-01-01', NULL, 0, 0, 0, '', '', '', '', 'HCFA|UB|', '1669571451', 0, 'Y', 0, '2013-09-27', NULL, NULL, 41.763, -88.1495, NULL, NULL),
('363247253', 'W12024866', 'W12024866', 'ILCHIGSTD', 'Badowski Druzak and Jensen MDS', 'Elena', '', 'Pirozhnik', 'DO', 'Obstetrics and Gynecology', '', '', NULL, 'O', '10 W Martin Ste 100', 'Naperville', 'Dupage', 'IL', '60540', '6303697700', '6303697705', '10 W Martin Ste 100', 'Naperville', 'Dupage', 'IL', '60540', '6303697700', '6303697705', 'CHIG2', 'CHIHCPCS13', '', '0.00', '40.00', '0.00', 3, '2013-01-01', NULL, 0, 0, 0, 'Edward Hospital', NULL, NULL, NULL, 'HCFA|UB|', '1073612800', 0, 'N', 0, '2013-09-27', NULL, NULL, 41.763, -88.1495, NULL, NULL),
('363247253', 'W12024868', 'W12024868', 'ILCHIGSTD', 'Badowski Druzak and Jensen MDS', 'Julie', 'R', 'Jensen', 'MD', 'Obstetrics and Gynecology', '', '', NULL, 'O', '10 W Martin Ste 100', 'Naperville', 'Dupage', 'IL', '60540', '6303697700', '6303697705', '10 W Martin Ste 100', 'Naperville', 'Dupage', 'IL', '60540', '6303697700', '6303697705', 'CHIG2', 'CHIHCPCS13', '', '0.00', '40.00', '0.00', 3, '2013-01-01', NULL, 0, 0, 0, 'Edward Hospital', NULL, NULL, NULL, 'HCFA|UB|', '1326147240', 0, 'N', 0, '2013-09-27', NULL, NULL, 41.763, -88.1495, NULL, NULL),
('363247253', 'W12024870', 'W12024870', 'ILCHIGSTD', 'Badowski Druzak and Jensen MDS', 'Karen', 'L', 'Druzak', 'MD', 'Obstetrics and Gynecology', '', '', NULL, 'O', '10 W Martin Ste 100', 'Naperville', 'Dupage', 'IL', '60540', '6303697700', '6303697705', '10 W Martin Ste 100', 'Naperville', 'Dupage', 'IL', '60540', '6303697700', '6303697705', 'CHIG2', 'CHIHCPCS13', '', '0.00', '40.00', '0.00', 3, '2013-01-01', NULL, 0, 0, 0, 'Edward Hospital', NULL, NULL, NULL, 'HCFA|UB|', '1861591612', 0, 'N', 0, '2013-09-27', NULL, NULL, 41.763, -88.1495, NULL, NULL),
('363247253', 'W12024872', 'W12024872', 'ILCHIGSTD', 'Badowski Druzak and Jensen MDS', 'Andrew', 'K', 'Badowski', 'MD', 'Obstetrics and Gynecology', '', '', NULL, 'O', '10 W Martin Ste 100', 'Naperville', 'Dupage', 'IL', '60540', '6303697700', '6303697705', '10 W Martin Ste 100', 'Naperville', 'Dupage', 'IL', '60540', '6303697700', '6303697705', 'CHIG2', 'CHIHCPCS13', '', '0.00', '40.00', '0.00', 3, '2013-01-01', NULL, 0, 0, 0, 'Edward Hospital', NULL, NULL, NULL, 'HCFA|UB|', '1104849272', 0, 'N', 0, '2013-09-27', NULL, NULL, 41.763, -88.1495, NULL, NULL),
('752770993', 'W12024873', 'W12024873', 'TXDALSTD', 'Suzanne M Smith DPM', 'Suzanne', 'M', 'Smith', 'DPM', 'Podiatry', '', '', NULL, 'O', '3136 Horizon Rd Ste 120', 'Rockwall', 'Rockwall', 'TX', '75032', '9724121347', '9724631185', '3136 Horizon Rd Ste 120', 'Rockwall', 'Rockwall', 'TX', '75032', '9724121347', '9724631185', 'DALLAS4', 'TXHCPC13', '', '0.00', '50.00', '0.00', 3, '2013-01-01', NULL, 0, 0, 0, '', '', '', '', 'HCFA|UB|', '1336317486', 0, 'N', 0, '2012-11-30', NULL, NULL, 32.8897, -96.469, NULL, NULL),
('870621745', 'W12024874', 'W12024874', 'UTMH1', 'David Christian PHD PC', 'David', 'E', 'Christian', 'PHD', 'Mental Health', 'Psychology', '', NULL, 'O', '629 S 575 W', 'Logan', 'Cache', 'UT', '84321', '4357872111', '4357539799', '629 S 575 W  ', 'Logan', 'Cache', 'UT', '84321', '4357872111', '4357539799', 'PHD', '', '', '0.00', '35.00', '0.00', 3, '2012-12-01', '2013-02-14', 0, 0, 0, '', '', '', '', 'HCFA|UB|', '1336273481', 0, 'N', 0, '2013-02-27', NULL, NULL, 0, 0, NULL, NULL),
('113696452', 'W12024875', 'W12024875', 'TXDALSTD', 'Denton', 'Rani', '', 'Anbarasu', 'MD', 'Internal Medicine', '', '', NULL, 'O', '4206 N I-35', 'Denton', 'Denton', 'TX', '76207', '9403826900', '9403821005', '4206 N Interstate 35  ', 'Denton', 'Denton', 'TX', '76207', '9403826900', '9403821005', 'DALLAS1', 'TXHCPC13', '', '0.00', '50.00', '0.00', 3, '2013-05-22', NULL, 0, 0, 0, '', '', '', '', 'HCFA|UB|', '1326252255', 0, 'N', 0, '2013-04-16', NULL, NULL, 33.234, -97.1748, NULL, NULL),
('113696452', 'W12024876', 'W12024876', 'TXDALSTD', 'Denton', 'Rani', '', 'Anbarasu', 'MD', 'Internal Medicine', '', '', NULL, 'B', 'PO Box 2446', 'Coppell', 'Dallas', 'TX', '75019', '9403826900', '9403821005', 'PO Box 2446   ', 'Coppell', 'Dallas', 'TX', '75019', '9403826900', '9403821005', 'DALLAS1', 'TXHCPC13', '', '0.00', '50.00', '0.00', 3, '2013-05-22', NULL, 0, 0, 0, '', '', '', '', 'HCFA|UB|', '1326252255', 0, 'N', 0, '2013-04-16', NULL, NULL, 0, 0, NULL, NULL),
('363833328', 'W12024877', 'W12024877', 'ILCHIGSTD', 'Oakbrook Pediatrics & Adolescent', 'Stanislava', '', 'Covfal', 'MD', 'Pediatrics', '', '', NULL, 'O', '3825 Highland Ave Tower 2 Ste 2C', 'Downers Grove', 'Dupage', 'IL', '60515', '6309716511', '6309716514', '3825 Highland Ave Ste 2C', 'Downers Grove', 'Dupage', 'IL', '60515', '6309716511', '6309716514', 'CHIG6', 'CHIHCPCS13', '', '0.00', '35.00', '0.00', 3, '2013-01-01', NULL, 0, 0, 0, NULL, NULL, '', '', 'HCFA|UB|', '1699701813', 0, 'N', 0, '2012-11-30', NULL, NULL, 41.8181, -88.0102, NULL, NULL),
('751762115', 'W12024878', 'W12024878', 'TXDALSTD', 'Passmore, James', 'James', 'A', 'Passmore ', 'MD', 'Ophthalmology', '', '', NULL, 'O', '4100 W 15th St Ste 210', 'Plano', 'Collin', 'TX', '75093', '9728677777', '9725191679', '4100 W 15th St Ste 210', 'Plano', 'Collin', 'TX', '75093', '9728677777', '9725191679', 'DALLAS4', 'TXHCPC13', '', '0.00', '50.00', '0.00', 3, '2013-01-01', NULL, 0, 0, 0, '', '', '', '', 'HCFA|UB|', '1083786479', 0, 'N', 0, '2013-04-17', NULL, NULL, 33.0177, -96.7708, NULL, NULL),
('751762115', 'W12024879', 'W12024879', 'TXDALSTD', 'Passmore, James', 'James', 'A', 'Passmore ', 'MD', 'Ophthalmology', '', '', NULL, 'O', '751 Hebron Pkwy Ste 230', 'Lewisville', 'Denton', 'TX', '75057', '9728677777', '9725191679', '751 Hebron Pkwy Ste 230', 'Lewisville', 'Denton', 'TX', '75057', '9728677777', '9725191679', 'DALLAS4', 'TXHCPC13', '', '0.00', '50.00', '0.00', 3, '2013-01-01', NULL, 0, 0, 0, '', '', '', '', 'HCFA|UB|', '1083786479', 0, 'N', 0, '2013-04-17', NULL, NULL, 33.0111, -96.9671, NULL, NULL),
('529355872', 'W12024880', 'W12024880', 'UT01', '', 'Nicholas', 'G', 'Hanson', 'MD', 'Family Practice', '', '', NULL, 'O', '230 N Hospital Dr Ste 4', 'Price', 'Carbon', 'UT', '84501', '4356372300', '4356371581', '230 N Hospital Dr Ste 4', 'Price', 'Carbon', 'UT', '84501', '4356372300', '4356371581', 'WISESTD', 'WUSTDHCPC5', '', '0.00', '35.00', '0.00', 3, '2013-02-15', '2013-02-15', 0, 0, 0, 'Castleview Hospital', 'Castleview Hospital', NULL, NULL, 'HCFA|UB|', '1710149794', 0, 'N', 0, '2013-03-27', NULL, NULL, 0, 0, NULL, NULL),
('529355872', 'W12024881', 'W12024881', 'UT01', '', 'Nicholas', 'G', 'Hanson', 'MD', 'Family Practice', '', '', NULL, 'B', 'PO Box 150610', 'Ogden', 'Weber', 'UT', '84415', '4356372300', '4356371581', 'PO Box 150610  ', 'Ogden', 'Weber', 'UT', '84415', '4356372300', '4356371581', 'WISESTD', 'WUSTDHCPC5', '', '0.00', '35.00', '0.00', 3, '2013-02-15', '2013-02-15', 0, 0, 0, 'Castleview Hospital', 'Castleview Hospital', NULL, NULL, 'HCFA|UB|', '1710149794', 0, 'N', 0, '2013-03-27', NULL, NULL, 0, 0, NULL, NULL),
('760729599', 'W12024882', 'W12024882', 'TXDALSTD', 'Karen Benz DO', 'Karen', '', 'Benz', 'DO', 'Obstetrics and Gynecology', '', '', NULL, 'O', '1250 8th Ave Ste 270', 'Fort Worth', 'Tarrant', 'TX', '76104', '8179279100', '8179299103', '1250 8th Ave Ste 270', 'Fort Worth', 'Tarrant', 'TX', '76104', '8179279100', '8179299103', 'DALLAS3', 'TXHCPC13', '', '0.00', '50.00', '0.00', 3, '2013-01-01', NULL, 0, 0, 0, 'Baylor Medical Center at Waxahachie', NULL, NULL, NULL, 'HCFA|UB|', '1407802093', 0, 'N', 0, '2013-06-04', NULL, NULL, 32.7312, -97.3437, NULL, NULL),
('363525049', 'W12024883', 'W12024883', 'ID02', 'West Valley Clinic at Middleton', 'Steven', 'B', 'Ollie', 'MD', 'Family Practice', '', '', NULL, 'O', '381 S Middleton Rd Ste B', 'Middleton', 'Canyon', 'ID', '83644', '2085856311', '2085856221', '381 S Middleton Rd Ste B', 'Middleton', 'Canyon', 'ID', '83644', '2085856311', '2085856221', 'IDACN', '', '', '0.00', '15.00', '0.00', 6, '2012-10-29', '2012-10-29', 0, 0, 1, 'West Valley Medical Center', NULL, NULL, NULL, 'HCFA|UB|', '1568432888', 0, 'N', 0, '2013-12-05', NULL, NULL, 0, 0, NULL, NULL),
('621560557', 'W12025187', 'W12025187', 'ID02', 'West Valley Clinic at Wilder', 'Steven', 'B', 'Ollie', 'MD', 'Family Practice', '', '', NULL, 'O', '124 5th St Ste A', 'Wilder', 'Canyon', 'ID', '83676', '2084827430', '2084827272', '124 5th St Ste A', 'Wilder', 'Canyon', 'ID', '83676', '2084827430', '2084827272', 'IDACN', '', '', '0.00', '15.00', '0.00', 3, '2012-10-29', '2013-07-24', 0, 0, 1, 'West Valley Medical Center', NULL, NULL, NULL, 'HCFA|UB|', '1568432888', 0, 'N', 0, '2013-11-12', NULL, NULL, 0, 0, NULL, NULL),
('381966107', 'W12024885', 'W12024885', 'ID02', 'Four Rivers DaVita Office', 'Nicholas', 'C', 'Hunt', 'MD', 'Nephrology', '', '', NULL, 'O', '515 E Ln', 'Ontario', 'Malheur', 'OR', '97914', '2083673370', '2083673332', '515 E Ln  ', 'Ontario', 'Malheur', 'OR', '97914', '2083673370', '2083673332', 'IDACN', '', '', '0.00', '15.00', '0.00', 3, '2012-09-01', NULL, 0, 0, 1, 'Saint Alphonsus Medical Center Nampa', NULL, '', '', 'HCFA|UB|', '1780621771', 0, 'N', 0, '2014-03-26', NULL, NULL, 0, 0, NULL, NULL),
('381966107', 'W12024886', 'W12024886', 'ID02', 'Four Rivers DaVita Office', 'Nicholas', 'C', 'Hunt', 'MD', 'Nephrology', '', '', NULL, 'B', '46640 Schieherr Rd', 'Utica', 'Macomb', 'MI', '48315', '5862474300', '0000000000', '46640 Schieherr Rd   ', 'Utica', 'Macomb', 'MI', '48315', '5862474300', '0000000000', 'IDACN', '', '', '0.00', '15.00', '0.00', 3, '2012-09-01', NULL, 0, 0, 1, 'Saint Alphonsus Medical Center Nampa', NULL, '', '', 'HCFA|UB|', '1780621771', 0, 'N', 0, '2014-03-26', NULL, NULL, 0, 0, NULL, NULL),
('381966107', 'W12024887', 'W12024887', 'ID02', 'Four Rivers DaVita Office', 'Christopher', '', 'Sjoberg', 'NPC', 'Nurse Practitioner', '', '', NULL, 'O', '515 E Ln', 'Ontario', 'Malheur', 'OR', '97914', '2083673370', '2083673332', '515 E Ln   ', 'Ontario', 'Malheur', 'OR', '97914', '2083673370', '2083673332', 'IDACN', '', '', '0.00', '15.00', '0.00', 3, '2012-09-01', NULL, 0, 0, 1, 'Saint Alphonsus Regional Medical Center', NULL, NULL, NULL, 'HCFA|UB|', '1235122284', 0, 'N', 0, '2012-11-08', NULL, NULL, 0, 0, NULL, NULL),
('381966107', 'W12025183', 'W12025183', 'ID02', 'DaVita Caldwell Dialysis Center', 'Christopher', '', 'Sjoberg', 'NPC', 'Nurse Practitioner', '', '', NULL, 'O', '821 S Smeed Pkwy', 'Caldwell', 'Canyon', 'ID', '83605', '2083673370', '2083673332', '821 S Smeed Pkwy   ', 'Caldwell', 'Canyon', 'ID', '83605', '2083673370', '2083673332', 'IDACN', '', '', '0.00', '15.00', '0.00', 3, '2012-09-01', NULL, 0, 0, 1, 'Saint Alphonsus Regional Medical Center', NULL, NULL, NULL, 'HCFA|UB|', '1235122284', 0, 'N', 0, '2014-03-18', NULL, NULL, 0, 0, NULL, NULL),
('381966107', 'W12024889', 'W12024889', 'ID02', 'DaVita Caldwell Dialysis Center', 'Christopher', '', 'Sjoberg', 'NPC', 'Nurse Practitioner', '', '', NULL, 'O', '846 Park Centre Way', 'Nampa', 'Canyon', 'ID', '83651', '2083673370', '2083673332', '846 Park Centre Way    ', 'Nampa', 'Canyon', 'ID', '83651', '2083673370', '2083673332', 'IDACN', '', '', '0.00', '15.00', '0.00', 3, '2012-09-01', NULL, 0, 0, 1, 'Saint Alphonsus Regional Medical Center', NULL, NULL, NULL, 'HCFA|UB|', '1235122284', 0, 'N', 0, '2014-03-18', NULL, NULL, 0, 0, NULL, NULL),
('942938348', 'W40006835', 'W40006835', 'UTMH1', 'Valley Mental Health  Inc', 'CHRISTINA B', NULL, 'NILSON', 'LCSW', 'Mental Health', 'Social Worker', '', NULL, 'B', '5965 S 900 E Ste 430', 'Salt Lake City', 'Salt Lake', 'UT', '84121', '8012637100', NULL, NULL, NULL, NULL, NULL, NULL, NULL, NULL, 'UTVMHMA', NULL, NULL, '0.00', '40.00', '0.00', 6, '2013-02-15', NULL, NULL, 0, NULL, NULL, NULL, NULL, NULL, 'HCFA|UB|', '1992776413', 0, 'Y', 0, '2013-02-28', NULL, NULL, 0, 0, NULL, NULL),
('381966107', 'W12024891', 'W12024891', 'ID02', 'Nampa DaVita Clinic', 'Michael', 'C', 'Mallea', 'MD', 'Nephrology', '', '', NULL, 'B', '45640 Schoenherr Rd', 'Utica', 'Macomb', 'MI', '48315', '5862474300', '0000000000', '45640 Schoenherr Rd  ', 'Utica', 'Macomb', 'MI', '48315', '5862474300', '0000000000', 'IDACN', '', '', '0.00', '15.00', '0.00', 3, '2012-09-01', NULL, 0, 0, 1, 'Saint Alphonsus Medical Center Nampa', NULL, '', '', 'HCFA|UB|', '1043235377', 0, 'N', 0, '2014-03-26', NULL, NULL, 0, 0, NULL, NULL),
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('621801973', 'W12025019', 'W12025019', 'UT01', 'Physician Group of Utah', 'Stephen', 'T', 'Kirk', 'MD', 'Sports Medicine', '', '', NULL, 'B', 'PO Box 281415', 'Atlanta', 'Fulton', 'GA', '30384', '8019843418', '8019843479', 'PO Box 281415  ', 'Atlanta', 'Fulton', 'GA', '30384', '8019843418', '8019843479', 'WUSTDINT5', 'WUSTDHCPC5', '', '0.00', '35.00', '0.00', 6, '2012-07-01', '2014-04-30', 0, 0, 0, 'Salt Lake Regional Medical Center', 'St Marks Hospital', NULL, NULL, 'HCFA|UB|', '1578737979', 0, 'N', 0, '2013-07-25', NULL, NULL, 0, 0, NULL, NULL),
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('760442909', 'W12025026', 'W12025026', 'TXHOUSTD', 'Southeast Houston Cardiology', 'David', 'S', 'Hamer', 'MD', 'Cardiology', '', '', NULL, 'O', '5010 Crenshaw Rd Ste 110 ', 'Pasadena', 'Harris', 'TX', '77505', '8323990400', '8323990401', '5010 Crenshaw Rd Ste 110 ', 'Pasadena', 'Harris', 'TX', '77505', '8323990400', '8323990401', 'HOUSTON2', 'TXHCPC13', '', '0.00', '45.00', '0.00', 3, '2013-01-01', NULL, 0, 0, 0, 'Bayshore Medical Center', NULL, NULL, NULL, 'HCFA|UB|', '1336176429', 0, 'N', 0, '2012-12-11', NULL, NULL, 29.6403, -95.165, NULL, NULL),
('760442909', 'W12025027', 'W12025027', 'TXHOUSTD', 'Southeast Houston Cardiology', 'David', 'S', 'Hamer', 'MD', 'Cardiology', '', '', NULL, 'O', '530 Orchard St', 'Webster', 'Harris', 'TX', '77598', '2813384004', '2815549380', '530 Orchard St   ', 'Webster', 'Harris', 'TX', '77598', '2813384004', '2815549380', 'HOUSTON2', 'TXHCPC13', '', '0.00', '45.00', '0.00', 3, '2013-01-01', NULL, 0, 0, 0, 'Bayshore Medical Center', NULL, NULL, NULL, 'HCFA|UB|', '1336176429', 0, 'N', 0, '2012-12-11', NULL, NULL, 29.5427, -95.1306, NULL, NULL),
('760442909', 'W12025030', 'W12025030', 'TXHOUSTD', 'Southeast Houston Cardiology', 'Gerard', '', 'Abreo', 'MD', 'Cardiology', '', '', NULL, 'O', '530 Orchard St', 'Webster', 'Harris', 'TX', '77598', '2813384004', '2815549380', '530 Orchard St   ', 'Webster', 'Harris', 'TX', '77598', '2813384004', '2815549380', 'HOUSTON2', 'TXHCPC13', '', '0.00', '45.00', '0.00', 3, '2013-01-01', NULL, 0, 0, 0, 'Bayshore Medical Center', NULL, NULL, NULL, 'HCFA|UB|', '1225072507', 0, 'N', 0, '2012-12-12', NULL, NULL, 29.5427, -95.1306, NULL, NULL),
('760442909', 'W12025029', 'W12025029', 'TXHOUSTD', 'Southeast Houston Cardiology', 'Gerard', '', 'Abreo', 'MD', 'Cardiology', '', '', NULL, 'O', '5010 Crenshaw Rd Ste 110 ', 'Pasadena', 'Harris', 'TX', '77505', '8323990400', '8323990401', '5010 Crenshaw Rd Ste 110 ', 'Pasadena', 'Harris', 'TX', '77505', '8323990400', '8323990401', 'HOUSTON2', 'TXHCPC13', '', '0.00', '45.00', '0.00', 3, '2013-01-01', NULL, 0, 0, 0, 'Bayshore Medical Center', NULL, NULL, NULL, 'HCFA|UB|', '1225072507', 0, 'N', 0, '2012-12-12', NULL, NULL, 29.6403, -95.165, NULL, NULL),
('760442909', 'W12025033', 'W12025033', 'TXHOUSTD', 'Southeast Houston Cardiology', 'Sathish', '', 'Cayenne', 'MD', 'Cardiology', '', '', NULL, 'O', '530 Orchard St', 'Webster', 'Harris', 'TX', '77598', '2813384004', '2815549380', '530 Orchard St   ', 'Webster', 'Harris', 'TX', '77598', '2813384004', '2815549380', 'HOUSTON2', 'TXHCPC13', '', '0.00', '45.00', '0.00', 3, '2013-01-01', NULL, 0, 0, 0, 'Bayshore Medical Center', NULL, NULL, NULL, 'HCFA|UB|', '1013964519', 0, 'N', 0, '2012-12-12', NULL, NULL, 29.5427, -95.1306, NULL, NULL),
('760442909', 'W12025032', 'W12025032', 'TXHOUSTD', 'Southeast Houston Cardiology', 'Sathish', '', 'Cayenne', 'MD', 'Cardiology', '', '', NULL, 'O', '5010 Crenshaw Rd Ste 110 ', 'Pasadena', 'Harris', 'TX', '77505', '8323990400', '8323990401', '5010 Crenshaw Rd Ste 110 ', 'Pasadena', 'Harris', 'TX', '77505', '8323990400', '8323990401', 'HOUSTON2', 'TXHCPC13', '', '0.00', '45.00', '0.00', 3, '2013-01-01', NULL, 0, 0, 0, 'Bayshore Medical Center', NULL, NULL, NULL, 'HCFA|UB|', '1013964519', 0, 'N', 0, '2012-12-12', NULL, NULL, 29.6403, -95.165, NULL, NULL),
('760442909', 'W12025036', 'W12025036', 'TXHOUSTD', 'Southeast Houston Cardiology', 'Mary', '', 'Mercado', 'MD', 'Cardiology', '', '', NULL, 'O', '530 Orchard St', 'Webster', 'Harris', 'TX', '77598', '2813384004', '2815549380', '530 Orchard St   ', 'Webster', 'Harris', 'TX', '77598', '2813384004', '2815549380', 'HOUSTON2', 'TXHCPC13', '', '0.00', '45.00', '0.00', 3, '2013-01-01', NULL, 0, 0, 0, 'Bayshore Medical Center', NULL, NULL, NULL, 'HCFA|UB|', '1366540023', 0, 'N', 0, '2012-12-11', NULL, NULL, 29.5427, -95.1306, NULL, NULL),
('760442909', 'W12025035', 'W12025035', 'TXHOUSTD', 'Southeast Houston Cardiology', 'Mary', '', 'Mercado', 'MD', 'Cardiology', '', '', NULL, 'O', '5010 Crenshaw Rd Ste 110 ', 'Pasadena', 'Harris', 'TX', '77505', '8323990400', '8323990401', '5010 Crenshaw Rd Ste 110 ', 'Pasadena', 'Harris', 'TX', '77505', '8323990400', '8323990401', 'HOUSTON2', 'TXHCPC13', '', '0.00', '45.00', '0.00', 3, '2013-01-01', NULL, 0, 0, 0, 'Bayshore Medical Center', NULL, NULL, NULL, 'HCFA|UB|', '1366540023', 0, 'N', 0, '2012-12-11', NULL, NULL, 29.6403, -95.165, NULL, NULL),
('760442909', 'W12025038', 'W12025038', 'TXHOUSTD', 'Southeast Houston Cardiology', 'Anna', 'Marie', 'Harkins Jr', 'DO', 'Cardiology', '', '', NULL, 'O', '5010 Crenshaw Rd Ste 110 ', 'Pasadena', 'Harris', 'TX', '77505', '8323990400', '8323990401', '5010 Crenshaw Rd Ste 110 ', 'Pasadena', 'Harris', 'TX', '77505', '8323990400', '8323990401', 'HOUSTON2', 'TXHCPC13', '', '0.00', '45.00', '0.00', 3, '2013-01-01', NULL, 0, 0, 0, 'Bayshore Medical Center', NULL, NULL, NULL, 'HCFA|UB|', '1316988215', 0, 'N', 0, '2012-12-11', NULL, NULL, 29.6403, -95.165, NULL, NULL),
('760442909', 'W12025039', 'W12025039', 'TXHOUSTD', 'Southeast Houston Cardiology', 'Anna', 'Marie', 'Harkins Jr', 'DO', 'Cardiology', '', '', NULL, 'O', '530 Orchard St', 'Webster', 'Harris', 'TX', '77598', '2813384004', '2815549380', '530 Orchard St   ', 'Webster', 'Harris', 'TX', '77598', '2813384004', '2815549380', 'HOUSTON2', 'TXHCPC13', '', '0.00', '45.00', '0.00', 3, '2013-01-01', NULL, 0, 0, 0, 'Bayshore Medical Center', NULL, NULL, NULL, 'HCFA|UB|', '1316988215', 0, 'N', 0, '2012-12-11', NULL, NULL, 29.5427, -95.1306, NULL, NULL),
('760442909', 'W12025041', 'W12025041', 'TXHOUSTD', 'Southeast Houston Cardiology', 'Michelle', '', 'Onorato', 'MD', 'Infectious Disease', '', '', NULL, 'O', '530 Orchard St', 'Webster', 'Harris', 'TX', '77598', '2813384004', '2815549380', '530 Orchard St   ', 'Webster', 'Harris', 'TX', '77598', '2813384004', '2815549380', 'HOUSTON2', 'TXHCPC13', '', '0.00', '45.00', '0.00', 3, '2013-01-01', '2013-05-19', 0, 0, 0, 'Bayshore Medical Center', 'Clear Lake Regional Medical Center', NULL, NULL, 'HCFA|UB|', '1417991795', 0, 'N', 0, '2013-05-20', NULL, NULL, 29.5426, -95.1313, NULL, NULL),
('800522450', 'W12025042', 'W12025042', 'UT01', 'Omega Interventional Pain', 'Whitney', '', 'Bancroft', 'FNP', 'Pain Management', '', '', NULL, 'O', '3838 S 700 E Ste 300A', 'Salt Lake City', 'Salt Lake', 'UT', '84106', '8012614988', '8012699425', '3838 S 700 E Ste 300A', 'Salt Lake City', 'Salt Lake', 'UT', '84106', '8012614988', '8012699425', 'WUSTDPAIN5', 'WUSTDHCPC5', '', '0.00', '35.00', '0.00', 3, '2030-01-01', '2030-01-01', 0, 0, 0, '', '', '', '', 'HCFA|UB|', '1447425293', 0, 'N', 1, '2013-04-15', NULL, NULL, 0, 0, NULL, NULL),
