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Details

* Entity/Group/Provider Name

* Contact Name

* Contact Email

* Contact Phone

* Billing NPI

* Billing TIN

* Legacy Medicaid ID

* BEP Provider

* Hospital Affiliations Y/N?

Hospital Affiliations

* Services

* Number of facilities from roster

* Number of groups from roster

* Number of PCPs from roster

* Number of specialists from roster

* Do you provide Telehealth Services?

Roster Resubmission

Record Info

Requested By Provider

Date Entered

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