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Phone*

E-mail*

Title

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Email

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Postal-mail

Provider Type *

Medical Group

   

Specialty

Sub-specialty

Physician

   

Specialty

Sub-specialty

DME

ASC

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Physician Information

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Last*

Credential*

   

State License Number*

Tax ID Number*

NPI Number*

DEA Number

Effective Date

Physician Locations

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Fax

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• If Yes, referred by:

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Please allow 6-8 weeks for your nomination to be processed and for contractual material to be issued.
* Denotes Required Field
 

 

The contact information for the Medical Access Assistant is:   The contact for your MPN is:
     
Toll Free Telephone Number: (866) 277-7395   Name: Signature Networks PLUS.
Fax Number: (714) 892-4825   Telephone Number: (888) 423-4228
Email Address: rccamaa@snp-plus.com    

To obtain a copy of any required MPN notifications, please call (888) 423-4228.

Date of Last Physician and Provider Listing Update: 09/15/2017