20131002162228248
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Cl ient ) Ordering Site Informat ion: Physician Informat ion:Account Name: Professional Arts Center Neurology Suites 603/609
Address 1: 1150 NW 14th Street Suite 609Address 2:
City, State Zip: Miami, Florida, 33136Phone: 305-243-6732
Ordering: Koch, SebastianDegree: MD
NPI: 1831155779UPIN: Not on file
Physician ID:
Patient Information:Name: CASTELLANOS FiERRERA,MARLENE
Gender: FemaleDate of Birth: 9/19/1951
Age: 62Address: 1780 SW 6 ST APT 3, APT 3
City, State Zip: MIAMI, FL 33135
SSN: w-)a-9075Patient ID: 20015193
Phone: 305-854-4214
Alt Controllil: 245758920BU20015193
Quest Diagnosticsm
OrdersCode7197
Responsible Party / Guarantor InformationName: CASTELLANOS HERRERA,MARLENE
Address: 1 7 8 0 SW 6 ST APT 3APT 3MIAMI, Florida 33135
Phone: 305-854-4214Relation to Patient: S e l f
Insurance InformationPrimary Insurance:
Carrier Code:Company Name:
Address:
Policy Number:Group Number:
Primary Policy Holder /Name:
Address:
Relation to Patient:
TestLYMPHOCYTE SUBSETPANEL 1
Dx
MEDICAIDMEDIPASS CPO BOX 7072Tallahassee, Florida 32314-70842440097021
Insured:CASTELLANOS HERRERA,MARLENE1780 SW 6 STARTSAPT 3MIAMI, Florida 33135Self
QuestDiagnosticsPSC-Hold
University ofMiami
PSC-Hold - University of Miami
334.3Specimen TypeBlood
Employer Name:ABN:
Worker's Comp: NDate of Injury:
28786-24575892(M
Account #: 28786
LAB REF # 24575892Q8U
Collection Date:
Collection Time:
Expected10/2/2013
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