Field 2: BILLING SERVICE NAME If applicable, enter the name of the billing service that the provider is enrolled. with. If you are not using a billing service, leave this field blank. Field 3: DATE Enter the date the Certification Statement is submitted to the fiscal agent.
Gregory Jerome Coleman (born September 9, 1954 in Jacksonville, Florida) is a retired American football punter who had a 12-year career in the National Football League playing for the Cleveland Browns, the Minnesota Vikings, and the Washington Redskins. He attended Florida A&M University.
For the American rapper from Chicago, Illinois, see Fredo Santana. Derrick D. Coleman (born June 21, 1967) is a retired American basketball player in the NBA. Coleman was born in Mobile, Alabama but grew up and attended high school in Detroit, Michigan and attended college at Syracuse University. He was selected first overall in the 1990 NBA draft by the New Jersey Nets.