PROVIDER TYPE CODE DESCRIPTION OF PROVIDER TYPE SPECIALITY CODE DESCRIPTION OF PROVIDER SPECIALITY 01 INPATIENT FACILITY 010 ACUTE CARE HOSPITAL 01

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1 PROVIDER TYPE CODE DESCRIPTION OF PROVIDER TYPE SPECIALITY CODE DESCRIPTION OF PROVIDER SPECIALITY 01 INPATIENT FACILITY 010 ACUTE CARE HOSPITAL PRIVATE PSYCHIATRIC HOSPITAL INPATIENT MEDICAL REHAB HOSPITAL RESIDENTIAL TREATMENT FACILITY (JCAHO INPATIENT MEDICAL REHAB UNIT CHILDREN'S SPECIALITY EMERGENCY ROOM ARRANGEMENT EMERGENCY ROOM ARRANGEMENT EXTENDED ACUTE PSYCH INPATIENT UNIT INPATIENT DRUG & ALCOHOL HOSPITAL SHORT PROCEDURE UNIT PRIVATE PSYCHIATRIC UNIT PUBLIC PSYCHIATRIC HOSPITAL HOSPITAL BASED MEDICAL CLINIC DRUG AND ALCOHOL REHAB UNIT PROGRAM EXCEPTION HEARING AID DISPENSER TOBACCO CESSATION 02 AMBULATORY SURGICAL CENTER 020 AMBULATORY SURGICAL CENTER 03 EXTENDED CARE FACILITY 030 NURSING FACILITY COUNTY NURSING FACILITY ICF/MR 8 BEDS OR LESS ICF/MR 9 BEDS OR MORE RESPITE CARE STATE LTC UNIT STATE MENTAL RETARDATION CENTER ICF/ORC SPECIAL REHAB NURSING FACILITY ATTENDANT CARE/PERSONAL ASSISTANCE INP. FACILITY BASED LTC EXT. CARE FACILITY ADULT DAY CARE HOMEMAKER SERVICES 04 REHABILITATION FACILITY 041 COMPREHENSIVE OUTPATIENT REHAB FACILITY 05 HOME HEALTH 025 PERSONAL EMERGENCY RESPONSE SYSTEM HOME HEALTH SERVICES PRIVATE DUTY NURSING DME / MEDICAL SUPPLIES PROGRAM EXCEPTION PERSONAL CARE - AGENCY ATTENDANT CARE/PERSONAL ASSISTANCE ADULT DAY CARE HOMEMAKER SERVICES

2 RESPITE CARE - HOME BASED TOBACCO CESSATION 06 HOSPICE 060 HOSPICE 07 CAPITATION 070 LTC CAP MANAGED CARE ORGANIZATION, PHYSICAL MANAGED CARE ORGANIZATION, BEHAVIORAL PCCM 08 CLINIC 074 MOBILE MENTAL HEALTH TREATMENT PEER SPECIALIST FEDERALLY QUALIFIED HEALTH CENTER RURAL HEALTH CLINIC INDEPENDENT MEDICAL / SURGICAL CLINIC FAMILY PLANNING CLINIC METHADONE MAINTENANCE DENTAL CLINIC PSYCHIATRIC OUTPATIENT PSYCHIATRIC REHABILITATION OUTPATIENT DRUG AND ALCOHOL PROGRAM EXCEPTION TOBACCO CESSATION FQHC THERAPEUTIC STAFF SUPPORT FQHC MOBILE THERAPY FQHC BEHAVIORAL SPECIALIST CONSULTANT FQHC SUMMER THERAPEUTIC ACTIVITY PROGRAM (STAP) RHC THERAPEUTIC STAFF SUPPORT RHC MOBILE THERAPY RHC BEHAVIORAL SPECIALIST CONSULTANT RHC SUMMER THERAPEUTIC ACTIVITY PROGRAM PSYCH OUTPT THERAPEUTIC STAFF SUPPORT PSYCH OUTPT MOBILE THERAPY PSYCH OUTPT BEHAVIORAL SPECIALIST PSYCHIATRIC OUTPATIENT (STAP) 09 CERTIFIED REGISTERED NURSE 090 PEDIATRIC OBSTETRICS / GYNECOLOGY FAMILY HEALTH NURSE PRACTITIONER (PRIMARY CARE) FAMILY HOME HEALTH ADULT HEALTH SCHOOL NURSE FAMILY PLANNING GERONTOLOGY EMERGENCY