('820470652', 'W12028906', 'W12028906', 'ID02', 'Riverside Rehabilitation', 'Lena', 'J', 'Biondolillo', 'LCPC', 'Mental Health', 'Counseling', '', NULL, 'O', '7711 W Riverside Dr', 'Garden City', 'Ada', 'ID', '83714', '2088538536', '2088532929', '7711 W Riverside Dr', 'Garden City', 'Ada', 'ID', '83714', '2088538536', '2088532929', 'IDMA', '', '', '0.00', '35.00', '0.00', 6, '2013-02-15', NULL, 0, 0, 1, '', '', '', '', 'HCFA|UB|', '1861503385', 0, 'N', 0, '2014-05-21', NULL, NULL, 0, 0, NULL, NULL),
('830330554', 'W12025043', 'W12025043', 'WY01', 'Evanston Clinic', 'Carol', 'C', 'Kavanaugh', 'DO', 'Internal Medicine', '', '', NULL, 'O', '196 Arrowhead Dr Ste 2', 'Evanston', 'Uinta', 'WY', '82930', '3077838143', '3077838131', '196 Arrowhead Dr Ste 2', 'Evanston', 'Uinta', 'WY', '82930', '3077838143', '3077838131', 'WYSTD', 'WYHCPCS', '', '0.00', '35.00', '0.00', 3, '2013-01-01', NULL, 0, 0, 0, 'Evanston Regional Hospital', '', '', '', 'HCFA|UB|', '1689649444', 0, 'N', 0, '2013-06-28', NULL, NULL, 41.2435, -110.998, NULL, NULL),
('830330554', 'W12025044', 'W12025044', 'WY01', 'Evanston Clinic', 'Carol', 'C', 'Kavanaugh', 'DO', 'Internal Medicine', '', '', NULL, 'B', 'PO Box 848407', 'Boston', 'Suffolk', 'MA', '02284', '3077838143', '3077838131', 'PO Box 848407  ', 'Boston', 'Suffolk', 'MA', '02284', '3077838143', '3077838131', 'WYSTD', 'WYHCPCS', '', '0.00', '35.00', '0.00', 3, '2013-01-01', NULL, 0, 0, 0, 'Evanston Regional Hospital', '', '', '', 'HCFA|UB|', '1689649444', 0, 'N', 0, '2013-06-28', NULL, NULL, 0, 0, NULL, NULL),
('870284475', 'W12025052', 'W12025052', 'UT01', 'Granger Medical Clinic', 'Craig', '', 'Depew', 'MD', 'Family Practice', '', '', NULL, 'B', 'PO Box 70658', 'Salt Lake City', 'Salt Lake', 'UT', '84170', '8019653720', '8019653740', 'PO Box 70658  ', 'Salt Lake City', 'Salt Lake', 'UT', '84170', '8019653720', '8019653740', 'WUGRANGER5', 'WUSTDHCPC5', '', '0.00', '35.00', '0.00', 3, '2013-03-01', NULL, 0, 0, 0, 'Pioneer Valley Hospital', NULL, NULL, NULL, 'HCFA|UB|', '1376505214', 0, 'N', 0, '2013-02-12', NULL, NULL, 0, 0, NULL, NULL),
('820492308', 'W12025056', 'W12025056', 'ID02', 'Idaho Gastroenterology Associates', 'Laura', 'L', 'Hartwig', 'NP', 'Gastroenterology', '', '', NULL, 'O', '2235 E Gala St', 'Meridian', 'Ada', 'ID', '83642', '2088873724', '2088871682', '2235 E Gala St  ', 'Meridian', 'Ada', 'ID', '83642', '2088873724', '2088871682', 'IDPPONONFAC', 'WUSTDHCPC5', '', '0.00', '30.00', '0.00', 3, '2013-01-01', NULL, 0, 0, 1, '', '', '', '', 'HCFA|UB|', '1023322856', 0, 'N', 0, '2012-12-19', NULL, NULL, 0, 0, NULL, NULL),
('830330554', 'W12025045', 'W12025045', 'WY01', 'Evanston Clinic', 'Tadge', '', 'Kanjo', 'MD', 'General Surgery', '', '', NULL, 'O', '196 Arrowhead Dr Ste 6', 'Evanston', 'Uinta', 'WY', '82930', '3077838398', '3077838398', '196 Arrowhead Dr Ste 6', 'Evanston', 'Uinta', 'WY', '82930', '3077838398', '3077838398', 'WYSTD', 'WYHCPCS', '', '0.00', '35.00', '0.00', 3, '2013-04-01', NULL, 0, 0, 0, 'Evanston Regional Hospital', NULL, NULL, NULL, 'HCFA|UB|', '1710970058', 0, 'N', 0, '2013-06-28', NULL, NULL, 41.2435, -110.998, NULL, NULL),
('830330554', 'W12025046', 'W12025046', 'WY01', 'Evanston Clinic', 'Tadge', '', 'Kanjo', 'MD', 'General Surgery', '', '', NULL, 'B', 'PO Box 848407', 'Boston', 'Suffolk', 'MA', '02284', '3077838143', '3077838131', 'PO Box 848407   ', 'Boston', 'Suffolk', 'MA', '02284', '3077838143', '3077838131', 'WYSTD', 'WYHCPCS', '', '0.00', '35.00', '0.00', 3, '2013-04-01', NULL, 0, 0, 0, 'Evanston Regional Hospital', NULL, NULL, NULL, 'HCFA|UB|', '1710970058', 0, 'N', 0, '2013-06-28', NULL, NULL, 0, 0, NULL, NULL),
('850452091', 'W12025020', 'W12025020', 'NM01', 'Southwest Endoscopy', '', '', 'Southwest Endoscopy LTD', '', 'Endoscopy Center', '', '', NULL, 'O', '7788 Jefferson NE', 'Albuquerque', 'Bernalillo', 'NM', '87109', '5059991600', '5059991650', '7788 Jefferson NE  ', 'Albuquerque', 'Bernalillo', 'NM', '87109', '5059991600', '5059991650', '', '', 'NM01', '0.00', '0.00', '0.00', 3, '2012-12-01', NULL, 0, 0, 0, '', '', '', '', 'HCFA|UB|', '1871538694', 0, 'N', 0, '2012-12-19', NULL, NULL, 35.1708, -106.589, NULL, NULL),
('850452091', 'W12025021', 'W12025021', 'NM01', 'Southwest Endoscopy', '', '', 'Southwest Endoscopy LTD', '', 'Endoscopy Center', '', '', NULL, 'B', 'PO Box 912507', 'Denver', 'Denver', 'CO', '80291', '5059991600', '5059991650', 'PO Box 912507   ', 'Denver', 'Denver', 'CO', '80291', '5059991600', '5059991650', '', '', 'NM01', '0.00', '0.00', '0.00', 3, '2012-12-01', NULL, 0, 0, 0, '', '', '', '', 'HCFA|UB|', '1871538694', 0, 'N', 0, '2012-12-19', NULL, NULL, 0, 0, NULL, NULL),
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('870546501', 'W12025049', 'W12025049', 'UT01', 'Alpine Pediatrics', 'Katrina', 'L', 'Duncan', 'NP', 'Pediatrics', '', '', NULL, 'O', '77 E Commerce Dr', 'Saratoga Springs', 'Utah', 'UT', '84045', '8019229222', NULL, '77 E Commerce Dr  ', 'Saratoga Springs', 'Utah', 'UT', '84045', '8019229222', '          ', 'WUUVPN11', 'WUSTDHCPC5', '', '0.00', '35.00', '0.00', 3, '2013-01-01', NULL, 0, 0, 0, '', '', '', '', 'HCFA|UB|', '1407108939', 0, 'N', 0, '2013-07-09', NULL, NULL, 40.3848, -111.914, NULL, NULL),
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('870284475', 'W12025053', 'W12025053', 'UT01', 'Granger Medical Clinic', 'Craig', '', 'Depew', 'MD', 'Family Practice', '', '', NULL, 'O', '3181 W 9000 S', 'West Jordan', 'Salt Lake', 'UT', '84088', '8013525900', '8013525914', '3181 W 9000 S  ', 'West Jordan', 'Salt Lake', 'UT', '84088', '8013525900', '8013525914', 'WUGRANGER5', 'WUSTDHCPC5', '', '0.00', '35.00', '0.00', 3, '2013-03-01', NULL, 0, 0, 0, 'Pioneer Valley Hospital', NULL, NULL, NULL, 'HCFA|UB|', '1376505214', 0, 'N', 0, '2013-02-12', NULL, NULL, 40.5877, -111.967, NULL, NULL),
('820492308', 'W12025055', 'W12025055', 'ID02', 'Idaho Gastroenterology Associates', 'Laura', 'L', 'Hartwig', 'NP', 'Gastroenterology', '', '', NULL, 'O', '425 W Bannock St', 'Boise', 'Ada', 'ID', '83702', '2083436458', '2083435031', '425 W Bannock St  ', 'Boise', 'Ada', 'ID', '83702', '2083436458', '2083435031', 'IDPPONONFAC', 'WUSTDHCPC5', '', '0.00', '30.00', '0.00', 3, '2013-01-01', NULL, 0, 0, 1, '', '', '', '', 'HCFA|UB|', '1023322856', 0, 'N', 0, '2012-12-19', NULL, NULL, 0, 0, NULL, NULL),
('752911073', 'W12025057', 'W12025057', 'TXDALSTD', 'Humberto Lopez MD', 'Humberto', '', 'Lopez', 'MD', 'Family Practice', '', '', NULL, 'O', '10 Medical Pkwy Plz 3 Ste 208', 'Dallas', 'Dallas', 'TX', '75234', '9722439607', '9724883323', '10 Medical Pkwy Plz 3 Ste 208', 'Dallas', 'Dallas', 'TX', '75234', '9722439607', '9724883323', 'DALLAS1', 'TXHCPC13', '', '0.00', '50.00', '0.00', 3, '2013-01-01', '2013-08-14', 0, 0, 0, 'Baylor Medical Center at Carrollton', NULL, '', '', 'HCFA|UB|', '1598845885', 0, 'N', 0, '2013-11-11', NULL, NULL, 0, 0, NULL, NULL),
('751453852', 'W12025058', 'W12025058', 'TXDALSTD', 'Retina Institute of Texas', 'Gregory', 'F', 'Kozielec', 'MD', 'Ophthalmology', '', '', NULL, 'O', '1010 E I-20', 'Arlington', 'Tarrant', 'TX', '76018', '8174177769', '8174177405', '1010 E I-20    ', 'Arlington', 'Tarrant', 'TX', '76018', '8174177769', '8174177405', 'DALLAS4', 'TXHCPC13', '', '0.00', '50.00', '0.00', 3, '2013-01-01', '2013-08-14', 0, 0, 0, 'Baylor Medical Center at Irving', 'Baylor Medical Center at Waxahachie', NULL, NULL, 'HCFA|UB|', '1053379081', 0, 'N', 0, '2013-11-11', NULL, NULL, 0, 0, NULL, NULL),
('751453852', 'W12025059', 'W12025059', 'TXDALSTD', 'Retina Institute of Texas', 'Gregory', 'F', 'Kozielec', 'MD', 'Ophthalmology', '', '', NULL, 'O', '3331 Unicorn Lake Blvd', 'Denton', 'Denton', 'TX', '76210', '9403819100', '9403819106', '3331 Unicorn Lake Blvd    ', 'Denton', 'Denton', 'TX', '76210', '9403819100', '9403819106', 'DALLAS4', 'TXHCPC13', '', '0.00', '50.00', '0.00', 3, '2013-01-01', '2013-08-14', 0, 0, 0, 'Baylor Medical Center at Irving', 'Baylor Medical Center at Waxahachie', NULL, NULL, 'HCFA|UB|', '1053379081', 0, 'N', 0, '2013-11-11', NULL, NULL, 0, 0, NULL, NULL),
('751453852', 'W12025061', 'W12025061', 'TXDALSTD', 'Retina Institute of Texas', 'Gregory', 'F', 'Kozielec', 'MD', 'Ophthalmology', '', '', NULL, 'M', '3414 Oak Grove Ave', 'Dallas', 'Dallas', 'TX', '75204', '2145211153', '2142193651', '3414 Oak Grove Ave   ', 'Dallas', 'Dallas', 'TX', '75204', '2145211153', '2142193651', 'DALLAS4', 'TXHCPC13', '', '0.00', '50.00', '0.00', 3, '2013-01-01', '2013-08-14', 0, 0, 0, 'Baylor Medical Center at Irving', 'Baylor Medical Center at Waxahachie', NULL, NULL, 'HCFA|UB|', '1053379081', 0, 'N', 0, '2013-11-11', NULL, NULL, 32.8042, -96.7971, NULL, NULL),
('751453852', 'W12025060', 'W12025060', 'TXDALSTD', 'Retina Institute of Texas', 'Gregory', 'F', 'Kozielec', 'MD', 'Ophthalmology', '', '', NULL, 'B', 'PO Box 848375', 'Dallas', 'Dallas', 'TX', '75284', '2145211153', '2142193651', 'PO Box 848375    ', 'Dallas', 'Dallas', 'TX', '75284', '2145211153', '2142193651', 'DALLAS4', 'TXHCPC13', '', '0.00', '50.00', '0.00', 3, '2013-01-01', '2013-08-14', 0, 0, 0, 'Baylor Medical Center at Irving', 'Baylor Medical Center at Waxahachie', NULL, NULL, 'HCFA|UB|', '1053379081', 0, 'N', 0, '2013-11-11', NULL, NULL, 0, 0, NULL, NULL),
('752673192', 'W12025063', 'W12025063', 'TXDALSTD', '', 'Ali', '', 'Jafarian', 'DO', 'Family Practice', '', '', NULL, 'O', '1143 S Buckner Blvd', 'Dallas', 'Dallas', 'TX', '75217', '2143984690', '2143984395', '1143 S Buckner Blvd   ', 'Dallas', 'Dallas', 'TX', '75217', '2143984690', '2143984395', 'DALLAS1', 'TXHCPC13', '', '0.00', '50.00', '0.00', 3, '2030-01-01', '2030-01-01', 0, 0, 0, NULL, '', '', '', 'HCFA|UB|', '1033127873', 0, 'N', 1, '2013-11-11', NULL, NULL, 32.7323, -96.6834, NULL, NULL),
('752673192', 'W12025062', 'W12025062', 'TXDALSTD', '', 'Ali', '', 'Jafarian', 'DO', 'Family Practice', '', '', NULL, 'O', '2696 N Galloway', 'Mesquite', 'Dallas', 'TX', '75150', '9726135500', '9726135015', '2696 N Galloway  ', 'Mesquite', 'Dallas', 'TX', '75150', '9726135500', '9726135015', 'TXHCPC13', '', '', '0.00', '50.00', '0.00', 3, '2030-01-01', '2030-01-01', 0, 0, 0, NULL, '', '', '', 'HCFA|UB|', '1033127873', 0, 'N', 1, '2013-11-11', NULL, NULL, 32.8013, -96.6107, NULL, NULL),
('752673192', 'W12025064', 'W12025064', 'TXDALSTD', '', 'Ali', '', 'Jafarian', 'DO', 'Family Practice', '', '', NULL, 'B', 'PO Box 851888', 'Mesquite', 'Dallas', 'TX', '75185', '9726135500', '9726135015', 'PO Box 851888   ', 'Mesquite', 'Dallas', 'TX', '75185', '9726135500', '9726135015', 'TXHCPC13', '', '', '0.00', '50.00', '0.00', 3, '2030-01-01', '2030-01-01', 0, 0, 0, NULL, '', '', '', 'HCFA|UB|', '1033127873', 0, 'N', 1, '2013-11-11', 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
('751453852', 'W12025065', 'W12025065', 'TXDALSTD', 'Retina Institute of Texas', 'Maurice', 'G', 'Syrquin', 'MD', 'Ophthalmology', '', '', NULL, 'O', '1010 E I-20', 'Arlington', 'Tarrant', 'TX', '76018', '8174177769', '8174177405', '1010 E I-20    ', 'Arlington', 'Tarrant', 'TX', '76018', '8174177769', '8174177405', 'DALLAS4', 'TXHCPC13', '', '0.00', '50.00', '0.00', 3, '2013-01-01', '2013-08-14', 0, 0, 0, 'Baylor Medical Center at Irving', 'Baylor Medical Center at Waxahachie', NULL, NULL, 'HCFA|UB|', '1376501635', 0, 'N', 0, '2013-11-11', NULL, NULL, 0, 0, NULL, NULL),
('751453852', 'W12025066', 'W12025066', 'TXDALSTD', 'Retina Institute of Texas', 'Maurice', 'G', 'Syrquin', 'MD', 'Ophthalmology', '', '', NULL, 'O', '3331 Unicorn Lake Blvd', 'Denton', 'Denton', 'TX', '76210', '9403819100', '9403819106', '3331 Unicorn Lake Blvd     ', 'Denton', 'Denton', 'TX', '76210', '9403819100', '9403819106', 'DALLAS4', 'TXHCPC13', '', '0.00', '50.00', '0.00', 3, '2013-01-01', '2013-08-14', 0, 0, 0, 'Baylor Medical Center at Irving', 'Baylor Medical Center at Waxahachie', NULL, NULL, 'HCFA|UB|', '1376501635', 0, 'N', 0, '2013-11-11', NULL, NULL, 0, 0, NULL, NULL),
('751453852', 'W12025067', 'W12025067', 'TXDALSTD', 'Retina Institute of Texas', 'Maurice', 'G', 'Syrquin', 'MD', 'Ophthalmology', '', '', NULL, 'B', 'PO Box 848375', 'Dallas', 'Dallas', 'TX', '75284', '0000000000', '0000000000', 'PO Box 848375     ', 'Dallas', 'Dallas', 'TX', '75284', '0000000000', '0000000000', 'DALLAS4', 'TXHCPC13', '', '0.00', '50.00', '0.00', 3, '2013-01-01', '2013-08-14', 0, 0, 0, 'Baylor Medical Center at Irving', 'Baylor Medical Center at Waxahachie', NULL, NULL, 'HCFA|UB|', '1376501635', 0, 'N', 0, '2013-11-11', NULL, NULL, 0, 0, NULL, NULL),
('260553931', 'W12025073', 'W12025073', 'IDBOISTD', 'Saint Alphonsus Medical Group Orthopedics ', 'Miers', 'C', 'Johnson', 'MD', 'Orthopedic Surgery', '', '', NULL, 'O', '4400 E Flamingo Ave', 'Nampa', 'Canyon', 'ID', '83687', '2082884700', '2082884720', '4400 E Flamingo Ave   ', 'Nampa', 'Canyon', 'ID', '83687', '2082884700', '2082884720', 'IDSAMG1', '', '', '0.00', '10.00', '0.00', 6, '2012-11-01', NULL, 0, 0, 0, 'Saint Alphonsus Regional Medical Center', 'Saint Alphonsus Medical Center Nampa', '', '', 'HCFA|UB|', '1942291521', 0, 'N', 0, '2014-03-20', NULL, NULL, 43.5966, -116.519, NULL, NULL),
('260553931', 'W12025075', 'W12025075', 'IDBOISTD', 'Saint Alphonsus Medical Group Orthopedics ', 'Shane', 'A', 'Andrew', 'DO', 'Orthopedic Surgery', '', '', NULL, 'O', '4400 E Flamingo Ave', 'Nampa', 'Canyon', 'ID', '83687', '2082884700', '2082884720', '4400 E Flamingo Ave   ', 'Nampa', 'Canyon', 'ID', '83687', '2082884700', '2082884720', 'IDSAMG1', '', '', '0.00', '10.00', '0.00', 6, '2012-11-01', NULL, 0, 0, 0, 'Saint Alphonsus Regional Medical Center', 'Saint Alphonsus Medical Center Nampa', '', '', 'HCFA|UB|', '1356308316', 0, 'N', 0, '2014-03-20', NULL, NULL, 43.5966, -116.519, NULL, NULL),
('260553931', 'W12025072', 'W12025072', 'IDBOISTD', 'Saint Alphonsus Medical Group Orthopedics ', 'Miers', 'C', 'Johnson', 'MD', 'Orthopedic Surgery', '', '', NULL, 'O', '3025 W Cherry Ln', 'Meridian', 'Ada', 'ID', '83642', '2082884700', '2082884720', '3025 W Cherry Ln  ', 'Meridian', 'Ada', 'ID', '83642', '2082884700', '2082884720', 'IDSAMG1', '', '', '0.00', '10.00', '0.00', 6, '2012-11-01', '2013-07-10', 0, 0, 0, 'Saint Alphonsus Regional Medical Center', 'Saint Alphonsus Medical Center Nampa', '', '', 'HCFA|UB|', '1942291521', 0, 'N', 0, '2014-03-20', NULL, NULL, 43.6188, -116.431, NULL, NULL),
('260553931', 'W12025074', 'W12025074', 'IDBOISTD', 'Saint Alphonsus Medical Group Orthopedics', 'Shane', 'A', 'Andrew', 'DO', 'Orthopedic Surgery', '', '', NULL, 'O', '3025 W Cherry Ln', 'Meridian', 'Ada', 'ID', '83642', '2082884700', '2082884720', '3025 W Cherry Ln  ', 'Meridian', 'Ada', 'ID', '83642', '2082884700', '2082884720', 'IDSAMG1', '', '', '0.00', '10.00', '0.00', 6, '2012-11-01', NULL, 0, 0, 0, 'Saint Alphonsus Regional Medical Center', 'Saint Alphonsus Medical Center Nampa', '', '', 'HCFA|UB|', '1356308316', 0, 'N', 0, '2014-03-20', NULL, NULL, 43.6193, -116.431, NULL, NULL),
('820200895', 'W12025076', 'W12025076', 'ID01', 'Saint Alphonsus Regional Medical Center Behavioral Health', 'Kafia', 'H', 'Abbasi', 'MD', 'Psychiatry', 'Mental Health', '', 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, '2012-08-20', NULL, 0, 0, 0, 'Saint Alphonsus Regional Medical Center', NULL, NULL, NULL, 'HCFA|', '1215114897', 0, 'N', 0, '2012-11-13', NULL, NULL, 43.6062, -116.266, NULL, NULL),
('260553931', 'W12025077', 'W12025077', 'IDBOISTD', 'Saint Alphonsus Medical Group Heart Care Fruitland Health Plaza', 'Christopher', '', 'Alessi', 'MD', 'Vascular Surgery', 'Cardiovascular Disease', '', NULL, 'O', '910 NW 16th St Ste 101', 'Fruitland', 'Payette', 'ID', '83619', '2084526851', '2084522140', '910 NW 16th St Ste 101', 'Fruitland', 'Payette', 'ID', '83619', '2084526851', '2084522140', 'IDSAMG1', '', '', '0.00', '10.00', '0.00', 6, '2012-10-15', '2012-10-15', 0, 0, 0, 'Saint Alphonsus Regional Medical Center', NULL, NULL, NULL, 'HCFA|UB|', '1598726960', 0, 'N', 0, '2013-05-07', NULL, NULL, 44.0254, -116.925, NULL, NULL),
('820200895', 'W12025080', 'W12025080', 'IDBOISTD', 'Saint Alphonsus Medical Group Heart Care Fruitland Health Plaza', 'William', 'Z', 'Allen', 'PA-C', 'Family Practice', '', '', NULL, 'O', '910 NW 16th St Ste 101', 'Fruitland', 'Payette', 'ID', '83619', '2084526851', '2084522140', '910 NW 16th St Ste 101', 'Fruitland', 'Payette', 'ID', '83619', '2084526851', '2084522140', 'IDSAMG2', '', '', '0.00', '10.00', '0.00', 6, '2012-10-15', '2013-03-31', 0, 0, 0, 'Saint Alphonsus Regional Medical Center', '', '', '', 'HCFA|', '1730497520', 0, 'N', 0, '2014-07-09', NULL, NULL, 44.0254, -116.925, NULL, NULL),
('820425454', 'W12025082', 'W12025082', 'ID01', 'Anderson, Jaxon ', 'Jaxon', '', 'Anderson', 'CRNA', 'Nurse Anesthetist', '', '', NULL, 'O', '1055 N Curtis Rd', 'Boise', 'Ada', 'ID', '83706', '2083676416', '2083759530', '1055 N Curtis Rd  ', 'Boise', 'Ada', 'ID', '83706', '2083676416', '2083759530', 'IDSAMG3', '', '', '62.80', '10.00', '0.00', 3, '2012-10-29', NULL, 1, 15, 0, '', '', '', '', 'HCFA|UB|', '1043568892', 0, 'Y', 0, '2014-01-08', NULL, NULL, 43.6145, -116.254, NULL, NULL),
('820425454', 'W12025083', 'W12025083', 'ID01', 'Anderson, Jaxon ', 'Jaxon', '', 'Anderson', 'CRNA', 'Nurse Anesthetist', '', '', NULL, 'O', '1717 Arlington Ave', 'Caldwell', 'Canyon', 'ID', '83605', '2084594641', '2083759530', '1717 Arlington Ave   ', 'Caldwell', 'Canyon', 'ID', '83605', '2084594641', '2083759530', 'IDSAMG3', '', '', '62.80', '10.00', '0.00', 3, '2012-10-29', NULL, 0, 15, 0, '', '', '', '', 'HCFA|UB|', '1043568892', 0, 'N', 0, '2014-01-08', NULL, NULL, 43.6542, -116.696, NULL, NULL),
('820425454', 'W12025084', 'W12025084', 'ID01', 'Anderson, Jaxon ', 'Jaxon', '', 'Anderson', 'CRNA', 'Nurse Anesthetist', '', '', NULL, 'O', '3025 W Cherry Ln', 'Meridian', 'Ada', 'ID', '83642', '2082884700', '2083759530', '3025 W Cherry Ln    ', 'Meridian', 'Ada', 'ID', '83642', '2082884700', '2083759530', 'IDSAMG3', '', '', '62.80', '10.00', '0.00', 3, '2012-10-29', NULL, 1, 15, 0, '', '', '', '', 'HCFA|UB|', '1043568892', 0, 'N', 0, '2014-01-08', NULL, NULL, 43.6193, -116.431, NULL, NULL),
('820425454', 'W12025085', 'W12025085', 'ID01', 'Anderson, Jaxon ', 'Jaxon', '', 'Anderson', 'CRNA', 'Anesthesia', '', '', NULL, 'O', '900 N Liberty St Ste 450 ', 'Boise', 'Ada', 'ID', '83704', '2083677431', '2083759530', '900 N Liberty St Ste 450 ', 'Boise', 'Ada', 'ID', '83704', '2083677431', '2083759530', 'IDSAMG3', '', '', '62.80', '10.00', '0.00', 3, '2012-10-29', NULL, 1, 15, 0, '', '', '', '', 'HCFA|UB|', '1043568892', 0, 'N', 0, '2014-01-13', NULL, NULL, 43.6124, -116.261, NULL, NULL),
('820200895', 'W12025088', 'W12025088', 'IDBOISTD', 'Saint Alphonsus Medical Group ENT Nampa', 'Charles', '', 'Anstrand', 'PA', 'Ear, Nose and Throat', '', '', NULL, 'O', '4400 E Flamingo Ave', 'Nampa', 'Canyon', 'ID', '83687', '2082884640', '2083676085', '4400 E Flamingo Ave  ', 'Nampa', 'Canyon', 'ID', '83687', '2082884640', '2083676085', 'IDSAMG2', '', '', '0.00', '10.00', '0.00', 6, '2012-11-01', NULL, 0, 0, 0, 'Saint Alphonsus Medical Center Nampa', NULL, NULL, NULL, 'HCFA|', '1427162874', 0, 'N', 0, '2014-03-10', NULL, NULL, 43.5966, -116.519, NULL, NULL),
('460500210', 'W12025089', 'W12025089', 'IDBOISTD', 'Saint Alphonsus Oncology Physician Services', 'Laura', 'L', 'Asaro', 'NP-C', 'Oncology', 'Hematology and Oncology', 'Orthopedic Surgery', NULL, 'O', '319 E Hawaii Ave', 'Nampa', 'Canyon', 'ID', '83686', '2082884679', '2083673174', '319 E Hawaii Ave  ', 'Nampa', 'Canyon', 'ID', '83686', '2082884679', '2083673174', 'IDSAMG2', '', '', '0.00', '10.00', '0.00', 6, '2012-11-01', '2013-04-30', 0, 0, 0, '', '', '', '', 'HCFA|UB|', '1003916636', 0, 'N', 0, '2014-05-28', NULL, NULL, 43.5551, -116.57, NULL, NULL),
