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Get WI Anthem Provider Letter of Intent

and BlueShield New Provider Contracting at 262-523-4783. If you have questions, contact Network Relations at 800-232-5869. Part I: Practice Name: (Name of Group/Corporation/Clinic/Agency) Practitioner Name: (First Name, Middle Initial, Last Name, Title (e.g. John A. Smith, MD) CAQH Number: Date of Birth: Gender F- Tax Identification Number: State License Number: M- Specialty: Note: If you are a Behavioral Health provider, please be specific (e.g. Counselor, Psychologist, Social W.

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