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Get PROVIDER/SUPPLIER ENROLLMENT

Letion, return this application and all necessary documentation to: Xact Provider Enrollment Services P.O. Box 890157 Camp Hill, PA 17089-0157 Definitions Authorized Representative: The appointed official (e.g., officer, chief executive officer, general partner, etc.) who has the authority to enroll the entity in Medicare or other federal health care programs as well as to make changes and/or updates to the applicant s status, and to commit the corporation to Medicare or other federal health.

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