3 NEONATAL ADULT PSYCH MENTAL HEALTH ADULT ACUTE CARE PEDIATRIC ACUTE CHRONIC PEDIATRIC CRITICAL CARE ADULT CARDIOPULMONARY ADULT SURGICAL ADULT RENAL METABOLIC ADULT CRITICAL CARE ADULT NEUROSCIENCE ADULT ONCOLOGY ADULT PERIOPERATIVE PEDIATRIC ONCOLOGY PERINATAL WOMEN'S HEALTH TOBACCO CESSATION THERAPEUTIC STAFF SUPPORT MOBILE THERAPY BEHAVIORAL SPECIALIST CONSULTANT 11 MENTAL HEALTH / SUBSTANCE ABUSE 076 PEER SPECIALIST PSYCHIATRIC OUTPATIENT COMMUNITY MENTAL HEALTH OUTPATIENT PRACTITIONER-MH PARTIAL PSYCH HOSPITALIZATION CHILDREN PARTIAL PSYCH HOSPITALIZATION ADULT FAMILY BASED MENTAL HEALTH LICENSED CLINICAL SOCIAL WORKER LICENSED SOCIAL WORKER MENTAL HEALTH CRISIS INTERVENTION MENTAL HEALTH - OMHSAS MARRIAGE AND FAMILY COUNSELOR PSYCHIATRIC REHABILITATION MENTAL ILLNESS/SUBSTANCE ABUSE MENTAL ILLNESS/SUBSTANCE ABUSE BEHAVIORAL SUPPORT D & A OUTPATIENT D & A INTENSIVE OUTPATIENT D & A PARTIAL HOSPITALIZATION D & A HALFWAY HOUSE D & A MEDICALLY MONITORED DETOXIFICATION D & A MEDICALLY MONITORED RESIDENTIAL, SHORT TERM

4 D & A MEDICALLY MONITORED RESIDENTIAL, LONG TERM CARN-AP (CERTD ADDICTIONS RN-ADVANCED OUTPATIENT DRUG AND ALCOHOL PROGRAM EXCEPTION PART PSYCH HOSP CHILD THERAPEUTIC STAFF SUPPORT PART PSYCH HOSP CHILD MOBILE THERAPY PART PSYCH HOSP CHILD BEHAV SPECIALIST CONSULTANT PART PSYCH HOSP CHILD (STAP) PART PSYCH HOSP ADULT THERAPEUTIC STAFF SUPPORT PART PSYCH HOSP ADULT MOBILE THERAPY PART PSYCH HOSP ADULT BEHAV SPECIALIST CONSULTANT PART PSYCH HOSP ADULT (STAP) FAMILY BASED MNTL HLTH THERAPEUTIC STAFF SUPPORT FAMILY BASED MNTL HLTH MOBILE THERAPY FAMILY BASED MNTL HLTH BEHAV SPECIALIST CONSULTANT FAMILY BASED MNTL HLTH (STAP) THERAPEUTIC STAFF SUPPORT MOBILE THERAPY BEHAVIORAL SPECIALIST CONSULTANT 12 SCHOOL CORPORATION 120 TEACHING INSTITUTE TEACHING INSTITUTE - DENTAL 14 PODIATRIST 140 PODIATRIST 15 CHIROPRACTOR 150 CHIROPRACTOR 16 NURSE 160 REGISTERED NURSE LICENSED PRACTICAL NURSE PSYCHIATRIC NURSE PROGRAM EXCEPTION EARLY INTERVENTION SERVICES 17 THERAPIST 170 PHYSICAL THERAPIST OCCUPATIONAL THERAPIST RESPIRATORY THERAPIST SPEECH/HEARING THERAPIST ART THERAPIST MUSIC THERAPIST PHYSICAL THERAPY / EARLY INTERVENTION (EI) OCCUPATIONAL THERAPY / EARLY INTERVENTION

