PPIPA Join Our Network

PPIPA Join Our Network

Join Our Network
Date

MonthDayYear
Date
IndividualGroupAncillaryPCPSpecialistSpecialty Type:
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Rows Provider Name Provider NPI

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Rows Group/Ancillary Name Group NPI

Enter:
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Rows CAQH TIN

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Primary Location:

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

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Rows	Phone	Fax	Email
Enter:

Add Additional Locations:

Physician Roster:

Rows	Name	Credentials	Email	CAQH
1
2
3
4
5

Please attach your W9:

Cancelof

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Rows	Contact Person	Fax	Email
Enter:

Please allow 24 hours for PPIPA Provider Network team to attend to your request.
Should be Empty: