Add an Additional Location

Group/Facility Name *

Group Mississippi Medicaid Number *

Tax ID Number *

Group NPI Number *

Practitioner First Name

Practitioner Last Name

Practitioner NPI

Multiple Practitioners

If multiple practitioners are adding this address as an additional location, please attach a spreadsheet with their names and NPI numbers.

Additional Location Address

Street Address *

Address Line 2

City *

State *

ZIP / Postal Code *

Appointment Phone Number *

Location Phone Number *

Office Hours (Monday) *

Office Hours (Tuesday) *

Office Hours (Wednesday) *

Office Hours (Thursday) *

Office Hours (Friday) *

Office Hours (Saturday) *

Office Hours (Sunday) *

Comments

Update Requested By:

First Name *

Last Name *

Date *

Contact Email *

Contact Phone *

Last Updated: 03/31/2026