('260553931', 'W12025091', 'W12025091', 'IDBOISTD', 'Saint Alphonsus Medical Group Heart Care Fruitland Health Plaza', 'Frederick', 'E', 'Badke', 'MD', 'Cardiology', '', '', NULL, 'O', '910 NW 16th St Ste 101', 'Fruitland', 'Payette', 'ID', '83619', '2084526851', '2084522140', '910 NW 16th St Ste 101', 'Fruitland', 'Payette', 'ID', '83619', '2084526851', '2084522140', 'IDSAMG1', '', '', '0.00', '10.00', '0.00', 6, '2012-10-15', NULL, 0, 0, 0, 'Saint Alphonsus Regional Medical Center', '', '', '', 'HCFA|UB|', '1407814411', 0, 'N', 0, '2014-06-11', NULL, NULL, 44.0254, -116.925, NULL, NULL),
('260553931', 'W12025093', 'W12025093', 'IDBOISTD', 'Saint Alphonsus Medical Group ENT Boise', 'Donald', '', 'Beasley', 'MD', 'Ear, Nose and Throat', '', '', NULL, 'O', '901 N Curtis Rd Ste 104', 'Boise', 'Ada', 'ID', '83706', '2083676099', '2083676085', '901 N Curtis Rd Ste 104', 'Boise', 'Ada', 'ID', '83706', '2083676099', '2083676085', 'IDSAMG1', '', '', '0.00', '10.00', '0.00', 6, '2012-10-02', NULL, 0, 0, 0, 'Saint Alphonsus Medical Center Nampa', NULL, NULL, NULL, 'HCFA|UB|', '1770573750', 0, 'N', 0, '2013-10-01', NULL, NULL, 43.6126, -116.254, NULL, NULL),
('820200895', 'W12025094', 'W12025094', 'IDBOISTD', 'Saint Alphonsus Medical Group Emerald Family Medicine', 'Tricia', 'A', 'Beveridge', 'NPC', 'Pediatric Surgery', 'Family Practice', '', NULL, 'O', '910 NW 16th St Ste 101', 'Fruitland', 'Payette', 'ID', '83619', '2084526851', '2084522140', '910 NW 16th St Ste 101', 'Fruitland', 'Payette', 'ID', '83619', '2084526851', '2084522140', 'IDSAMG2', '', '', '0.00', '10.00', '0.00', 6, '2012-10-15', NULL, 0, 0, 0, '', '', '', '', 'HCFA|', '1295053189', 0, 'N', 0, '2014-06-20', NULL, NULL, 44.0254, -116.925, NULL, NULL),
('820200895', 'W12025095', 'W12025095', 'IDBOISTD', 'Saint Alphonsus Medical Group Emerald Family Medicine', 'Tricia', 'A', 'Beveridge', 'NPC', 'Pediatric Surgery', 'Family Practice', '', NULL, 'O', '6533 Emerald St', 'Boise', 'Ada', 'ID', '83704', '2083674170', '2083672968', '6533 Emerald St  ', 'Boise', 'Ada', 'ID', '83704', '2083674170', '2083672968', 'IDSAMG2', '', '', '0.00', '10.00', '0.00', 6, '2012-08-20', NULL, 0, 0, 0, '', '', '', '', 'HCFA|', '1295053189', 0, 'N', 0, '2014-06-20', NULL, NULL, 43.6119, -116.263, NULL, NULL),
('820200895', 'W12025096', 'W12025096', 'IDBOISTD', 'Saint Alphonsus Express Care Inc', 'Tricia', 'A', 'Beveridge', 'NPC', 'Pediatric Surgery', 'Family Practice', '', NULL, 'O', '4700 N Eagle Rd', 'Boise', 'Ada', 'ID', '83713', '2089384797', '2083678555', '4700 N Eagle Rd  ', 'Boise', 'Ada', 'ID', '83713', '2089384797', '2083678555', 'IDSAMG2', '', '', '0.00', '10.00', '0.00', 6, '2012-08-20', NULL, 0, 0, 0, '', '', '', '', 'HCFA|', '1295053189', 0, 'N', 0, '2014-06-20', NULL, NULL, 43.6474, -116.354, NULL, NULL),
('820200895', 'W12025097', 'W12025097', 'IDBOISTD', 'Saint Alphonsus Medical Group Elm Family Medicine', 'Tricia', 'A', 'Beveridge', 'NPC', 'Pediatric Surgery', '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, '2012-08-20', NULL, 0, 0, 0, '', '', '', '', 'HCFA|', '1295053189', 0, 'N', 0, '2014-06-20', NULL, NULL, 43.6534, -116.695, NULL, NULL),
('820200895', 'W12025098', 'W12025098', 'IDBOISTD', 'Saint Alphonsus Medical Group MHP Family Medicine ', 'Tricia', 'A', 'Beveridge', 'NPC', 'Pediatric Surgery', '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, '2012-08-20', NULL, 0, 0, 0, '', '', '', '', 'HCFA|', '1295053189', 0, 'N', 0, '2014-06-20', NULL, NULL, 43.6193, -116.431, NULL, NULL),
('820200895', 'W12025099', 'W12025099', 'IDBOISTD', 'Saint Alphonsus Medical Group Garrity Family Medicine', 'Tricia', 'A', 'Beveridge', 'NPC', 'Pediatric Surgery', 'Family Practice', '', NULL, 'O', '1200 Garrity Blvd', 'Nampa', 'Canyon', 'ID', '83687', '2084669092', '2084665322', '1200 Garrity Blvd  ', 'Nampa', 'Canyon', 'ID', '83687', '2084669092', '2084665322', 'IDSAMG2', '', '', '0.00', '10.00', '0.00', 6, '2012-08-20', NULL, 0, 0, 0, '', '', '', '', 'HCFA|', '1295053189', 0, 'N', 0, '2014-06-20', NULL, NULL, 43.5867, -116.549, NULL, NULL),
('820200895', 'W12025100', 'W12025100', 'IDBOISTD', 'Saint Alphonsus Medical Group Family Medicine Dominican', 'Tricia', 'A', 'Beveridge', 'NPC', 'Pediatric Surgery', 'Family Practice', '', NULL, 'O', '1118 Nw 16th St Ste A', 'Fruitland', 'Payette', 'ID', '83619', '2083674000', '2083674052', '1118 Nw 16th St Ste A', 'Fruitland', 'Payette', 'ID', '83619', '2083674000', '2083674052', 'IDSAMG2', '', '', '0.00', '10.00', '0.00', 6, '2012-08-20', NULL, 0, 0, 0, '', '', '', '', 'HCFA|', '1295053189', 0, 'N', 0, '2014-06-20', NULL, NULL, 44.0254, -116.928, NULL, NULL),
('820200895', 'W12025101', 'W12025101', 'ID01', 'Saint Alphonsus Regional Medical Center Behavioral Health', 'Michele', 'L', 'Boyer', '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, '2012-08-20', NULL, 0, 0, 0, 'Saint Alphonsus Regional Medical Center', NULL, NULL, NULL, 'HCFA|', '1770513939', 0, 'N', 0, '2014-06-20', NULL, NULL, 43.6062, -116.266, NULL, NULL),
('820200895', 'W12025102', 'W12025102', 'ID01', 'Saint Alphonsus Regional Medical Center Behavioral Health', 'Christopher', 'T', 'Clancy', 'MD', '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, '2012-08-20', NULL, 0, 0, 0, 'Saint Alphonsus Medical Center Nampa', '', '', '', 'HCFA|', '1669402103', 0, 'N', 0, '2014-06-20', NULL, NULL, 43.6062, -116.266, NULL, NULL),
('820200895', 'W12025103', 'W12025103', 'IDBOISTD', 'Saint Alphonsus Regional Medical Center Behavioral Health', 'Shelly', '', 'Conley Durkin', 'LCSW', 'Counseling', '', '', 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, '2012-08-20', NULL, 0, 0, 0, 'Saint Alphonsus Regional Medical Center', NULL, NULL, NULL, 'HCFA|', '1588862304', 0, 'N', 0, '2012-11-13', NULL, NULL, 43.6062, -116.266, NULL, NULL),
('260553931', 'W12025105', 'W12025105', 'IDBOISTD', 'Saint Alphonsus Gynecology Oncology', 'Amy', 'L', 'Cooper', 'MD', 'Gynecologic Oncology', '', '', NULL, 'O', '1055 N Curtis Rd', 'Boise', 'Ada', 'ID', '83706', '2083675227', '2083675225', '1055 N Curtis Rd  ', 'Boise', 'Ada', 'ID', '83706', '2083675227', '2083675225', 'IDSAMG2', '', '', '0.00', '10.00', '0.00', 6, '2012-08-20', '2012-10-17', 0, 0, 0, 'Saint Alphonsus Medical Center Nampa', NULL, '', '', 'HCFA|UB|', '1306880398', 0, 'N', 0, '2013-06-24', NULL, NULL, 43.6127, -116.254, NULL, NULL),
('364314354', 'ELPPA0271', 'ELPPA0271', 'ILCHIGSTD', 'Provena Medical Group - Coal City Family Health Ctr', 'Hung', '', 'Nguyen', 'DO', 'Family Practice', '', '', NULL, 'O', '410 N Broadway St', 'Coal City', 'Grundy', 'IL', '60416', '8156344545', '8156348136', '410 N Broadway St', 'Coal City', 'Grundy', 'IL', '60416', '8156344545', '8156348136', 'CHIGP1', 'CHIHCPCS13', '', '0.00', '40.00', '0.00', 3, '2013-01-01', NULL, 0, 0, 0, 'Presence Saint Joseph Hospital Elgin', NULL, NULL, NULL, 'HCFA|UB|', '1588688832', 0, 'N', 0, '2013-09-06', NULL, NULL, 41.2929, -88.2856, NULL, NULL),
('260553931', 'W12016743', 'W12016743', 'ID01', 'Saint Alphonsus Gynecology Oncology', 'Amy', 'L', 'Cooper', 'MD', 'Gynecologic Oncology', '', '', NULL, 'B', '3340 E Goldstone', 'Meridian', 'Ada', 'ID', '83642', '2083675171', '2083675225', '3340 E Goldstone', 'Meridian', 'Ada', 'ID', '83642', '2083675171', '2083675225', 'IDSAMG2', '', '', '0.00', '10.00', '0.00', 6, '2011-10-24', '2012-08-19', 0, 0, 0, 'Saint Alphonsus Medical Center Nampa', NULL, '', '', 'HCFA|UB|', '1306880398', 0, 'N', 0, '2013-06-24', NULL, NULL, 0, 0, NULL, NULL),
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('205873288', 'W12025168', 'W12025168', 'TXDALSTD', 'MacArthur OB GYN Management', 'Kimberly', '', 'Sakovich', 'NP', 'Obstetrics and Gynecology', '', '', NULL, 'O', '3501 N MacArthur Blvd Ste 500', 'Irving', 'Dallas', 'TX', '75062', '9722563700', '9727860334', '3501 N MacArthur Blvd Ste 500', 'Irving', 'Dallas', 'TX', '75062', '9722563700', '9727860334', 'DALLAS3', 'TXHCPC13', '', '0.00', '50.00', '0.00', 3, '2013-01-01', NULL, 0, 0, 0, 'Baylor Medical Center at Irving', NULL, NULL, NULL, 'HCFA|UB|', '1750612792', 0, 'Y', 0, '2014-01-30', NULL, NULL, 32.8525, -96.9591, NULL, NULL),
('205873288', 'W12025170', 'W12025170', 'TXDALSTD', 'MacArthur OB GYN Management', 'Rachel', '', 'Zimmer', 'MD', 'Obstetrics and Gynecology', '', '', NULL, 'O', '3501 N MacArthur Blvd Ste 500', 'Irving', 'Dallas', 'TX', '75062', '9722563700', '9727860334', '3501 N MacArthur Blvd Ste 500', 'Irving', 'Dallas', 'TX', '75062', '9722563700', '9727860334', 'DALLAS3', 'TXHCPC13', '', '0.00', '50.00', '0.00', 3, '2013-01-01', NULL, 0, 0, 0, 'Baylor Medical Center at Irving', NULL, NULL, NULL, 'HCFA|UB|', '1609169085', 0, 'N', 0, '2014-01-30', NULL, NULL, 32.8525, -96.9591, NULL, NULL),
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('760646424', 'W12025273', 'W12025273', 'TXHOUSTD', 'The Multi Specialty Clinic of Baytown', 'Shamsa', '', 'Hasan', 'MD', 'Family Practice', '', '', NULL, 'O', '2802 Garth Rd Ste 107', 'Baytown', 'Harris', 'TX', '77521', '2814259200', '2814285548', '2802 Garth Rd Ste 107', 'Baytown', 'Harris', 'TX', '77521', '2814259200', '2814285548', 'HOUSTON1', 'TXHCPC13', '', '0.00', '45.00', '0.00', 3, '2013-01-01', NULL, 0, 0, 0, 'Houston Methodist San Jacinto Hospital', NULL, '', '', 'HCFA|UB|', '1952412538', 0, 'N', 0, '2012-12-07', NULL, NULL, 29.7512, -94.9771, NULL, NULL),
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('260553931', 'W12025173', 'W12025173', 'IDBOISTD', 'Saint Alphonsus Medical Group Orthopedics Meridian ', 'Andrew', 'R', 'Curran', 'DO', 'Orthopedic Surgery', '', '', NULL, 'O', '3025 W Cherry Ln', 'Meridian', 'Ada', 'ID', '83642', '2082884700', '2082884720', '3025 W Cherry Ln  ', 'Meridian', 'Ada', 'ID', '83642', '2082884700', '2082884720', 'IDSAMG1', '', '', '0.00', '10.00', '0.00', 6, '2012-11-01', NULL, 0, 0, 0, 'Saint Alphonsus Regional Medical Center', 'Saint Alphonsus Medical Center Nampa', '', '', 'HCFA|UB|', '1093705071', 0, 'N', 0, '2014-03-20', NULL, NULL, 43.6193, -116.431, NULL, NULL),
('260553931', 'W12025174', 'W12025174', 'IDBOISTD', 'Saint Alphonsus Medical Group Orthopedics Nampa ', 'Andrew', 'R', 'Curran', 'DO', 'Orthopedic Surgery', '', '', NULL, 'O', '4400 E Flamingo Ave', 'Nampa', 'Canyon', 'ID', '83687', '2082884700', '2082884720', '4400 E Flamingo Ave   ', 'Nampa', 'Canyon', 'ID', '83687', '2082884700', '2082884720', 'IDSAMG1', '', '', '0.00', '10.00', '0.00', 6, '2012-11-01', NULL, 0, 0, 0, 'Saint Alphonsus Regional Medical Center', 'Saint Alphonsus Medical Center Nampa', '', '', 'HCFA|UB|', '1093705071', 0, 'Y', 0, '2014-03-20', NULL, NULL, 43.5966, -116.519, NULL, NULL),
('820200895', 'W12025176', 'W12025176', 'IDBOISTD', 'Durham, Joshua ', 'Joshua', '', 'Durham', 'DO', 'Family Practice', '', '', NULL, 'O', '1515 W State St', 'Boise', 'Ada', 'ID', '83702', '2083457684', NULL, '1515 W State St  ', 'Boise', 'Ada', 'ID', '83702', '2083457684', '          ', 'IDSAMG2', '', '', '0.00', '10.00', '0.00', 6, '2012-10-29', NULL, 0, 0, 0, 'Saint Alphonsus Regional Medical Center', NULL, '', '', 'HCFA|', '1013194208', 0, 'N', 0, '2013-09-05', NULL, NULL, 43.6229, -116.209, NULL, NULL),
('820200895', 'W12025177', 'W12025177', 'IDBOISTD', 'Saint Alphonsus Medical Group MHP', 'Joshua', '', 'Durham', 'DO', '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, '2012-10-29', NULL, 0, 0, 0, 'Saint Alphonsus Regional Medical Center', NULL, '', '', 'HCFA|', '1013194208', 0, 'N', 0, '2013-09-05', NULL, NULL, 43.6193, -116.431, NULL, NULL),
('820200895', 'W12025178', 'W12025178', 'IDBOISTD', 'Saint Alphonsus Medical Group Elm Family Medicine', 'Joshua', '', 'Durham', 'DO', '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, '2012-10-29', NULL, 0, 0, 0, 'Saint Alphonsus Regional Medical Center', NULL, '', '', 'HCFA|', '1013194208', 0, 'N', 0, '2013-09-05', NULL, NULL, 43.6534, -116.695, NULL, NULL),
('820200895', 'W12025179', 'W12025179', 'IDBOISTD', 'Saint Alphonsus Medical Group NHP Family Medicine', 'Joshua', '', 'Durham', 'DO', '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, '2012-10-29', NULL, 0, 0, 0, 'Saint Alphonsus Regional Medical Center', NULL, '', '', 'HCFA|', '1013194208', 0, 'N', 0, '2013-09-05', NULL, NULL, 43.5966, -116.519, NULL, NULL),
('820200895', 'W12025180', 'W12025180', 'IDBOISTD', 'Durham, Joshua ', 'Joshua', '', 'Durham', 'DO', '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, '2012-10-29', NULL, 0, 0, 0, 'Saint Alphonsus Regional Medical Center', NULL, '', '', 'HCFA|', '1013194208', 0, 'N', 0, '2013-09-05', NULL, NULL, 43.6474, -116.354, NULL, NULL),
('820200895', 'W12025181', 'W12025181', 'IDBOISTD', 'Saint Alphonsus Medical Group Emerald Family Medicine', 'Joshua', '', 'Durham', 'DO', 'Family Practice', '', '', NULL, 'O', '6533 Emerald St', 'Boise', 'Ada', 'ID', '83704', '2083674170', '2083678135', '6533 Emerald St  ', 'Boise', 'Ada', 'ID', '83704', '2083674170', '2083678135', 'IDSAMG2', '', '', '0.00', '10.00', '0.00', 6, '2012-10-29', NULL, 0, 0, 0, 'Saint Alphonsus Regional Medical Center', NULL, '', '', 'HCFA|', '1013194208', 0, 'N', 0, '2014-06-11', NULL, NULL, 43.6119, -116.263, NULL, NULL),
('820200895', 'W12025182', 'W12025182', 'IDBOISTD', 'Saint Alphonsus Medical Group Heart Care Fruitland Health Plaza', 'Joshua', '', 'Durham', 'DO', 'Family Practice', '', '', NULL, 'O', '910 NW 16th St Ste 101', 'Fruitland', 'Payette', 'ID', '83619', '2084526851', '2084522140', '910 NW 16th St Ste 101', 'Fruitland', 'Payette', 'ID', '83619', '2084526851', '2084522140', 'IDSAMG2', '', '', '0.00', '10.00', '0.00', 6, '2012-10-29', NULL, 0, 0, 0, 'Saint Alphonsus Regional Medical Center', NULL, '', '', 'HCFA|', '1013194208', 0, 'N', 0, '2013-09-05', NULL, NULL, 44.0254, -116.925, NULL, NULL),
('381966107', 'W12025185', 'W12025185', 'ID02', 'DaVita Caldwell Dialysis Center', 'Heather', 'J', 'Spero', 'PAC', 'Physician Assistant', '', '', NULL, 'O', '821 S Smeed Pkwy', 'Caldwell', 'Canyon', 'ID', '83605', '2083673370', '2083673332', '821 S Smeed Pkwy   ', 'Caldwell', 'Canyon', 'ID', '83605', '2083673370', '2083673332', 'IDACN', '', '', '0.00', '15.00', '0.00', 3, '2012-09-01', NULL, 0, 0, 1, '', '', '', '', 'HCFA|UB|', '1972545473', 0, 'N', 0, '2014-03-18', NULL, NULL, 0, 0, NULL, NULL),
('621560557', 'W12025188', 'W12025188', 'ID02', 'West Valley Clinic at Parma', 'Steven', 'B', 'Ollie', 'MD', 'Family Practice', '', '', NULL, 'O', '307 Grove St', 'Parma', 'Canyon', 'ID', '83660', '2087225147', '2087225148', '307 Grove St  ', 'Parma', 'Canyon', 'ID', '83660', '2087225147', '2087225148', 'IDACN', '', '', '0.00', '15.00', '0.00', 3, '2012-10-29', NULL, 0, 0, 1, 'West Valley Medical Center', NULL, NULL, NULL, 'HCFA|UB|', '1568432888', 0, 'N', 0, '2013-11-12', NULL, NULL, 0, 0, NULL, NULL),
('621560557', 'W12025189', 'W12025189', 'ID02', 'West Valley Clinic at New Plymouth', 'Steven', 'B', 'Ollie', 'MD', 'Family Practice', '', '', NULL, 'O', '112 S Plymouth St', 'New Plymouth', 'Payette', 'ID', '83655', '2082783406', '2082783418', '112 S Plymouth St   ', 'New Plymouth', 'Payette', 'ID', '83655', '2082783406', '2082783418', 'IDACN', '', '', '0.00', '15.00', '0.00', 3, '2012-10-29', NULL, 0, 0, 1, 'West Valley Medical Center', NULL, NULL, NULL, 'HCFA|UB|', '1568432888', 0, 'N', 0, '2013-11-12', NULL, NULL, 0, 0, NULL, NULL),
('202630141', 'W12025190', 'W12025190', 'ID02', 'Primary Health Medical Group - Caldwell', 'Scott', '', 'Frisby', 'PA', 'Family Practice', '', '', NULL, 'O', '4815 Cleveland Blvd', 'Caldwell', 'Canyon', 'ID', '83605', '2084553545', '2084549690', '4815 Cleveland Blvd    ', 'Caldwell', 'Canyon', 'ID', '83605', '2084553545', '2084549690', 'IDSTDPPO', 'WUSTDHCPC5', '', '0.00', '30.00', '0.00', 3, '2012-10-29', '2013-02-28', 0, 0, 1, 'Saint Alphonsus Medical Center Nampa', NULL, NULL, NULL, 'HCFA|UB|', '1982857702', 0, 'N', 0, '2013-02-28', NULL, NULL, 43.6356, -116.647, NULL, NULL),
('452716222', 'W12025192', 'W12025192', 'ID02', 'St. Lukes Clinic - Treasure Valley ', 'Dwaine Anthony', '', 'Tesnohlidek', 'MD', 'General Surgery', '', '', NULL, 'O', '1210 NW 16th St', 'Fruitland', 'Payette', 'ID', '83619', '2084528600', '2084528601', '1210 NW 16th St  ', 'Fruitland', 'Payette', 'ID', '83619', '2084528600', '2084528601', 'IDACN', '', '', '0.00', '15.00', '0.00', 8, '2012-10-30', NULL, 0, 0, 1, '', '', '', '', 'HCFA|UB|', '1437240009', 0, 'N', 0, '2013-10-16', 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
('820200895', 'W12025194', 'W12025194', 'IDBOISTD', 'Saint Alphonsus Medical Group Cardiothoracic Services', 'Tyrell', '', 'Erlebach', 'PA-C', 'Cardiology', '', '', NULL, 'O', '6140 W Curtisian Ave Ste 102', 'Boise', 'Ada', 'ID', '83704', '2083677787', '2083677798', '6140 W Curtisian Ave Ste 102', 'Boise', 'Ada', 'ID', '83704', '2083677787', '2083677798', 'IDSAMG2', '', '', '0.00', '10.00', '0.00', 6, '2012-10-29', NULL, 0, 0, 0, '', '', '', '', 'HCFA|', '1033391396', 0, 'Y', 0, '2013-04-02', NULL, NULL, 43.6146, -116.258, NULL, NULL),
('820200895', 'W12025196', 'W12025196', 'IDBOISTD', 'Saint Alphonsus Wound Healing & Hyperbaric Medicine', 'Andrea', '', 'Gabica', 'NP', 'Family Practice', '', '', NULL, 'O', '1055 N Curtis Rd', 'Boise', 'Ada', 'ID', '83706', '2083672121', '2083676022', '1055 N Curtis Rd  ', 'Boise', 'Ada', 'ID', '83706', '2083672121', '2083676022', 'IDSAMG2', '', '', '0.00', '10.00', '0.00', 6, '2012-10-29', NULL, 0, 0, 0, 'Saint Alphonsus Regional Medical Center', 'Saint Alphonsus Medical Center Nampa', '', '', 'HCFA|', '1750641197', 0, 'Y', 0, '2014-03-27', NULL, NULL, 43.6145, -116.254, NULL, NULL),
('820200895', 'W12025197', 'W12025197', 'IDBOISTD', 'Saint Alphonsus Wound Healing & Hyperbaric Medicine', 'Andrea', '', 'Gabica', 'NP', 'Family Practice', '', '', NULL, 'O', '4400 Flamingo Ave E', 'Boise', 'Ada', 'ID', '83706', '2082884560', '2082884578', '4400 Flamingo Ave E   ', 'Boise', 'Ada', 'ID', '83706', '2082884560', '2082884578', 'IDSAMG2', '', '', '0.00', '10.00', '0.00', 6, '2012-10-29', NULL, 0, 0, 0, 'Saint Alphonsus Regional Medical Center', 'Saint Alphonsus Medical Center Nampa', '', '', 'HCFA|', '1750641197', 0, 'Y', 0, '2014-03-27', NULL, NULL, 43.6213, -116.255, NULL, NULL),
('820200895', 'W12025198', 'W12025198', 'IDBOISTD', 'Saint Alphonsus Medical Group Family Medicine Fruitland Health Plaza', 'James', 'W', 'Gardner', 'MD', 'Family Practice', '', '', NULL, 'O', '910 NW 16th St Ste 101', 'Fruitland', 'Payette', 'ID', '83619', '2084526851', '2084522140', '910 NW 16th St Ste 101', 'Fruitland', 'Payette', 'ID', '83619', '2084526851', '2084522140', 'IDSAMG2', '', '', '0.00', '10.00', '0.00', 6, '2012-10-15', NULL, 0, 0, 0, 'West Valley Medical Center', NULL, NULL, NULL, 'HCFA|', '1730275876', 0, 'N', 0, '2014-03-24', NULL, NULL, 44.0254, -116.925, NULL, NULL),
('820200895', 'W12025199', 'W12025199', 'ID01', 'Saint Alphonsus Regional Medical Center Behavioral Health', 'Ninon', '', 'Germain', '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, '2012-10-24', NULL, 0, 0, 0, 'Saint Alphonsus Regional Medical Center', NULL, NULL, NULL, 'HCFA|', '1588705560', 0, 'N', 0, '2014-06-20', NULL, NULL, 43.6062, -116.266, NULL, NULL),
('820200895', 'W12025200', 'W12025200', 'IDBOISTD', 'Saint Alphonsus Medical Group Family Medicine Dominican ', 'Sheila', 'M', 'Giffen', 'MD', 'Family Practice', '', '', NULL, 'O', '910 NW 16th St Ste 101', 'Fruitland', 'Payette', 'ID', '83619', '2084526851', '2084522140', '910 NW 16th St Ste 101', 'Fruitland', 'Payette', 'ID', '83619', '2084526851', '2084522140', 'IDSAMG2', '', '', '0.00', '10.00', '0.00', 6, '2012-10-15', NULL, 0, 0, 0, 'Saint Alphonsus Medical Center Nampa', '', '', '', 'HCFA|', '1013957802', 0, 'N', 0, '2013-07-31', NULL, NULL, 44.0254, -116.925, NULL, NULL),
