Sharon Rodriguez

  
 Gulf Coast 
 SURGICAL CENTER, LLC 
 402 Dunn Street 
 Houma, LA 75560 (985) 855-1551 Fax (955) 855-6558 
 Tax ID: 20-3317415
 NPI #: 124147811 
 B/C#: 1426871144174Z 
 Insurance Verification Form 
 Pt. Name: Sharon Rodriguez 
 birthdate: 1986 September 10 
 MR# 48455-3 
 BCBS OF LA HMO 
 Insurance Company: 
 Phone Number: 1-255-849-7193
 Insured Name: SELF 
 Relationship to Patient: 
 Policy Number: IHQ842687114417 
 Group Number: 
 Effective Date: 2017 December 02
 Policy paid thru: ACTIVE 
 date of procedure: 2020 May 15
 Pre-cert company name: 
 Claims Address: BCBS OF LA 
 Does policy follow MNRP/MRC2? yes or no 
 PO BOX 95529 
 Do benefits co-incide? 
 yes or no 
 BATON ROUGE, LA 70558 
 Rep. Name: ONLINE 1 Austin 
