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Get New Code Request 2008-2024

Tion’s Specialty Code: New Location’s Provider Type Code 67 (see reverse for provider type codes) 98 New Location’s License Number: (For a list of available codes, see the “Guide for Completing the Medicaid Provider Enrollment Application”, on the web site listed at the bottom of this page, or contact the fiscal agent at 1-800-289-7799, Option 4.) (if applicable) NOTE: Home Health Agency branches and PPEC providers must complete this section and attach a copy of the license. Se.

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