5 1 01 22 16 1 11 1 N I 17003 7 I I B I 350 00 I 7 I NPI 932138211 1 I ) I 1 I I NPII , H I NPI 2... FEDERAL TAX NUMBER SSW EN 21 PATIENTS ACCOUNT NO 133843772 n 31 0000008048 27 ACCEPT ASSIGNMENT? _iraraaan s ()see. se back) LJ 2a TOTAL CHARGE s 1275.00 29 AMOUNT