Timothy Scott

  
 Gulf Coast 
 SURGICAL CENTER, LLC 
 402 Dunn Street 
 Houma, LA 71060 (985) 810-1101 Fax (910) 810-6108 
 Tax ID: 20-3334947
 NPI #: 125801046 
 B/C#: 1298536943034Z 
 Insurance Verification Form 
 Pt. Name: Timothy Scott 
 DOB: 10 October 2001 
 MR# 48410-3 
 BCBS OF LA HMO 
 Insurance Company: 
 Phone Number: 1-102-310-5785
 Insured Name: SELF 
 Relationship to Patient: 
 Policy Number: IHQ829853694303 
 Group Number: 
 Effective Date: 21 September 2018
 Policy paid thru: ACTIVE 
 Date of Procedure: 22 December 2014
 Pre-cert company name: 
 Claims Address: BCBS OF LA 
 Does policy follow MNRP/MRC2? yes or no 
 PO BOX 91029 
 Do benefits co-incide? 
 yes or no 
 BATON ROUGE, LA 70108 
 Rep. Name: ONLINE 1 Austin 