('820200895', 'W12025201', 'W12025201', 'ID01', 'Saint Alphonsus Regional Medical Center Behavioral Health', 'Eric', '', 'Gilbreath', '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, '2012-08-20', NULL, 0, 0, 0, 'Saint Alphonsus Regional Medical Center', '', '', '', 'HCFA|', '1548290711', 0, 'N', 0, '2014-07-23', NULL, NULL, 43.6062, -116.266, NULL, NULL),
('820200895', 'W12025202', 'W12025202', 'IDBOISTD', 'Saint Alphonsus Medical Group Family Medicine Dominican ', 'Marcel', 'A', 'Goldberg', 'MD', 'Family Practice', '', '', NULL, 'O', '910 NW 16th St Ste 101', 'Fruitland', 'Payette', 'ID', '83619', '2084526851', '2084522140', '910 NW 16th St Ste 101', 'Fruitland', 'Payette', 'ID', '83619', '2084526851', '2084522140', 'IDSAMG2', '', '', '0.00', '10.00', '0.00', 6, '2012-10-15', NULL, 0, 0, 0, 'Saint Alphonsus Regional Medical Center', NULL, NULL, NULL, 'HCFA|', '1801837141', 0, 'N', 0, '2013-09-05', NULL, NULL, 44.0254, -116.925, NULL, NULL),
('820200895', 'W12025204', 'W12025204', 'IDBOISTD', 'Saint Alphonsus Inpatient Medicine', 'Rieneke', '', 'Govreau', 'CNM', 'Obstetrics and Gynecology', '', '', NULL, 'O', '1055 N Curtis Rd', 'Boise', 'Ada', 'ID', '83706', '2083672121', '2083675180', '1055 N Curtis Rd  ', 'Boise', 'Ada', 'ID', '83706', '2083672121', '2083675180', 'IDSAMG2', '', '', '0.00', '10.00', '0.00', 6, '2012-10-29', NULL, 0, 0, 0, 'Saint Alphonsus Regional Medical Center', NULL, NULL, NULL, 'HCFA|', '1851649933', 0, 'Y', 0, '2013-11-15', NULL, NULL, 43.6145, -116.254, NULL, NULL),
('820200895', 'W12025206', 'W12025206', 'IDBOISTD', 'Saint Alphonsus Medical Group Womens Health', 'Rieneke', '', 'Govreau', 'CNM', 'Obstetrics and Gynecology', '', '', NULL, 'O', '6140 W Curtisian Ste 100', 'Boise', 'Ada', 'ID', '83704', '2083674224', '2083677806', '6140 W Curtisian Ste 100', 'Boise', 'Ada', 'ID', '83704', '2083674224', '2083677806', 'IDSAMG2', '', '', '0.00', '10.00', '0.00', 6, '2012-10-29', '2013-10-10', 0, 0, 0, 'Saint Alphonsus Regional Medical Center', NULL, NULL, NULL, 'HCFA|', '1851649933', 0, 'N', 0, '2013-11-15', NULL, NULL, 43.6151, -116.256, NULL, NULL),
('752896018', 'W12025219', 'W12025219', 'TXDALSTD', 'Muhammad Khan MD', 'Muhammad', 'A', 'Khan', 'MD', 'Internal Medicine', '', '', NULL, 'O', '820 Grainger St', 'Fort Worth', 'Tarrant', 'TX', '76104', '8178109222', '8178109202', '820 Grainger St  ', 'Fort Worth', 'Tarrant', 'TX', '76104', '8178109222', '8178109202', 'DALLAS1', 'TXHCPC13', '', '0.00', '50.00', '0.00', 3, '2013-01-01', NULL, 0, 0, 0, 'Baylor Surgical Hospital at Fort Worth', NULL, NULL, NULL, 'HCFA|UB|', '1487600342', 0, 'N', 0, '2013-05-28', NULL, NULL, 32.7363, -97.3309, NULL, NULL),
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('760682477', 'W12025228', 'W12025228', 'TXHOUSTD', 'Mainland Pulmonary Associates', 'Joseph', '', 'Prince', 'MD', 'Pulmonary', '', '', NULL, 'O', '6807 Emmett F Lowry Expwy Ste 303', 'Texas City', 'Galveston', 'TX', '77591', '4099352995', '4099353433', '6807 Emmett F Lowry Expwy Ste 303', 'Texas City', 'Galveston', 'TX', '77591', '4099352995', '4099353433', 'HOUSTON4', 'TXHCPC13', '', '0.00', '45.00', '0.00', 3, '2013-01-01', NULL, 0, 0, 0, 'Clear Lake Regional Medical Center', NULL, '', '', 'HCFA|UB', '1477518314', 0, 'N', 0, '2012-12-05', NULL, NULL, 29.3953, -94.9874, NULL, NULL),
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('460500210', 'W12025232', 'W12025232', 'IDBOISTD', 'Saint Alphonsus Oncology Physician Services ', 'Alan', 'B', 'Grossett', 'MD', 'Hematology and Oncology', '', '', NULL, 'O', '319 E Hawaii Ave', 'Nampa', 'Canyon', 'ID', '83686', '2082884679', '2083673174', '319 E Hawaii Ave  ', 'Nampa', 'Canyon', 'ID', '83686', '2082884679', '2083673174', 'IDSAMG1', '', '', '0.00', '10.00', '0.00', 6, '2012-11-01', '2013-04-30', 0, 0, 0, 'Saint Alphonsus Regional Medical Center', '', '', '', 'HCFA|UB|', '1689667263', 0, 'N', 0, '2013-05-07', NULL, NULL, 43.5551, -116.57, NULL, NULL),
('820200895', 'W12025233', 'W12025233', 'IDBOISTD', 'Saint Alphonsus Medical Group Family Medicine Dominican ', 'Jennifer', '', 'Hale', 'DO', 'Sleep Medicine', '', '', NULL, 'O', '910 NW 16th St Ste 101', 'Fruitland', 'Payette', 'ID', '83619', '2084526851', '2084522140', '910 NW 16th St Ste 101', 'Fruitland', 'Payette', 'ID', '83619', '2084526851', '2084522140', 'IDSAMG2', '', '', '0.00', '10.00', '0.00', 6, '2012-10-15', NULL, 0, 0, 0, 'Saint Alphonsus Regional Medical Center', '', '', '', 'HCFA|', '1831143338', 0, 'N', 0, '2014-05-06', NULL, NULL, 44.0254, -116.925, NULL, NULL),
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('260553931', 'W12025235', 'W12025235', 'IDBOISTD', 'Saint Alphonsus Medical Group General Surgery Boise ', 'Bren', '', 'Heaton', 'MD', 'General Surgery', '', '', NULL, 'O', '900 N Liberty Ste 204', 'Boise', 'Ada', 'ID', '83704', '2083677090', '2083677092', '900 N Liberty Ste 204', 'Boise', 'Ada', 'ID', '83704', '2083677090', '2083677092', 'IDSAMG1', '', '', '0.00', '10.00', '0.00', 6, '2012-11-01', NULL, 0, 0, 0, 'Saint Alphonsus Regional Medical Center', NULL, '', '', 'HCFA|UB|', '1629244355', 0, 'N', 0, '2013-07-03', NULL, NULL, 43.6124, -116.261, NULL, NULL),
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('820200895', 'W12025238', 'W12025238', 'IDBOISTD', 'Saint AlphonsusMedical Group Neurosurgery Fruitland', 'Stephanie', '', 'Hilpert', 'NP-C', 'Neurosurgery', 'Nurse Practitioner', '', NULL, 'O', '910 NW 16th St Ste 101', 'Fruitland', 'Payette', 'ID', '83619', '2083674000', '2083674052', '910 NW 16th St Ste 101', 'Fruitland', 'Payette', 'ID', '83619', '2083674000', '2083674052', 'IDSAMG1', '', '', '0.00', '10.00', '0.00', 6, '2012-10-15', '2012-10-15', 0, 0, 0, 'Saint Alphonsus Medical Center Nampa', '', '', '', 'HCFA|', '1760584346', 0, 'N', 0, '2014-07-09', NULL, NULL, 44.0254, -116.925, NULL, NULL),
('460500210', 'W12025239', 'W12025239', 'IDBOISTD', 'Saint Alphonsus Oncology Physician Services ', 'Stephanie', 'B', 'Hodson', 'MD', 'Hematology and Oncology', 'Oncology', '', NULL, 'O', '319 E Hawaii Ave', 'Nampa', 'Canyon', 'ID', '83686', '2082884679', '2083673174', '319 E Hawaii Ave  ', 'Nampa', 'Canyon', 'ID', '83686', '2082884679', '2083673174', 'IDSAMG1', '', '', '0.00', '10.00', '0.00', 6, '2012-11-01', '2013-04-30', 0, 0, 0, 'Saint Alphonsus Medical Center Nampa', '', 'West Valley Medical Center', 'Saint Alphonsus Medical Center Nampa', 'HCFA|UB|', '1265478374', 0, 'Y', 0, '2014-05-28', NULL, NULL, 43.5551, -116.57, NULL, NULL),
('260553931', 'W12025247', 'W12025247', 'IDBOISTD', 'Saint Alphonsus Medical Group Orthopedics Meridian ', 'Keith', 'G', 'Holley', 'MD', 'Orthopedic Surgery', '', '', NULL, 'O', '3025 W Cherry Ln', 'Meridian', 'Ada', 'ID', '83642', '2082884700', '2082884720', '3025 W Cherry Ln  ', 'Meridian', 'Ada', 'ID', '83642', '2082884700', '2082884720', 'IDSAMG1', '', '', '0.00', '10.00', '0.00', 6, '2012-11-01', NULL, 0, 0, 0, 'Saint Alphonsus Regional Medical Center', 'Saint Alphonsus Medical Center Nampa', '', '', 'HCFA|UB|', '1386616183', 0, 'N', 0, '2014-03-20', NULL, NULL, 43.6193, -116.431, NULL, NULL),
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('820200895', 'W12025250', 'W12025250', 'IDBOISTD', 'Saint Alphonsus Medical Group Wound & Hyperbaric Nampa', 'Cory', '', 'Huffine', 'NP-C', 'Wound Care', '', '', NULL, 'O', '4400 E Flamingo Ave', 'Nampa', 'Canyon', 'ID', '83687', '2082884640', '2084656910', '4400 E Flamingo Ave', 'Nampa', 'Canyon', 'ID', '83687', '2082884640', '2084656910', 'IDSAMG2', '', '', '0.00', '10.00', '0.00', 6, '2012-11-01', NULL, 0, 0, 0, 'Saint Alphonsus Medical Center Nampa', '', '', '', 'HCFA|', '1700879459', 0, 'N', 0, '2014-06-20', NULL, NULL, 43.5966, -116.519, NULL, NULL),
('820425454', 'W12025252', 'W12025252', 'ID01', 'Boise Anesthesia', 'Christopher', '', 'Ilgenfritz', 'CRNA', 'Nurse Anesthetist', '', '', NULL, 'O', '1055 N Curtis Rd', 'Boise', 'Ada', 'ID', '83706', '2083676416', '2083759530', '1055 N Curtis Rd  ', 'Boise', 'Ada', 'ID', '83706', '2083676416', '2083759530', 'IDSAMG3', '', '', '62.80', '10.00', '0.00', 3, '2012-10-22', NULL, 0, 15, 0, '', '', '', '', 'HCFA|UB|', '1598026205', 0, 'Y', 0, '2014-01-08', NULL, NULL, 43.6145, -116.254, NULL, NULL),
('271790052', 'W12025254', 'W12025254', 'IDBOISTD', 'Saint Alphonsus Medical Group Baker Clinic', 'Leslie', '', 'Jackson', 'MD', 'Internal Medicine', '', '', NULL, 'O', '3175 Pocahontas Rd', 'Baker City', 'Baker', 'OR', '97814', '5415234415', '5415242399', '3175 Pocahontas Rd  ', 'Baker City', 'Baker', 'OR', '97814', '5415234415', '5415242399', 'IDSAMG2', '', '', '0.00', '10.00', '0.00', 6, '2012-10-29', '2012-10-29', 0, 0, 0, '', '', '', '', 'HCFA|UB|', '1972690774', 0, 'N', 0, '2013-12-23', NULL, NULL, 0, 0, NULL, NULL),
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('820200895', 'W12025258', 'W12025258', 'IDBOISTD', 'Saint Alphonsus Medical Group Heart Care Fruitland Health Plaza', 'Helen', '', 'Lawler', 'PAC', 'Cardiology', 'Physician Assistant', '', NULL, 'O', '910 NW 16th St Ste 101', 'Fruitland', 'Payette', 'ID', '83619', '2084526851', '2084522140', '910 NW 16th St Ste 101', 'Fruitland', 'Payette', 'ID', '83619', '2084526851', '2084522140', 'IDSAMG2', '', '', '0.00', '10.00', '0.00', 6, '2012-10-15', NULL, 0, 0, 0, 'Saint Alphonsus Regional Medical Center', NULL, NULL, NULL, 'HCFA|', '1336184803', 0, 'N', 0, '2013-01-10', NULL, NULL, 44.0254, -116.925, NULL, NULL),
('460500210', 'W12025259', 'W12025259', 'IDBOISTD', 'Saint Alphonsus Oncology Physician Services ', 'Alan', 'D', 'Langerak', 'MD', 'Hematology and Oncology', 'Oncology', '', NULL, 'O', '319 E Hawaii Ave', 'Nampa', 'Canyon', 'ID', '83686', '2082884679', '2083673174', '319 E Hawaii Ave  ', 'Nampa', 'Canyon', 'ID', '83686', '2082884679', '2083673174', 'IDSAMG1', '', '', '0.00', '10.00', '0.00', 6, '2012-11-01', '2013-04-30', 0, 0, 0, 'Saint Alphonsus Regional Medical Center', '', '', '', 'HCFA|UB|', '1902853294', 0, 'Y', 0, '2014-05-28', NULL, NULL, 43.5551, -116.57, NULL, NULL),
('820200895', 'W12025260', 'W12025260', 'IDBOISTD', 'Saint Alphonsus Medical Group Wound & Hyperbaric Nampa', 'Scott', 'D', 'Lossmann', 'MD', 'Family Practice', '', '', NULL, 'O', '4400 E Flamingo Ave', 'Nampa', 'Canyon', 'ID', '83687', '2082884640', '2084656910', '4400 E Flamingo Ave', 'Nampa', 'Canyon', 'ID', '83687', '2082884640', '2084656910', 'IDSAMG2', '', '', '0.00', '10.00', '0.00', 6, '2012-11-01', NULL, 0, 0, 0, 'Saint Alphonsus Regional Medical Center', '', '', '', 'HCFA|', '1720032725', 0, 'Y', 0, '2014-06-20', NULL, NULL, 43.5966, -116.519, NULL, NULL),
('820200895', 'W12026179', 'W12026179', 'ID01', 'Saint Alphonsus Behavioral Health', 'Roberto', '', 'Negron', '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, '2013-01-08', NULL, 0, 0, 0, 'Saint Alphonsus Regional Medical Center', NULL, NULL, NULL, 'HCFA|', '1932139961', 0, 'N', 0, '2014-06-20', NULL, NULL, 43.6062, -116.266, NULL, NULL),
('820200895', 'W12025261', 'W12025261', 'IDBOISTD', 'Saint Alphonsus Medical Group Heart Care Fruitland Health Plaza', 'Mylynda', 'B', 'Massart', 'MD', 'Family Practice', '', '', NULL, 'O', '910 NW 16th St Ste 101', 'Fruitland', 'Payette', 'ID', '83619', '2084526851', '2084522140', '910 NW 16th St Ste 101', 'Fruitland', 'Payette', 'ID', '83619', '2084526851', '2084522140', 'IDSAMG2', '', '', '0.00', '10.00', '0.00', 6, '2012-10-15', NULL, 0, 0, 0, 'West Valley Medical Center', NULL, NULL, NULL, 'HCFA|', '1497936587', 0, 'N', 0, '2013-09-05', NULL, NULL, 44.0254, -116.925, NULL, NULL),
('820200895', 'W12025262', 'W12025262', 'IDBOISTD', 'Saint Alphonsus Medical Group Heart Care Fruitland Health Plaza', 'Ryan', 'A', 'Moore', 'MD', 'Family Practice', '', '', NULL, 'O', '910 NW 16th Str Ste 101', 'Fruitland', 'Payette', 'ID', '83619', '2084526851', '2084522140', '910 NW 16th Str Ste 101', 'Fruitland', 'Payette', 'ID', '83619', '2084526851', '2084522140', 'IDSAMG2', '', '', '0.00', '10.00', '0.00', 6, '2012-10-15', NULL, 0, 0, 0, 'West Valley Medical Center', NULL, NULL, NULL, 'HCFA|', '1386664654', 0, 'N', 0, '2012-11-15', NULL, NULL, 44.0254, -116.925, NULL, NULL),
('820200895', 'W12025263', 'W12025263', 'IDBOISTD', 'Saint Alphonsus Medical Group Family Medicine Dominican Health ', 'Mary', '', 'Morgan', 'NP-C', 'Family Practice', 'Nurse Practitioner', '', NULL, 'O', '1118 Nw 16th St Ste A', 'Fruitland', 'Payette', 'ID', '83619', '2084526851', '2084522140', '1118 Nw 16th St Ste A', 'Fruitland', 'Payette', 'ID', '83619', '2084526851', '2084522140', 'IDSAMG2', '', '', '0.00', '10.00', '0.00', 6, '2012-08-20', '2013-12-31', 0, 0, 0, 'Saint Alphonsus Medical Center Nampa', '', '', '', 'HCFA|', '1437381209', 0, 'Y', 0, '2014-02-10', NULL, NULL, 44.025, -116.928, NULL, NULL),
('820200895', 'W12025264', 'W12025264', 'IDBOISTD', 'Saint Alphonsus Medical Group Family Medicine Dominican Health ', 'Mary', '', 'Morgan', 'NP-C', 'Family Practice', 'Nurse Practitioner', '', NULL, 'O', '910 NW 16th St Ste 101', 'Fruitland', 'Payette', 'ID', '83619', '2084526851', '2084522140', '910 NW 16th St Ste 101', 'Fruitland', 'Payette', 'ID', '83619', '2084526851', '2084522140', 'IDSAMG2', '', '', '0.00', '10.00', '0.00', 6, '2012-08-20', '2013-12-31', 0, 0, 0, 'Saint Alphonsus Medical Center Nampa', '', '', '', 'HCFA|', '1437381209', 0, 'Y', 0, '2014-02-10', NULL, NULL, 44.0254, -116.925, NULL, NULL),
('364247796', 'W12025275', 'W12025275', 'ILCHIGSTD', 'Sher Ahsan Niazi MD', 'Sher Ahsan', 'K', 'Niazi', 'MD', 'Pediatrics', '', '', NULL, 'O', '215 Remington Rd', 'Bolingbrook', 'Will', 'IL', '60440', '6303781111', '6303781112', '215 Remington Rd   ', 'Bolingbrook', 'Will', 'IL', '60440', '6303781111', '6303781112', 'CHIG11', 'CHIHCPCS13', '', '0.00', '40.00', '0.00', 3, '2013-01-01', NULL, 0, 0, 0, 'Presence Saint Joseph Hospital Chicago', NULL, '', '', 'HCFA|UB|', '1902972516', 0, 'N', 0, '2014-04-25', NULL, NULL, 41.6838, -88.0749, NULL, NULL),
('364247796', 'W12025274', 'W12025274', 'ILCHIGSTD', 'Sher Ahsan Niazi MD', 'Sher Ahsan', 'K', 'Niazi', 'MD', 'Pediatrics', '', '', NULL, 'O', '831 N Larkin Ave', 'Joliet', 'Will', 'IL', '60435', '8157418888', '8057303323', '831 N Larkin Ave  ', 'Joliet', 'Will', 'IL', '60435', '8157418888', '8057303323', 'CHIG11', 'CHIHCPCS13', '', '0.00', '40.00', '0.00', 3, '2013-01-01', NULL, 0, 0, 0, 'Presence Saint Joseph Hospital Chicago', NULL, '', '', 'HCFA|UB|', '1902972516', 0, 'N', 0, '2014-04-25', NULL, NULL, 41.5377, -88.1253, NULL, NULL),
('820200895', 'W12025277', 'W12025277', 'ID01', 'Saint Alphonsus Employee Assistance Program', 'Roxanne', '', 'Nichols', 'LCPC', 'Mental Health', 'Counseling', '', NULL, 'O', '6140 Emerald St', 'Boise', 'Ada', 'ID', '83704', '2083673300', '2083673308', '6140 Emerald St  ', 'Boise', 'Ada', 'ID', '83704', '2083673300', '2083673308', 'IDSAMG1', '', '', '0.00', '10.00', '0.00', 6, '2012-09-01', NULL, 0, 0, 0, '', '', '', '', 'HCFA|', '1003101189', 0, 'N', 0, '2014-06-20', NULL, NULL, 43.6118, -116.258, NULL, NULL),
('820200895', 'W12025278', 'W12025278', 'IDBOISTD', 'Saint Alphonsus Medical Group Orthopedics ', 'Todd', 'M', 'Otstot', 'PAC', 'Physician Assistant', '', '', NULL, 'O', '4400 E Flamingo Ave', 'Nampa', 'Canyon', 'ID', '83687', '2082884700', '2082884720', '4400 E Flamingo Ave  ', 'Nampa', 'Canyon', 'ID', '83687', '2082884700', '2082884720', 'IDSAMG2', '', '', '0.00', '10.00', '0.00', 6, '2012-11-01', NULL, 0, 0, 0, 'Saint Alphonsus Medical Center Nampa', NULL, NULL, NULL, 'HCFA|', '1275523276', 0, 'N', 0, '2014-01-24', NULL, NULL, 43.5966, -116.519, NULL, NULL),
('260553931', 'W12025279', 'W12025279', 'IDBOISTD', 'Saint Alphonsus Medical Group Heart Care Fruitland ', 'Mark', 'G', 'Parent', 'MD', 'Cardiology', '', '', NULL, 'O', '910 NW 16th St', 'Fruitland', 'Payette', 'ID', '83619', '2084526851', '2084522140', '910 NW 16th St  ', 'Fruitland', 'Payette', 'ID', '83619', '2084526851', '2084522140', 'IDSAMG1', '', '', '0.00', '10.00', '0.00', 6, '2012-10-15', NULL, 0, 0, 0, 'Saint Alphonsus Regional Medical Center', NULL, NULL, NULL, 'HCFA|UB|', '1558301515', 0, 'N', 0, '2013-01-10', NULL, NULL, 44.0254, -116.925, NULL, NULL),
('820200895', 'W12025280', 'W12025280', 'IDBOISTD', 'Saint Alphonsus Medical Group General Surgery  Boise ', 'Molly', 'C', 'Piccono', 'PAC', 'Physician Assistant', '', '', NULL, 'O', '900 N Liberty Ste 204', 'Boise', 'Ada', 'ID', '83704', '2083677090', '2083677092', '900 N Liberty Ste 204', 'Boise', 'Ada', 'ID', '83704', '2083677090', '2083677092', 'IDSAMG2', '', '', '0.00', '10.00', '0.00', 6, '2012-11-01', '2013-12-14', 0, 0, 0, '', '', '', '', 'HCFA|', '1881739274', 0, 'Y', 0, '2013-12-11', NULL, NULL, 43.6133, -116.259, NULL, NULL),
('460500210', 'W12025281', 'W12025281', 'IDBOISTD', 'Saint Alphonsus Oncology Physician Services ', 'Andrew', '', 'Pierson', 'MD', 'Hematology and Oncology', 'Oncology', '', NULL, 'O', '319 E Hawaii Ave', 'Nampa', 'Canyon', 'ID', '83686', '2082884679', '2083673174', '319 E Hawaii Ave  ', 'Nampa', 'Canyon', 'ID', '83686', '2082884679', '2083673174', 'IDSAMG1', '', '', '0.00', '10.00', '0.00', 6, '2012-11-01', '2013-04-30', 0, 0, 0, 'Saint Alphonsus Regional Medical Center', '', '', '', 'HCFA|UB|', '1992760664', 0, 'N', 0, '2014-05-28', NULL, NULL, 43.5551, -116.57, NULL, NULL),
('460500210', 'W12025282', 'W12025282', 'IDBOISTD', 'Saint Alphonsus Oncology Physician Services ', 'Andrew', '', 'Pierson', 'MD', 'Hematology and Oncology', 'Oncology', '', NULL, 'O', '1055 N Curtis Rd', 'Boise', 'Ada', 'ID', '83706', '2083673627', '2083673174', '1055 N Curtis Rd  ', 'Boise', 'Ada', 'ID', '83706', '2083673627', '2083673174', 'IDSAMG1', '', '', '0.00', '10.00', '0.00', 6, '2012-11-01', '2013-04-30', 0, 0, 0, 'Saint Alphonsus Regional Medical Center', '', '', '', 'HCFA|UB|', '1992760664', 0, 'N', 0, '2014-05-28', NULL, NULL, 43.6127, -116.254, NULL, NULL),
('460500210', 'W12025283', 'W12025283', 'IDBOISTD', 'Saint Alphonsus Oncology Physician Services', 'Kerry', 'P', 'Pulver', 'MD', 'Hematology and Oncology', 'Oncology', '', NULL, 'O', '319 E Hawaii Ave', 'Nampa', 'Canyon', 'ID', '83686', '2082884679', '2083673174', '319 E Hawaii Ave  ', 'Nampa', 'Canyon', 'ID', '83686', '2082884679', '2083673174', 'IDSAMG1', '', '', '0.00', '10.00', '0.00', 6, '2012-11-01', '2013-04-30', 0, 0, 0, 'Saint Alphonsus Medical Center Nampa', '', 'West Valley Medical Center', 'Saint Alphonsus Medical Center Nampa', 'HCFA|UB|', '1376596247', 0, 'Y', 0, '2014-05-28', NULL, NULL, 43.5551, -116.57, NULL, NULL),
('820200895', 'W12025284', 'W12025284', 'IDBOISTD', 'Saint Alphonsus Medical Group Heart Care Fruitland', 'Mary', 'S', 'Randall', 'NP', 'Cardiology', '', '', NULL, 'O', '910 NW 16th St', 'Fruitland', 'Payette', 'ID', '83619', '2084526851', '2084522140', '910 NW 16th St  ', 'Fruitland', 'Payette', 'ID', '83619', '2084526851', '2084522140', 'IDSAMG2', '', '', '0.00', '10.00', '0.00', 6, '2012-10-15', '2012-10-15', 0, 0, 0, 'Saint Alphonsus Regional Medical Center', NULL, '', '', 'HCFA|', '1174871420', 0, 'N', 0, '2013-04-30', NULL, NULL, 44.0254, -116.925, NULL, NULL),
('820200895', 'W12025286', 'W12025286', 'IDBOISTD', 'Saint Alphonsus Medical Group Heart Care Fruitland Health Plaza', 'Cynthia', '', 'Reed', 'NP-C', 'Family Practice', '', '', NULL, 'O', '910 NW 16th St Ste 101', 'Fruitland', 'Payette', 'ID', '83619', '2084526851', '2084522140', '910 NW 16th St Ste 101', 'Fruitland', 'Payette', 'ID', '83619', '2084526851', '2084522140', 'IDSAMG2', '', '', '0.00', '10.00', '0.00', 6, '2012-10-15', '2013-01-04', 0, 0, 0, 'Saint Alphonsus Regional Medical Center', NULL, '', '', 'HCFA|', '1902119423', 0, 'N', 0, '2013-12-19', NULL, NULL, 44.0254, -116.925, NULL, NULL),
