Professional s Adult Care Nurse Adult Psychiatric Mental Health Nursing 363LA2200X 364SP0809X Adult Health Nursing s Clinical Nurse Specialist Adult Psychiatric/Mental Health Allergy and Immunology 207K00000X Allergy and Immunology W1 W7 Type(s) 03 MD/DO/CLN Ambulance Company 341600000X Transportation Services Ambulance 59 AMB Ambulatory Health Care Facility Ambulatory Surgical Center 261QR0200X Freestanding Radiology Centers 30 FRC 261QA1903X Ambulatory Health Care Facilities Clinic/ Center Ambulatory Surgical Anesthesiology 207L00000X Anesthesiology Audiologist 231H00000X Speech, Language and Hearing s Audiologists Behavior Analyst 103K00000X Behavior Analyst, Mental Health, and Counseling Cardiovascular Disease 207RC0000X Internal Medicine Cardiovascular Disease Certified Registered Nurse Anesthetist 367500000X Nursing s Certified Registered Nurse Anesthetist Certified Social Worker 104100000X Behavioral Health and Social Service s Social Worker Child/Adolescent Psychiatric Nursing 364SP0807X Nursing s Clinical Nurse Specialist Psychiatric/Mental Health, Child & Adolescent Clinical Nurse Specialist 364S00000X Nursing s Clinical Nurse Specialist Clinical Psychologist 103TC0700X Behavioral Health and Social Service s Psychologist Clinical Critical Care Medicine 207RC0200X Internal Medicine Critical Care Medicine 49 AMS 05 MD/DO/CLN 64 AUD/CLN 4N DE/CLN 06 MD/DO/CLN 43 80/P2 SP/CLN W8 89 68 PSY/CLN 37 MD/DO/CLN Revised 1/7/16
Professional s Dental Group/Clinic 261QD0000X Ambulatory Health Care Facilities Clinic/ Center Dental Dermatology 207N00000X Dermatology Diagnostic Radiology 2085R0202X Radiology Diagnostic Radiology Doctor of Chiropractic Medicine Type(s) 00 DDS/CP 07 MD/DO/CLN 31 MD/DO/CLN 111N00000X Chiropractic s Chiropractors 95 DC/CLN Doctor of Dentistry 122300000X Dental s Dentists 19 DDS/CLN Doctor of Podiatric Medicine 213E00000X Podiatric Medicine and Surgery s Podiatrists Emergency Medicine 207P00000X Emergency Medicine 48 DPM/CLN 77 MD/DO/CLN Endodontics 1223E0200X Dental s Dentists Endodontics S9 DDS/CP Family Nurse 363LF0000X Family Family Practice 207Q00000X Family Medicine Gastroenterology 207RG0100X Internal Medicine Gastroenterology General Practice 208D00000X Allopathic & Osteopathic Physicians General Practice General Surgery 208600000X Allopathic & Osteopathic Physicians Surgery Geriatric Medicine 207RG0300X Internal Medicine Geriatric Medicine Geriatric Nurse 363LG0600X Gerontology W2 08 MD/DO/CLN 10 MD/DO/CLN 01 MD/DO/CLN 02 MD/DO/CLN 38 MD/DO/CLN W4 Multispecialty Group/Clinic 193200000X Group Multispecialty 70 CLN Gynecology 207VG0400X Obstetrics and Gynecology Gynecology 09 MD/DO/CLN Home Infusion Therapy 251F00000X Agency Home Infusion 47 HIT Immunization Practices 261QH0100X Ambulatory Health Care Facilities Clinic/ Center Health Service 87 PHA
Professional s Infectious Diseases 207RI0200X Internal Medicine Infectious Disease Type(s) 44 MD/DO/CLN Infusion Therapy 261QI0500X Ambulatory Infusion Therapy IF CLN Internal Medicine 207R00000X Internal Medicine 11 MD/DO/CLN Laboratory 291U00000X Laboratories Clinical Medical Laboratories 69 LAB/SUP/CLN Licensed Professional Counselor Limited License Psychologist Mammography Screening Center 101Y00000X 103T00000X 261QR0206X Behavioral Health and Social Service s Licensed Professional Counselor Behavioral Health and Social Service s Psychologist Ambulatory Health Care Facilities Clinic/ Center Radiology, Mammography Medical Surgical Nursing 364SM0705X Nursing s Clinical Nurse Specialist Medical Surgical Neonatal Nurse 363LN0000X Neonatal Neurological Surgery 207T00000X Neurological Surgery Neurology 2084N0400X Psychiatry and Neurology Neurology Neuromuscular Medicine Psychiatry and Neurology Neuromusculoskeletal Medicine & OMM 2084N0008X 204D00000X Psychiatry and Neurology Psychiatry Neuromusculoskeletal Medicine & OMM Nuclear Medicine 207U00000X Nuclear Medicine Nurse Midwife 367A00000X Nursing s Certified Nurse Midwife Nurse 363L00000X OB/GYN Nurse 363LX0001X Obstetrics & Gynecology Obstetrics 207VX0000X Obstetrics and Gynecology Obstetrics CO P1 LPC/CLN SP/CLN 45 SUP W6 W0 14 MD/DO/CLN 13 MD/DO/CLN 27 MD/DO/CLN 12 MD/DO/CLN 36 MD/DO/CLN 42 50 W9 15 MD/DO/CLN
