<documentationOf typeCode=“DOC”>
<serviceEvent classCode="PCPR"> <!-- care provision --> <effectiveTime> <low nullFlavor="UNK"/> <high nullFlavor="UNK"/> </effectiveTime> <!-- You can include multiple performers, each with an NPI, TIN, CCN. --> <performer typeCode="PRF"> <time> <low nullFlavor="UNK"/> <high nullFlavor="UNK"/> </time> {{#provider}} <assignedEntity> {{#provider_npi}} <id extension="{{value}}" root="2.16.840.1.113883.4.6"/> {{/provider_npi}} {{#provider_ccn}} <id extension="{{value}}" root="2.16.840.1.113883.4.336"/> {{/provider_ccn}} {{#specialty}} <code code="{{specialty}}" codeSystem="2.16.840.1.113883.6.101" codeSystemName="Healthcare Provider Taxonomy (HIPAA)"/> {{/specialty}} {{#addresses}} <addr use="HP"> <streetAddressLine>{{{provider_street}}}</streetAddressLine> <city>{{city}}</city> <state>{{state}}</state> <postalCode>{{zip}}</postalCode> <country>{{country}}</country> </addr> {{/addresses}} <assignedPerson> <name> <given>{{{given_name}}}</given> <family>{{familyName}}</family> </name> </assignedPerson> <representedOrganization> {{#provider_tin}} <id extension="{{value}}" root="2.16.840.1.113883.4.2"/> {{/provider_tin}} {{#addresses}} <addr use="HP"> <streetAddressLine>{{{provider_street}}}</streetAddressLine> <city>{{city}}</city> <state>{{state}}</state> <postalCode>{{zip}}</postalCode> <country>{{country}}</country> </addr> {{/addresses}} </representedOrganization> </assignedEntity> {{/provider}} {{^provider}} <assignedEntity> <id extension="1982671962" root="2.16.840.1.113883.4.6"/> <id extension="463132" root="2.16.840.1.113883.4.336"/> <code code="282N00000X" codeSystem="2.16.840.1.113883.6.101" codeSystemName="Healthcare Provider Taxonomy (HIPAA)"/> <addr use="HP"> <streetAddressLine>16432 Jayme Viaduct Manor</streetAddressLine> <city>Clairland</city> <state>MS</state> <postalCode>38796</postalCode> <country>US</country> </addr> <assignedPerson> <name> <given>Daryl</given> <family>Carroll</family> </name> </assignedPerson> <representedOrganization> <id extension="695939209" root="2.16.840.1.113883.4.2"/> <addr use="HP"> <streetAddressLine>16432 Jayme Viaduct Manor</streetAddressLine> <city>Clairland</city> <state>MS</state> <postalCode>38796</postalCode> <country>US</country> </addr> </representedOrganization> </assignedEntity> {{/provider}} </performer> </serviceEvent>
</documentationOf>