5 SPEECH/HEARING THERAPY / EARLY INTERVENTION PROGRAM EXCEPTION 18 OPTOMETRIST 180 OPTOMETRIST 19 PSYCHOLOGIST 190 GENERAL PSYCHOLOGIST CLINICAL NEUROPSYCHOLOGIST CLINICAL HEALTH PSYCHOLOGIST SCHOOL PSYCHOLOGIST CLINICAL PSYCHOLOGIST CLINICAL CHILD PSYCHOLOGIST COUNSELING PSYCHOLOGIST INDUSTRIAL ORGANIZATIONAL PSYCHOLOGIST BEHAVIORAL PSYCHOLOGIST FORENSIC PSYCHOLOGIST FAMILY PSYCHOLOGIST CLINICAL GEROPSYCHOLOGIST TRTMT OF ALCOL AND OTHER PSYCAV SBSTC USE DSORDRS COGNITIVE THERAPIST BEHAVIORAL THERAPIST CONSULTANT PROGRAM EXCEPTION TOBACCO CESSATION THERAPEUTIC STAFF SUPPORT MOBILE THERAPY BEHAVIORAL SPECIALIST CONSULTANT EARLY INTERVENTION SERVICES 20 AUDIOLOGIST 200 AUDIOLOGIST HEARING AID DISPENSER EARLY INTERVENTION SERVICES 21 CASE MANAGER 076 PEER SPECIALIST D & A TARGETED CASE MANAGEMENT MEDICAL ASSISTANCE CASE MANAGEMENT FOR HIV & AIDS MEDICAL ASSISTANCE CASE MANAGEMENT FOR UNDER EARLY INTERVENTION CASE MANAGEMENT MH CASE MANAGEMENT - ADMINISTRATIVE LICENSED SOCIAL WORKER, EI MR TARGETED CASE MANAGEMENT MH TARGETED CASE MGT, RESOURCE MH TARGETED CASE MANAGEMENT, INTENSIVE 22 DEPARTMENT OF HEALTH 225 ENVIRONMENTAL INVESTIGATION NEWBORN HEARING SCREENING NEWBORN SCREENING

6 WIC 23 NUTRITIONIST 230 REGISTERED NUTRITIONIST 24 PHARMACY 025 PERSONAL EMERGENCY RESPONSE SYSTEM HEARING AID DISPENSER INDEPENDENT INSTITUTIONAL INDEPENDENT CHAIN INSTITUTIONAL CHAIN LONG TERM CARE (LTC) MAIL ORDER 25 DME/MEDICAL SUPPLIES 220 HEARING AID DISPENSER DME / MEDICAL SUPPLIES PROSTHETIST ORTHOTIST OPTICIAN 26 TRANSPORTATION 260 AMBULANCE - BASIC LIFE SUPPORT AMBULANCE - ADVANCED LIFE SUPPORT AIR AMBULANCE MASS TRANSIT PARA-TRANSIT CLIENT REIMBURSEMENT (MILEAGE, TOLL) NON-EMERGENCY OTHER 27 DENTIST 270 ENDODONTIST GENERAL DENTISTRY ORAL / MAXILLOFACIAL SURGEON ORTHODONTIST/DENTOFACIAL ORTHOPEDIST PEDIATRIC DENTIST PERIODONTIST ORAL PATHOLOGIST PROSTHODONTIST ORAL / MAXILLOFACIAL PATHOLOGIST ORAL / MAXILLOFACIAL RADIOLOGIST DENTAL PUBLIC HEALTH CLEFT PALATE DENTAL ANESTHESIOLOGIST, APU DENTAL ANESTHESIOLOGIST, AP DENTAL ANESTHESIOLOGIST, AP TOBACCO CESSATION 28 LABORATORY 280 INDEPENDENT LABORATORY 29 X-RAY CLINIC 291 MOBILE X-RAY CLINIC 30 RENAL DIALYSIS CENTER 300 RENAL DIALYSIS CENTER 31 PHYSICIAN 310 ALLERGY & IMMUNOLOGY

