Organization Information:

Organization Name (LBN):	Sample Hospital Home Health Agency
Doing Business As (DBA):	Sample Hospital
EIN:	<UNAVAIL>
Organization Subpart:	X
Parent Organization LBN:
Parent Organization TIN:

Authorized Official Information:

Name:	Gregory House, M.D.
Title/Position:	Chief of Diagnostic Medicine
Phone Number	(123) 555-1212

NPI Information:

NPI:	1234567890
Entity Type:	2 – ORGANIZATION
Enumeration Date:	09/20/2006
Last Update Date:	07/09/2007
Replacement NPI:
Deactivation Date:
Reactivation Date:

Provider Business Mailing Address:

Address:	PO BOX 1234 Princeton, NJ  08544
Phone Number:
FAX Number:

Provider Business Practice Location Address:

Address:	PO BOX 1234 Princeton, NJ  08544
Phone Number:
FAX Number:

Organization Taxonomy:

Primary Taxonomy	Selected Taxonomy	State	License Number
Y	282N00000X – General Acute Care Hospital

Other Provider Identifier:

Type	Number	State	Issuer
MEDICARE OSCAR/CERTIFICATION	31-1234	NJ
MEDICAID	01234567	NJ