| *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) | Letter of Intent? (Y/N) |
| OMB Control Number: 0938-1346 (Expires: TBD) |
| Action Number |
Date | Time | Who | Change | Sheet | Range | New Value |
Old Value |
Action Type |
Losing Action |
| 1 | 9/6/2022 | 6:20 AM | Amber Casserly | Cell Change | Providers Table | O1 | Letter of Intent? (Y/N) | <blank> | ||
| The history ends with the changes saved on 09/06/2022 at 6:20 AM. |
| File Type | application/vnd.openxmlformats-officedocument.spreadsheetml.sheet |
| File Modified | 0000-00-00 |
| File Created | 0000-00-00 |