7 ANESTHESIOLOGY DERMATOLOGY EMERGENCY MEDICINE FAMILY PRACTICE GENERAL PRACTITIONER SURGERY INTERNAL MEDICINE OBSTETRICS AND GYNECOLOGY OPHTHALMOLOGIST ORTHOPAEDIC SURGERY OTOLARYNGOLOGY PATHOLOGY PHYSICAL MEDICINE & REHABILITATION PLASTIC SURGERY PSYCHIATRY AND NEUROLOGY PROGRAM EXCEPTION RADIOLOGY PREVENTIVE MEDICINE UROLOGIST PEDIATRICS RADIATION THERAPIST TOBACCO CESSATION THERAPEUTIC STAFF SUPPORT MOBILE THERAPY BEHAVIORAL SPECIALIST CONSULTANT HEARING AID DISPENSER 32 CERTIFIED REGISTERED NURSE 320 CERTIFIED REGISTERED NURSE ANESTHETIST 33 CERTIFIED NURSE MIDWIFE 335 CERTIFIED NURSE MIDWIFE 34 PROGRAM EXCEPTION 340 PROGRAM EXCEPTION 35 PUBLIC SCHOOLS 350 PUBLIC SCHOOL 36 PERSONAL CARE SERVICES 361 PERSONAL CARE - AGENCY PERSONAL CARE - INDIVIDUAL 37 TOBACCO CESSATION 370 TOBACCO CESSATION 40 MEDICALLY FRAGILE FOSTER CARE 400 MEDICALLY FRAGILE FOSTER CARE 41 ADULT DAY CARE 410 ADULT DAY CARE 43 HOMEMAKER AGENCY 430 HOMEMAKER SERVICES HOMEMAKER / CHORE SERVICES HOME DELIVERED MEALS RESPITE CARE - HOME BASED 47 BIRTHING CENTER 470 BIRTHING CENTER 48 SERVICE BUREAU 480 SERVICE BUREAU 51 HOME AND COMMUNITY HABILITATION 025 PERSONAL EMERGENCY RESPONSE SYSTEM ATTENDANT CARE/PERSONAL ASSISTANCE

8 ADULT DAY CARE HOME AND COMMUNITY HABILITATION RESPITE CARE - HOME BASED RESPITE CARE - OUT OF HOME ADULT TRAINING PRE-VOCATIONAL TRANSITIONAL WORK SERVICES VISUAL & MOBILITY THERAPY RECREATION FSS/CONSUMER PAYMENT WAS FAMILY SUPPORT SERVICES COMMUNITY INTEGRATION NIGHT SUPERVISION HABILITATION PLUS STRUCTURED DAY PROGRAM COACHING AND CUEING EDUCATIONAL SERVICE SUPPORTED EMPLOYMENT ENVIRONMENTAL ACCESSIBILITY ADAPTATIONS ASSISTIVE TECHNOLOGIES HOME FINDING 52 COMMUNITY RESIDENTIAL 340 PROGRAM EXCEPTION CRR-ADULT CHILD & YOUTH LIC GRP HOME W MNTL HLTH TRTMNT COMP ADULT RESIDENTIAL FAMILY LIVING HOMES HOST HOME / CHILDREN UNLICENSED 53 EMPLOYMENT - COMPETITIVE 530 JOB FINDING JOB SUPPORT 54 INTERMEDIATE SERVICE ORGANIZATION 540 ISO - AGENCY WITH CHOICE ISO - FISCAL/EMPLOYER AGENT TRANSPORTATION BROKER ENVIRONMENTAL ACCESSIBILITY ADAPTATIONS EARLY INTERVENTION SERVICES 55 VENDOR 025 PERSONAL EMERGENCY RESPONSE SYSTEM DME / MEDICAL SUPPLIES ATTENDANT ESCORT NON-EMERGENCY PERSONAL CARE - AGENCY PERSONAL CARE - INDIVIDUAL ATTENDANT CARE/PERSONAL ASSISTANCE

9 COMPANION SERVICE ADULT DAY CARE HOMEMAKER SERVICES HOMEMAKER / CHORE SERVICES HOME DELIVERED MEALS RESPITE CARE - HOME BASED FSS/CONSUMER PAYMENT WAS FAMILY SUPPORT SERVICES ENVIRONMENTAL ACCESSIBILITY ADAPTATIONS VENDOR COMMUNITY TRANSITION SERVICES ADAPTIVE APPLIANCES/EQUIPMENT HABILITATION SUPPLIES RESPITE, OVERNIGHT CAMP RESPITE, DAY CAMP 56 RESIDENTIAL TREATMENT FACILITY 340 PROGRAM EXCEPTION RESIDENTIAL TRTMT FACILITY (NON-JCAHO 58 INTERPRETER 580 SIGN LANGUAGE 59 ATTENDANT CARE 362 ATTENDANT CARE/PERSONAL ASSISTANCE 65 LIEN HOLDER 650 LIEN HOLDER 66 FUNERAL DIRECTOR 660 FUNERAL HOME

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