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Get Organizational Provider Credentialing Application 2011-2024

Ment (Level I, II, III, IV, V)  PT, OT, Speech Therapy  Imaging Department  Laboratory/Pathology Department  Skilled Nursing  Outpatient Surgery  Hospice  Infusion Therapy  Home Health  Other _________________________ ____________________________ ____________________________ II. CERTIFICATION AND ACCREDITATION A. Certification 1. Is this provider participating in the Medicare program?  Yes  No  Pending If Yes, please provide the following: 2. Date of in.

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