Mid-Level Practitioner Form - Health Care Professionals

Primary service address and contact information

*Group/Practice/Department Name

*Primary service address Please do not include a P.O Box

Address 2

*City

*STATE

*5 Digit Zip code

*Primary Service PHONE NUMBER (10 DIGITS)

Primary Service FAX NUMBER (10 DIGITS)

*Is the primary location wheelchair accessible?

Yes

No

Primary service address and contact information

*Group/Practice/Department Name

*Primary service address Please do not include a P.O Box

Address 2

*City

*STATE

*5 Digit Zip code

*Primary Service PHONE NUMBER (10 DIGITS)

Primary Service FAX NUMBER (10 DIGITS)

*Is the primary location wheelchair accessible?

Yes

No

Service address and contact information 2

*Group/Practice/Department Name

*Primary service address Please do not include a P.O Box

Address 2

*City

*STATE

*5 Digit Zip code

*Primary Service PHONE NUMBER (10 DIGITS)

Primary Service FAX NUMBER (10 DIGITS)

*Is the primary location wheelchair accessible?

Yes

No

Primary service address and contact information

*Group/Practice/Department Name

*Primary service address Please do not include a P.O Box

Address 2

*City

*STATE

*5 Digit Zip code

*Primary Service PHONE NUMBER (10 DIGITS)

Primary Service FAX NUMBER (10 DIGITS)

*Is the primary location wheelchair accessible?

Yes

No

Service address and contact information 2

*Group/Practice/Department Name

*Primary service address Please do not include a P.O Box

Address 2

*City

*STATE

*5 Digit Zip code

*Primary Service PHONE NUMBER (10 DIGITS)

Primary Service FAX NUMBER (10 DIGITS)

*Is the primary location wheelchair accessible?

Yes

No

Service address and contact information 3

*Group/Practice/Department Name

*Primary service address Please do not include a P.O Box

Address 2

*City

*STATE

*5 Digit Zip code

*Primary Service PHONE NUMBER (10 DIGITS)

Primary Service FAX NUMBER (10 DIGITS)

*Is the primary location wheelchair accessible?

Yes

No

Primary service address and contact information

*Group/Practice/Department Name

*Primary service address Please do not include a P.O Box

Address 2

*City

*STATE

*5 Digit Zip code

*Primary Service PHONE NUMBER (10 DIGITS)

Primary Service FAX NUMBER (10 DIGITS)

*Is the primary location wheelchair accessible?

Yes

No

Service address and contact information 2

*Group/Practice/Department Name

*Primary service address Please do not include a P.O Box

Address 2

*City

*STATE

*5 Digit Zip code

*Primary Service PHONE NUMBER (10 DIGITS)

Primary Service FAX NUMBER (10 DIGITS)

*Is the primary location wheelchair accessible?

Yes

No

Service address and contact information 3

*Group/Practice/Department Name

*Primary service address Please do not include a P.O Box

Address 2

*City

*STATE

*5 Digit Zip code

*Primary Service PHONE NUMBER (10 DIGITS)

Primary Service FAX NUMBER (10 DIGITS)

*Is the primary location wheelchair accessible?

Yes

No

Service address and contact information 4

*Group/Practice/Department Name

*Primary service address Please do not include a P.O Box

Address 2

*City

*STATE

*5 Digit Zip code

*Primary Service PHONE NUMBER (10 DIGITS)

Primary Service FAX NUMBER (10 DIGITS)

*Is the primary location wheelchair accessible?

Yes

No

For members

Helpful links

Helpful links

Helpful links

Practitioner Information

License and Tax Information

Address and Contact Information - Part A

Address and Contact Information - Part B

National Provider Identifier (NPI) Information

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