PROVIDER TYPE CODE DESCRIPTION OF PROVIDER TYPE …

Provider Type Code

01 01 01 01 01 01 01 01 01 01 01 01 01 01 01 01 01 02 03 03 03 03 03 03 03 03 03 03 03 03 04 05 05 05 05 05 05 05 05 05 05 05 06 07 07 07

Provider Type Desc

Inpatient Facility Inpatient Facility Inpatient Facility Inpatient Facility Inpatient Facility Inpatient Facility Inpatient Facility Inpatient Facility Inpatient Facility Inpatient Facility Inpatient Facility Inpatient Facility Inpatient Facility Inpatient Facility Inpatient Facility Inpatient Facility Inpatient Facility Ambulatory Surgical Center Extended Care Facility Extended Care Facility Extended Care Facility Extended Care Facility Extended Care Facility Extended Care Facility Extended Care Facility Extended Care Facility Extended Care Facility Extended Care Facility Extended Care Facility Extended Care Facility Rehabilitation Facility Home Health Home Health Home Health Home Health Home Health Home Health Home Health Home Health Home Health Home Health Home Health Hospice Capitation Capitation Capitation

Specialty Code

Specialty Desc

010

Acute Care Hospital

011

Private Psychiatric Hospital

012

Inpatient Medical Rehab Hospital

013

Residential Treatment Facility (Jcaho Certified)

014

Inpatient Medical Rehab Unit

016

Emergency Room Arrangement 1

017

Emergency Room Arrangement 2

018

Extended Acute Psych Inpatient Unit

019

Inpatient Drug & Alcohol Hospital

021

Short Procedure Unit

022

Private Psychiatric Unit

023

Public Psychiatric Hospital

183

Hospital Based Medical Clinic

220

Hearing Aid Dispenser

232

Center Of Excellence

370

Tobacco Cessation

441

Drug And Alcohol Rehab Unit

020

Ambulatory Surgical Center

030

Nursing Facility

031

County Nursing Facility

032

Icf/Mr 8 Beds Or Less

033

Icf/Mr 9 Beds Or More

035

Residential Nursing Facility

037

State Ltc Unit

038

State Mental Retardation Center

039

Icf/Orc

040

Certified Rehab Agency

042

Dmva Nursing Facilities

382

Inp. Facility Based Ltc Ext. Care Facility

430

Homemaker Agency

041

Comprehensive Outpatient Rehab Facility

025

Personal Emergency Response System

026

Home Infusion Therapy

050

Home Health Agency

051

Private Duty Nursing

250

Dme / Medical Supplies

361

Personal Care - Agency

362

Attendant Care/Personal Assistance Service

370

Tobacco Cessation

410

Adult Day Care

430

Homemaker Agency

512

Respite Care - Home Based

060

Hospice

070

Ltc Cap

071

Managed Care Organization, Physical Health

072

Managed Care Organization, Behavioral Health

07

Capitation

079

Community Healthchoices

07

Capitation

770

Managed Care Organization, Chip

08

Clinic

074

Mobile Mental Health Treatment

08

Clinic

075

Targeted Outpatient Treatment

08

Clinic

080

Federally Qualified Health Center

08

Clinic

081

Rural Health Clinic

08

Clinic

082

Independent Medical / Surgical Clinic

08

Clinic

083

Family Planning Clinic

08

Clinic

084

Methadone Maintenance

08

Clinic

086

Dental Clinic

08

Clinic

089

Tuberculosis Clinic

08

Clinic

110

Psychiatric Outpatient

08

Clinic

111

Community Mental Health

08

Clinic

163

Nurse Family Partnership

08

Clinic

181

Maternity Clinic

08

Clinic

182

Speech/Hearing Clinic

08

Clinic

184

Outpatient Drug And Alcohol

08

Clinic

232

Center Of Excellence

08

Clinic

370

Tobacco Cessation

09

Certified Registered Nurse Practitioner 090

Pediatric

09

Certified Registered Nurse Practitioner 091

Obstetrics / Gynecology

09

Certified Registered Nurse Practitioner 092

Family Health

09

Certified Registered Nurse Practitioner 093

Nurse Practitioner (Primary Care)

