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Get New Allied Practitioner Enrollment Form - Blue Cross Blue Shield Of ...

O. Box 217 Southfield Mi 48034 Questions Call 1-800-822-2761 WF 10577 AUG 12 Page 1 of 10 NEW ALLIED PRACTITIONER ENROLLMENT FORM FAX OR MAIL COVER SHEET FOR DOCUMENTS IMPORTANT Attach this page to the top of your document to avoid processing delays. Fax To 866-900-0250 Provider Enrollment From Date Mail to Form Number P. O. Box 217 Southfield MI 48034 10577 Type 1 NPI State License Number Type 1 National provider identifier Please complete this .

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