Attachment_4_-_List_of_Provider_Information_Requirements.pdf
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- Solicitation number
- RFPP05081500001
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Attachment 4
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Attachment 4 – RFPP05081500001 List of Provider Information Requirements
Single Practitioners
Full Name (Last name, first name, middle initial, and generation) Physical Address Mailing Address (if different) National Provider Identifier Number (NPI) Social Security Number Provider Specialty Contract rate applicable to each provider for each contract period
Group Practices and Suppliers
Group Name Physical Address Mailing Address (if different) National Provider Identifier Number (NPI) for the group National Provider Identifier Number (NPI) for each rendering physician in the group Employer Identification Number (EIN) Contract rate applicable to each provider for each contract period
Institutional Providers
Institution Name Physical Address Mailing Address (if different) National Provider Identifier Number (NPI) Employer Identification Number (EIN) Contract rate applicable to each provider for each contract period
Doing Business As (DBA) Providers
Group or Individual Name Physical Address Mailing Address (if different) National Provider Identifier Number (NPI) Employer Identification Number (EIN) Contract rate applicable to each provider for each contract period
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