Mary Hall

  
 Gulf Coast 
 SURGICAL CENTER, LLC 
 402 Dunn Street 
 Houma, LA 72960 (985) 829-1291 Fax (929) 829-6298 
 Tax ID: 20-3337370
 NPI #: 122140617 
 B/C#: 1126476488834Z 
 Insurance Verification Form 
 Pt. Name: Mary Hall 
 birth date: 05 April 1999 
 MR# 48429-3 
 BCBS OF LA HMO 
 Insurance Company: 
 Phone Number: 1-583-230-2514
 Insured Name: SELF 
 Relationship to Patient: 
 Policy Number: IHQ812647648883 
 Group Number: 
 Effective Date: 21 October 2019
 Policy paid thru: ACTIVE 
 DATE OF PROCEDURE: 28 October 2014
 Pre-cert company name: 
 Claims Address: BCBS OF LA 
 Does policy follow MNRP/MRC2? yes or no 
 PO BOX 92929 
 Do benefits co-incide? 
 yes or no 
 BATON ROUGE, LA 70298 
 Rep. Name: ONLINE 1 Austin 
