| NAME | SOURCE LEVEL MINIMUM | X12 CODE | FACILITY'S DEFAULT ID # | RESTRICT EDITING | VALID FOR PERFORMING PROVIDER | ALLOWABLE FORM TYPE | ACTIVE | STATE DEA# | FEDERAL DEA# | STATE LICENSE # | FEDERAL TAX # - FACILITY | EMC ID TYPE | NETWORK ID TYPE | PROVIDER'S OWN ID | STORED OUTSIDE OF BILLING | BILLING PROVIDER PRIMARY ID |
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