Get the free Completed and signed Individual Provider Application ... - mmcp dhmh maryland
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To obtain a NPI please visit the following website https //nppes. cms. hhs. gov/NPPES/Welcome. do. Please attach a printout from the previous website that lists the NPI information. If you are an Atypical provider and are not eligible to obtain a NPI leave this field blank and Maryland Medicaid will assign a NPI to you. State Issued License Number Professional CLIA DEA MDLAB NCPDP Pharmacy Other Primary Specialty If more space is needed please attach additional pages. V2 2016 effective...
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