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Required Information<br />
FIELD NUMBER NAME AND DESCRIPTION<br />
33 Physician/ Supplier’s Billing Name, Address, Zip Code and Phone Number<br />
Enter the provider’s name, address, zip code and phone number (including area<br />
code).<br />
33A<br />
EXCEPTION:<br />
33A<br />
NPI<br />
Enter the appropriate Pay to NPI Number.<br />
Provider types ONLY: Hands, Commission for Handicapped Children, Title V, First<br />
Steps, Impact Plus and Non Emergency Transportation, LEAVE BLANK<br />
33B<br />
EXCEPTION:<br />
33B<br />
(Shaded Area)<br />
Enter ZZ and the Pay to Taxonomy Number.<br />
Enter 1D and the Pay to Provider Number. (Provider types ONLY: Hands,<br />
Commission for Handicapped Children, Title V, First Steps, Impact Plus and Non<br />
Emergency Transportation)<br />
Cabinet for Health and Family Services<br />
14
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