Managed Care Roundtable Meeting
March 4, 2010
Provider Name
*
What Products do you currently have contracts with:
(choose all that apply)
*
HMO
PPO
Blue
Choice
Billing NPI Number(s)
IPA Number
(Required for HMO Providers only.)
Address:
*
City:
*
State:
*
Zip Code:
*
Telephone Number
*
Fax Number
*
E-mail Address
*
Number of Attendees
*
Name(s) of Attendees
*
Questions marked with an asterisk (*) are mandatory.