09

Certified Registered Nurse Practitioner 095

Adult Health

09

Certified Registered Nurse Practitioner 098

Gerontology

09

Certified Registered Nurse Practitioner 099

Emergency

09

Certified Registered Nurse Practitioner 103

Family And Adult Psych Mental Health

09

Certified Registered Nurse Practitioner 370

Tobacco Cessation

10

Mid-Level Practitioner

100

Physician Assistant

10

Mid-Level Practitioner

141

Acupuncturist

10

Mid-Level Practitioner

269

Public Health Dental Hygiene Practitioner (Phdhp)

11

Mental Health / Substance Abuse

076

Peer Specialist

11

Mental Health / Substance Abuse

084

Methadone Maintenance

11

Mental Health / Substance Abuse

110

Psychiatric Outpatient

11

Mental Health / Substance Abuse

111

Community Mental Health

11

Mental Health / Substance Abuse

112

Outpatient Practitioner-Mh

11

Mental Health / Substance Abuse

113

Partial Psych Hospitalization Children

11

Mental Health / Substance Abuse

114

Partial Psych Hospitalization Adult

11

Mental Health / Substance Abuse

115

Family Based Mental Health

11

Mental Health / Substance Abuse

116

Licensed Clinical Social Worker

11

Mental Health / Substance Abuse

117

Licensed Social Worker

11

Mental Health / Substance Abuse

118

Mental Health Crisis Intervention

11

Mental Health / Substance Abuse

119

Mental Health - Omhsas

11

Mental Health / Substance Abuse

122

Marriage And Family Counselor

11

Mental Health / Substance Abuse

123

Psychiatric Rehabilitation

11

Mental Health / Substance Abuse

124

Mental Illness/Substance Abuse Professional I

11

Mental Health / Substance Abuse

126

Behavioral Support

11

Mental Health / Substance Abuse

127

D & A Outpatient

11

Mental Health / Substance Abuse

128

D & A Intensive Outpatient

11

Mental Health / Substance Abuse

129

D & A Partial Hospitalization

11

Mental Health / Substance Abuse

131

D & A Halfway House

11

Mental Health / Substance Abuse

132

D & A Medically Monitored Detoxification

11

Mental Health / Substance Abuse

184

Outpatient Drug And Alcohol

11

Mental Health / Substance Abuse

185

D&A Non-Hosp Residential Clinically Managed

11

Mental Health / Substance Abuse

186

D&A Non-Hosp Residential Medically Monitored

11

Mental Health / Substance Abuse

232

Center Of Excellence

11

Mental Health / Substance Abuse

267

Non-Emergency

11

Mental Health / Substance Abuse

420

Autism Behavioral Specialist

11

Mental Health / Substance Abuse

421

Autism Social Worker

11

Mental Health / Substance Abuse

422

Autism Marriage And Family Therapist

11

Mental Health / Substance Abuse

423

Autism Professional Counselor

11

Mental Health / Substance Abuse

424

Autism Counseling Agency

11

Mental Health / Substance Abuse

559

Behavioral Specialist Consultant

11

Mental Health / Substance Abuse

590

Ibhs Individual Services

11

Mental Health / Substance Abuse

591

Ibhs Group Services

11

Mental Health / Substance Abuse

592

Ibhs Aba Services

11

Mental Health / Substance Abuse

593

License Marriage And Family Therapist

11

Mental Health / Substance Abuse

594

License Professional Counselor

12

School Corporation

120

Teaching Institute

12

School Corporation

121

Teaching Institute - Dental

14

Podiatrist

140

Podiatrist

15

Chiropractor

150

Chiropractor

16

Nurse

160

Registered Nurse

16

Nurse

161

Licensed Practical Nurse

16

Nurse

162

Psychiatric Nurse

16

Nurse

163

Nurse Family Partnership

16

Nurse

572

Early Intervention Services

17

Therapist

169

Equine Assisted Therapy

17

Therapist

170

Physical Therapist

17

Therapist

171

Occupational Therapist

17

Therapist

172

Respiratory Therapist

17

Therapist

173

Speech/Hearing Therapist

17

Therapist

174

Art Therapist

17

Therapist

175

Music Therapist

17

Therapist

176

Physical Therapy / Early Intervention (Ei)

17

Therapist

177

Occupational Therapy / Early Intervention (Ei)

