Add an Additional Location

New TIN or Group NPI * Yes No After selecting an answer, please complete the required forms and information inputs below.

Facility Add Form *

Please attach a Facility Add Form

Tax ID (99-9999999) *

Group NPI/Type 2 (Organizational) * (10 Digits)

Location Specialty *

Location Taxonomy *

Group/Practice Name * This is the location name that will display in the provider directory. We recommend using the name that patients are familiar with and will likely search for on the provider directory for this address.

Location Name * This is the location name that will display in the provider directory. We recommend using the name that patients are familiar with and will likely search for on the provider directory for this address.

Location Address Line 1 *

Location Address Line 2

Location City *

Location State *

Location Zip *

Location County *

Location Phone Number *

Location Fax Number *

Location Office Hours

Please list your office hours for each day of the week, Monday through Sunday

Location Office Hours (Monday) *

Location Office Hours (Tuesday) *

Location Office Hours (Wednesday) *

Location Office Hours (Thursday) *

Location Office Hours (Friday) *

Location Office Hours (Saturday) *

Location Office Hours (Sunday) *

Location Handicap Access * Yes No

Telemedicine Services * Yes No

Language Assistance Services * Yes No

Provider Billing Street Address *

Provider Billing City *

Provider Billing State *

Provider Billing Zip Code *

Provider Billing Fax Number *

Provider Billing Phone Number *

Provider One ID

Enrolling Practioners

After adding your location information, please navigate back and go through the Add Provider to Group section.

Comments

First Name *

Last Name *

Provider One ID

Date *

Contact Email *

Contact Phone Number *

Additional Attachments