Existing Contracted Entity

Tax Identification Number *

Provider/Group NPI (if additional NPIs are needed please submit a new request) *

Provider/Group Indiana Medicaid Number

Provider/Group Name *

Provider/Group Specialty *

Service/Location Name *

Service/Location Address (only 1 per TIN/GNPI) *

Service/Location Suite Number

Service/Location City *

Service/Location Zip *

Service/Location Main Phone Number *

Service/Location Main Fax Number

Billing Name *

Billing Address *

Billing City *

Billing Zip *

Billing Phone Number *

Billing Fax Number

First Name *

Last Name *

Practitioner NPI *

If other, what degree?

Practitioner Taxonomy Code *

Practitioner Email Address *

Practitioner Specialty *

Practitioner Indiana Medicaid Number

First Name *

Last Name *

Contact Email *

Contact Phone *

Date *