Derrick Lamb

 Encounter # 
 MR# 
 Enc Start Date Time 
 Pt Location 
 50267997726 
 6561073 
 2017-07-05 07:11 
 ADLT ED Waiting Indy 
 ECD# 
 Level of Care 
 Clin Svc 
 EPT 
 Enc Type 
 4116500704 
 Other 
 EMR 
 ER 
 OP 
 Riverfront Hospital 
 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 
 DATE OF BIRTH 
 Religion\ Church 
 Adm Clerk 
 58Y 
 1991-01-20 
 COG \ UKN 
 016 
 PATIENT Address, Phone 
 Employer Name, Address, Phone 
 Emplm Sts, Class, Cat 
 Derrick Lamb 
 EXTENDED STAY AMERICA 
 Empl 
 69482 Lee Overpass Suite 377
New Sandraport, AS 36580 
 Indianapolis, IN 46254 
 County: Marion 
 Home: 231-279-2195 
 Day: 
 Cell: 389-457-4668 
 Guarantor Name, Pt Rel, Address, Phone 
 Guarantor Empr, Address, Phone 
 Empim Sts, Class, Cat 
 Derrick Lamb 
 Self 
 EXTENDED STAY AMERICA 
 Empl  
 Phone: 317-298-0651 
 317-514-7862 
 Emergency Contact 1 
 Emergency Contact 2 
 Derrick Lamb 
 PO Box 1575 
 Authorization # 
 Eligibility # 
 1991-01-20 
 Primary Physician 
 Reason for Encounter 
 Dr Carl Moore
 HBS 
 Admitting Physician 
 Copy to Physician 
 Emergency, Indianapolis 
 Attending Physician 
 Emergency, Indianapolis 
 Printed: 2019-06-07 14:28 
 User: jdunl444 
  02A 
 4118867004 
 SVI 0044