('820200895', 'W12025287', 'W12025287', 'IDBOISTD', 'Saint Alphonsus Medical Group Neurology Fruitland', 'Mary', 'E', 'River', 'MD', 'Neurology', '', '', NULL, 'O', '910 NW 16th St', 'Fruitland', 'Payette', 'ID', '83619', '2083674000', '2083674052', '910 NW 16th St  ', 'Fruitland', 'Payette', 'ID', '83619', '2083674000', '2083674052', 'IDSAMG1', '', '', '0.00', '10.00', '0.00', 6, '2012-10-15', NULL, 0, 0, 0, 'Saint Alphonsus Regional Medical Center', '', '', '', 'HCFA|', '1205882743', 0, 'N', 0, '2014-05-20', NULL, NULL, 44.0254, -116.925, NULL, NULL),
('820200895', 'W12025288', 'W12025288', 'IDBOISTD', 'Saint Alphonsus Medical Group Family Medicine Dominican', 'Michael', 'L', 'Roach', 'MD', 'Family Practice', '', '', NULL, 'O', '910 NW 16th St Ste 101', 'Fruitland', 'Payette', 'ID', '83619', '2084526851', '2083676170', '910 NW 16th St Ste 101', 'Fruitland', 'Payette', 'ID', '83619', '2084526851', '2083676170', 'IDSAMG2', '', '', '0.00', '10.00', '0.00', 6, '2012-10-15', '2013-07-15', 0, 0, 0, 'West Valley Medical Center', NULL, NULL, NULL, 'HCFA|', '1528004389', 0, 'N', 0, '2013-09-05', NULL, NULL, 44.0254, -116.925, NULL, NULL),
('743040723', 'W12029594', 'W12029594', 'UT01', 'UUHC Redstone Center', '', '', 'University of Utah Hospital Professional Services', 'GROUP', 'Clinics', '', '', NULL, 'O', '1743 W Redstone Ctr', 'Park City', 'Summit', 'UT', '84098', '4356589200', NULL, '1743 W Redstone Ctr', 'Park City', 'Summit', 'UT', '84098', '4356589200', '          ', 'WUUUMG5', 'WUSTDHCPC5', '', '0.00', '25.00', '0.00', 3, '2013-01-30', NULL, 0, 0, 0, '', '', '', '', 'HCFA|UB|', '0000009312', 0, 'N', 0, '2013-01-30', NULL, NULL, 40.7208, -111.543, NULL, NULL),
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('820299231', 'W12029588', 'W12029588', 'IDBOISTD', 'Saltzer Medical Group- Caldwell', 'Tildon', 'C', 'Robinson', 'MD', 'Orthopedic Surgery', '', '', NULL, 'O', '3025 W Cherry Ln', 'Meridian', 'Ada', 'ID', '83642', '2082884700', '2082884720', '3025 W Cherry Ln  ', 'Meridian', 'Ada', 'ID', '83642', '2082884700', '2082884720', 'IDSAMG1', '', '', '0.00', '10.00', '0.00', 6, '2012-11-01', '2012-11-01', 0, 0, 0, 'Saint Alphonsus Medical Center Nampa', NULL, NULL, NULL, 'HCFA|UB|', '1457340481', 0, 'N', 0, '2014-03-20', NULL, NULL, 43.6188, -116.431, NULL, NULL),
('820200895', 'W12025292', 'W12025292', 'IDBOISTD', 'Saint Alphonsus Medical Group Heart Care Fruitland Health Plaza', 'Louis', 'A', 'Roser', 'MD', 'Family Practice', '', '', NULL, 'O', '910 NW 16th S Ste 101', 'Fruitland', 'Payette', 'ID', '83619', '2084526851', '2084522140', '910 NW 16th S Ste 101', 'Fruitland', 'Payette', 'ID', '83619', '2084526851', '2084522140', 'IDSAMG2', '', '', '0.00', '10.00', '0.00', 6, '2012-10-15', NULL, 0, 0, 0, 'Saint Alphonsus Regional Medical Center', NULL, NULL, NULL, 'HCFA|', '1497715866', 0, 'N', 0, '2012-11-16', NULL, NULL, 44.0254, -116.925, NULL, NULL),
('820200895', 'W12025293', 'W12025293', 'ID01', 'Saint Alphonsus Medical Group Neurology Boise', 'Raymond', '', 'Ryan', 'MD', 'Psychiatry', '', '', NULL, 'O', '901 N Curtis Ste 403', 'Boise', 'Ada', 'ID', '83706', '2083677272', '2083677111', '901 N Curtis Ste 403', 'Boise', 'Ada', 'ID', '83706', '2083677272', '2083677111', 'IDSAMG1', '', '', '0.00', '10.00', '0.00', 6, '2012-08-20', '2014-05-26', 0, 0, 0, 'Saint Alphonsus Regional Medical Center', '', '', '', 'HCFA|', '1154498152', 0, 'N', 0, '2014-06-20', NULL, NULL, 43.6126, -116.254, NULL, NULL),
('460500210', 'W12025294', 'W12025294', 'IDBOISTD', 'Saint Alphonsus Oncology Physician Services ', 'Karl', 'J', 'Schultheiss', 'MD', 'Hematology and Oncology', 'Oncology', '', NULL, 'O', '319 E Hawaii Ave', 'Nampa', 'Canyon', 'ID', '83686', '2082884679', '2083673174', '319 E Hawaii Ave  ', 'Nampa', 'Canyon', 'ID', '83686', '2082884679', '2083673174', 'IDSAMG1', '', '', '0.00', '10.00', '0.00', 6, '2012-11-01', '2013-04-30', 0, 0, 0, 'Saint Alphonsus Medical Center Nampa', '', 'West Valley Medical Center', 'Saint Alphonsus Medical Center Nampa', 'HCFA|UB|', '1265478325', 0, 'N', 0, '2014-05-28', NULL, NULL, 43.5551, -116.57, NULL, NULL),
('260553931', 'W12025295', 'W12025295', 'IDBOISTD', 'Saint Alphonsus Medical Group Heart Care Fruitland ', 'Walter', 'L', 'Seale', 'MD', 'Cardiology', '', '', NULL, 'O', '910 NW 16th St Ste 101', 'Fruitland', 'Payette', 'ID', '83619', '2084526851', '2084522140', '910 NW 16th St Ste 101', 'Fruitland', 'Payette', 'ID', '83619', '2084526851', '2084522140', 'IDSAMG1', '', '', '0.00', '10.00', '0.00', 6, '2012-10-15', '2013-11-01', 0, 0, 0, 'Saint Alphonsus Regional Medical Center', NULL, NULL, NULL, 'HCFA|UB|', '1720033459', 0, 'Y', 0, '2014-01-24', NULL, NULL, 44.0254, -116.925, NULL, NULL),
('820200895', 'W12025296', 'W12025296', 'IDBOISTD', 'Saint Alphonsus Medical Group Family Medicine Dominican', 'Cherese', 'R', 'Severson', 'NPC', 'Family Practice', '', '', NULL, 'O', '1118 NW 16th St Ste A', 'Fruitland', 'Payette', 'ID', '83619', '2084526851', '2084522140', '1118 NW 16th St Ste A', 'Fruitland', 'Payette', 'ID', '83619', '2084526851', '2084522140', 'IDSAMG1', '', '', '0.00', '10.00', '0.00', 6, '2012-08-20', '2012-10-14', 0, 0, 0, 'Saint Alphonsus Medical Center Nampa', NULL, NULL, NULL, 'HCFA|', '1275631244', 0, 'N', 0, '2013-09-05', NULL, NULL, 44.025, -116.928, NULL, NULL),
('820200895', 'W12025298', 'W12025298', 'IDBOISTD', 'Saint Alphonsus Medical Group Family Medicine Dominican', 'Cherese', 'R', 'Severson', 'NPC', 'Family Practice', '', '', NULL, 'O', '910 NW 16th St Ste 101', 'Fruitland', 'Payette', 'ID', '83619', '2084526851', '2084522140', '910 NW 16th St Ste 101', 'Fruitland', 'Payette', 'ID', '83619', '2084526851', '2084522140', 'IDSAMG1', '', '', '0.00', '10.00', '0.00', 6, '2012-10-15', '2012-11-20', 0, 0, 0, 'Saint Alphonsus Medical Center Nampa', NULL, NULL, NULL, 'HCFA|', '1275631244', 0, 'N', 0, '2013-09-05', NULL, NULL, 44.0254, -116.925, NULL, NULL),
('820200895', 'W12025300', 'W12025300', 'IDBOISTD', 'Saint Alphonsus Medical Group NHP Family Medicine', 'Heidi', '', 'Shields', 'MD', 'Family Practice', 'Hospitalist', '', 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, '2012-10-29', NULL, 0, 0, 0, 'Saint Alphonsus Medical Center Nampa', NULL, NULL, NULL, 'HCFA|', '1053406488', 0, 'Y', 0, '2014-02-07', NULL, NULL, 43.5966, -116.519, NULL, NULL),
('820200895', 'W12025301', 'W12025301', 'IDBOISTD', 'Saint Alphonsus Medical Group Heart Care Fruitland Health Plaza', 'Jocele', 'A', 'Skinner', 'MD', 'Family Practice', '', '', NULL, 'O', '910 NW 16th St Ste 101', 'Fruitland', 'Payette', 'ID', '83619', '2084526851', '2084522140', '910 NW 16th St Ste 101', 'Fruitland', 'Payette', 'ID', '83619', '2084526851', '2084522140', 'IDSAMG2', '', '', '0.00', '10.00', '0.00', 6, '2012-10-15', '2013-03-31', 0, 0, 0, 'Saint Alphonsus Regional Medical Center', '', '', '', 'HCFA|', '1831133164', 0, 'N', 0, '2014-06-13', NULL, NULL, 44.0254, -116.925, NULL, NULL),
('260553931', 'W12025302', 'W12025302', 'IDBOISTD', 'Saint Alphonsus Medical Group Heart Care Boise', 'Josef', '', 'Stehlik', 'MD', 'Cardiovascular Disease', NULL, NULL, 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, '2012-10-29', NULL, 0, 0, 0, 'University Health Care University Hospital', NULL, NULL, NULL, 'HCFA|UB|', '1558458992', 0, 'Y', 0, '2014-01-24', NULL, NULL, 43.6146, -116.258, NULL, NULL),
('820200895', 'W12025303', 'W12025303', 'IDBOISTD', 'Dominican Health Services', 'Colette', 'D', 'Weber', 'PAC', 'Family Practice', 'Physician Assistant', '', NULL, 'O', '1118 NW 16th Ste A', 'Fruitland', 'Payette', 'ID', '83619', '2084526851', '2084522140', '1118 NW 16th Ste A', 'Fruitland', 'Payette', 'ID', '83619', '2084526851', '2084522140', 'IDSAMG2', '', '', '0.00', '10.00', '0.00', 6, '2012-08-20', '2012-10-14', 0, 0, 0, 'Saint Alphonsus Regional Medical Center', NULL, '', '', 'HCFA|', '1922042464', 0, 'N', 0, '2013-09-05', NULL, NULL, 0, 0, NULL, NULL),
('820200895', 'W12025304', 'W12025304', 'IDBOISTD', 'Saint Alphonsus Medical Group Heart Care Fruitland Health Plaza', 'Colette', 'D', 'Weber', 'PAC', 'Family Practice', 'Physician Assistant', '', NULL, 'O', '910 NW 16th St Ste 101', 'Fruitland', 'Payette', 'ID', '83619', '2084526851', '2084522140', '910 NW 16th St Ste 101', 'Fruitland', 'Payette', 'ID', '83619', '2084526851', '2084522140', 'IDSAMG2', '', '', '0.00', '10.00', '0.00', 6, '2012-10-15', NULL, 0, 0, 0, 'Saint Alphonsus Regional Medical Center', NULL, '', '', 'HCFA|', '1922042464', 0, 'N', 0, '2013-09-05', NULL, NULL, 44.0254, -116.925, NULL, NULL),
('820200895', 'W12025306', 'W12025306', 'IDBOISTD', 'Saint Alphonsus Medical Group Pedicatics Boise', 'Colette', 'D', 'Weber', 'PAC', 'Family Practice', 'Physician Assistant', '', NULL, 'O', '999 N Curtis Rd Ste 407', 'Boise', 'Ada', 'ID', '83706', '2083674321', '2083674525', '999 N Curtis Rd Ste 407', 'Boise', 'Ada', 'ID', '83706', '2083674321', '2083674525', 'IDSAMG2', '', '', '0.00', '10.00', '0.00', 6, '2012-10-15', '2013-06-24', 0, 0, 0, 'Saint Alphonsus Regional Medical Center', NULL, '', '', 'HCFA|', '1922042464', 0, 'Y', 0, '2013-09-05', NULL, NULL, 43.6132, -116.255, NULL, NULL),
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('820200895', 'W12025314', 'W12025314', 'IDBOISTD', 'Saint Alphonsus Medical Group Heart Care Fruitland Health Plaza', 'Jenifer', '', 'Stewart Greene', 'NP-C', 'Family Practice', '', '', NULL, 'O', '910 NW 16th St Ste 101', 'Fruitland', 'Payette', 'ID', '83619', '2084526851', '2084522140', '910 NW 16th St Ste 101', 'Fruitland', 'Payette', 'ID', '83619', '2084526851', '2084522140', 'IDSAMG1', '', '', '0.00', '10.00', '0.00', 6, '2012-10-15', '2013-03-31', 0, 0, 0, 'Saint Alphonsus Regional Medical Center', '', '', '', 'HCFA|', '1679892335', 0, 'N', 0, '2014-06-13', NULL, NULL, 44.0254, -116.925, NULL, NULL),
('820200895', 'W12025315', 'W12025315', 'IDBOISTD', 'Saint Alphonsus Medical Group Heart Care Fruitland Health Plaza', 'Gayle', 'A', 'Stockslager', 'NP-C', 'Nurse Practitioner', '', '', NULL, 'O', '910 NW 16th St Ste 101', 'Fruitland', 'Payette', 'ID', '83619', '2084526851', '2083676170', '910 NW 16th St Ste 101', 'Fruitland', 'Payette', 'ID', '83619', '2084526851', '2083676170', 'IDSAMG2', '', '', '0.00', '10.00', '0.00', 6, '2012-10-15', NULL, 0, 0, 0, '', '', '', '', 'HCFA|', '1740475680', 0, 'N', 0, '2013-02-13', NULL, NULL, 44.0254, -116.925, NULL, NULL),
('460500210', 'W12025316', 'W12025316', 'IDBOISTD', 'Saint Alphonsus Oncology Physician Services', 'Holly', '', 'Swensen', 'NP', 'Hematology and Oncology', 'Oncology', '', NULL, 'O', '319 E Hawaii Ave', 'Nampa', 'Canyon', 'ID', '83686', '2082884679', '2083673174', '319 E Hawaii Ave  ', 'Nampa', 'Canyon', 'ID', '83686', '2082884679', '2083673174', 'IDSAMG1', '', '', '0.00', '10.00', '0.00', 6, '2012-11-01', '2013-04-30', 0, 0, 0, 'Saint Alphonsus Regional Medical Center', '', '', '', 'HCFA|UB|', '1386672012', 0, 'N', 0, '2014-06-20', NULL, NULL, 43.5551, -116.57, NULL, NULL),
('460500210', 'W12025317', 'W12025317', 'IDBOISTD', 'Saint Alphonsus Oncology Physician Services', 'Holly', '', 'Swensen', 'NP', 'Hematology and Oncology', 'Oncology', '', NULL, 'O', '1717 Arlington Ave', 'Caldwell', 'Canyon', 'ID', '83605', '2083673627', '2083673174', '1717 Arlington Ave  ', 'Caldwell', 'Canyon', 'ID', '83605', '2083673627', '2083673174', 'IDSAMG1', '', '', '0.00', '10.00', '0.00', 6, '2012-11-01', '2013-04-30', 0, 0, 0, 'Saint Alphonsus Regional Medical Center', '', '', '', 'HCFA|UB|', '1386672012', 0, 'Y', 0, '2014-06-20', 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
('820200895', 'W12025318', 'W12025318', 'ID01', 'Saint Alphonsus Regional Medical Center Behavioral Health', 'Damiana', '', 'Uberuaga', 'LCSW', 'Mental Health', 'Counseling', '', 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, '2012-10-24', NULL, 0, 0, 0, 'Saint Alphonsus Regional Medical Center', NULL, NULL, NULL, 'HCFA|', '1689609190', 0, 'N', 0, '2014-06-20', NULL, NULL, 43.6062, -116.266, NULL, NULL),
('820200895', 'W12025319', 'W12025319', 'IDBOISTD', 'Saint Alphonsus Medical Group Neurosurgery Fruitland', 'Christian', 'G', 'Zimmerman', 'MD', 'Neurosurgery', '', '', NULL, 'O', '910 NW 16th St', 'Fruitland', 'Payette', 'ID', '83619', '2083674000', '2083674052', '910 NW 16th St  ', 'Fruitland', 'Payette', 'ID', '83619', '2083674000', '2083674052', 'IDSAMG1', '', '', '0.00', '10.00', '0.00', 6, '2012-10-15', NULL, 0, 0, 0, 'Saint Alphonsus Regional Medical Center', '', '', '', 'HCFA|', '1407874068', 0, 'Y', 0, '2014-07-09', NULL, NULL, 44.0254, -116.925, NULL, NULL),
('260553931', 'W12025320', 'W12025320', 'IDBOISTD', 'Saint Alphonsus Medical Group General Surgery  Boise ', 'Steven', 'W', 'Williams', 'MD', 'General Surgery', '', '', NULL, 'O', '900 N Liberty Ste 204', 'Boise', 'Ada', 'ID', '83704', '2083677090', '2083677092', '900 N Liberty Ste 204', 'Boise', 'Ada', 'ID', '83704', '2083677090', '2083677092', 'IDSAMG1', '', '', '0.00', '10.00', '0.00', 6, '2012-11-01', NULL, 0, 0, 0, 'Saint Alphonsus Regional Medical Center', NULL, NULL, NULL, 'HCFA|UB|', '1568451581', 0, 'N', 0, '2014-03-20', NULL, NULL, 43.6124, -116.261, NULL, NULL),
('820200895', 'W12025321', 'W12025321', 'IDBOISTD', 'Saint Alphonsus Medical Group Heart Care Fruitland Health Plaza', 'John', 'E', 'White', 'MD', 'Family Practice', '', '', NULL, 'O', '910 NW 16th S Ste 101', 'Fruitland', 'Payette', 'ID', '83619', '2084526851', '2084522140', '910 NW 16th S Ste 101', 'Fruitland', 'Payette', 'ID', '83619', '2084526851', '2084522140', 'IDSAMG2', '', '', '0.00', '10.00', '0.00', 6, '2012-10-15', '2013-03-31', 0, 0, 0, '', '', '', '', 'HCFA|', '1013982081', 0, 'N', 0, '2013-08-05', NULL, NULL, 44.0254, -116.925, NULL, NULL),
('460500210', 'W12025322', 'W12025322', 'IDBOISTD', 'Saint Alphonsus Oncology Physician Services ', 'Bruce', 'H', 'Zietz', 'MD', 'Hematology and Oncology', '', '', NULL, 'O', '319 E Hawaii Ave', 'Nampa', 'Canyon', 'ID', '83686', '2082884679', '2083673174', '319 E Hawaii Ave  ', 'Nampa', 'Canyon', 'ID', '83686', '2082884679', '2083673174', 'IDSAMG1', '', '', '0.00', '10.00', '0.00', 6, '2012-11-01', '2012-11-01', 0, 0, 0, 'Saint Alphonsus Regional Medical Center', '', '', '', 'HCFA|UB|', '1184689002', 0, 'N', 0, '2012-11-16', NULL, NULL, 43.5551, -116.57, NULL, NULL),
('820200895', 'W12025323', 'W12025323', 'IDBOISTD', 'Saint Alphonsus Medical Group Heart Care Fruitland Health Plaza', 'Kelly', 'R', 'Whitehead Price', 'NP-C', 'Family Practice', '', '', NULL, 'O', '910 NW 16th Str Ste 101', 'Fruitland', 'Payette', 'ID', '83619', '2084526851', '2084522140', '910 NW 16th Str Ste 101', 'Fruitland', 'Payette', 'ID', '83619', '2084526851', '2084522140', 'IDSAMG2', '', '', '0.00', '10.00', '0.00', 6, '2012-10-15', NULL, 0, 0, 0, 'Saint Alphonsus Regional Medical Center', NULL, NULL, NULL, 'HCFA|', '1710268099', 0, 'N', 0, '2012-12-26', NULL, NULL, 44.0254, -116.925, NULL, NULL),
('820200895', 'W12025324', 'W12025324', 'IDBOISTD', 'Saint Alphonsus Regional Medical Center', 'Kelly', 'W', 'Wedeven', 'LCSW', 'Mental Health', 'Social Worker', '', NULL, 'O', '131 N Allumbaugh', 'Boise', 'Ada', 'ID', '83704', '2083672175', '2083674052', '131 N Allumbaugh  ', 'Boise', 'Ada', 'ID', '83704', '2083672175', '2083674052', 'IDSAMG1', '', '', '0.00', '10.00', '0.00', 6, '2012-08-20', '2014-02-20', 0, 0, 0, 'Saint Alphonsus Regional Medical Center', '', '', '', 'HCFA|', '1912923871', 0, 'N', 0, '2014-04-04', NULL, NULL, 43.6062, -116.266, NULL, NULL),
('820200895', 'W12025332', 'W12025332', 'IDBOISTD', 'Saint Alphonsus Diabetes Care and Education', '', '', 'Saint Alphonsus Diabetes Care and Education', '', 'Diabetic Education', '', '', NULL, 'O', '1000 N Curtis Rd Ste 305', 'Boise', 'Ada', 'ID', '83706', '2083678879', NULL, '1000 N Curtis Rd Ste 305', 'Boise', 'Ada', 'ID', '83706', '2083678879', '          ', '', '', 'ID01', '0.00', '0.00', '0.00', 6, '2012-11-19', NULL, 0, 0, 0, '', '', '', '', 'HCFA|', '0000009975', 0, 'N', 0, '2012-11-28', NULL, NULL, 43.6134, -116.254, NULL, NULL),
('820200895', 'W12025326', 'W12025326', 'IDBOISTD', 'Saint Alphonsus Medical Group Neurosurgery Fruitland', 'Teresa', 'A', 'Weeks', 'NP-C', 'Neurosurgery', 'Nurse Practitioner', '', NULL, 'O', '910 NW 16th St Ste 101', 'Fruitland', 'Payette', 'ID', '83619', '2083674000', '2083674052', '910 NW 16th St Ste 101', 'Fruitland', 'Payette', 'ID', '83619', '2083674000', '2083674052', 'IDSAMG1', '', '', '0.00', '10.00', '0.00', 6, '2012-10-15', '2012-10-15', 0, 0, 0, 'Saint Alphonsus Medical Center Nampa', '', '', '', 'HCFA|', '1346259454', 0, 'Y', 0, '2013-04-30', NULL, NULL, 44.0254, -116.925, NULL, NULL),
('820200895', 'W12025333', 'W12025333', 'IDBOISTD', 'Saint Alphonsus Diabetes Care and Education', '', '', 'Saint Alphonsus Diabetes Care and Education', '', 'Diabetic Education', '', '', NULL, 'O', '3025 W Cherry Ln', 'Meridian', 'Ada', 'ID', '83642', '2083676130', NULL, '3025 W Cherry Ln  ', 'Meridian', 'Ada', 'ID', '83642', '2083676130', '          ', '', '', 'ID01', '0.00', '0.00', '0.00', 6, '2012-11-19', NULL, 0, 0, 0, '', '', '', '', 'HCFA|', '0000009975', 0, 'N', 0, '2012-11-28', NULL, NULL, 43.6193, -116.431, NULL, NULL),
('820200895', 'W12025334', 'W12025334', 'IDBOISTD', 'Saint Alphonsus Diabetes Care and Education', '', '', 'Saint Alphonsus Diabetes Care and Education', '', 'Diabetic Education', '', '', NULL, 'O', '4400 E Flamingo Ave', 'Nampa', 'Canyon', 'ID', '83687', '2083676130', NULL, '4400 E Flamingo Ave  ', 'Nampa', 'Canyon', 'ID', '83687', '2083676130', '          ', '', '', 'ID01', '0.00', '0.00', '0.00', 6, '2012-11-19', NULL, 0, 0, 0, '', '', '', '', 'HCFA|', '0000009975', 0, 'N', 0, '2012-11-28', NULL, NULL, 43.5966, -116.519, NULL, NULL),
('820200895', 'W12025335', 'W12025335', 'IDBOISTD', 'Saint Alphonsus Diabetes Care and Education', '', '', 'Saint Alphonsus Diabetes Care and Education', '', 'Diabetic Education', '', '', NULL, 'B', 'PO Box 3527', 'Portland', 'Multnomah', 'OR', '97208', '2083672130', NULL, 'PO Box 3527  ', 'Portland', 'Multnomah', 'OR', '97208', '2083672130', '          ', '', '', 'ID01', '0.00', '0.00', '0.00', 6, '2012-11-19', NULL, 0, 0, 0, '', '', '', '', 'HCFA|', '0000009975', 0, 'N', 0, '2012-11-28', NULL, NULL, 0, 0, NULL, NULL),
('870683406', 'W12025336', 'W12025336', 'UTMH1', '', 'Cary', '', 'Chamberlain', 'LCSW', 'Mental Health', 'Social Worker', '', NULL, 'O', '1224 S River Rd Ste B-230', 'St George', 'Washington', 'UT', '84790', '4356320946', '4359862276', '1224 S River Rd Ste B-230', 'St George', 'Washington', 'UT', '84790', '4356320946', '4359862276', 'ma', '', '', '0.00', '100.00', '0.00', 3, '2012-10-01', '2013-02-14', 0, 0, 0, '', '', '', '', 'HCFA|UB|', '1144430844', 0, 'N', 0, '2013-02-27', NULL, NULL, 0, 0, NULL, NULL),
('870683406', 'W12025337', 'W12025337', 'UTMH1', '', 'Cary', '', 'Chamberlain', 'LCSW', 'Mental Health', 'Social Worker', '', NULL, 'B', 'PO Box 0145', 'Washington', 'Washington', 'UT', '84780', '4356320946', '4359862276', 'PO Box 0145  ', 'Washington', 'Washington', 'UT', '84780', '4356320946', '4359862276', 'ma', '', '', '0.00', '100.00', '0.00', 3, '2012-10-01', '2013-02-14', 0, 0, 0, '', '', '', '', 'HCFA|UB|', '1144430844', 0, 'N', 0, '2013-02-27', NULL, NULL, 0, 0, NULL, NULL),
