Primary Information Physician's Name Clinic Name Board certified: Yes   No Accepting Patients? New   Existing Only   Only Family Members    National Provider Identifier (NPI) Specialty(ies) List in Directory Yes   No Board Certified in the Specialty Yes   No Sub_Specialty(ies) List in Directory Yes   No Board certified in that Specialty Yes   No Hospital Affiliation (Name of Hospital, if applicable) Active  Courtesy  Other (Specify)   Active  Courtesy  Other (Specify)   Active  Courtesy  Other (Specify)   Billing Address (Payment Register/Reimbursement Checks) Clinic Name TIN# Address City State AlaskaAlabamaArkansasArizonaCaliforniaColoradoConnecticutDelawareFloridaGeorgiaHawaiiIowaIdahoIllinoisIndianaKansasKentuckyLouisianaMassachusettsMarylandMaineMichiganMinnesotaMissouriMississippiMontanaNorth CarolinaNorth DakotaNebraskaNew HampshireNew JerseyNew MexicoNevadaNew YorkOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVirginiaVermontWashingtonWisconsinWest VirginiaWyoming Zip + 4 Parish AcadiaAllenAscensionAssumptionAvoyellesBeauregardBienvilleBossierCaddoCalcasieuCaldwellCameronCatahoulaClaiborneConcordiaDesotoEast Baton RougeEast CarrollEast FelicianaEvangelineFranklinGrantIberiaIbervilleJacksonJeffersonJefferson DavisLafayetteLafourcheLasalleLincolnLivingstonMadisonMorehouseNatchitochesOrleansOuachitaPlaqueminesPointe CoupeeRapidesRed RiverRichlandSabineSt. BernardSt. CharlesSt. HelenaSt. JamesSt. John the BaptistSt. LandrySt. MartinSt. MarySt. TammanyTangipahoaTensasTerrebonneUnionVermilionVernonWashingtonWebsterWest Baton RougeWest CarrollWest FelicianaWinn Phone Number Fax Number Effective Date of change E-Mail Address Medical Records Address (Address for Medical Records Request) Clinic Name TIN# Address City State AlaskaAlabamaArkansasArizonaCaliforniaColoradoConnecticutDelawareFloridaGeorgiaHawaiiIowaIdahoIllinoisIndianaKansasKentuckyLouisianaMassachusettsMarylandMaineMichiganMinnesotaMissouriMississippiMontanaNorth CarolinaNorth DakotaNebraskaNew HampshireNew JerseyNew MexicoNevadaNew YorkOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVirginiaVermontWashingtonWisconsinWest VirginiaWyoming Zip + 4 Parish AcadiaAllenAscensionAssumptionAvoyellesBeauregardBienvilleBossierCaddoCalcasieuCaldwellCameronCatahoulaClaiborneConcordiaDesotoEast Baton RougeEast CarrollEast FelicianaEvangelineFranklinGrantIberiaIbervilleJacksonJeffersonJefferson DavisLafayetteLafourcheLasalleLincolnLivingstonMadisonMorehouseNatchitochesOrleansOuachitaPlaqueminesPointe CoupeeRapidesRed RiverRichlandSabineSt. BernardSt. CharlesSt. HelenaSt. JamesSt. John the BaptistSt. LandrySt. MartinSt. MarySt. TammanyTangipahoaTensasTerrebonneUnionVermilionVernonWashingtonWebsterWest Baton RougeWest CarrollWest FelicianaWinn Phone Number Fax Number Effective Date of change E-Mail Address Correspondence Address (Office Manuals, Newsletters, Agreements, Member Listing) Clinic Name TIN# Address City State AlaskaAlabamaArkansasArizonaCaliforniaColoradoConnecticutDelawareFloridaGeorgiaHawaiiIowaIdahoIllinoisIndianaKansasKentuckyLouisianaMassachusettsMarylandMaineMichiganMinnesotaMissouriMississippiMontanaNorth CarolinaNorth DakotaNebraskaNew HampshireNew JerseyNew MexicoNevadaNew YorkOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVirginiaVermontWashingtonWisconsinWest VirginiaWyoming Zip + 4 Parish AcadiaAllenAscensionAssumptionAvoyellesBeauregardBienvilleBossierCaddoCalcasieuCaldwellCameronCatahoulaClaiborneConcordiaDesotoEast Baton RougeEast CarrollEast FelicianaEvangelineFranklinGrantIberiaIbervilleJacksonJeffersonJefferson DavisLafayetteLafourcheLasalleLincolnLivingstonMadisonMorehouseNatchitochesOrleansOuachitaPlaqueminesPointe CoupeeRapidesRed RiverRichlandSabineSt. BernardSt. CharlesSt. HelenaSt. JamesSt. John the BaptistSt. LandrySt. MartinSt. MarySt. TammanyTangipahoaTensasTerrebonneUnionVermilionVernonWashingtonWebsterWest Baton RougeWest CarrollWest FelicianaWinn Phone Number Fax Number Effective Date of Change E-Mail Address Primary Address (Main Physical Location) Clinic Name Address City State AlaskaAlabamaArkansasArizonaCaliforniaColoradoConnecticutDelawareFloridaGeorgiaHawaiiIowaIdahoIllinoisIndianaKansasKentuckyLouisianaMassachusettsMarylandMaineMichiganMinnesotaMissouriMississippiMontanaNorth CarolinaNorth