Add an Additional Location

MHS asks that additional addresses only be requested for practitioners that display on the directory. Additional address are utilized for directory purposes only and are not needed for claims payment. For more information on addresses and practitioner enrollment please refer to Chapter 17 of the MHS Provider Manual (PDF).

MHS will not process additional address requests for these practitioner types: Emergency Medicine, Radiology, Anesthesiology (excluding Pain Management), Pathology, CRNA, Midwives, Physician Assistants not acting as a PCP holding a panel, and Practitioners who practice exclusively in a facility setting.

Is the Provider TIN/GNPI already enrolled with MHS? Yes No

Is the GNPI tied to the Location Address already enrolled at the provider level? Yes No

Is the Practitioner already enrolled under the same group NPI (GNPI) Yes No

Submit Provider Enrollment: New Contract or Add to Existing Contract.

Submit Provider Enrollment: New Contract or Add to Existing Contract

Enroll Practitioner with Group NPI First

Group/Facility Name *

Group Indiana Medicaid Number *

Tax ID Number *

Group NPI Number *

Practitioner First Name

Practitioner Last Name

Practitioner NPI

Multiple Practitioners

If multiple practitioners are adding this address as an additional location, please attach a spreadsheet with their names and NPI numbers.

Additional Location Address

Street Address *

Address Line 2 *

City *

State *

ZIP / Postal Code *

Appointment Phone Number *

Location Phone Number *

Office Hours (Monday) *

Office Hours (Tuesday) *

Office Hours (Wednesday) *

Office Hours (Thursday) *

Office Hours (Friday) *

Office Hours (Saturday) *

Office Hours (Sunday) *

Comments

Update Requested By:

First Name *

Last Name *

Date *

Contact Email *

Contact Phone *

Last Updated: 06/01/2026