PRV Provider Information

Opt

AtMax 1

To specify the identifying characteristics of a provider

Elements

Position	Element	Name		Type	Min/Max	Repeat

1	1221	Provider Code	Mandatory	ID	1/3	Exact 1
2	128	Reference Identification Qualifier	Mandatory	ID	2/3	Exact 1
3	127	Reference Identification	Mandatory	Alphanumeric	1/30	Exact 1
4	156	State or Province Code	Opt	ID	2/2	Exact 1
C035Provider Specialty InformationOpt Exact 1
6	1223	Provider Organization Code	Opt	ID	3/3	Exact 1

ID1221

NameProvider Code

LengthMin 1 / Max 3

Position1

RequirementMandatory

Codes