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Get and Sign Provider Information Form PIF 1 TMHP Com 2015

Get and Sign Provider Information Form PIF 1 TMHP Com 2015

Use a Provider Information Form PIF 1 TMHP com 2015 template to make your document workflow more streamlined.

Providers and medical entities that you have a contractual relationship with and if known the NPI/API and TPI of each provider or entity. Last First Middle Initial OR Group/Company name Maiden Name List any other alias name or form of your name ever used National Provider Identifier NPI 10-digit Primary Taxonomy Code 10-digit Secondary Taxonomy Code 10-digit the provider may indicate up to 15 taxonomy codes attach additional pages if needed Non-Texas-enrolled Taxonomy Code these codes are...
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