WALMART #1854

NPI: 1023144474 · HATILLO, PR 00659 · Eyewear Supplier · NPI assigned 02/27/2007

$999.90

Total Medicaid Paid

Total Claims

Beneficiaries

Codes Billed

2023-10

First Month

2023-10

Last Month

Provider Details

Authorized Official	HERNANDEZ, JORGE (DIRECTOR OF SPECIALTY DIVISIONS)
NPI Enumeration Date	02/27/2007

Other providers sharing the same authorized official: HERNANDEZ, JORGE

Provider	City	State	Total Paid
GWINNETT PHYSICIAN GROUP, LLC	LAWRENCEVILLE	GA	$8.28M
NORTH ATLANTA PROFESSIONAL SERVICES LLC	ATLANTA	GA	$849K
GEORGIA SURGICAL PROFESSIONAL SERVICES, LLC	ATLANTA	GA	$709K
WALMART #2067	MAYAGUEZ	PR	$98K
WALMART #2501	BAYAMON	PR	$59K
WALMART #2085	ISABELA	PR	$37K
PULMONARY MEDICINE ASSOCIATES, P.A.	OCOEE	FL	$4K
NSH CANCER INSTITUTE PROFESSIONAL SERVICES G, LLC	ATLANTA	GA	$3K
JORGE L HERNANDEZ MD PA	BRADENTON	FL	$3K
NORTHSIDE HOSPITAL, INC.	ATLANTA	GA	$953.17

Year	Claims	Total Paid
2023	26	$999.90

Code	Description	Claims	Beneficiaries	Total Paid
V2103	Spherocylinder, single vision, plano to plus or minus 4.00d sphere, .12 to 2.00d cylinder, per lens	26	13	$999.90