17

Therapist

178

Speech/Hearing Therapy / Early Intervention (Ei)

18

Optometrist

180

Optometrist

19

Psychologist

190

General Psychologist

19

Psychologist

191

Clinical Neuropsychologist

19

Psychologist

192

Clinical Health Psychologist

19

Psychologist

194

School Psychologist

19

Psychologist

195

Clinical Psychologist

19

Psychologist

196

Clinical Child Psychologist

19

Psychologist

197

Counseling Psychologist

19

Psychologist

198

Industrial Organizational Psychologist

19

Psychologist

19

Psychologist

19

Psychologist

19

Psychologist

19

Psychologist

19

Psychologist

19

Psychologist

19

Psychologist

19

Psychologist

19

Psychologist

19

Psychologist

20

Audiologist

20

Audiologist

20

Audiologist

21

Case Manager

21

Case Manager

21

Case Manager

21

Case Manager

21

Case Manager

21

Case Manager

21

Case Manager

21

Case Manager

21

Case Manager

21

Case Manager

21

Case Manager

22

Department Of Health

22

Department Of Health

22

Department Of Health

23

Nutritionist

23

Nutritionist

24

Pharmacy

24

Pharmacy

24

Pharmacy

24

Pharmacy

24

Pharmacy

24

Pharmacy

24

Pharmacy

24

Pharmacy

24

Pharmacy

25

Dme/Medical Supplies

25

Dme/Medical Supplies

25

Dme/Medical Supplies

25

Dme/Medical Supplies

25

Dme/Medical Supplies

25

Dme/Medical Supplies

26

Transportation

26

Transportation

26

Transportation

199

Behavioral Psychologist

201

Forensic Psychologist

202

Family Psychologist

204

Clinical Geropsychologist

206

Trtmt Of Alcol And Other Psycav Sbstc Use Dsordrs

207

Cognitive Therapist

232

Center Of Excellence

370

Tobacco Cessation

425

Autism Certified Psychologist

508

Behavioral Support - Odp

572

Early Intervention Services

200

Audiologist

220

Hearing Aid Dispenser

572

Early Intervention Services

138

D & A Targeted Case Management

211

Medical Assistance Case Management For Hiv & Aids

212

Medical Assistance Case Management For Under 21

213

Early Intervention Case Management

214

Supports Coordination Agency

215

Mh Case Management - Administrative

216

Licensed Social Worker/Ei

218

Mr Case Management

221

Mh Targeted Case Mgt, Resource Coordination

222

Mh Targeted Case Management, Intensive

232

Center Of Excellence

226

Newborn Hearing Screening

227

Newborn Screening

228

Wic

230

Registered Nutritionist

460

Home Delivered Meals

220

Hearing Aid Dispenser

232

Center Of Excellence

240

Independent

241

Institutional Independent

242

Chain

243

Institutional Chain

244

Long Term Care (Ltc)

245

Mail Order

247

Pharmacist

220

Hearing Aid Dispenser

250

Dme / Medical Supplies

251

Prosthetist

252

Orthotist

253

Optician

256

Human Milk Bank

260

Ambulance - Basic Life Support

261

Ambulance - Advanced Life Support

262

Air Ambulance

26

Transportation

26

Transportation

26

Transportation

26

Transportation

27

Dentist

27

Dentist

27

Dentist

27

Dentist

27

Dentist

27

Dentist

27

Dentist

27

Dentist

27

Dentist

27

Dentist

27

Dentist

27

Dentist

27

Dentist

27

Dentist

27

Dentist

27

Dentist

28

Laboratory

29

X-Ray Clinic

30

Renal Dialysis Center

31

Physician

31

Physician

31

Physician

31

Physician

31

Physician

31

Physician

31

Physician

31

Physician

31

Physician

31

Physician

31

Physician

31

Physician

31

Physician

31

Physician

31

Physician

31

Physician

31

Physician

31

Physician

31

Physician

31

Physician

31

Physician

31

Physician

31

Physician

31

Physician

31

Physician

264

Mass Transit

265

Para-Transit

266

Client Reimbursement (Mileage, Toll)

