Margaret Crosby

 Encounter # 
 MR# 
 Enc Start Date Time 
 Pt Location 
 76912806155 
 4352073 
 16/03/22 07:11 
 ADLT ED Waiting Indy 
 ECD# 
 Level of Care 
 Clin Svc 
 EPT 
 Enc Type 
 4118030004 
 Other 
 EMR 
 ER 
 OP 
 Silverlake Medical Center 
 Preferred Language 
 Admit Source 
 Confidential 
 Infectious Disease 
 English 
 Phys Ref 
 Email 
 Admit Type 
 Incident Date 
 Incident Type 
 prettygang222@gmail.com 
 Emergent 
 Advance Dir: 
 Race: 
 Soc Sec # 
 Gdr 
 MS 
 No 
 Black 
 F 
 S 
 Age 
 birthdate 
 Religion\ Church 
 Adm Clerk 
 51Y 
 93/05/13 
 COG \ UKN 
 016 
 Patient name Address, Phone 
 Employer Name, Address, Phone 
 Emplm Sts, Class, Cat 
 Margaret Crosby 
 EXTENDED STAY AMERICA 
 Empl 
 726 Banks Port
North Sandrashire, MP 34317 
 Indianapolis, IN 46254 
 County: Marion 
 Home: 861-144-4455 
 Day: 
 Cell: 662-284-1202 
 Guarantor Name, Pt Rel, Address, Phone 
 Guarantor Empr, Address, Phone 
 Empim Sts, Class, Cat 
 Margaret Crosby 
 Self 
 EXTENDED STAY AMERICA 
 Empl  
 Phone: 317-298-0651 
 317-514-7862 
 Emergency Contact 1 
 Emergency Contact 2 
 Margaret Crosby 
 PO Box 1575 
 Authorization # 
 Eligibility # 
 93/05/13 
 Primary Physician 
 Reason for Encounter 
 Dr Jacob Love
 HBS 
 Admitting Physician 
 Copy to Physician 
 Emergency, Indianapolis 
 Attending Physician 
 Emergency, Indianapolis 
 Printed: 16/01/28 14:42 
 User: jdunl104 
  02A 
 4118867004 
 SVI 0010