('548700079', 'W12012873', 'W12012873', 'UTMH1', 'Holistic Balance', 'Laraine', '', 'Miner', 'LPC', 'Mental Health', 'Counseling', '', NULL, 'O', '865 E 4800 S Ste 222', 'Murray', 'Salt Lake', 'UT', '84107', '8016568827', '8012663358', '865 E 4800 S Ste 222', 'Murray', 'Salt Lake', 'UT', '84107', '8016568827', '8012663358', 'UTMA', '', '', '0.00', '35.00', '0.00', 3, '2011-09-01', '2013-02-14', 0, 0, 0, '', '', '', '', 'HCFA|UB|', '1871571638', 0, 'N', 0, '2014-05-06', NULL, NULL, 0, 0, NULL, NULL),
('548700079', 'W12012874', 'W12012874', 'UTMH1', 'Holistic Balance', 'Laraine', '', 'Miner', 'LPC', 'Mental Health', 'Counseling', '', NULL, 'B', 'PO Box 18415', 'Taylorsville', 'Salt Lake', 'UT', '84118', '8016568827', '8012663358', 'PO Box 18415', 'Taylorsville', 'Salt Lake', 'UT', '84118', '8016568827', '8012663358', 'UTMA', '', '', '0.00', '35.00', '0.00', 3, '2011-09-01', '2013-02-14', 0, 0, 0, '', '', '', '', 'HCFA|UB|', '1871571638', 0, 'N', 0, '2014-05-06', NULL, NULL, 0, 0, NULL, NULL),
('521458557', 'W12025340', 'W12025340', 'ILCHIGSTD', 'Advanced Surgical Associates', '', '', 'Advanced Surgical Associates', '', 'General Surgery', '', '', NULL, 'O', '800 Biesterfield Rd Wimmer Bldg Ste 304', 'Elk Grove Village', 'Cook', 'IL', '60007', '8474398000', '8474396982', '800 Biesterfield Rd Wimmer Bldg Ste 304', 'Elk Grove Village', 'Cook', 'IL', '60007', '8474398000', '8474396982', 'CHIG2', 'CHIHCPCS13', '', '0.00', '40.00', '0.00', 3, '2013-01-01', NULL, 0, 0, 0, '', '', '', '', 'HCFA|UB|', '1346205390', 0, 'Y', 0, '2013-08-02', NULL, NULL, 42.0034, -88.0174, NULL, NULL),
('521458557', 'W12025339', 'W12025339', 'ILCHIGSTD', 'Advanced Surgical Associates', '', '', 'Advanced Surgical Associates', '', 'General Surgery', '', '', NULL, 'O', '880 W Central Rd Ste 3800', 'Arlington Heights', 'Cook', 'IL', '60005', '8474839800', '8472536121', '880 W Central Rd Ste 3800', 'Arlington Heights', 'Cook', 'IL', '60005', '8474839800', '8472536121', 'CHIG2', 'CHIHCPCS13', '', '0.00', '40.00', '0.00', 3, '2013-01-01', NULL, 0, 0, 0, '', '', '', '', 'HCFA|UB|', '1346205390', 0, 'Y', 0, '2013-08-02', NULL, NULL, 42.0666, -87.9939, NULL, NULL),
('521458557', 'W12025341', 'W12025341', 'ILCHIGSTD', 'Advanced Surgical Associates', '', '', 'Advanced Surgical Associates', '', 'General Surgery', '', '', NULL, 'B', 'Dept 20-1036 PO Box 5940', 'Carol Stream', 'Dupage', 'IL', '60197', '8474839800', '8472536121', 'Dept 20-1036 PO Box 5940', 'Carol Stream', 'Dupage', 'IL', '60197', '8474839800', '8472536121', 'CHIG2', 'CHIHCPCS13', '', '0.00', '40.00', '0.00', 3, '2013-01-01', NULL, 0, 0, 0, '', '', '', '', 'HCFA|UB|', '1346205390', 0, 'N', 0, '2013-08-02', NULL, NULL, 0, 0, NULL, NULL),
('521458557', 'W12025346', 'W12025346', 'ILCHIGSTD', 'Advanced Surgical Associates', 'Alan', 'Bruce', 'Loren', 'MD', 'General Surgery', '', '', NULL, 'B', 'Dept 20-1036 PO Box 5940', 'Carol Stream', 'Dupage', 'IL', '60197', '8474839800', '8472536121', 'Dept 20-1036 PO Box 5940', 'Carol Stream', 'Dupage', 'IL', '60197', '8474839800', '8472536121', 'CHIG2', 'CHIHCPCS13', '', '0.00', '40.00', '0.00', 3, '2013-01-01', NULL, 0, 0, 0, 'Northwest Community Hospital', NULL, NULL, NULL, 'HCFA|UB|', '1891750949', 0, 'N', 0, '2013-04-03', NULL, NULL, 0, 0, NULL, NULL),
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('521458557', 'W12025345', 'W12025345', 'ILCHIGSTD', 'Advanced Surgical Associates', 'Alan', 'Bruce', 'Loren', 'MD', 'General Surgery', '', '', NULL, 'O', '880 W Central Rd Ste 3800', 'Arlington Heights', 'Cook', 'IL', '60005', '8474839800', '8472536121', '880 W Central Rd Ste 3800', 'Arlington Heights', 'Cook', 'IL', '60005', '8474839800', '8472536121', 'CHIG2', 'CHIHCPCS13', '', '0.00', '40.00', '0.00', 3, '2013-01-01', NULL, 0, 0, 0, 'Northwest Community Hospital', NULL, NULL, NULL, 'HCFA|UB|', '1891750949', 0, 'N', 0, '2013-04-03', NULL, NULL, 42.0666, -87.9939, NULL, NULL),
('521458557', 'W12025350', 'W12025350', 'ILCHIGSTD', 'Advanced Surgical Associates', 'Daniel', 'R', 'Conway', 'MD', 'General Surgery', '', '', NULL, 'B', 'Dept 20-1036 PO Box 5940', 'Carol Stream', 'Dupage', 'IL', '60197', '8474839800', '8472536121', 'Dept 20-1036 PO Box 5940', 'Carol Stream', 'Dupage', 'IL', '60197', '8474839800', '8472536121', 'CHIG2', 'CHIHCPCS13', '', '0.00', '40.00', '0.00', 3, '2013-01-01', NULL, 0, 0, 0, 'Northwest Community Hospital', NULL, NULL, NULL, 'HCFA|UB|', '1477518462', 0, 'N', 0, '2012-12-01', NULL, NULL, 0, 0, NULL, NULL),
('521458557', 'W12025348', 'W12025348', 'ILCHIGSTD', 'Advanced Surgical Associates', 'Daniel', 'R', 'Conway', 'MD', 'General Surgery', '', '', NULL, 'O', '800 Biesterfield Rd Wimmer Bldg Ste 304', 'Elk Grove Village', 'Cook', 'IL', '60007', '8474398000', '8474396982', '800 Biesterfield Rd Ste 304', 'Elk Grove Village', 'Cook', 'IL', '60007', '8474398000', '8474396982', 'CHIG2', 'CHIHCPCS13', '', '0.00', '40.00', '0.00', 3, '2013-01-01', NULL, 0, 0, 0, 'Northwest Community Hospital', NULL, NULL, NULL, 'HCFA|UB|', '1477518462', 0, 'N', 0, '2012-12-01', NULL, NULL, 42.0034, -88.0174, NULL, NULL),
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('521458557', 'W12025354', 'W12025354', 'ILCHIGSTD', 'Advanced Surgical Associates', 'Robert', '', 'Rao', 'MD', 'General Surgery', '', '', NULL, 'B', 'Dept 20-1036 PO Box 5940', 'Carol Stream', 'Dupage', 'IL', '60197', '8474839800', '8472536121', 'Dept 20-1036 PO Box 5940', 'Carol Stream', 'Dupage', 'IL', '60197', '8474839800', '8472536121', 'CHIG2', 'CHIHCPCS13', '', '0.00', '40.00', '0.00', 3, '2013-01-01', NULL, 0, 0, 0, 'Northwest Community Hospital', NULL, NULL, NULL, 'HCFA|UB|', '1437114485', 0, 'N', 0, '2013-04-26', NULL, NULL, 0, 0, NULL, NULL),
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('521458557', 'W12025362', 'W12025362', 'ILCHIGSTD', 'Advanced Surgical Associates', 'William', 'D', 'Soper', 'MD', 'General Surgery', '', '', NULL, 'B', 'Dept 20-1036 PO Box 5940', 'Carol Stream', 'Dupage', 'IL', '60197', '8474839800', '8472536121', 'Dept 20-1036 PO Box 5940', 'Carol Stream', 'Dupage', 'IL', '60197', '8474839800', '8472536121', 'CHIG2', 'CHIHCPCS13', '', '0.00', '40.00', '0.00', 3, '2013-01-01', NULL, 0, 0, 0, 'Northwest Community Hospital', NULL, NULL, NULL, 'HCFA|UB|', '1053318691', 0, 'N', 0, '2012-12-03', NULL, NULL, 0, 0, NULL, NULL),
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('200062801', 'W12025366', 'W12025366', 'ILCHIGSTD', 'Roseann Brady DO', 'Roseann', '', 'Brady', 'DO', 'Internal Medicine', '', '', NULL, '', '110 S Wynstone Pk Dr Ste 101', 'Barrington', 'Lake', 'IL', '60010', '2248484256', '8472779997', '110 S Wynstone Pk Dr Ste 101', 'Barrington', 'Lake', 'IL', '60010', '2248484256', '8472779997', 'CHIG1', 'CHIHCPCS13', '', '0.00', '35.00', '0.00', 3, '2013-01-01', NULL, 0, 0, 0, '', '', '', '', 'HCFA|UB|', '1124297056', 0, 'N', 0, '2013-05-30', NULL, NULL, 0, 0, NULL, NULL),
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('362935762', 'W12025382', 'W12025382', 'ILCHIGSTD', 'Personal Physicians West', 'Manish', 'I', 'Desai', 'DO', 'Internal Medicine', '', '', NULL, 'O', '5909 W 35th St', 'Cicero', 'Cook', 'IL', '60804', '7086522040', '7086520058', '5909 W 35th St   ', 'Cicero', 'Cook', 'IL', '60804', '7086522040', '7086520058', 'CHIG1', 'CHIHCPCS13', '', '0.00', '40.00', '0.00', 3, '2030-01-01', NULL, 0, 0, 0, 'Elmhurst Memorial Hospital', '', '', '', 'HCFA|UB|', '1881699080', 0, 'N', 1, '2012-12-04', NULL, NULL, 0, 0, NULL, NULL),
('364201731', 'W12025395', 'W12025395', 'ILCHIGSTD', 'Dupage Health Specialists', 'Betty', '', 'Hsia', 'MD', 'Obstetrics and Gynecology', '', '', NULL, 'O', '3033 Ogden Ave Ste 300', 'Lisle', 'Dupage', 'IL', '60532', '6307175700', '6307170665', '3033 Ogden Ave Ste 300', 'Lisle', 'Dupage', 'IL', '60532', '6307175700', '6307170665', 'CHIG2', 'CHIHCPCS13', '', '0.00', '40.00', '0.00', 3, '2013-01-01', NULL, 0, 0, 0, 'Edward Hospital', NULL, NULL, NULL, 'HCFA|UB|', '1871588137', 0, 'N', 0, '2012-12-10', NULL, NULL, 41.7981, -88.0983, NULL, NULL),
('362935762', 'W12025385', 'W12025385', 'ILCHIGSTD', 'Personal Physicians West', 'Ramnik', '', 'Gokani', 'MD', 'Internal Medicine', '', '', NULL, 'O', '5909 W 35th St', 'Cicero', 'Cook', 'IL', '60804', '7086522040', '7086520058', '5909 W 35th St   ', 'Cicero', 'Cook', 'IL', '60804', '7086522040', '7086520058', 'CHIG1', 'CHIHCPCS13', '', '0.00', '40.00', '0.00', 3, '2030-01-01', NULL, 0, 0, 0, '', '', '', '', 'HCFA|UB|', '1497843494', 0, 'N', 1, '2012-12-04', NULL, NULL, 0, 0, NULL, NULL),
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('364201731', 'W12025397', 'W12025397', 'ILCHIGSTD', 'Dupage Health Specialists', 'Audrey', 'A', 'Bromberger', 'MD', 'Obstetrics and Gynecology', '', '', NULL, 'O', '3033 Ogden Ave Ste 300', 'Lisle', 'Dupage', 'IL', '60532', '6307175700', '6307170665', '3033 Ogden Ave Ste 300', 'Lisle', 'Dupage', 'IL', '60532', '6307175700', '6307170665', 'CHIG2', 'CHIHCPCS13', '', '0.00', '40.00', '0.00', 3, '2013-01-01', NULL, 0, 0, 0, 'Edward Hospital', NULL, NULL, NULL, 'HCFA|UB|', '1376537233', 0, 'N', 0, '2012-12-10', NULL, NULL, 41.7981, -88.0983, NULL, NULL),
('362935762', 'W12025390', 'W12025390', 'ILCHIGSTD', 'Personal Physicians West', 'Nausheen', '', 'Samee', 'MD', 'Internal Medicine', '', '', NULL, 'O', '235 Remington Blvd Ste E', 'Bolingbrook', 'Will', 'IL', '60440', '6307711201', '6307711203', '235 Remington Blvd Ste E', 'Bolingbrook', 'Will', 'IL', '60440', '6307711201', '6307711203', 'CHIG1', 'CHIHCPCS13', '', '0.00', '40.00', '0.00', 3, '2030-01-01', NULL, 0, 0, 0, '', '', '', '', 'HCFA|UB|', '1487818415', 0, 'N', 1, '2012-12-02', NULL, NULL, 0, 0, NULL, NULL),
('362935762', 'W12025391', 'W12025391', 'ILCHIGSTD', 'Personal Physicians West', 'Nausheen', '', 'Samee', 'MD', 'Internal Medicine', '', '', NULL, 'O', '5909 W 35th St', 'Cicero', 'Cook', 'IL', '60804', '7086522040', '7086520058', '5909 W 35th St   ', 'Cicero', 'Cook', 'IL', '60804', '7086522040', '7086520058', 'CHIG1', 'CHIHCPCS13', '', '0.00', '40.00', '0.00', 3, '2030-01-01', NULL, 0, 0, 0, '', '', '', '', 'HCFA|UB|', '1487818415', 0, 'N', 1, '2012-12-02', NULL, NULL, 0, 0, NULL, NULL),
('364201731', 'W12025409', 'W12025409', 'ILCHIGSTD', 'Dupage Health Specialists', 'Jennifer', 'C', 'Dunn', 'MD', 'Obstetrics and Gynecology', '', '', NULL, 'O', '3033 Ogden Ave Ste 300', 'Lisle', 'Dupage', 'IL', '60532', '6307175700', '6307170665', '3033 Ogden Ave Ste 300', 'Lisle', 'Dupage', 'IL', '60532', '6307175700', '6307170665', 'CHIG2', 'CHIHCPCS13', '', '0.00', '40.00', '0.00', 3, '2013-01-01', NULL, 0, 0, 0, 'Edward Hospital', NULL, NULL, NULL, 'HCFA|UB|', '1417941139', 0, 'N', 0, '2012-12-10', NULL, NULL, 41.7981, -88.0983, NULL, NULL),
('363980044', 'W12025410', 'W12025410', 'ILCHIGSTD', 'Illinois Cancer Specialists', '', '', 'Illinois Cancer Specialists', '', 'Oncology', '', '', NULL, 'B', '25070 Network Pl', 'Chicago', 'Cook', 'IL', '60673', '8475857000', '8472409092', '25070 Network Pl  ', 'Chicago', 'Cook', 'IL', '60673', '8475857000', '8472409092', 'CHIG7', 'CHIHCPCS13', '', '0.00', '35.00', '0.00', 3, '2013-01-01', NULL, 0, 0, 0, '', '', '', '', 'HCFA|UB|', '1164483913', 0, 'Y', 0, '2012-11-30', NULL, NULL, 0, 0, NULL, NULL),
('363980044', 'W12025415', 'W12025415', 'ILCHIGSTD', 'Illinois Cancer Specialists', '', '', 'Illinois Cancer Specialists', '', 'Oncology', '', '', NULL, 'O', '396 Remington Blvd Ste 141', 'Bolingbrook', 'Will', 'IL', '60440', '6306541790', '6309083610', '396 Remington Blvd Ste 141', 'Bolingbrook', 'Will', 'IL', '60440', '6306541790', '6309083610', 'CHIG7', 'CHIHCPCS13', '', '0.00', '35.00', '0.00', 3, '2013-01-01', NULL, 0, 0, 0, '', '', '', '', 'HCFA|UB|', '1164483913', 0, 'Y', 0, '2013-05-10', NULL, NULL, 41.6816, -88.0821, NULL, NULL),
('363980044', 'W12025413', 'W12025413', 'ILCHIGSTD', 'Illinois Cancer Specialists', '', '', 'Illinois Cancer Specialists', '', 'Oncology', '', '', NULL, 'O', '7447 W Talcott Ave Ste 400', 'Chicago', 'Cook', 'IL', '60631', '7737639300', '7737631622', '7447 W Talcott Ave Ste 400', 'Chicago', 'Cook', 'IL', '60631', '7737639300', '7737631622', 'CHIG7', 'CHIHCPCS13', '', '0.00', '35.00', '0.00', 3, '2013-01-01', NULL, 0, 0, 0, '', '', '', '', 'HCFA|UB|', '1164483913', 0, 'Y', 0, '2013-05-10', NULL, NULL, 41.9887, -87.8131, NULL, NULL),
('363980044', 'W12025412', 'W12025412', 'ILCHIGSTD', 'Illinois Cancer Specialists', '', '', 'Illinois Cancer Specialists', '', 'Oncology', '', '', NULL, 'O', '880 W Central Rd Ste 8200', 'Arlington Heights', 'Cook', 'IL', '60005', '8472594482', '8472596406', '880 W Central Rd Ste 8200', 'Arlington Heights', 'Cook', 'IL', '60005', '8472594482', '8472596406', 'CHIG7', 'CHIHCPCS13', '', '0.00', '35.00', '0.00', 3, '2013-01-01', NULL, 0, 0, 0, '', '', '', '', 'HCFA|UB|', '1164483913', 0, 'Y', 0, '2013-05-10', NULL, NULL, 42.0666, -87.9939, NULL, NULL),
('363980044', 'W12025411', 'W12025411', 'ILCHIGSTD', 'Illinois Cancer Specialists', '', '', 'Illinois Cancer Specialists', '', 'Oncology', '', '', NULL, 'O', '8915 W Golf Rd', 'Niles', 'Cook', 'IL', '60714', '8478279060', '8478277196', '8915 W Golf Rd   ', 'Niles', 'Cook', 'IL', '60714', '8478279060', '8478277196', 'CHIG7', 'CHIHCPCS13', '', '0.00', '35.00', '0.00', 3, '2013-01-01', NULL, 0, 0, 0, '', '', '', '', 'HCFA|UB|', '1164483913', 0, 'Y', 0, '2013-05-10', NULL, NULL, 42.0305, -87.815, NULL, NULL),
('363980044', 'W12025414', 'W12025414', 'ILCHIGSTD', 'Illinois Cancer Specialists', '', '', 'Illinois Cancer Specialists', '', 'Oncology', '', '', NULL, 'O', '908 N Elm St Ste 210', 'Hinsdale', 'Dupage', 'IL', '60521', '6306541790', '6306541845', '908 N Elm St Ste 210', 'Hinsdale', 'Dupage', 'IL', '60521', '6306541790', '6306541845', 'CHIG7', 'CHIHCPCS13', '', '0.00', '35.00', '0.00', 3, '2013-01-01', NULL, 0, 0, 0, '', '', '', '', 'HCFA|UB|', '1164483913', 0, 'Y', 0, '2013-05-10', NULL, NULL, 41.8178, -87.9233, NULL, NULL),
('752646217', 'W12025416', 'W12025416', 'TXDALSTD', 'J W Eye Associates', '', '', 'J W Eye Associates', '', 'Ophthalmology', '', '', NULL, 'O', '2801 Lemmon Ave Ste 400', 'Dallas', 'Dallas', 'TX', '75204', '2147540000', '2143791849', '2801 Lemmon Ave Suite 400', 'Dallas', 'Dallas', 'TX', '75204', '2147540000', '2143791849', 'DALLAS4', 'TXHCPC13', '', '0.00', '50.00', '0.00', 3, '2013-01-01', NULL, 0, 0, 0, '', '', '', '', 'HCFA|UB|', '1285679803', 0, 'N', 0, '2012-12-05', NULL, NULL, 32.8042, -96.7963, NULL, NULL),
('752646217', 'W12025418', 'W12025418', 'TXDALSTD', 'J W Eye Associates', 'Jeffrey', '', 'Whitman', 'MD', 'Ophthalmology', '', '', NULL, 'O', '2801 Lemmon Ave STE 400', 'Dallas', 'Dallas', 'TX', '75204', '2147540000', '2143791849', '2801 Lemmon Ave   STE 400', 'Dallas', 'Dallas', 'TX', '75204', '2147540000', '2143791849', 'DALLAS4', 'TXHCPC13', '', '0.00', '50.00', '0.00', 3, '2013-01-01', NULL, 0, 0, 0, '', '', '', '', 'HCFA|UB|', '1669401162', 0, 'N', 0, '2012-12-06', NULL, NULL, 32.8042, -96.7963, NULL, NULL),
('752646217', 'W12025420', 'W12025420', 'TXDALSTD', 'J W Eye Associates', 'Kimberly', 'S', 'Warren', 'MD', 'Ophthalmology', '', '', NULL, 'O', '2801 Lemmon Ave Ste 400', 'Dallas', 'Dallas', 'TX', '75204', '2147540000', '2143791849', '2801 Lemmon Ave Ste 400', 'Dallas', 'Dallas', 'TX', '75204', '2147540000', '2143791849', 'DALLAS4', 'TXHCPC13', '', '0.00', '50.00', '0.00', 3, '2013-01-01', NULL, 0, 0, 0, '', '', '', '', 'HCFA|UB|', '1942239172', 0, 'N', 0, '2012-12-06', NULL, NULL, 32.8042, -96.7963, NULL, NULL),
('752646217', 'W12025422', 'W12025422', 'TXDALSTD', 'J W Eye Associates', 'Faisal', 'E', 'Haq', 'MD', 'Ophthalmology', '', '', NULL, 'O', '2801 Lemmon Ave Ste 400', 'Dallas', 'Dallas', 'TX', '75204', '2147540000', '2143791849', '2801 Lemmon Ave   Ste 400', 'Dallas', 'Dallas', 'TX', '75204', '2147540000', '2143791849', 'DALLAS4', 'TXHCPC13', '', '0.00', '50.00', '0.00', 3, '2013-01-01', NULL, 0, 0, 0, '', '', '', '', 'HCFA|UB|', '1023044658', 0, 'N', 0, '2012-12-07', NULL, NULL, 32.8042, -96.7963, NULL, NULL),
('752646217', 'W12025424', 'W12025424', 'TXDALSTD', 'J W Eye Associates', 'Chian-Huey', '', 'Hong', 'MD', 'Ophthalmology', '', '', NULL, 'O', '2801 Lemmon Ave STE 400', 'Dallas', 'Dallas', 'TX', '75204', '2147540000', '2143791849', '2801 Lemmon Ave   STE 400', 'Dallas', 'Dallas', 'TX', '75204', '2147540000', '2143791849', 'DALLAS4', 'TXHCPC13', '', '0.00', '50.00', '0.00', 3, '2013-01-01', NULL, 0, 0, 0, '', '', '', '', 'HCFA|UB|', '1912933581', 0, 'N', 0, '2012-12-07', NULL, NULL, 32.8042, -96.7963, NULL, NULL),
('752646217', 'W12025426', 'W12025426', 'TXDALSTD', 'J W Eye Associates', 'Alfred', 'L', 'Humphrey', 'MD', 'Ophthalmology', '', '', NULL, 'O', '2801 Lemmon Ave STE 400', 'Dallas', 'Dallas', 'TX', '75204', '2147540000', '2143791849', '2801 Lemmon Ave   STE 400', 'Dallas', 'Dallas', 'TX', '75204', '2147540000', '2143791849', 'DALLAS4', 'TXHCPC13', '', '0.00', '50.00', '0.00', 3, '2013-01-01', NULL, 0, 0, 0, '', '', '', '', 'HCFA|UB|', '1164426946', 0, 'N', 0, '2012-12-07', NULL, NULL, 32.8042, -96.7963, NULL, NULL),
('752646217', 'W12025428', 'W12025428', 'TXDALSTD', 'J W Eye Associates', 'Thomas', 'J', 'Jennings', 'MD', 'Ophthalmology', '', '', NULL, 'O', '2801 Lemmon Ave Ste 400', 'Dallas', 'Dallas', 'TX', '75204', '2147540000', '2143791849', '2801 Lemmon Ave   Ste 400', 'Dallas', 'Dallas', 'TX', '75204', '2147540000', '2143791849', 'DALLAS4', 'TXHCPC13', '', '0.00', '50.00', '0.00', 3, '2013-01-01', NULL, 0, 0, 0, '', '', '', '', 'HCFA|UB|', '1962466797', 0, 'N', 0, '2012-12-07', NULL, NULL, 32.8042, -96.7963, NULL, NULL),
('760636117', 'W12025429', 'W12025429', 'TXHOUSTD', 'Forest Pediatrics', 'Trecia', 'L', 'Elahee', 'MD', 'Pediatrics', '', '', NULL, 'O', '3115 College Park Dr Ste 104', 'Conroe', 'Montgomery', 'TX', '77384', '9363215030', '9362715033', '3115 College Park Dr Ste 104', 'Conroe', 'Montgomery', 'TX', '77384', '9363215030', '9362715033', 'HOUSTON1', 'TXHCPC13', '', '0.00', '45.00', '0.00', 3, '2013-01-01', NULL, 0, 0, 0, '', '', '', '', 'HCFA|UB|', '1306922182', 0, 'N', 0, '2013-06-04', NULL, NULL, 30.207, -95.4643, NULL, NULL),
('262905960', 'W12025430', 'W12025430', 'TXDALSTD', 'Paul Wang MD', 'Paul', '', 'Wang', 'MD', 'Internal Medicine', '', '', NULL, 'O', '3550 Parkwood Blvd Ste B100', 'Frisco', 'Denton', 'TX', '75034', '2146189715', '2146189716', '3550 Parkwood Blvd Ste B100', 'Frisco', 'Denton', 'TX', '75034', '2146189715', '2146189716', 'DALLAS1', 'TXHCPC13', '', '0.00', '50.00', '0.00', 3, '2013-01-01', NULL, 0, 0, 0, 'Baylor Medical Center at Carrollton', NULL, NULL, NULL, 'HCFA|UB|', '1356341465', 0, 'N', 0, '2013-05-24', NULL, NULL, 33.1097, -96.8163, NULL, NULL),
('205377681', 'W12025431', 'W12025431', 'TXDALSTD', 'Carlos Molina MD', 'Carlos', '', 'Molina', 'MD', 'Family Practice', '', '', NULL, 'O', '8 Medical Pkwy Prof Plz 2 Ste 202', 'Dallas', 'Dallas', 'TX', '75234', '9726202626', '9726202527', '8 Medical Pkwy Prof Plz 2 Ste 202', 'Dallas', 'Dallas', 'TX', '75234', '9726202626', '9726202527', 'DALLAS1', 'TXHCPC13', '', '0.00', '50.00', '0.00', 3, '2013-01-01', NULL, 0, 0, 0, '', '', '', '', 'HCFA|UB|', '1538260245', 0, 'N', 0, '2013-05-24', NULL, NULL, 32.9242, -96.8673, NULL, NULL),
('262458104', 'W12025432', 'W12025432', 'TXDALSTD', '', 'Jun', '', 'Lee', 'MD', 'Internal Medicine', '', '', NULL, 'O', '4525 Ohio Dr', 'Frisco', 'Collin', 'TX', '75035', '9727317717', '9727317733', '4525 Ohio Dr', 'Frisco', 'Collin', 'TX', '75035', '9727317717', '9727317733', 'DALLAS1', 'TXHCPC13', '', '0.00', '50.00', '0.00', 3, '2013-01-01', NULL, 0, 0, 0, 'Baylor Regional Medical Center at Plano', NULL, '', '', 'HCFA|UB|', '1891795522', 0, 'N', 0, '2012-12-07', NULL, NULL, 33.1158, -96.8021, NULL, NULL),
