Remove a Location

Use this form if you want to remove a location from a practitioner or group

Group/Facility Name *

Group Mississippi Medicaid # *

Tax ID # *

Group NPI # *

Practitioner First Name

Practitioner Last Name

Practitioner NPI

Is this location closing completely? Yes No

Delete Location Address:

Street Address *

Address Line 2

City *

ZIP / Postal Code *

State *

Location Phone Number

Add supporting document

Comments

Update Requested By:

First Name *

Last Name *

Date *

Contact Email *

Contact Phone *

Last Updated: 07/01/2024