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1755 Telstar Drive Ste 400 Colorado Springs CO 80920 www. optum.com WIMCR Thank you for choosing Electronic Network Systems Clearinghouse a division of Optum to submit your ERAs. This form is for Optum use only and will not be forwarded on to the payer with your Optum user ID Group Name Group Billing TIN Group Legacy ID Taxonomy Code Please list all providers for this Payer below Provider Name Individual PTAN or Legacy ID if applicable Individual NPI Payer Name My ERA Enrollment Form RID is...
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