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Get Electronic Data Interchange (EDI) Provider Change Form - Emdeon

Provider Name Tax ID Client ID Site ID Address City/State Zip Code Contact Name E-mail Address 2 Telephone Fax Vendor (Emdeon certified vendor used to submit files to Emdeon) Vendor Submitter ID Vendor Name Division ID Contact Name E-mail Address 3 Payer Payer ID 12M88 CO, NM, OK, TX - MEDICARE PART A (MAC J4) LEGACY WPS Group ID Individual Provider ID 4 NPI ID Confirmations Send Emdeon Claim Confirmations To: Special Instructions: All Payer Registration forms must con.

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