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1755 Telstar Drive Ste 400 Colorado Springs CO 80920 www. optum.com MABLS 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 Contact Name Group Name Group Billing TIN Group Legacy ID Taxonomy Code Please list all providers for this Payer below Individual PTAN or Legacy ID if applicable Individual NPI Payer Name. The Enrollments Department will...
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