1835 South Bragaw, Suite 200 Anchorage, AK 99508 (907) 644-6800 https://medicaidalaska.com
NPI VERIFICATION FORM
SECTION I (Please verify that the following pre-populated information is correct) Provider/Company Name: MCI: XX0000 (Medicaid ID #) Service Address Provider/Company Name: DBA: Address: City: State: ZIP+4: Did not obtain an NPI because I/we are not a healthcare provider. Did not obtain an NPI because...
Fill & Sign Online, Print, Email, Fax, or Download
April 19, 2010- Please view the notice regarding the verification of Taxonomy
codes ... CHAMPS is a NPI based system and all providers, groups and/or
facilities .... The password will be mailed to you via U.S. mail. ... Take the Web site
EFT authorization form that you completed and printed to your bank for
verification and a ...