| Document Date: 2013-11-18 14:11:40
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City Mechanicsburg / Baltimore / / Company Applicant (Check one) Hospital Physician Physician Group / / Country United States / / Currency USD / / Facility Hospital Election / Hospital Name / / IndustryTerm physician services / physician groups / ambulance services / search existing data resources / bank / correct banking information / services / hospital services / / Organization Internal Revenue Service / SSN Hospital / DEPARTMENT OF HEALTH AND HUMAN SERVICES / NPI / MEDICARE / / Position Secretary of Health / official / chief financial officer / chief executive officer / Chancellor / Chief / PRA Reports Clearance Officer / Individual Physician / treasurer / Physician / Chief / Vice President / PtAn SSn PHYSiciAn / authorized official for individual physician / Authorized official / Administrator / County Commissioner / chief operating officer / president / County Commissioner / Chancellor / Secretary / chief executive officer / chief operating officer / chairman of the board / chief financial officer / Director / Administrator / / ProvinceOrState Pennsylvania / Maryland / / Technology laser / /
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Please check one. directions for completing this form begin on page 3. New Application Change Request Voluntary Termination