Add Location to Existing Ancillary Facility

Group Information

Group Name: Required

Business Name: Required

Group NPI: Required

Group TIN: Required

State: Required

Completed By

Completed By Name: Required

Completed By Email: Required

Completed By Phone: Required

Example: (555) 555-5555 or 555-555-5555

Phone Extension:

Completed By Comments:

Add This Location: Location 1

Location 1 Name: Required

Location 1 Address: Required

Location 1 Phone: Required

Example: (555) 555-5555 or 555-555-5555

Location 1 Fax: Required

Example: (555) 555-5555 or 555-555-5555

Do you want this location added to the provider directory?:

Add This Location: Location 2

Location 2 Name:

Location 2 Address:

Location 2 Phone:

Example: (555) 555-5555 or 555-555-5555

Location 2 Fax:

Example: (555) 555-5555 or 555-555-5555

Do you want this location added to the provider directory?:

Add This Location: Location 3

Location 3 Name:

Location 3 Address:

Location 3 Phone:

Example: (555) 555-5555 or 555-555-5555

Location 3 Fax:

Example: (555) 555-5555 or 555-555-5555

Do you want this location added to the provider directory?:

Add This Location: Location 4

Location 4 Name:

Location 4 Address:

Location 4 Phone:

Example: (555) 555-5555 or 555-555-5555

Location 4 Fax:

Example: (555) 555-5555 or 555-555-5555

Do you want this location added to the provider directory?:

Add This Location: Location 5

Location 5 Name:

Location 5 Address:

Location 5 Phone:

Example: (555) 555-5555 or 555-555-5555

Location 5 Fax:

Example: (555) 555-5555 or 555-555-5555

Do you want this location added to the provider directory?:

Add This Location: Location 6

Location 6 Name:

Location 6 Address:

Location 6 Phone:

Example: (555) 555-5555 or 555-555-5555

Location 6 Fax:

Example: (555) 555-5555 or 555-555-5555

Do you want this location added to the provider directory?:

Add This Location: Location 7

Location 7 Name:

Location 7 Address:

Location 7 Phone:

Example: (555) 555-5555 or 555-555-5555

Location 7 Fax:

Example: (555) 555-5555 or 555-555-5555

Do you want this location added to the provider directory?:

Add This Location: Location 8

Location 8 Name:

Location 8 Address:

Location 8 Phone:

Example: (555) 555-5555 or 555-555-5555

Location 8 Fax:

Example: (555) 555-5555 or 555-555-5555

Do you want this location added to the provider directory?:

Add This Location: Location 9

Location 9 Name:

Location 9 Address:

Location 9 Phone:

Example: (555) 555-5555 or 555-555-5555

Location 9 Fax:

Example: (555) 555-5555 or 555-555-5555

Do you want this location added to the provider directory?:

Add This Location: Location 10

Locaiton 10 Name:

Location 10 Address:

Location 10 Phone:

Example: (555) 555-5555 or 555-555-5555

Location 10 Fax:

Example: (555) 555-5555 or 555-555-5555

Do you want this location added to the provider directory?:

If you need to add more locations than permitted on this form, please complete another form for the remaining locations.