Professional s Obstetrics and Gynecology 207V00000X Obstetrics and Gynecology Occupational Therapist 225X00000X Respiratory, Developmental, Rehabilitative and Restorative Service s Occupational Therapist Ophthalmology 207W00000X Ophthalmology Ophthalmology and Otorhinolaryngology 207W00000X Ophthalmology Optometrist 152W00000X Eye and Vision Service s Optometrists Oral Surgery Medical Benefit Oral Surgery Dental Benefit 1223S0112X 1223S0112X Dental s Dentists Oral and Maxillofacial Surgery Dental s Dentists Oral and Maxillofacial Surgery Orthodontics 1223X0400X Dental s Dentists Orthodontics and Dentofacial Orthopedics Orthopaedic Surgery 207X00000X Orthopaedic Surgery Orthotist 222Z00000X Respiratory, Developmental, Rehabilitative and Restorative Service s Orthotist Otolaryngology 207Y00000X Otolaryngology Outpatient Psychiatric Facility Pain Management Anesthesiology, Psychiatry/Neurology Pathological Anatomy and Clinical Pathology 261QM0801X 208VP0014X 207ZP0102X Ambulatory Health Facility Clinic/Center Mental Health Allopathic & Osteopathic Physicians Pain Medicine Interventional Pain Medicine Pathology Anatomic Pathology & Clinical Pathology Pathology 207ZP0102X Pathology Anatomic Pathology and Clinical Pathology Pediatric Dentistry 1223P0221X Dental s Dentists Pediatric Dentistry Type(s) 16 MD/DO/CLN 67 CHP/CLN 18 MD/DO/CLN 17 MD/DO/CLN 90 OD/CLN 97 DDS/CLN S1 S2 DDS/CP DDS/CP 20 MD/DO/CLN 51 SUP 04 MD/DO/CLN 75 OPF 05/H1 MD/DO/CLN 21 MD/DO/CLN 22 MD/DO/CLN S3 DDS/CP
Professional s Pediatric Nurse 363LP0200X Pediatrics Pediatrics 208000000X Pediatrics W5 Type(s) 35 MD/DO/CLN Periodontics 1223P0300X Dental s Dentists Periodontics S4 DDS/CP Pharmacy/Hemophilia Pharmacy Physical Medicine and Rehab 333600000X Suppliers Pharmacy 94 PHA 208100000X Physical Medicine and Rehab Physical Therapist 225100000X Respiratory, Developmental, Rehabilitative and Restorative Service s Physical Therapists Physician Assistant 363A00000X Nursing s Physician Assistant Plastic Surgery 208200000X Plastic Surgery 25 MD/DO/CLN 65 PT/CLN 86 PA 24 MD/DO/CLN Portable X-ray Supplier 335V00000X Suppliers Portable X-ray Supplier 30/63 PXS Preventive Medicine 2083P0500X Preventive Medicine Preventive Medicine /Occupational Environment Medicine Proctology 208C00000X Colon and Rectal Surgery Prosthetist 224P00000X Respiratory, Developmental, Rehabilitative and Restorative Service s Prosthetist Prosthetist and Orthotist 225000000X Respiratory, Developmental, Rehabilitative and Restorative Service s Orthotist/Prosthetist Fitter 39 MD/DO/CLN 28 MD/DO/CLN 52 SUP 53 SUP Prosthodontics 1223P0700X Dental s Dentists Prosthodontics S5 DDS/CP Psychiatry 2084P0800X Psychiatry and Neurology Psychiatry Psychiatry and Neurology 2084P0800X Psychiatry and Neurology Psychiatry 26 MD/DO/CLN 27 MD/DO/CLN Public Health and Welfare 251K00000X Agency Public Health or Welfare 60 LAB/SUP/CLN
Professional s Pulmonary Disease 207RP1001X Internal Medicine Pulmonary Disease Radiation Oncology 2085R0001X Radiology Radiation Oncology Radiology 2085R0202X Radiology Diagnostic Radiology Registered Nurse Certified 163W00000X Nursing Service s Registered Nurse School Nurse 363LS0200X School Select Outpatient Psychiatric Facility 261QM0801X Ambulatory Health Facility Clinic/Center Mental Health Type(s) 29 MD/DO/CLN 32 MD/DO/CLN 30 MD/DO/CLN 50/N2 W3 76 OPF Service Entity 171W00000X Other Service Contractor 92 SE Speech Therapy 235Z00000X Speech Therapy 57 ST/CLN Pharmacy and Limited Distribution Pharmacy 3336S0011X Suppliers Pharmacy Pharmacy Supplier 332B00000X Suppliers Durable Medical Equipment and Medical Supplies Thoracic Surgery 208G00000X Allopathic and Osteopathic Physicians Thoracic Surgery (Cardiothoracic Vascular Surgery) Urology 208800000X Allopathic and Osteopathic Physicians Urology SP/LX PHA 54 SUP/CLN 33 MD/DO/CLN 34 MD/DO/CLN Revised 1/7/16 R049571