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A.NTHEl? BLUE CROS5 AND BLUE SHIEi,D <br />PROVIDER MAINTENAN+CE FORM <br />Anthem9 0 W. <br />sectian A. cE-NERA. liNFOR-NIATIaN <br />Pracrice Tax ID Number (EIN/SSN) Group's NPI ? <br />3y- l000/8?/?/ /73o3?9S S? <br />Group/Pracrice Name <br />V%l-t-f9GE Oh /f?A /=/ELQ <br />If paper claim submission or Exempt from iNPI fill out Legacy ID or Anthem PLN number <br />IN, KY and OH Provider ld Number/PIN: <br />If paper claim submission or Exempt from NPI fill out Legacy ID or Anthem PIN number <br />Missouri Frovider ID Number: <br />If paper claim submission or Exempt from iNPI fill out Legacy ID or Anthem PIN number <br />Wisconsin Provider ID Number: <br />Number of hysicians this submission is pertaining to <br />SecEion B. I-CEA4LDiN F€l3Z SUWMIT'I'ENG **RE(jUIRED*? One Tax I? er +y <br />* DATE REQUIRED* Effecrive Date of Add, Change or DeIete: ? New Conhact <br />? Adding Provider ? Specialty Change E] Practice ?Tame Chanoe ? Remit Name Change <br />? Deleting Provider (suPply. belw+) ? Provider Name Change ? Practice Address Change E] Remit Address Change <br />? Addino Location ? Deleting Locarion ? Pracfice Phone # Change ? Remit Phone # Change <br />? Adding Provider To Location ? Deleting Provider From Location ? Practice Fax # change ? Remit Fax # Change <br />? Adding Web site ? Changing Office Hours ? Change email address E] Add email address <br />? Add Medicaid Number ? Change Iv'PI ? Change Web site ? Change Medicaid Number <br />? Add NPI ? Add Non Participating Provider ? Adding Medicare Number [:] Change Medicare Number <br />? Other. BriefIy describe the reason for su bmittino this form: <br />0 T3.Y ID Ch2agP, Ye5 (old Tar ID# is): <br />CO iViMEN'I'S ? <br /> <br />Seetioa C. PRUVI73ER IINFOI2MA'I'ION Nate: * indicates re zcired fselds for hysician zt date. <br />*Provider First Name *M I *Last Name 'xT'itle (MD/DO/etc.) <br /> <br />Please fill in *Primaty Specialty Physician (i.e. FPR,IIVNn *Speciaity Care Physician (i.e. Cardioiou, Gen.Smj?) *Other (i.e. PA, CRNA, CINNI) <br />only one of the <br />fouowj.g: <br />Is provider wozidn; in a Lociun Tenen or Hospitalist capacity? Yes ? No ? <br /> Is the provider workin' in a Primary Care or Specialists capacity Yes ? No ? <br />Taxonomy Code <br />3 60 Ub D X Is this Pracrice a Rural Health Clinic? <br />Yes ? No ? Is this Practice a Federally Qualified Health Center? <br />Yes ? No ? <br />Is the provider Board Certified for the specialty listed: Yes ? No ? Not applicable to specialry ? <br />If No, when will you be sitting for the exam? <br />*Social Security Number NPI <br />Numeric 10 in length UPIN Number *Professional License Number <br />CAQH ID Number: Current Status of CAQH application: briefly explain: <br />*Date of Birth *Gender: <br />M ? F ? <br />List in Anthem's directory/web paaes for members to make an <br />a pointment? Yes ? No ? Accepting New Patients? <br />Yes ? No ? Age limitarions? <br />Minimum aQe Maximum agge <br />5/2008 .anchem eiue c- ar,d si <br />RightCHOIC? ManaGed Care, Inc. (RIT), Heattt <br />Inc. RIT a?M ceRain affiliates only provide admini. <br />administers the PPO and iMemruN policies; Cort <br />poliaes. Indeoendent licansees of fhe Blue Crass <br />C(os antl Bltie Shield Associatio.