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Get Ny Emedny-610301 2021-2024

Must complete Section A and sign Section B or complete Section A and sign Section C adding all (submit multiple pages if necessary) active DEA numbers associated with their professional practice to this form. Section A: PROVIDER NUMBERS: 8-digit Medicaid Number (Required IF Available) 10-digit NPI (Required) NAME: NAME EXACTLY AS IT APPEARS ON YOUR LICENSE/REGISTRATION PROVIDER CORRESPONDENCE ADDRESS Street Address 1 Street Address 2 City (Do NOT use abbreviations) STATE ZIP CODE COUNTY.

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