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provider-center

Add Location to My Existing Ancillary Group

The entered values cannot be saved. Please see the fields below for details.

Group Information

Group Name: Required

Please enter a value.

Business Name: Required

Please enter a value.

Group NPI: Required

Requires 10 numerical characters.

Group TIN: Required

Requires 9 numerical characters.

State: Required

Completed By

Completed By Name: Required

Please enter a value.

Completed By Email: Required

Please enter email value in format 'mymail@domain.com'.

Completed By Phone: Required

Invalid phone number.

Phone Extension: Required

Example: (555) 555-5555 or 555-555-5555

Completed By Comments: Required

Please enter a value.

Add This Location: Location 1

Location 1 Name: Required

Please enter a value.

Location 1 Address: Required

Please enter a value.

Location 1 Phone: Required

Invalid phone number.

Example: (555) 555-5555 or 555-555-5555

Location 1 Fax: Required

Invalid phone number.

Example: (555) 555-5555 or 555-555-5555

Required

Do you want this location added to the provider directory?:

Add This Location: Location 2

Location 2 Name: Required

Location 2 Address: Required

Location 2 Phone: Required

Example: (555) 555-5555 or 555-555-5555

Location 2 Fax: Required

Example: (555) 555-5555 or 555-555-5555

Required

Do you want this location added to the provider directory?:

Add This Location: Location 3

Location 3 Name: Required

Location 3 Address: Required

Location 3 Phone: Required

Example: (555) 555-5555 or 555-555-5555

Location 3 Fax: Required

Example: (555) 555-5555 or 555-555-5555

Required

Do you want this location added to the provider directory?:

Add This Location: Location 4

Location 4 Name: Required

Location 4 Address: Required

Location 4 Phone: Required

Example: (555) 555-5555 or 555-555-5555

Location 4 Fax: Required

Example: (555) 555-5555 or 555-555-5555

Required

Do you want this location added to the provider directory?:

Add This Location: Location 5

Location 5 Name: Required

Location 5 Address: Required

Location 5 Phone: Required

Example: (555) 555-5555 or 555-555-5555

Location 5 Fax: Required

Example: (555) 555-5555 or 555-555-5555

Required

Do you want this location added to the provider directory?:

Add This Location: Location 6

Location 6 Name: Required

Location 6 Address: Required

Location 6 Phone: Required

Example: (555) 555-5555 or 555-555-5555

Location 6 Fax: Required

Example: (555) 555-5555 or 555-555-5555

Required

Do you want this location added to the provider directory?:

Add This Location: Location 7

Location 7 Name: Required

Location 7 Address: Required

Location 7 Phone: Required

Example: (555) 555-5555 or 555-555-5555

Location 7 Fax: Required

Example: (555) 555-5555 or 555-555-5555

Required

Do you want this location added to the provider directory?:

Add This Location: Location 8

Location 8 Name: Required

Location 8 Address: Required

Location 8 Phone: Required

Example: (555) 555-5555 or 555-555-5555

Location 8 Fax: Required

Example: (555) 555-5555 or 555-555-5555

Required

Do you want this location added to the provider directory?:

Add This Location: Location 9

Location 9 Name: Required

Location 9 Address: Required

Location 9 Phone: Required

Example: (555) 555-5555 or 555-555-5555

Location 9 Fax: Required

Example: (555) 555-5555 or 555-555-5555

Required

Do you want this location added to the provider directory?:

Add This Location: Location 10

Location 10 Name: Required

Location 10 Address: Required

Location 10 Phone: Required

Example: (555) 555-5555 or 555-555-5555

Location 10 Fax: Required

Example: (555) 555-5555 or 555-555-5555

Required

Do you want this location added to the provider directory?:

If you need to add more locations than permitted on this form, please complete another form for the remaining locations.

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