* Indicates a required field | ||
National Provider Identifier (NPI) Number(s): | ||
* Tax Identification Number: | ||
* Provider Name: | ||
* Primary Specialty: | ||
* Address: | ||
* City/ State/Zip: | ||
* County: | ||
* Provider Office Phone Number: | Ex: ###-###-#### | |
* Contact Name: | ||
* Contact Phone Number: | Ex: ###-###-#### | |
* Contact Fax: | Ex: ###-###-#### | |
* Contact E-mail: | ||
* Product: | BlueChoiceSM Facility Non - Facility Blue Advantage HMOSM Facility Non - Facility Blue Medicare Advantage (PPO)SM Facility Non - Facility Blue Medicare Advantage (HMO)SM Facility Non - Facility Blue EssentialsSM Facility Non - Facility Blue PremierSM Texas Facility Non - Facility ParPlan Facility Non - Facility Blue High Performance Network® (BlueHPN)® Facility Non - Facility |
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* Fee Schedule Effective Date :
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Note: Enter day followed by comma (i.e., for September 1, 2021: enter 1,) |
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