('113658797', 'W12025433', 'W12025433', 'TXDALSTD', 'Suzette Boyd MD', 'Suzette', 'L', 'Boyd', 'MD', 'Obstetrics and Gynecology', '', '', NULL, 'O', '5575 Warren Pkwy Ste 314', 'Frisco', 'Denton', 'TX', '75034', '2146184170', '2146184171', '5575 Warren Pkwy Ste 314', 'Frisco', 'Denton', 'TX', '75034', '2146184170', '2146184171', 'DALLAS3', 'TXHCPC13', '', '0.00', '50.00', '0.00', 3, '2013-01-01', NULL, 0, 0, 0, 'Baylor Medical Center at Carrollton', NULL, '', '', 'HCFA|UB|', '1851490635', 0, 'N', 0, '2013-05-24', NULL, NULL, 33.1067, -96.8401, NULL, NULL),
('200348753', 'W12025434', 'W12025434', 'TXHOUSTD', 'Donald Nino MD', 'Donald', 'R', 'Nino', 'MD', 'Family Practice', '', '', NULL, 'O', '15055 E Fwy Ste A10', 'Channelview', 'Harris', 'TX', '77530', '2814524747', '2814572762', '15055 E Fwy Ste A10', 'Channelview', 'Harris', 'TX', '77530', '2814524747', '2814572762', 'HOUSTON1', 'TXHCPC13', '', '0.00', '45.00', '0.00', 3, '2013-01-01', NULL, 0, 0, 0, 'East Houston Regional Medical Center', NULL, NULL, NULL, 'HCFA|UB|', '1851384952', 0, 'N', 0, '2013-05-28', NULL, NULL, 29.7733, -95.1457, NULL, NULL),
('262458104', 'W12025435', 'W12025435', 'TXDALSTD', 'Frisco Primary Care', 'Subashini', '', 'Narayanan', 'MD', 'Internal Medicine', '', '', NULL, 'O', '4525 Ohio Dr', 'Frisco', 'Collin', 'TX', '75035', '9727317717', '9727317733', '4525 Ohio Dr   ', 'Frisco', 'Collin', 'TX', '75035', '9727317717', '9727317733', 'DALLAS1', 'TXHCPC13', '', '0.00', '50.00', '0.00', 3, '2013-01-01', NULL, 0, 0, 0, 'Baylor Regional Medical Center at Plano', NULL, '', '', 'HCFA|UB|', '1710986864', 0, 'N', 0, '2012-12-05', NULL, NULL, 33.1158, -96.8021, NULL, NULL),
('300369495', 'W12025437', 'W12025437', 'TXHOUSTD', 'Mubarak A Khawaja MD', 'Mubarak', 'A', 'Khawaja', 'MD', 'Internal Medicine', '', '', NULL, 'O', '707 S Fry Rd Ste 375', 'Katy', 'Harris', 'TX', '77450', '2815998070', '2815998805', '707 S Fry Rd Ste 375', 'Katy', 'Harris', 'TX', '77450', '2815998070', '2815998805', 'HOUSTON1', 'TXHCPC13', '', '0.00', '45.00', '0.00', 3, '2013-01-01', NULL, 0, 0, 0, NULL, NULL, '', '', 'HCFA|UB|', '1548285406', 0, 'N', 0, '2013-05-30', NULL, NULL, 29.7765, -95.7189, NULL, NULL),
('760636117', 'W12025438', 'W12025438', 'TXHOUSTD', 'Forest Pediatrics', 'Samuel', 'J', 'Heardmon', 'MD', 'Pediatrics', '', '', NULL, 'O', '3115 College Park Dr Ste 104', 'Conroe', 'Montgomery', 'TX', '77384', '9363215030', '9362715033', '3115 College Park Dr Ste 104', 'Conroe', 'Montgomery', 'TX', '77384', '9363215030', '9362715033', 'HOUSTON1', 'TXHCPC13', '', '0.00', '45.00', '0.00', 3, '2013-01-01', NULL, 0, 0, 0, 'Conroe Regional Medical Center', NULL, '', '', 'HCFA|UB|', '1912205741', 0, 'N', 0, '2013-06-04', NULL, NULL, 30.207, -95.4643, NULL, NULL),
('363399794', 'W12025439', 'W12025439', 'ILCHIGSTD', 'WomanCare PC', '', '', 'WomanCare PC', '', 'Obstetrics and Gynecology', '', '', NULL, 'O', '355 W Northwest Hwy Century Plaza', 'Palatine', 'Cook', 'IL', '60067', '8472214700', '8472212196', '355 W Northwest Hwy Century Plaza', 'Palatine', 'Cook', 'IL', '60067', '8472214700', '8472212196', 'CHIG2', 'CHIHCPCS13', '', '0.00', '40.00', '0.00', 3, '2013-01-01', NULL, 0, 0, 0, 'Northwest Community Hospital', '', '', '', 'HCFA|UB|', '1487650982', 0, 'Y', 0, '2014-04-25', NULL, NULL, 42.123, -88.0508, NULL, NULL),
('363399794', 'W12025440', 'W12025440', 'ILCHIGSTD', 'WomanCare PC', '', '', 'WomanCare PC', '', 'Obstetrics and Gynecology', '', '', NULL, 'B', '363 W Northwest Hwy Century Plaza', 'Palatine', 'Cook', 'IL', '60067', '8472214600', '8472214696', '363 W Northwest Hwy Century Plaza', 'Palatine', 'Cook', 'IL', '60067', '8472214600', '8472214696', 'CHIG2', 'CHIHCPCS13', '', '0.00', '40.00', '0.00', 3, '2013-01-01', NULL, 0, 0, 0, 'Northwest Community Hospital', '', '', '', 'HCFA|UB|', '1487650982', 0, 'N', 0, '2014-04-25', NULL, NULL, 0, 0, NULL, NULL),
('363399794', 'W12025441', 'W12025441', 'ILCHIGSTD', 'WomanCare PC', '', '', 'WomanCare PC', '', 'Obstetrics and Gynecology', '', '', NULL, 'O', '1051 W Rand Rd Ste 101', 'Arlington Heights', 'Cook', 'IL', '60004', '8472214900', '8472214996', '1051 W Rand Rd Ste 101', 'Arlington Heights', 'Cook', 'IL', '60004', '8472214900', '8472214996', 'CHIG2', 'CHIHCPCS13', '', '0.00', '40.00', '0.00', 3, '2013-01-01', NULL, 0, 0, 0, 'Northwest Community Hospital', '', '', '', 'HCFA|UB|', '1487650982', 0, 'Y', 0, '2014-04-25', NULL, NULL, 42.1228, -87.9956, NULL, NULL),
('363399794', 'W12025442', 'W12025442', 'ILCHIGSTD', 'WomanCare PC', '', '', 'WomanCare PC', '', 'Obstetrics and Gynecology', '', '', NULL, 'O', '216 S Arlington Heights Rd', 'Arlington Heights', 'Cook', 'IL', '60005', '8472214400', '8472214465', '216 S Arlington Heights Rd    ', 'Arlington Heights', 'Cook', 'IL', '60005', '8472214400', '8472214465', 'CHIG2', 'CHIHCPCS13', '', '0.00', '40.00', '0.00', 3, '2013-01-01', NULL, 0, 0, 0, 'Northwest Community Hospital', '', '', '', 'HCFA|UB|', '1487650982', 0, 'Y', 0, '2014-04-25', NULL, NULL, 42.0794, -87.9805, NULL, NULL),
('363399794', 'W12025443', 'W12025443', 'ILCHIGSTD', 'WomanCare PC', '', '', 'WomanCare PC', '', 'Obstetrics and Gynecology', '', '', NULL, 'O', '1450 Busch Pkwy Ste 110', 'Buffalo Grove', 'Lake', 'IL', '60089', '8472212200', '8472212196', '1450 Busch Pkwy Ste 110', 'Buffalo Grove', 'Lake', 'IL', '60089', '8472212200', '8472212196', 'CHIG2', 'CHIHCPCS13', '', '0.00', '40.00', '0.00', 3, '2013-01-01', NULL, 0, 0, 0, 'Northwest Community Hospital', '', '', '', 'HCFA|UB|', '1487650982', 0, 'Y', 0, '2014-04-25', NULL, NULL, 42.1717, -87.9275, NULL, NULL),
('363399794', 'W12025444', 'W12025444', 'ILCHIGSTD', 'WomanCare PC', '', '', 'WomanCare PC', '', 'Obstetrics and Gynecology', '', '', NULL, 'O', '455 S Roselle Rd Ste 120', 'Schaumburg', 'Cook', 'IL', '60193', '8472214300', '8472214396', '455 S Roselle Rd Ste 120', 'Schaumburg', 'Cook', 'IL', '60193', '8472214300', '8472214396', 'CHIG2', 'CHIHCPCS13', '', '0.00', '40.00', '0.00', 3, '2013-01-01', NULL, 0, 0, 0, 'Northwest Community Hospital', '', '', '', 'HCFA|UB|', '1487650982', 0, 'Y', 0, '2014-04-25', NULL, NULL, 42.0192, -88.0799, NULL, NULL),
('363399794', 'W12025445', 'W12025445', 'ILCHIGSTD', 'WomanCare PC', '', '', 'WomanCare PC', '', 'Obstetrics and Gynecology', '', '', NULL, 'O', '814 E Woodfield Rd', 'Schaumburg', 'Cook', 'IL', '60193', '8472214800', '8472214896', '814 E Woodfield Rd     ', 'Schaumburg', 'Cook', 'IL', '60193', '8472214800', '8472214896', 'CHIG2', 'CHIHCPCS13', '', '0.00', '40.00', '0.00', 3, '2013-01-01', NULL, 0, 0, 0, 'Northwest Community Hospital', '', '', '', 'HCFA|UB|', '1487650982', 0, 'Y', 0, '2014-04-25', NULL, NULL, 42.0429, -88.0596, NULL, NULL),
('272293581', 'W12025446', 'W12025446', 'TXHOUSTD', 'Greater Houston Digestive Disease Consultants', 'Serge-Alain', 'B', 'Awasum', 'MD', 'Gastroenterology', '', '', NULL, 'O', '1120 Medical Plaza Dr Ste 255', 'The Woodlands', 'Montgomery', 'TX', '77380', '2812051111', '2814192111', '1120 Medical Plaza Dr Ste 255', 'The Woodlands', 'Montgomery', 'TX', '77380', '2812051111', '2814192111', 'HOUSTON5', 'TXHCPC13', '', '0.00', '45.00', '0.00', 3, '2013-01-01', NULL, 0, 0, 0, 'Conroe Regional Medical Center', NULL, NULL, NULL, 'HCFA|UB|', '1396050514', 0, 'N', 0, '2012-12-17', NULL, NULL, 30.1728, -95.455, NULL, NULL),
('272293581', 'W12025447', 'W12025447', 'TXHOUSTD', 'Greater Houston Digestive Disease Consultants', 'Serge-Alain', 'B', 'Awasum', 'MD', 'Gastroenterology', '', '', NULL, 'B', 'PO Box 9299', 'The Woodlands', 'Montgomery', 'TX', '77380', '2812051111', '2814192111', 'PO Box 9299  ', 'The Woodlands', 'Montgomery', 'TX', '77380', '2812051111', '2814192111', 'HOUSTON5', 'TXHCPC13', '', '0.00', '45.00', '0.00', 3, '2013-01-01', NULL, 0, 0, 0, 'Conroe Regional Medical Center', NULL, NULL, NULL, 'HCFA|UB|', '1396050514', 0, 'N', 0, '2012-12-17', NULL, NULL, 0, 0, NULL, NULL),
('262458104', 'W12025448', 'W12025448', 'TXDALSTD', 'Frisco Primary Care', 'Bo', '', 'Wang', 'MD', 'Internal Medicine', '', '', NULL, 'O', '4525 Ohio Dr', 'Frisco', 'Collin', 'TX', '75035', '9727317717', '9727317733', '4525 Ohio Dr   ', 'Frisco', 'Collin', 'TX', '75035', '9727317717', '9727317733', 'DALLAS1', 'TXHCPC13', '', '0.00', '50.00', '0.00', 3, '2013-01-01', NULL, 0, 0, 0, 'Baylor Regional Medical Center at Plano', NULL, '', '', 'HCFA|UB|', '1386643260', 0, 'N', 0, '2012-12-07', NULL, NULL, 33.1158, -96.8021, NULL, NULL),
('364377910', 'W12025449', 'W12025449', 'ILCHIGSTD', 'Elk Grove Internists', 'Premalatha', '', 'Nandkumar', 'MD', 'Internal Medicine', '', '', NULL, 'O', '800 Biesterfield Rd Ste 40', 'Elk Grove Village', 'Cook', 'IL', '60007', '8479818856', '8479818927', '800 Biesterfield Rd Ste 40', 'Elk Grove Village', 'Cook', 'IL', '60007', '8479818856', '8479818927', 'CHIG1', 'CHIHCPCS13', '', '0.00', '35.00', '0.00', 3, '2013-01-01', NULL, 0, 0, 0, '', '', '', '', 'HCFA|UB|', '1366471898', 0, 'N', 0, '2013-07-03', NULL, NULL, 42.0034, -88.0174, NULL, NULL),
('364343066', 'W12025450', 'W12025450', 'ILCHIGSTD', 'Northwest Medical Clinic SC', 'Kamal', 'A', 'Patel', 'MD', 'Internal Medicine', '', '', NULL, 'O', '1100 W Central Rd Ste 309', 'Arlington Heights', 'Cook', 'IL', '60005', '8472598777', '8472599994', '1100 W Central Rd Ste 309', 'Arlington Heights', 'Cook', 'IL', '60005', '8472598777', '8472599994', 'CHIG1', 'CHIHCPCS13', '', '0.00', '35.00', '0.00', 3, '2013-01-01', '2013-01-02', 0, 0, 0, 'Northwest Community Hospital', NULL, '', '', 'HCFA|UB|', '1700981917', 0, 'N', 0, '2014-04-25', NULL, NULL, 0, 0, NULL, NULL),
('364343066', 'W12025451', 'W12025451', 'ILCHIGSTD', 'Northwest Medical Clinic SC', 'Kamal', 'A', 'Patel', 'MD', 'Internal Medicine', '', '', NULL, 'B', 'PO Box 967', 'Tinley Park', 'Cook', 'IL', '60477', '8472598777', '8472599994', 'PO Box 967  ', 'Tinley Park', 'Cook', 'IL', '60477', '8472598777', '8472599994', 'CHIG1', 'CHIHCPCS13', '', '0.00', '35.00', '0.00', 3, '2013-01-01', NULL, 0, 0, 0, 'Northwest Community Hospital', NULL, '', '', 'HCFA|UB|', '1700981917', 0, 'N', 0, '2014-04-25', NULL, NULL, 0, 0, NULL, NULL),
('870502207', 'W12025457', 'W12025457', 'UT01', 'Wasatch Therapy, Inc', 'Jaime', 'Ann', 'Pedersen', 'DPT', 'Physical Medicine and Rehabilitation', '', '', NULL, 'O', '1967 W 5700 S', 'Roy', 'Weber', 'UT', '84067', '8017748600', '8017748681', '1967 W 5700 S', 'Roy', 'Weber', 'UT', '84067', '8017748600', '8017748681', 'WestRehab', 'WUSTDHCPC5', '', '0.00', '0.00', '73.00', 3, '2012-11-01', '2013-04-16', 0, 0, 0, '', '', '', '', 'HCFA|UB|', '1851641435', 0, 'N', 0, '2013-05-10', 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
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('752536818', 'W12030871', 'W12030871', 'TXDALSTD', 'Health Texas Provider Network', 'Jeffrey', '', 'Zsohar', 'MD', 'Internal Medicine', '', '', NULL, 'O', '4001 Worth St', 'Dallas', 'Dallas', 'TX', '75246', '2148281745', '2148281734', '4001 Worth St', 'Dallas', 'Dallas', 'TX', '75246', '2148281745', '2148281734', 'HTPN', 'TXHCPCHTPN', '', '0.00', '45.00', '0.00', 3, '2013-04-01', NULL, 0, 0, 0, 'Baylor University Medical Center', NULL, NULL, NULL, 'HCFA|UB|', '1063494839', 0, 'N', 0, '2013-09-24', NULL, NULL, 32.7912, -96.7759, NULL, NULL),
('752582845', 'W12030858', 'W12030858', 'TXDALSTD', 'Plano IPCU', 'Sarah', '', 'Boucher', 'MD', 'Internal Medicine', '', '', 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, '2013-04-01', NULL, 0, 0, 0, 'Baylor Regional Medical Center at Plano', NULL, '', '', 'HCFA|UB|', '1982805339', 0, 'N', 0, '2013-03-13', NULL, NULL, 0, 0, NULL, NULL),
('752582845', 'W12030859', 'W12030859', 'TXDALSTD', 'Plano IPCU', 'Sarah', '', 'Boucher', 'MD', 'Internal Medicine', '', '', NULL, 'O', '4700 Alliance Blvd Ste 400', 'Plano', 'Collin', 'TX', '75093', '4698146631', '4698143110', '4700 Alliance Blvd Ste 400', 'Plano', 'Collin', 'TX', '75093', '4698146631', '4698143110', 'HTPN', 'TXHCPCHTPN', '', '0.00', '45.00', '0.00', 3, '2013-04-01', NULL, 0, 0, 0, 'Baylor Regional Medical Center at Plano', NULL, '', '', 'HCFA|UB|', '1982805339', 0, 'N', 0, '2013-03-13', NULL, NULL, 33.0144, -96.7924, NULL, NULL),
('900657541', 'W12025460', 'W12025460', 'UT01', 'Seasons of Hope', 'Lyn', '', 'Gibson', 'PHD', 'Mental Health', 'Psychology', '', NULL, 'O', '4650 Hawthorne Rd Ste 3B', 'Cubbuck', 'Bannock', 'ID', '83202', '2082379833', '2082371800', '4650 Hawthorne Rd Ste 3B', 'Cubbuck', 'Bannock', 'ID', '83202', '2082379833', '2082371800', 'PHD', '', '', '0.00', '35.00', '0.00', 3, '2013-01-01', '2013-02-14', 0, 0, 0, '', '', '', '', 'HCFA|UB|', '1952615619', 0, 'N', 0, '2012-12-28', NULL, NULL, 0, 0, NULL, NULL),
('751654999', 'W12025461', 'W12025461', 'TXDALSTD', 'Fort Worth Eye Associates', 'Ann', 'E', 'Ranelle', 'DO', 'Ophthalmology', '', '', NULL, 'O', '5000 Collinwood Ave', 'Fort Worth', 'Tarrant', 'TX', '76107', '8177325593', '8173420388', '5000 Collinwood Ave', 'Fort Worth', 'Tarrant', 'TX', '76107', '8177325593', '8173420388', 'DALLAS4', 'TXHCPC13', '', '0.00', '50.00', '0.00', 3, '2013-01-01', '2013-09-14', 0, 0, 0, 'Baylor All Saints Medical Center', NULL, '', '', 'HCFA|UB|', '1427030139', 0, 'N', 0, '2014-03-28', NULL, NULL, 32.7377, -97.395, NULL, NULL),
('751654999', 'W12025462', 'W12025462', 'TXDALSTD', 'Fort Worth Eye Associates', 'Harold', 'W', 'Ranelle', 'DO', 'Ophthalmology', '', '', NULL, 'O', '5000 Collinwood Ave', 'Fort Worth', 'Tarrant', 'TX', '76107', '8177325593', '8173420388', '5000 Collinwood Ave', 'Fort Worth', 'Tarrant', 'TX', '76107', '8177325593', '8173420388', 'DALLAS4', 'TXHCPC13', '', '0.00', '50.00', '0.00', 3, '2013-01-01', NULL, 0, 0, 0, 'Baylor All Saints Medical Center', NULL, '', '', 'HCFA|UB|', '1417007527', 0, 'N', 0, '2012-12-05', NULL, NULL, 32.7377, -97.395, NULL, NULL),
('460805129', 'W12025463', 'W12025463', 'WY01', '', 'David', '', 'Hoffman', 'MD', 'Family Practice', 'General Surgery', '', NULL, 'O', '229 E Main St', 'Lovell', 'Big Horn', 'WY', '82431', '3075489123', '3075489124', '229 E Main St', 'Lovell', 'Big Horn', 'WY', '82431', '3075489123', '3075489124', 'WYSTD', '', '', '0.00', '35.00', '0.00', 3, '2012-12-01', NULL, 0, 0, 0, NULL, '', '', '', 'HCFA|UB|', '1144332552', 0, 'N', 0, '2014-02-26', NULL, NULL, 44.8376, -108.389, NULL, NULL),
('204420454', 'W12025468', 'W12025468', 'TXHOUSTD', 'Avanta Health Professionals', 'Antonio', 'J', 'Ramos', 'MD', 'Internal Medicine', '', '', NULL, 'O', '1302 N Shepherd', 'Houston', 'Harris', 'TX', '77008', '7138859899', '7138859871', '1302 N Shepherd', 'Houston', 'Harris', 'TX', '77008', '7138859899', '7138859871', 'HOUSTON1', 'TXHCPC13', '', '0.00', '45.00', '0.00', 3, '2013-01-01', NULL, 0, 0, 0, '', '', '', '', 'HCFA|UB|', '1063424992', 0, 'N', 0, '2012-12-05', NULL, NULL, 29.7942, -95.41, NULL, NULL),
('900657541', 'W12025469', 'W12025469', 'UT01', 'Seasons of Hope', 'Brandy', '', 'Gilea', 'SLP', 'Speech Therapy', '', '', NULL, 'O', '4650 Hawthorne Rd Ste 3B', 'Chubbuck', 'Bannock', 'ID', '83202', '2082379833', '2082371800', '4650 Hawthorne Rd Ste 3B', 'Chubbuck', 'Bannock', 'ID', '83202', '2082379833', '2082371800', 'ma', '', '', '0.00', '35.00', '0.00', 3, '2013-01-01', NULL, 0, 0, 0, '', '', '', '', 'HCFA|UB|', '1053610469', 0, 'N', 0, '2012-12-28', NULL, NULL, 42.9177, -112.476, NULL, NULL),
('000009771', 'W12025480', 'W12025480', 'UT01', 'Network Management Group', '', '', 'Network Management Group', '', 'Chiropractic', '', '', NULL, '', 'Change ', 'Salt Lake City', 'Salt Lake', 'UT', '84126', '          ', '          ', 'Change ', 'Salt Lake City', 'Salt Lake', 'UT', '84126', '          ', '          ', 'WLABRAD', 'WUSTDHCPC5', '', '0.00', '0.00', '57.12', 3, '2010-11-01', '2014-06-30', 0, 0, 0, '', '', '', '', 'HCFA|UB|', '0000009771', 0, 'N', 0, '2014-06-24', NULL, NULL, 0, 0, NULL, NULL),
('460803374', 'W12025482', 'W12025482', 'UT01', 'South Jordan Health and Wellness', 'Matthew', 'W', 'Peterson', 'DC', 'Chiropractic', '', '', NULL, 'O', '352 N Main St', 'Tooele', 'Tooele', 'UT', '84074', '4358821621', '8014328072', '352 N Main St', 'Tooele', 'Tooele', 'UT', '84074', '4358821621', '8014328072', 'WLABRAD', 'WUSTDHCPC5', '', '0.00', '0.00', '57.12', 3, '2012-11-01', '2014-06-30', 0, 0, 0, '', '', '', '', 'HCFA|UB|', '1326011891', 0, 'N', 0, '2014-06-24', NULL, NULL, 40.5376, -112.298, NULL, NULL),
('454196819', 'W12025483', 'W12025483', 'UT01', 'Taylorsville Chiropractic ', 'Michael', 'Loren', 'Massengale', 'DC', 'Chiropractic', '', '', NULL, 'O', '1951 W 4700 S Ste 3', 'Salt Lake City', 'Salt Lake', 'UT', '84129', '8019694700', '8019697217', '1951 W 4700 S Ste 3', 'Salt Lake City', 'Salt Lake', 'UT', '84129', '8019694700', '8019697217', 'WLABRAD', 'WUSTDHCPC5', '', '0.00', '0.00', '57.12', 3, '2012-11-01', '2013-12-09', 0, 0, 0, '', '', '', '', 'HCFA|UB|', '1962507848', 0, 'N', 0, '2013-12-30', NULL, NULL, 0, 0, NULL, NULL),
('204043287', 'W12025488', 'W12025488', 'NM01', 'ABQ Health Partners', 'Susan', '', 'Anderson', 'PA-C', 'Urgent Care', '', '', NULL, 'O', '5150 Journal Ctr Blvd NE', 'Albuquerque', 'Bernalillo', 'NM', '87109', '5052623233', '5052623191', '5150 Journal Ctr Blvd NE', 'Albuquerque', 'Bernalillo', 'NM', '87109', '5052623233', '5052623191', 'NMABQ', 'WUSTDHCPC5', '', '0.00', '40.00', '0.00', 3, '2012-10-29', NULL, 0, 0, 0, '', '', '', '', 'HCFA|UB|', '1225028004', 0, 'Y', 0, '2012-11-21', NULL, NULL, 35.1702, -106.586, NULL, NULL),
('204043287', 'W12025489', 'W12025489', 'NM01', 'ABQ Health Partners', 'Susan', '', 'Anderson', 'PA-C', 'Urgent Care', '', '', NULL, 'O', '9101 Montgomery Blvd NE', 'Albuquerque', 'Bernalillo', 'NM', '87111', '5052754259', '5052754223', '9101 Montgomery Blvd NE', 'Albuquerque', 'Bernalillo', 'NM', '87111', '5052754259', '5052754223', 'NMABQ', 'WUSTDHCPC5', '', '0.00', '40.00', '0.00', 3, '2012-10-29', NULL, 0, 0, 0, '', '', '', '', 'HCFA|UB|', '1225028004', 0, 'Y', 0, '2012-11-21', NULL, NULL, 35.1307, -106.542, NULL, NULL),
('204043287', 'W12025490', 'W12025490', 'NM01', 'ABQ Health Partners', 'Susan', '', 'Anderson', 'PA-C', 'Urgent Care', '', '', NULL, 'B', 'PO Box 27829', 'Albuquerque', 'Bernalillo', 'NM', '87125', '5052627600', '0000000000', 'PO Box 27829', 'Albuquerque', 'Bernalillo', 'NM', '87125', '5052627600', '0000000000', 'NMABQ', 'WUSTDHCPC5', '', '0.00', '40.00', '0.00', 3, '2012-10-29', NULL, 0, 0, 0, '', '', '', '', 'HCFA|UB|', '1225028004', 0, 'Y', 0, '2012-11-21', NULL, NULL, 0, 0, NULL, NULL),
('204043287', 'W12025492', 'W12025492', 'NM01', 'ABQ Health Partners', 'Susan', '', 'Anderson', 'PA-C', 'Urgent Care', '', '', NULL, 'M', '5400 Gibson Blvd SE', 'Albuquerque', 'Bernalillo', 'NM', '87108', '0000000000', '0000000000', '5400 Gibson Blvd SE', 'Albuquerque', 'Bernalillo', 'NM', '87108', '0000000000', '0000000000', 'NMABQ', 'WUSTDHCPC5', '', '0.00', '40.00', '0.00', 3, '2012-10-29', NULL, 0, 0, 0, '', '', '', '', 'HCFA|UB|', '1225028004', 0, 'Y', 0, '2012-11-21', NULL, NULL, 0, 0, NULL, NULL),
('204043287', 'W12025494', 'W12025494', 'NM01', 'ABQ Health Partners', 'Andrew', '', 'Gaffney', 'PA-C', 'Cardiology', '', '', NULL, 'O', '500 Walter St NE Ste 401', 'Albuquerque', 'Bernalillo', 'NM', '87102', '5052627451', '5052627870', '500 Walter St NE Ste 401', 'Albuquerque', 'Bernalillo', 'NM', '87102', '5052627451', '5052627870', 'NMABQ', 'WUSTDHCPC5', '', '0.00', '40.00', '0.00', 3, '2012-10-16', NULL, 0, 0, 0, 'Lovelace Medical Center', NULL, NULL, NULL, 'HCFA|UB|', '1023367588', 0, 'N', 0, '2012-11-21', NULL, NULL, 35.0863, -106.64, NULL, NULL),
('204043287', 'W12025495', 'W12025495', 'NM01', 'ABQ Health Partners', 'Andrew', '', 'Gaffney', 'PA-C', 'Cardiology', '', '', NULL, 'B', 'PO Box 27829', 'Albuquerque', 'Bernalillo', 'NM', '87125', '5052627600', '0000000000', 'PO Box 27829', 'Albuquerque', 'Bernalillo', 'NM', '87125', '5052627600', '0000000000', 'NMABQ', 'WUSTDHCPC5', '', '0.00', '40.00', '0.00', 3, '2012-10-16', NULL, 0, 0, 0, 'Lovelace Medical Center', NULL, NULL, NULL, 'HCFA|UB|', '1023367588', 0, 'Y', 0, '2012-11-21', NULL, NULL, 0, 0, NULL, NULL),
