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Ingenix User ID Group Name Group Billing TIN Group Legacy ID Please list all providers for this Payer below Revised 11/2010 Individual PTAN or Legacy ID if applicable Individual NPI Payer Name. 1755 Telstar Drive Ste 400 Colorado Springs CO 80920 phone 719 277-7545 www. ingenix. com/connectivity INGENIX ERA ENROLLMENT AGREEMENT INSTRUCTIONS Notification Ingenix provides this agreement as a courtesy for our customers. Com Additional Contact Individual Please return completed form to ACS EDI...
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