267

Non-Emergency

270

Endodontist

271

General Dentistry

272

Oral / Maxillofacial Surgeon

273

Orthodontist/Dentofacial Orthopedist

274

Pediatric Dentist

275

Periodontist

276

Oral Pathologist

277

Prosthodontist

278

Oral / Maxillofacial Pathologist

279

Oral / Maxillofacial Radiologist

282

Dental Public Health

283

Cleft Palate

284

Unrestricted Dental Anesthesia

285

Restricted (1) Dental Anesthesia

286

Restricted (2) Dental Anesthesia

370

Tobacco Cessation

280

Independent Laboratory

291

Mobile X-Ray Clinic

300

Renal Dialysis Center

220

Hearing Aid Dispenser

232

Center Of Excellence

301

Medical And Osteopathic Trainee

310

Allergy & Immunology

311

Anesthesiology

314

Dermatology

315

Emergency Medicine

316

Family Practice

318

General Practitioner

319

Surgery

322

Internal Medicine

328

Obstetrics And Gynecology

330

Ophthalmologist

331

Orthopaedic Surgery

332

Otolaryngology

333

Pathology

336

Physical Medicine & Rehabilitation

337

Plastic Surgery

338

Neurology

339

Psychiatry

341

Radiology

342

Preventive Medicine

343

Urologist

345

Pediatrics

347

Radiation Therapist

31

Physician

370

Tobacco Cessation

31

Physician

426

Autism Certified Psychiatrist

32

Certified Registered Nurse Anesthetist 320

Certified Registered Nurse Anesthetist

33

Certified Nurse Midwife

335

Certified Nurse Midwife

34

Program Exception

340

Program Exception

35

Public Schools

350

Public School

37

Tobacco Cessation

370

Tobacco Cessation

40

Medically Fragile Foster Care

400

Medically Fragile Foster Care

47

Birthing Center

470

Birthing Center

48

Service Bureau

480

Service Bureau

51

Home And Community Habilitation

092

Family Health

51

Home And Community Habilitation

117

Licensed Social Worker

51

Home And Community Habilitation

122

Marriage And Family Counselor

51

Home And Community Habilitation

190

General Psychologist

51

Home And Community Habilitation

202

Family Psychologist

51

Home And Community Habilitation

362

Attendant Care/Personal Assistance Service

51

Home And Community Habilitation

363

Companion Service

51

Home And Community Habilitation

364

Remote Supports

51

Home And Community Habilitation

410

Adult Day Care

51

Home And Community Habilitation

420

Autism Behavioral Specialist

51

Home And Community Habilitation

427

Systematic Skill Building

51

Home And Community Habilitation

430

Homemaker Agency

51

Home And Community Habilitation

431

Homemaker / Chore Services

51

Home And Community Habilitation

508

Behavioral Support - Odp

51

Home And Community Habilitation

509

Supports Broker Services - Odp

51

Home And Community Habilitation

510

Home And Community Habilitation

51

Home And Community Habilitation

512

Respite Care - Home Based

51

Home And Community Habilitation

513

Respite Care - Out Of Home

51

Home And Community Habilitation

514

Adult Training - 2380

51

Home And Community Habilitation

515

Pre-Vocational - 2390

51

Home And Community Habilitation

516

Transitional Work Services

51

Home And Community Habilitation

517

Visual & Mobility Therapy

51

Home And Community Habilitation

519

Fss/Consumer Payment Was Family Support Services

51

Home And Community Habilitation

525

Community Integration

51

Home And Community Habilitation

529

Coaching And Cueing

51

Home And Community Habilitation

536

Temporary Crisis Staff Assistance

51

Home And Community Habilitation

544

Assistive Technologies

51

Home And Community Habilitation

554

Respite, Overnight Camp

51

Home And Community Habilitation

559

Behavioral Specialist Consultant

51

Home And Community Habilitation

571

Home Finding

51

Home And Community Habilitation

572

Early Intervention Services

51

Home And Community Habilitation

573

Nutritional Support/Early Intervention (Ei)

51

Home And Community Habilitation

575

Special Instruct-Behavior/Early Intervention(Ei)