('204043287', 'W12025496', 'W12025496', 'NM01', 'ABQ Health Partners', 'Andrew', '', 'Gaffney', 'PA-C', 'Cardiology', '', '', NULL, 'M', '5400 Gibson Blvd SE ', 'Albuquerque', 'Bernalillo', 'NM', '87108', '0000000000', '0000000000', '5400 Gibson Blvd SE ', 'Albuquerque', 'Bernalillo', 'NM', '87108', '0000000000', '0000000000', 'NMABQ', 'WUSTDHCPC5', '', '0.00', '40.00', '0.00', 3, '2012-10-16', NULL, 0, 0, 0, 'Lovelace Medical Center', NULL, NULL, NULL, 'HCFA|UB|', '1023367588', 0, 'Y', 0, '2012-11-21', NULL, NULL, 0, 0, NULL, NULL),
('204043287', 'W12025498', 'W12025498', 'NM01', 'ABQ Health Partners', 'Andrea', '', 'Thelen', 'PA-C', 'Family Practice', '', '', NULL, 'O', '5150 Journal Ctr Blvd NE', 'Albuquerque', 'Bernalillo', 'NM', '87109', '5052623233', '5052623191', '5150 Journal Ctr Blvd NE', 'Albuquerque', 'Bernalillo', 'NM', '87109', '5052623233', '5052623191', 'NMABQ', 'WUSTDHCPC5', '', '0.00', '40.00', '0.00', 3, '2012-11-04', NULL, 0, 0, 0, '', '', '', '', 'HCFA|UB|', '1629394945', 0, 'N', 0, '2012-11-21', NULL, NULL, 35.1702, -106.586, NULL, NULL),
('204043287', 'W12025499', 'W12025499', 'NM01', 'ABQ Health Partners', 'Andrea', '', 'Thelen', 'PA-C', 'Family Practice', '', '', NULL, 'O', '1721 Rio Rancho Blvd SE', 'Rio Rancho', 'Sandoval', 'NM', '87124', '5058968604', '5058968697', '1721 Rio Rancho Blvd SE', 'Rio Rancho', 'Sandoval', 'NM', '87124', '5058968604', '5058968697', 'NMABQ', 'WUSTDHCPC5', '', '0.00', '40.00', '0.00', 3, '2012-11-04', NULL, 0, 0, 0, '', '', '', '', 'HCFA|UB|', '1629394945', 0, 'N', 0, '2012-11-21', NULL, NULL, 35.2284, -106.66, NULL, NULL),
('461108458', 'W12025500', 'W12025500', 'UTMH1', 'Alpine Counseling Center', 'Victoria', 'E', 'Anderson', 'PHD', 'Mental Health', 'Psychology', '', NULL, 'O', '475 W 50 N', 'American Fork', 'Utah', 'UT', '84003', '8017563664', '8017563698', '475 W 50 N', 'American Fork', 'Utah', 'UT', '84003', '8017563664', '8017563698', 'UTPHD', '', '', '0.00', '35.00', '0.00', 3, '2012-10-22', '2013-02-14', 0, 0, 0, '', '', '', '', 'HCFA|UB|', '1548323017', 0, 'N', 0, '2013-03-12', NULL, NULL, 0, 0, NULL, NULL),
('870284475', 'W12025501', 'W12025501', 'UT01', 'Granger Medical Clinic', '', '', 'Granger Medical Clinic', 'GROUP', 'Primary Care with Extended Hours', 'Urgent Care', '', NULL, 'O', '2356 N 400 E Ste 201', 'Tooele', 'Tooele', 'UT', '84074', '8013525900', '8013525914', '2356 N 400 E Ste 201', 'Tooele', 'Tooele', 'UT', '84074', '8013525900', '8013525914', 'WUGRANGER5', 'WUSTDHCPC5', '', '0.00', '35.00', '0.00', 3, '2012-11-12', NULL, 0, 0, 0, '', '', '', '', 'HCFA|UB|', '1184657041', 0, 'Y', 0, '2014-01-20', NULL, NULL, 40.5621, -112.293, NULL, NULL),
('461108458', 'W12025502', 'W12025502', 'UTMH1', 'Alpine Counseling Center', 'Doug', 'T', 'Wagstaff', 'LPC', 'Mental Health', 'Counseling', '', NULL, 'O', '475 W 50 N', 'American Fork', 'Utah', 'UT', '84003', '8017563664', '8017563698', '475 W 50 N', 'American Fork', 'Utah', 'UT', '84003', '8017563664', '8017563698', 'UTPHD', '', '', '0.00', '35.00', '0.00', 3, '2012-10-22', '2013-02-14', 0, 0, 0, '', '', '', '', 'HCFA|UB|', '1457414930', 0, 'N', 0, '2013-03-12', NULL, NULL, 0, 0, NULL, NULL),
('820492308', 'W12025503', 'W12025503', 'ID02', 'Idaho Gastroenterology Associates', 'Heather', 'A', 'Stolworthy', 'NP', 'Gastroenterology', '', '', NULL, 'O', '425 W Bannock St', 'Boise', 'Ada', 'ID', '83702', '2083436458', '2083435031', '425 W Bannock St', 'Boise', 'Ada', 'ID', '83702', '2083436458', '2083435031', 'IDPPONONFAC', 'WUSTDHCPC5', '', '0.00', '30.00', '0.00', 3, '2013-02-01', NULL, 0, 0, 1, '', '', '', '', 'HCFA|UB|', '1487623179', 0, 'N', 0, '2013-01-24', NULL, NULL, 0, 0, NULL, NULL),
('820492308', 'W12025504', 'W12025504', 'ID02', 'Idaho Gastroenterology Associates', 'Heather', 'A', 'Stolworthy', 'NP', 'Gastroenterology', '', '', NULL, 'O', '2235 E Gala St', 'Meridian', 'Ada', 'ID', '83642', '2088873724', NULL, '2235 E Gala St', 'Meridian', 'Ada', 'ID', '83642', '2088873724', '          ', 'IDPPONONFAC', 'WUSTDHCPC5', '', '0.00', '30.00', '0.00', 3, '2013-02-01', NULL, 0, 0, 1, '', '', '', '', 'HCFA|UB|', '1487623179', 0, 'N', 0, '2013-01-24', NULL, NULL, 0, 0, NULL, NULL),
('820529971', 'W12025505', 'W12025505', 'ID02', 'Childrens Therapy Place Inc', 'Teresa', 'L', 'Hutton', 'SLP', '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', '0.00', 3, '2013-01-01', NULL, 0, 0, 1, '', '', '', '', 'HCFA|UB|', '1528207206', 0, 'N', 0, '2014-05-30', NULL, NULL, 0, 0, NULL, NULL),
('800701770', 'W12025507', 'W12025507', 'UT01', 'Wasatch Neurosurgery & Spine Asso at St Marks', 'Ryan', 'D', 'Church', 'FNP', 'Orthopedic Surgery', '', '', NULL, 'O', '1220 E 3900 S Ste 4E', 'Salt Lake City', 'Salt Lake', 'UT', '84124', '8012618507', '8012618511', '1220 E 3900 S Ste 4E', 'Salt Lake City', 'Salt Lake', 'UT', '84124', '8012618507', '8012618511', 'UTHCAPS', 'WUSTDHCPC5', '', '0.00', '35.00', '0.00', 3, '2012-12-15', NULL, 0, 0, 0, 'Dixie Regional Medical Center', '', '', '', 'HCFA|UB|', '1912909714', 0, 'N', 0, '2014-06-04', NULL, NULL, 40.6871, -111.856, NULL, NULL),
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('870617336', 'W12025572', 'W12025572', 'UTDT01', 'Monarch Dental', 'Mark', '', 'Naisbitt', 'DDS', 'Dentist', '', '', NULL, 'O', '1140 W Riverdale Rd Ste D', 'Ogden', 'Weber', 'UT', '84405', '8019171502', NULL, '1140 W Riverdale Rd Ste D', 'Ogden', 'Weber', 'UT', '84405', '8019171502', '          ', 'UT0SPA', '', '', '0.00', '20.00', '0.00', 8, '2012-09-01', NULL, 0, 0, 0, '', '', '', '', 'DEN|', '1477524411', 0, 'N', 0, '2012-11-21', NULL, NULL, 0, 0, NULL, NULL),
('830401457', 'W12025591', 'W12025591', 'NM01', 'Sheridan Children Healthcare Services  of New Mexico', '', '', 'Sheridan Children Healthcare Services  of New Mexico', '', 'Neonatology', '', '', NULL, 'O', '4701 Montgomery Blvd NE', 'Albuquerque', 'Bernalillo', 'NM', '87109', '5057278104', '9548511758', '4701 Montgomery Blvd NE', 'Albuquerque', 'Bernalillo', 'NM', '87109', '5057278104', '9548511758', '', '', '', '0.00', '0.00', '0.00', 3, '2012-12-01', NULL, 0, 0, 1, '', '', '', '', 'HCFA|UB', '1316152382', 0, 'N', 0, '2012-12-03', NULL, NULL, 35.131, -106.591, NULL, NULL),
('830401457', 'W12025592', 'W12025592', 'NM01', 'Sheridan Children Healthcare Services  of New Mexico', '', '', 'Sheridan Children Healthcare Services  of New Mexico', '', 'Neonatology', '', '', NULL, 'B', 'PO Box 452036', 'Fort Lauderdale', 'Broward', 'FL', '33345', '5057278104', '9548511758', 'PO Box 452036', 'Fort Lauderdale', 'Broward', 'FL', '33345', '5057278104', '9548511758', '', '', '', '0.00', '0.00', '0.00', 3, '2012-12-01', NULL, 0, 0, 0, '', '', '', '', 'HCFA|UB', '1316152382', 0, 'N', 1, '2012-12-03', NULL, NULL, 0, 0, NULL, NULL),
('760376108', 'W12025594', 'W12025594', 'TXHOUSTD', 'Cypress Orthopedics', '', '', 'Cypress Orthopedics', '', 'Orthopedic Surgery', '', '', NULL, 'O', '11325 Fallbrook Dr', 'Houston', 'Harris', 'TX', '77065', '2818907773', '2818907778', '11325 Fallbrook Dr', 'Houston', 'Harris', 'TX', '77065', '2818907773', '2818907778', 'HOUSTON4', 'TXHCPC13', '', '0.00', '45.00', '0.00', 3, '2013-01-01', NULL, 0, 0, 0, '', '', '', '', 'HCFA|UB|', '1770543191', 0, 'Y', 0, '2013-03-30', NULL, NULL, 29.9258, -95.5908, NULL, NULL),
('760376108', 'W12025597', 'W12025597', 'TXHOUSTD', 'Cypress Orthopedics', 'Robert', 'S', 'Bell', 'MD', 'Orthopedic Surgery', '', '', NULL, 'O', '11325 Fallbrook Dr', 'Houston', 'Harris', 'TX', '77065', '2818907773', '2818907778', '11325 Fallbrook', 'Houston', 'Harris', 'TX', '77065', '2818907773', '2818907778', 'HOUSTON4', 'TXHCPC13', '', '0.00', '45.00', '0.00', 3, '2013-01-01', NULL, 0, 0, 0, 'Houston Methodist Hospital', NULL, NULL, NULL, 'HCFA|UB|', '1366403735', 0, 'N', 0, '2012-12-10', NULL, NULL, 29.9258, -95.5908, NULL, NULL),
('760376108', 'W12025600', 'W12025600', 'TXHOUSTD', 'Cypress Orthopedics', 'Russell', 'David', 'Calvo', 'MD', 'Orthopedic Surgery', '', '', NULL, 'O', '11325 Fallbrook Dr', 'Houston', 'Harris', 'TX', '77065', '2818907773', '2818907798', '11325 Fallbrook Dr', 'Houston', 'Harris', 'TX', '77065', '2818907773', '2818907798', 'HOUSTON4', 'TXHCPC13', '', '0.00', '45.00', '0.00', 3, '2013-01-01', '2013-01-01', 0, 0, 0, '', '', '', '', 'HCFA|UB|', '1295796431', 0, 'N', 0, '2013-07-29', NULL, NULL, 29.9254, -95.591, NULL, NULL),
('760376108', 'W12025602', 'W12025602', 'TXHOUSTD', 'Cypress Orthopedics', 'Pierre', '', 'Le Baud', 'MD', 'Orthopedic Surgery', '', '', NULL, 'O', '11325 Fallbrook Dr', 'Houston', 'Harris', 'TX', '77065', '2818907773', '2818907778', '11325 Fallbrook', 'Houston', 'Harris', 'TX', '77065', '2818907773', '2818907778', 'HOUSTON4', 'TXHCPC13', '', '0.00', '45.00', '0.00', 3, '2013-01-01', NULL, 0, 0, 0, 'Houston Methodist Hospital', NULL, NULL, NULL, 'HCFA|UB|', '1073574455', 0, 'N', 0, '2012-12-06', NULL, NULL, 29.9258, -95.5908, NULL, NULL),
('760376108', 'W12025604', 'W12025604', 'TXHOUSTD', 'Cypress Orthopedics', 'Kimberlea', 'W', 'Staton', 'MD', 'Orthopedic Surgery', '', '', NULL, 'O', '11325 Fallbrook Dr', 'Houston', 'Harris', 'TX', '77065', '2818907773', '2818907778', '11325 Fallbrook', 'Houston', 'Harris', 'TX', '77065', '2818907773', '2818907778', 'HOUSTON4', 'TXHCPC13', '', '0.00', '45.00', '0.00', 3, '2013-01-01', NULL, 0, 0, 0, 'Houston Methodist Sugar Land Hospital', NULL, '', '', 'HCFA|UB|', '1396798799', 0, 'N', 0, '2012-11-30', NULL, NULL, 29.9258, -95.5908, NULL, NULL),
('363092972', 'W12025606', 'W12025606', 'ILCHIGSTD', 'Phillip Oncology & Hematology', '', '', 'Phillip Oncology & Hematology', '', 'Oncology', '', '', NULL, 'O', '5140 N California Ave', 'Chicago', 'Cook', 'IL', '60625', '7738788200', '7738785726', '5140 N California Ave', 'Chicago', 'Cook', 'IL', '60625', '7738788200', '7738785726', 'CHIG7', 'CHIHCPCS13', '', '0.00', '35.00', '0.00', 3, '2013-01-01', NULL, 0, 0, 0, '', '', '', '', 'HCFA|UB|', '1407961923', 0, 'Y', 0, '2013-05-10', NULL, NULL, 41.9752, -87.6989, NULL, NULL),
('363092972', 'W12026055', 'W12026055', 'ILCHIGSTD', 'Phillip Oncology & Hematology', 'Javed', '', 'Imam', 'MD', 'Oncology', '', '', NULL, 'O', '800 Austin St West Tower Ste 607', 'Evanston', 'Cook', 'IL', '60202', '8474756063', '8474756065', '800 Austin West Tower Ste 607', 'Evanston', 'Cook', 'IL', '60202', '8474756063', '8474756065', 'CHIG7', 'CHIHCPCS13', '', '0.00', '35.00', '0.00', 3, '2013-01-01', NULL, 0, 0, 0, 'Presence Saints Mary and Elizabeth Medical Center Saint Mary Campus', NULL, '', '', 'HCFA|UB|', '1548271380', 0, 'N', 0, '2012-12-04', NULL, NULL, 42.0255, -87.6819, NULL, NULL),
('363092972', 'W12025608', 'W12025608', 'ILCHIGSTD', 'Phillip Oncology & Hematology', 'KJ', '', 'Philip', 'MD', 'Oncology', '', '', NULL, 'O', '5140 N California Ave', 'Chicago', 'Cook', 'IL', '60625', '7738788200', '7738785726', '5140 N California', 'Chicago', 'Cook', 'IL', '60625', '7738788200', '7738785726', 'CHIG7', 'CHIHCPCS13', '', '0.00', '35.00', '0.00', 3, '2013-01-01', NULL, 0, 0, 0, 'Presence Our Lady Of The Resurrection Medical Center', 'Presence Saint Francis Hospital', '', '', 'HCFA|UB|', '1598776494', 0, 'N', 0, '2012-12-04', NULL, NULL, 41.9752, -87.6989, NULL, NULL),
('363092972', 'W12026057', 'W12026057', 'ILCHIGSTD', 'Phillip Oncology & Hematology', 'Laura', 'L', 'Raftery', 'MD', 'Oncology', '', '', NULL, 'O', '800 Austin St West Tower Ste 607', 'Evanston', 'Cook', 'IL', '60202', '8474756063', '8474756065', '800 Austin West Tower Ste 607', 'Evanston', 'Cook', 'IL', '60202', '8474756063', '8474756065', 'CHIG7', 'CHIHCPCS13', '', '0.00', '35.00', '0.00', 3, '2013-01-01', NULL, 0, 0, 0, 'Presence Saint Francis Hospital', NULL, '', '', 'HCFA|UB|', '1992862551', 0, 'N', 0, '2012-12-04', NULL, NULL, 42.0255, -87.6819, NULL, NULL),
('363092972', 'W12025611', 'W12025611', 'ILCHIGSTD', 'Phillip Oncology & Hematology', 'Javed', '', 'Imam', 'MD', 'Oncology', '', '', NULL, 'O', '5140 N California Ave', 'Chicago', 'Cook', 'IL', '60625', '7738788200', '7738785726', '5140 N California', 'Chicago', 'Cook', 'IL', '60625', '7738788200', '7738785726', 'CHIG7', 'CHIHCPCS13', '', '0.00', '35.00', '0.00', 3, '2013-01-01', NULL, 0, 0, 0, 'Presence Saints Mary and Elizabeth Medical Center Saint Mary Campus', NULL, '', '', 'HCFA|UB|', '1548271380', 0, 'N', 0, '2012-12-04', NULL, NULL, 41.9752, -87.6989, NULL, NULL),
('363092972', 'W12026056', 'W12026056', 'ILCHIGSTD', 'Phillip Oncology & Hematology', 'KJ', '', 'Philip', 'MD', 'Oncology', '', '', NULL, 'O', '800 Austin St West Tower Ste 607', 'Evanston', 'Cook', 'IL', '60202', '8474756063', '8474756065', '800 Austin West Tower Ste 607', 'Evanston', 'Cook', 'IL', '60202', '8474756063', '8474756065', 'CHIG7', 'CHIHCPCS13', '', '0.00', '35.00', '0.00', 3, '2013-01-01', NULL, 0, 0, 0, 'Presence Our Lady Of The Resurrection Medical Center', 'Presence Saint Francis Hospital', '', '', 'HCFA|UB|', '1598776494', 0, 'N', 0, '2012-12-04', NULL, NULL, 42.0255, -87.6819, NULL, NULL),
('363092972', 'W12025614', 'W12025614', 'ILCHIGSTD', 'Phillip Oncology & Hematology', 'Laura', 'L', 'Raftery', 'MD', 'Oncology', '', '', NULL, 'O', '5140 N California Ave', 'Chicago', 'Cook', 'IL', '60625', '7738788200', '7738785726', '5140 N California', 'Chicago', 'Cook', 'IL', '60625', '7738788200', '7738785726', 'CHIG7', 'CHIHCPCS13', '', '0.00', '35.00', '0.00', 3, '2013-01-01', NULL, 0, 0, 0, 'Presence Saint Francis Hospital', NULL, '', '', 'HCFA|UB|', '1992862551', 0, 'N', 0, '2012-12-04', NULL, NULL, 41.9752, -87.6989, NULL, NULL),
('203193817', 'W12025617', 'W12025617', 'ILCHIGSTD', 'Broadway Medical Group', '', '', 'Broadway Medical Group', '', 'Family Practice', '', '', NULL, 'O', '4826 N Broadway Ave', 'Chicago', 'Cook', 'IL', '60640', '7732758333', '7732759297', '4826 N Broadway Ave', 'Chicago', 'Cook', 'IL', '60640', '7732758333', '7732759297', 'CHIG11', 'CHIHCPCS13', '', '0.00', '40.00', '0.00', 3, '2013-01-01', NULL, 0, 0, 0, '', '', '', '', 'HCFA|UB|', '1306952858', 0, 'Y', 0, '2013-05-10', NULL, NULL, 41.9697, -87.6597, NULL, NULL),
('364088232', 'W12027238', 'W12027238', 'ILCHIGSTD', 'Dreyer Medical Clinic', '', '', 'Dreyer Medical Clinic', '', 'Clinics', '', '', NULL, 'B', '62199 Collection Ctr Dr', 'Chicago', 'Cook', 'IL', '60693', '6302648990', NULL, '62199 Collection Ctr Dr', 'Chicago', 'Cook', 'IL', '60693', '6302648990', '', 'CHIG17', 'CHIHCPCSMA', '', '0.00', '35.00', '0.00', 3, '2013-01-01', NULL, 0, 0, 0, '', '', '', '', 'HCFA|UB|', '0000010021', 0, 'Y', 0, '2014-04-22', NULL, NULL, 0, 0, NULL, NULL),
('521458557', 'W12026062', 'W12026062', 'ILCHIGSTD', 'Advanced Surgical Associates', 'David', 'Edward', 'Mahon', 'MD', 'General Surgery', '', '', NULL, 'O', '800 Biesterfield Rd Wimmer Bldg Ste 304', 'Elk Grove Village', 'Cook', 'IL', '60007', '8474839800', '8474396982', '800 Biesterfield Rd Wimmer Bldg Ste 304', 'Elk Grove Village', 'Cook', 'IL', '60007', '8474839800', '8474396982', 'CHIG2', 'CHIHCPCS13', '', '0.00', '40.00', '0.00', 3, '2013-01-01', NULL, 0, 0, 0, 'Northwest Community Hospital', NULL, NULL, NULL, 'HCFA|UB|', '1710983325', 0, 'N', 0, '2013-07-02', NULL, NULL, 42.0034, -88.0174, NULL, NULL),
('203193817', 'W12025619', 'W12025619', 'ILCHIGSTD', 'Broadway Medical Group', 'Sean', 'Adam', 'Le', 'MD', 'Internal Medicine', '', '', NULL, 'O', '4826 N Broadway Ave', 'Chicago', 'Cook', 'IL', '60640', '7732758333', '7732759297', '4826 N Broadway Ave', 'Chicago', 'Cook', 'IL', '60640', '7732758333', '7732759297', 'CHIG11', 'CHIHCPCS13', '', '0.00', '40.00', '0.00', 3, '2013-01-01', NULL, 0, 0, 0, 'Presence Saint Francis Hospital', NULL, '', '', 'HCFA|UB|', '1578552915', 0, 'N', 0, '2013-03-26', NULL, NULL, 41.9697, -87.6597, NULL, NULL),
('201780406', 'W12026461', 'W12026461', 'ILCHIGSTD', 'UroPartners', 'Shivani', 'T', 'Patel', 'PAC', 'Urology', '', '', NULL, 'B', '3183 Paysphere Cir', 'Chicago', 'Cook', 'IL', '60674', '7084920502', '7084920565', '3183 Paysphere Cir', 'Chicago', 'Cook', 'IL', '60674', '7084920502', '7084920565', 'CHIG10', 'UROHCPCS13', '', '0.00', '40.00', '0.00', 3, '2013-01-01', NULL, 0, 0, 0, '', '', '', '', 'HCFA|UB|', '1023301454', 0, 'Y', 0, '2014-04-24', NULL, NULL, 0, 0, NULL, NULL),
('203193817', 'W12025622', 'W12025622', 'ILCHIGSTD', 'Broadway Medical Group', 'Matthew', 'B', 'Ajluni', 'DO', 'Family Practice', '', '', NULL, 'O', '4826 N Broadway Ave', 'Chicago', 'Cook', 'IL', '60640', '7732758333', '7732759297', '4826 N Broadway Ave', 'Chicago', 'Cook', 'IL', '60640', '7732758333', '7732759297', 'CHIG11', 'CHIHCPCS13', '', '0.00', '40.00', '0.00', 3, '2013-01-01', '2014-07-17', 0, 0, 0, 'Presence Saint Francis Hospital', '', '', '', 'HCFA|UB|', '1124072400', 0, 'N', 0, '2014-07-17', NULL, NULL, 41.9697, -87.6597, NULL, NULL),
('203193817', 'W12026154', 'W12026154', 'ILCHIGSTD', 'Broadway Medical Group', 'John', 'P', 'Cosgrove', 'DO', 'Family Practice', '', '', NULL, 'O', '800 Austin St West Tower Ste 201', 'Evanston', 'Cook', 'IL', '60202', '8477337500', '8477331266', '800 Austin St West Tower Ste 201', 'Evanston', 'Cook', 'IL', '60202', '8477337500', '8477331266', 'CHIG11', 'CHIHCPCS13', '', '0.00', '40.00', '0.00', 3, '2013-01-01', NULL, 0, 0, 0, 'Presence Saint Francis Hospital', NULL, '', '', 'HCFA|UB|', '1669638425', 0, 'N', 0, '2013-03-26', NULL, NULL, 42.0255, -87.6819, NULL, NULL),
('203193817', 'W12025625', 'W12025625', 'ILCHIGSTD', 'Broadway Medical Group', 'John', 'P', 'Cosgrove', 'DO', 'Family Practice', '', '', NULL, 'O', '4826 N Broadway Ave', 'Chicago', 'Cook', 'IL', '60640', '7732758333', '7732759297', '4826 N Broadway Ave', 'Chicago', 'Cook', 'IL', '60640', '7732758333', '7732759297', 'CHIG11', 'CHIHCPCS13', '', '0.00', '40.00', '0.00', 3, '2013-01-01', NULL, 0, 0, 0, 'Presence Saint Francis Hospital', NULL, '', '', 'HCFA|UB|', '1669638425', 0, 'N', 0, '2013-03-26', NULL, NULL, 41.9697, -87.6597, NULL, NULL),
('201780406', 'IL0000285', 'IL0000285', 'ILCHIGSTD', 'UroPartners', 'Ronald', 'D', 'Lee', 'MD', 'Urology', '', '', NULL, 'O', '1555 Barrington Rd Ste 2500', 'Hoffman Estates', 'Cook', 'IL', '60169', '8478233185', '8478233318', '1555 Barrington Rd Ste 2500', 'Hoffman Estates', 'Cook', 'IL', '60169', '8478233185', '8478233318', 'CHIG10', 'UROHCPCS13', '', '0.00', '40.00', '0.00', 3, '2013-01-01', NULL, 0, 0, 0, 'Presence Resurrection Medical Center', 'Northwest Community Hospital', '', '', 'HCFA|UB|', '1023091667', 0, 'N', 0, '2014-04-25', NULL, NULL, 42.0542, -88.1444, NULL, NULL),
('460805129', 'W12025627', 'W12025627', 'WYT1', '', 'David', '', 'Hoffman', 'MD', 'Family Practice', 'General Surgery', '', NULL, 'O', '229 E Main St', 'Lovell', 'Big Horn', 'WY', '82431', '3075489123', '3075489124', '229 E Main St', 'Lovell', 'Big Horn', 'WY', '82431', '3075489123', '3075489124', 'WYSTD', '', '', '0.00', '35.00', '0.00', 3, '2012-12-01', NULL, 0, 0, 0, NULL, '', '', '', 'HCFA|UB|', '1144332552', 0, 'N', 0, '2013-06-18', NULL, NULL, 0, 0, NULL, NULL),
('453778194', 'W12025628', 'W12025628', 'WY01', 'Premier Surgical Center', '', '', 'Premier Surgical Center', '', 'Ambulatory Surgery Center', '', '', NULL, 'O', '195 Overthrust Rd', 'Evanston', 'Uinta', 'WY', '82930', '3074443600', '3074443610', '195 Overthrust Rd', 'Evanston', 'Uinta', 'WY', '82930', '3074443600', '3074443610', '', '', '2', '0.00', '0.00', '0.00', 3, '2012-12-10', NULL, 0, 0, 0, '', '', '', '', 'HCFA|UB|', '1417228370', 0, 'N', 0, '2012-12-06', NULL, NULL, 41.257, -110.985, NULL, NULL);
