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KENTUCKY DEPARTMENT FOR MEDICAID SERVICES PROVIDER COMPLAINT FORM Please complete this information and submit by mail email or fax to Division of Program Quality Outcomes Department for Medicaid Services 275 E. Main Street 6C-C Frankfort KY 40621 502-564-9444 502-564-0223 Fax ProviderMCOInquiry ky. Gov GENERAL PROVIDER INFORMATION Provider Name NPI Provider Specialty Provider s Place of Service Address City St ZIP Provider s Contact Person s Name Contact Person s Company Mailing Address Phone...
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