| SSA State/County Code | Name of Physician or Mid-Level Practitioner |
National Provider Identifier (NPI) Number | Specialty | Specialty Code | Contract Type | Provider Service Address | Provider Previously Listed? |
Contracted Hospital Where Privelaged |
Hospital NPI Number | If PCP, Accepts New Patients? |
If PCP, Accepts Only Established Patients? |
Does MCO Delegate Credentialing? | If Credentialing is Delegated, List Entity | Medical Group Affiliation | Employment Status | |||
| Street Address | City | State | Zip Code | Y or N | Y or N | Y or N | Y or N | MGA or DC | ||||||||||
| File Type | application/vnd.ms-excel |
| File Title | HSD Table Templates |
| Author | CGI Federal |
| Last Modified By | CMS |
| File Modified | 2010-05-19 |
| File Created | 2009-08-04 |