Add Location to Existing Ancillary Facility

All fields marked with * are required.

Group information

Enter the primary group details.

Group Name Required

Please enter a value.

Business Name Required

Please enter a value.

Group NPI Required

Requires 10 numerical characters.

Group TIN Required

Requires 9 numerical characters.

State Required

Add locations

Add locations from your facility listing.

Location 1 Name Required

Please enter a value.

Location 1 Address Required

Please enter a value.

Location 1 Phone Required

Invalid phone number.

Location 1 FAX Required

Invalid phone number.

Location 2 Name Required

Location 2 Address Required

Location 2 Phone Required

Location 2 FAX Required

Location 3 Name Required

Location 3 Address Required

Location 3 Phone Required

Location 3 FAX Required

Location 4 Name Required

Location 4 Address Required

Location 4 Phone Required

Location 4 FAX Required

Location 5 Name Required

Location 5 Address Required

Location 5 Phone Required

Location 5 FAX Required

Location 6 Name Required

Location 6 Address Required

Location 6 Phone Required

Location 6 FAX Required

Location 7 Name Required

Location 7 Address Required

Location 7 Phone Required

Location 7 FAX Required

Location 8 Name Required

Location 8 Address Required

Location 8 Phone Required

Location 8 FAX Required

Location 9 Name Required

Location 9 Address Required

Location 9 Phone Required

Location 9 FAX Required

Location 10 Name Required

Location 10 Address Required

Location 10 Phone Required

Location 10 FAX Required

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

Completed by

Provide contact information for the person completing this request.

Completed By Name Required

Please enter a value.

Completed By Email Required

Please enter email value in format 'mymail@domain.com'.

Completed By Phone Number Required

Invalid phone number.

Phone Extension (optional) Required

Completed By Comments Required 0/100

Please enter a value.

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

Add Location to My Existing Ancillary Group

1 Location 1 No information provided

2 Location 2 No information provided

3 Location 3 No information provided

4 Location 4 No information provided

5 Location 5 No information provided

6 Location 6 No information provided

7 Location 7 No information provided

8 Location 8 No information provided

9 Location 9 No information provided

10 Location 10 No information provided