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Change Accepting New Member Status

Provider Name

First Name *

Last Name *

Provider NPI # *

Tax ID # *

Group Name *

Group NPI # *

Group Medicaid Number *

Service Location Address

Street Address *

Address Line 2

City *

ZIP / Postal Code *

State *

Provider Type (Choose one) *

Primary Care Provider (PCP) Specialist

Is Provider Accepting New Members *

Yes No

Programs to Update (Choose all that apply) *

Ambetter from Magnolia Health Magnolia Health

Comments

Requested By:

First Name *

Last Name *

Date *

Contact Email *

Contact Phone *

Last Updated: 07/01/2024