52

Community Residential Rehabilitation 456

Crr-Adult

52

Community Residential Rehabilitation 513

Respite Care - Out Of Home

52

Community Residential Rehabilitation 520

Child & Youth Lic Grp Home W Mntl Hlth Trtmnt Comp

52

Community Residential Rehabilitation 521

Adult Residential - 6400

52

Community Residential Rehabilitation 522

Family Living Homes - 6500

52

Community Residential Rehabilitation 523

Host Home / Children

52

Community Residential Rehabilitation 524

Unlicensed

52

Community Residential Rehabilitation 584

Medically Complex Conditions

53

Employment - Competitive

530

Job Finding

53

Employment - Competitive

531

Job Support

53

Employment - Competitive

534

Supported Employment

54

Intermediate Service Organization

362

Attendant Care/Personal Assistance Service

54

Intermediate Service Organization

512

Respite Care - Home Based

54

Intermediate Service Organization

537

Admin Fee For Vendor And Vendor Fiscal

54

Intermediate Service Organization

539

Admin Fee For Agency With Choice

54

Intermediate Service Organization

540

Iso - Agency With Choice

54

Intermediate Service Organization

541

Iso - Fiscal/Employer Agent

55

Vendor

223

Diabetes Prevention Program

55

Vendor

224

Environmental Asthma Surveillance

55

Vendor

225

Environmental Investigation

55

Vendor

250

Dme / Medical Supplies

55

Vendor

267

Non-Emergency

55

Vendor

430

Homemaker Agency

55

Vendor

431

Homemaker / Chore Services

55

Vendor

460

Home Delivered Meals

55

Vendor

519

Fss/Consumer Payment Was Family Support Services

55

Vendor

533

Educational Service

55

Vendor

537

Admin Fee For Vendor And Vendor Fiscal

55

Vendor

543

Environmental Accessibility Adaptations

55

Vendor

551

Community Transition Services

55

Vendor

552

Adaptive Appliances/Equipment

55

Vendor

553

Habilitation Supplies

55

Vendor

554

Respite, Overnight Camp

55

Vendor

555

Respite, Day Camp

55

Vendor

557

Unenrolled Hospital For Hospital Assessment Proj

56

Residential Treatment Facility

560

Residential Trtmt Facility (Non-Jcaho Certified)

58

Communication Services

580

Sign Language

58

Communication Services

582

Communication Specialist

58

Communication Services

583

Communication Specialist Deaf And Hard-Of-Hearing

59

Oltl Programs

025

Personal Emergency Response System

59

Oltl Programs

028

Pers-Monthly Maintenance

59

Oltl Programs

029

Telecare Services

59

Oltl Programs

050

Home Health Agency

59

Oltl Programs

160

Registered Nurse

59

Oltl Programs

161

Licensed Practical Nurse

59

Oltl Programs

170

Physical Therapist

59

Oltl Programs

171

Occupational Therapist

59

Oltl Programs

173

Speech/Hearing Therapist

59

Oltl Programs

207

Cognitive Therapist

59

Oltl Programs

209

Behavior Therapy

59

Oltl Programs

219

Service Coordination

59

Oltl Programs

230

Registered Nutritionist

59

Oltl Programs

231

Non-Medical Counseling

59

Oltl Programs

59

Oltl Programs

59

Oltl Programs

59

Oltl Programs

59

Oltl Programs

59

Oltl Programs

59

Oltl Programs

59

Oltl Programs

59

Oltl Programs

59

Oltl Programs

59

Oltl Programs

59

Oltl Programs

59

Oltl Programs

59

Oltl Programs

59

Oltl Programs

59

Oltl Programs

59

Oltl Programs

59

Oltl Programs

59

Oltl Programs

59

Oltl Programs

59

Oltl Programs

59

Oltl Programs

59

Oltl Programs

65

Lien Holder

66

Funeral Director

250

Dme / Medical Supplies

255

Vehicle Modifications

267

Non-Emergency

340

Program Exception

360

Personal Care - Individual

362

Attendant Care/Personal Assistance Service

410

Adult Day Care

411

Adult Day Services-Enhanced

440

Architectural Modifications

460

Home Delivered Meals

501

Pest Eradication

502

Employment - Benefits Counseling

503

Employment - Career Assessment

504

Employment - Job Coaching

505

Employment - Skills Development

510

Home And Community Habilitation

512

Respite Care - Home Based

525

Community Integration

528

Structured Day Program

530

Job Finding

541

Iso - Fiscal/Employer Agent

544

Assistive Technologies

551

Community Transition Services

650

Lien Holder

660

Funeral Director

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