*SSA State/County Code | *Name of Physician or Mid-Level Practitioner | *National Provider Identifier (NPI) Number | Specialty | *Specialty Code | Contract Type | *Street Address | *City | *State | *ZIP Code | If PCP, Accepts New Patients? (Y/N) | Name of Medical Group Affiliation or "DC" | Uses CMS MA Contract Amendment? (Y/N) | RPPO-Specific Exception to Written Agreements? (Y/N) |
OMB Control Number: 0938-1346 (Expires: 12/31/20xx) |
File Type | application/vnd.openxmlformats-officedocument.spreadsheetml.sheet |
File Modified | 0000-00-00 |
File Created | 0000-00-00 |