STATE LICENSE (23) IB PROVIDER ID # TYPE (355.97)
Name
Value
NAME
STATE LICENSE
SOURCE LEVEL MINIMUM
LICENSING/GOVT AGENCY - EACH PROV
X12 CODE
0B
VALID FOR PERFORMING PROVIDER
YES
ALLOWABLE FORM TYPE
BOTH INSTITUTIONAL AND PROFESSIONAL
ACTIVE
YES
STATE LICENSE #
YES
PROVIDER'S OWN ID
YES
STORED OUTSIDE OF BILLING
YES
