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Get WV Credentialing Form

Rse Manager’s Name Check if not applicable Monday Tuesday AM AM PM PM NA Public Transit Available? NA Does the office have other services available for disabled? (TTY, ASI, Mental/physical impairments, etc.) Yes Medicaid Number Are you currently accepting new patients? Yes Long Range Beeper Number ( Medicare Number - Credentialing Contact N/A N/A Name Phone # Office Hours ______ Check if practitioner is not available to see patient during hours indicated Wednesday Thursday Friday .

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