DakotaNebraskaNew HampshireNew JerseyNew MexicoNevadaNew YorkOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVirginiaVermontWashingtonWisconsinWest VirginiaWyoming Zip + 4 Parish AcadiaAllenAscensionAssumptionAvoyellesBeauregardBienvilleBossierCaddoCalcasieuCaldwellCameronCatahoulaClaiborneConcordiaDesotoEast Baton RougeEast CarrollEast FelicianaEvangelineFranklinGrantIberiaIbervilleJacksonJeffersonJefferson DavisLafayetteLafourcheLasalleLincolnLivingstonMadisonMorehouseNatchitochesOrleansOuachitaPlaqueminesPointe CoupeeRapidesRed RiverRichlandSabineSt. BernardSt. CharlesSt. HelenaSt. JamesSt. John the BaptistSt. LandrySt. MartinSt. MarySt. TammanyTangipahoaTensasTerrebonneUnionVermilionVernonWashingtonWebsterWest Baton RougeWest CarrollWest FelicianaWinn Phone Number Fax Number Effective Date of Change Office Hours TIN# E-mail Address Other Locations (Where You See Patients) Second Office Location New   Change  Correction  Third Office Location New  Change  Correction  Parish AcadiaAllenAscensionAssumptionAvoyellesBeauregardBienvilleBossierCaddoCalcasieuCaldwellCameronCatahoulaClaiborneConcordiaDesotoEast Baton RougeEast CarrollEast FelicianaEvangelineFranklinGrantIberiaIbervilleJacksonJeffersonJefferson DavisLafayetteLafourcheLasalleLincolnLivingstonMadisonMorehouseNatchitochesOrleansOuachitaPlaqueminesPointe CoupeeRapidesRed RiverRichlandSabineSt. BernardSt. CharlesSt. HelenaSt. JamesSt. John the BaptistSt. LandrySt. MartinSt. MarySt. TammanyTangipahoaTensasTerrebonneUnionVermilionVernonWashingtonWebsterWest Baton RougeWest CarrollWest FelicianaWinn Parish AcadiaAllenAscensionAssumptionAvoyellesBeauregardBienvilleBossierCaddoCalcasieuCaldwellCameronCatahoulaClaiborneConcordiaDesotoEast Baton RougeEast CarrollEast FelicianaEvangelineFranklinGrantIberiaIbervilleJacksonJeffersonJefferson DavisLafayetteLafourcheLasalleLincolnLivingstonMadisonMorehouseNatchitochesOrleansOuachitaPlaqueminesPointe CoupeeRapidesRed RiverRichlandSabineSt. BernardSt. CharlesSt. HelenaSt. JamesSt. John the BaptistSt. LandrySt. MartinSt. MarySt. TammanyTangipahoaTensasTerrebonneUnionVermilionVernonWashingtonWebsterWest Baton RougeWest CarrollWest FelicianaWinn Clinic Name Clinic Name Street Address Street Address City City State AlaskaAlabamaArkansasArizonaCaliforniaColoradoConnecticutDelawareFloridaGeorgiaHawaiiIowaIdahoIllinoisIndianaKansasKentuckyLouisianaMassachusettsMarylandMaineMichiganMinnesotaMissouriMississippiMontanaNorth CarolinaNorth DakotaNebraskaNew HampshireNew JerseyNew MexicoNevadaNew YorkOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVirginiaVermontWashingtonWisconsinWest VirginiaWyoming State AlaskaAlabamaArkansasArizonaCaliforniaColoradoConnecticutDelawareFloridaGeorgiaHawaiiIowaIdahoIllinoisIndianaKansasKentuckyLouisianaMassachusettsMarylandMaineMichiganMinnesotaMissouriMississippiMontanaNorth CarolinaNorth DakotaNebraskaNew HampshireNew JerseyNew MexicoNevadaNew YorkOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVirginiaVermontWashingtonWisconsinWest VirginiaWyoming Zip + 4 Zip + 4 Phone Phone Fax No. Fax No. TIN# TIN# Office Hours Office Hours Existing Information to be Removed Clinic Name TIN# Address City State AlaskaAlabamaArkansasArizonaCaliforniaColoradoConnecticutDelawareFloridaGeorgiaHawaiiIowaIdahoIllinoisIndianaKansasKentuckyLouisianaMassachusettsMarylandMaineMichiganMinnesotaMissouriMississippiMontanaNorth CarolinaNorth DakotaNebraskaNew HampshireNew JerseyNew MexicoNevadaNew YorkOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVirginiaVermontWashingtonWisconsinWest VirginiaWyoming Zip + 4 Parish AcadiaAllenAscensionAssumptionAvoyellesBeauregardBienvilleBossierCaddoCalcasieuCaldwellCameronCatahoulaClaiborneConcordiaDesotoEast Baton RougeEast CarrollEast FelicianaEvangelineFranklinGrantIberiaIbervilleJacksonJeffersonJefferson DavisLafayetteLafourcheLasalleLincolnLivingstonMadisonMorehouseNatchitochesOrleansOuachitaPlaqueminesPointe CoupeeRapidesRed RiverRichlandSabineSt. BernardSt. CharlesSt. HelenaSt. JamesSt. John the BaptistSt. LandrySt. MartinSt. MarySt. TammanyTangipahoaTensasTerrebonneUnionVermilionVernonWashingtonWebsterWest Baton RougeWest CarrollWest FelicianaWinn Phone Number Fax Number Effective Date of Change Other Information Person Completing this Form Phone Number Comments