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AiNTHEM BLUE CROSS AND BLUE SHIEI,D
<br />PRO"i' 1??R MAI1\ 1 E17Al? ?? FORM
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<br />Returning tha Pravider PVlaintenance Form tv Anthem
<br />Subanit the form to the AntInem iocation Este4 in the left cmiuum af #.he coa¢s?ty wherQ yoaa practice.
<br />5eud b mail or fax Attention: ProvidQr IZeIations
<br />Anthem Blue Cross and Blue Shield Niissouri CouaBes:
<br />1831 Chestnut Street MISSOURI: Adair, Audrain, Bairy, Barton, Bollinaer, Boone, Butler, Callaway, Camden, Cape Girardeau, Carter, Cedar,
<br />St. I.ouis, MO 63103 Chariton, Christian, Clazic, Cole, Cooper, Crawford, Dade, Dallas, Dent, Douglas, Dunklin, Franklin, Crasconade, Greene,
<br />ATTN: Provider Contract Hickory, Howard, Howell, Iron, 7asper, Jeffeison, Knox, Laclede, Lawrence, Lewis, Lincoln, Linn, Macon, Madison, Marion,
<br />Adminisirarion: MOM903-N335 McDonald, Miller, Mississippi, Moniteau, Monroe, Montgomery, Morgan, New Madrid, Newton, Ore;on, Osage, Ozazk,
<br /> Pemiscot, Perry, Pettis, Phelps, Pike, Polk, PuIaski, Putnam, Ralls, Randolph, Reynolds, Ripley, Saline, Schuyler, Scotland,
<br />Fax #: (314) 923-4919 Scott, Shannon, Sfielby, St. Charles, St. Francois, St. Louis, St. Louis City, Ste. Genevieve, Stoddard, Sione, Sullivan, Taney,
<br /> Texas, Warreu, Wasfiiua on, Wayne, Webster, Wrigbx
<br /> ILLINOIS: Madison, Monroe, St. Ciair
<br /> Wisconsin All Counties
<br />Anthem Blue Cmss and Blue Shield North Centrat•
<br />Attention Network Services Florence, Forest, Langlade, Lincoln, Marathon, Oneida, Portage, Vilas, Wood
<br />N17 W24340 Riverwood Drive North East•
<br />Waukesha, WI 53188 Adams, Brown, Calumet, Door, Fond du Lac, Green Lake, Kewaunee, Manitowoc, Marinette, Marquette, Menominee, Oconto,
<br />Fax #: (262-523-4783) Qutagamie, Shawano, Waupaca, Waushara, Winnebago
<br /> North West:
<br /> Ashland, Bazron, Bayfield, Buffalo, Burnett, Chippewa, Clark, Douglas, Ilunn, Eau Claire, Iron, Pepin, Pierce, PoIk, Price,
<br /> Rusk, Sawyer, Saint Croix, Taylor, Washbum
<br /> South Ceutrai:
<br /> Columbia, Dane, Crreen, Iowa, Lafayette, Rock, Sauk
<br /> Southeasi:
<br /> Dodge, Jefferson, Kenosha, Milwaukee, Ozankee, Racine, Sheboygan, Walworfh, Washino on, Waukesha
<br /> Southwest:
<br /> Crawford, Grant, Jackson, Juneau, La Crosse, Monroe, Ricfiland, Trempealeau, Vemon
<br /> Michigan: Iron, Dickinson, Nienominee, Gonebic
<br /> Mimnesota: Carlton, CIusago, Dakota, Goodhue, Houston, Fiae, St. Louis, Wabasha, Washington, Winona
<br /> Illinoas: Jo Daviess, Stephenson, Winnebago, Boone, Lake, McAenry
<br /> Iowa: Allamakee, Clayton, Dubuque
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<br />Ne reCistered marks of the Blue
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