Download:
pdf |
pdfSSA State/County
Code
Name of Physician or
Mid-Level
Practitioner
National Provider
Identifier (NPI)
Number
Specialty
Specialty Code
Contract Type
Provider Street
Address
Provider City
Provider State
Provider Zip Code
Provider Previously
Listed? (Y or N)
Contracted Hospital
Where Privileged
Hospital NPI Number
If PCP, Accepts New
Patients? (Y or N)
If PCP, Accepts Only
Established
Patients? (Y or N)
Does MCO Delegate
If Credentialing is
Credentialing? (Y or
Delegated, List Entity
N)
Medical Group
Affiliation (MGA or
DC)
Employment Status
| File Type | application/pdf |
| File Title | HSD Table Templates |
| Author | CGI Federal |
| File Modified | 2011-10-18 |
| File Created | 2011-10-18 |