CMS-10636 Provider Table

Triennial Network Adequacy Review for Medicare Advantage Organizations and 1876 Cost Plans (CMS-10636)

MA_Provider_Table_Template_06_14_19.xlsx

Three-Year Network Adequacy Review for Medicare Advantage Organizations

OMB: 0938-1346

Document [xlsx]
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*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)












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