Add an Additional Location

Group/Facility Name *

Group Mississippi Medicaid # *

Tax ID # *

Group NPI # *

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 *

City *

State *

ZIP / Postal Code *

Update Requested By:

First Name *

Last Name *

Contact Email *