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Get CA Participating Practitioner App 2012-2024

Roup Multi Specialty Group Languages spoken by Staff: Tertiary Office Hours of Operation Languages spoken by Provider: Group Medicare PTAN/UPIN #: Group NPI #: Mailing Address Which of your practices is your primary mailing address? Primary Secondary Tertiary Other If your mailing address is different from your practice address, please provide it: IV. Billing Information Which of your practices handles your billing? Primary Secondary Tertiary If none, please provide billing informa.

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