CMS-10237 Medicare Advantage Provider HSD Table

Medicare Advantage Application - Part C and 1876 Cost Plan Expansion Application Regulations under 42 CFR 422 (Subpart K) & 417.400 (CMS-10237)

CY2016 CMS MA Provider HSD Table (30day) clean

Part C Medicare Advantage Application and 1876 Cost Plan Expansion Application

OMB: 0938-0935

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2016 CMS MA Provider HSD Table

SSA State/County
Code

Name of Physician or
National Provider
Mid-Level Practitioner Identifier (NPI) Number

Specialty

Specialty Code

Contract Type

Provider Street
Address

Provider City

Provider State

Provider Zip Code

Provider Previously
Listed? (Y or N)

If PCP, Accepts New
Patients? (Y or N)

Name of Medical
Group Affiliation or
"DC"

Employment Status


File Typeapplication/pdf
File TitleHSD Table Templates
AuthorCGI Federal
File Modified2014-09-22
File Created2014-09-22

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