Specialist Term

Specialist NPI # *

Specialist Name

First Name *

Last Name *

Degree *

Tax ID # * Practitioner will be termed from all locations associated with this TIN

Group Name *

Group NPI # *

Group Medicaid Number *

If the provider is still working for your Group, and only needs to remove a physical location tied to your Group NPI, please refer to the Demographic Update Tool section: Make and Address Change and Choose “Remove a Location".

Date Term Effective *

Other (Reasons)

Programs to Term (choose all that apply) * Ambetter from Magnolia Health(Medical) Ambetter from Magnolia Health(Behavioral Health) Magnolia MSCAN (Medical) Magnolia MSCAN (Behavioral Health) Magnolia CHIP (Medical) Magnolia CHIP (Behavioral Health)

Update Requested By:

First Name *

Last Name *

Date *

Contact Email *

Contact Phone Number *

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Last Updated: 11/03/2025