Termination Date: Last date this facility will be open

Terminating Location Name: The complete legal name of institution, corporate entity, practice or individual provider

Physical Address: The number and street name associated with organization

City: City associated with physical address

State: State associated with physical address

Zip: Zip Code associated with physical address

Phone: Telephone number associated with terminating location

Billing NPI: The unique 10-digit identification number for covered health care providers

Tax ID: The nine-digit identification number used by the Internal Revenue Service in the administration of tax laws for this location

Reason for Termination: Detailed reason for location termination


Where are practitioners relocating?

Practitioner Name: Complete name of each practitioner who will be relocating as a result of the location termination

New Site: If known, the facility name and address to which each practitioner will be relocating

Practitioner NPI: The unique 10-digit identification number for each health care practitioner who will be relocating

Completed by: Name of the individual completing this form. Individual must be authorized to represent the provider office for enrollment with health insurance payers

Email Address: Email address associated with contact

Phone: Telephone number associated with contact