example - dme w900000 wcmed insurance 16 avengers …

1

W900000 WCMed Insurance 16 Avengers Street White Plains, NY 10604 Coyote, Wiley E 07 06 1972 124 Roadrunner Avenue 1 Boulder Circle Staten Island NY NY 10306 111 1111111 G9999999 Coyote^^^Wiley Y4 0000WC1700010000 WCMed Insurance Signature on File 05 14 19 431 0B 4567890 Foghorn, Rooster MD 1111111119 0 M25511 01 08 20 01 08 20 12 E2631 NU A 252 10 7 8822222229 261211111 36111-52222 252 10 2222222 OrthoDME Supplies OrthoDME Supplies 2 Acme Street, Suite A 2 Acme Street, Suite A Robert Fastus New York, NY 10022 New York, NY 10022 01/10/2020 8822222229 8822222229 222 987-65-4321 ACME ZipRunners Manhattan 10001 888 8888888 EXAMPLE - DME REFX5016182-8^^^G2CIM^^^PWK09EAC00985621^^^NTEADD20200302 DK

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Page 1: EXAMPLE - DME W900000 WCMed Insurance 16 Avengers …

W900000WCMed Insurance16 Avengers StreetWhite Plains, NY 10604

Coyote, Wiley E 07 06 1972

124 Roadrunner Avenue 1 Boulder Circle

Staten Island NY NY

10306 111 1111111

G9999999

Coyote^^^Wiley Y4 0000WC1700010000

WCMed Insurance

Signature on File

05 14 19 4310B 4567890

Foghorn, Rooster MD 1111111119

0M25511

01 08 20 01 08 20 12 E2631 NU A 252 10 7 8822222229

261211111 36111-52222 252 102222222

OrthoDME Supplies OrthoDME Supplies2 Acme Street, Suite A 2 Acme Street, Suite A

Robert Fastus New York, NY 10022 New York, NY 1002201/10/2020 8822222229 8822222229

222

987-65-4321

ACME ZipRunners

Manhattan

10001 888 8888888

EXAMPLE - DME

REFX5016182-8^^^G2CIM^^^PWK09EAC00985621^^^NTEADD20200302

DK

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