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PROVIDER IDENTIFIER: STATE OFFICE USE ONLYPARM:EFF: CLINIC/GROUP #:STATUS:END:CROSS REF:KEYED:INITIALS:DEPARTMENT OF SOCIAL SERVICES MISSOURI MEDICAID AUDIT AND COMPLIANCE MISSOURI MEDICAID REASSESSMENTS PROVIDER QUESTIONNAIRE (PLEASE TYPE OR PRINT ALL FORMS IN BLACK INK) PROVIDER NAME AS LICENSEDPROVIDER ADDRESS AS LICENSED (do not use PO Box only)STATE OFFICE USE ONLYCITYCOUNTYSTATEZIP CODEPROVIDER NAME, AS REGISTERED WITH THE IRS, THAT MATCHES THE NUMBER ENTERED IN
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