*SSA State/County Code *Specialty Code *National Provider Identifier (NPI) Number *Name of Physician or Mid-Level Practitioner *Street Address *City *State *ZIP Code If PCP, Accepts New Patients? (Y/N) RPPO-Specific Exception to Written Agreements? (Y/N) Letter of Intent? (Y/N) Only applicable for MA Applicants
| File Type | application/pdf |
| File Title | HSD Table Templates |
| Author | CGI Federal |
| File Modified | 2024-03-04 |
| File Created | 2024-03-04 |