Retail Site; brick-and-mortar licensed/certified place of transaction 4 that is not solely a health care entity, i.e., pharmacies, independent laboratories, vision services. E-Site; internet-based order/logistic system of health care services, typically in the form of durable medical equipment, pharmacy or 5 vision services. Address assigned should be the address of the company delivering services or order fulfillment. Financial Parent; financial governing body that does not perform health care services itself 6 but directs and finances health care service entities, usually through a Board of Directors. Transportation; any form of 7 transport that conveys a patient to/from a healthcare provider. Other; any type of entity not 0 otherwise defined that performs health care services. Report the SSN of the individual Required Provider's Social provider in PV002. Do not zero-fill. PV 35 SSN Id 11/8/12 Numeric ID Tax char[9] when 98% A1 Security Number Do not report any value here if not = 1 available or not applicable. Report the Medicare ID Required Provider's Medicare Certification, Other, Unspecified, when Medicare PV 36 6/24/10 Text ID Medicare Number, other than NSC or PIN) of the provider or entity PV034 = 0, 90% B ID UPIN in PV002. Do not report UPIN here, 1, 2, 3, 4, see PV004. or 5
4 Retail Site; brick-and-mortar licensed/certified place of transaction that is not solely a health care entity, i.e., pharmacies, independent laboratories, vision services. 5 E-Site; internet-based order/logistic system of health care services, typically in the form of durable medical equipment, pharmacy or vision services. Address assigned should be the address of the company delivering services or order fulfillment. 6 Financial Parent; financial governing body that does not perform health care services itself but directs and finances health care service entities, usually through a Board of Directors. 7 Transportation; any form of transport that conveys a patient to/from a healthcare provider. 0 Other; any type of entity not otherwise defined that performs health care services. PV 35 SSN Id 11/8/12 Numeric ID Tax char[9] Provider's Social Security Number Report the SSN of the individual provider in PV002. Do not zero-fill. Do not report any value here if not available or not applicable. Required when = 1 98% A1 PV 36 Medicare ID 6/24/10 Text ID Medicare Provider's Medicare Number, other than UPIN Report the Medicare ID Certification, Other, Unspecified, NSC or PIN) of the provider or entity in PV002. Do not report UPIN here, see PV004. Required when PV034 = 0, 1, 2, 3, 4, or 5 90% B