Provider Last Name or Organization Name. Service Facility 10/1/2014 Text 20 National Provider ID for National Provider laboratory or service facility IDdentifier If blank or not specified, – populate with MC077 -- Service Facility National Provider ID – Billing Provider. Refer to Appendix A MC087 Service Facility 10/1/2014 Text 55 Address information for Location Address laboratory or service facility Line 1 If blank or not specified, populate with MC080 -- Billing Provider Address Line 1. MC088 Service Facility 10/1/2014 Text 55 Address information for Location Address laboratory or service facility Line 2 If blank or not specified, populate with MC081 -- Billing Provider Address Line 2. MC089 Service Facility 10/1/2014 Text 30 City name of laboratory or Location City service facility Name If blank or not specified, populate with MC082 -- Billing Provider City Name. Refer to Appendix A MC090 Service Facility 10/1/2014 Text 2 As defined by the US Postal Location Address Service and Canada Post
Provider Last Name or Organization Name. Service Facility National Provider IDdentifier – Service Facility 10/1/2014 Text 20 National Provider ID for laboratory or service facility If blank or not specified, populate with MC077 -- National Provider ID – Billing Provider. Refer to Appendix A MC087 Service Facility Location Address Line 1 10/1/2014 Text 55 Address information for laboratory or service facility If blank or not specified, populate with MC080 -- Billing Provider Address Line 1. MC088 Service Facility Location Address Line 2 10/1/2014 Text 55 Address information for laboratory or service facility If blank or not specified, populate with MC081 -- Billing Provider Address Line 2. MC089 Service Facility Location City Name 10/1/2014 Text 30 City name of laboratory or service facility If blank or not specified, populate with MC082 -- Billing Provider City Name. Refer to Appendix A MC090 Service Facility Location Address 10/1/2014 Text 2 As defined by the US Postal Service and Canada Post
Chapter%20243_2015.docx