Transcription of Initial Provider Application Network Role - Aetna
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Initial Provider Application Network Role - Aetna
Network Role Initial Provider Application PCP. Allied Specialist Both Please include all forms and attachments upon return. Provider information - Please check the box if additional information is attached (Please type or print). Name - Last First Middle (Jr., Sr., etc.) Any Prior Names Degree Birthdate (mm/dd/yyyy) Social Security Number UPIN Are you eligible to lawfully Language(s) Spoken By Language(s) Spoken In Office Practitioner work in the Yes No Aetna Participating Group Name: (If applicable) E-Mail Address Group Address - Number and Street Telephone Number Group TIN County Building/ Box City State ZIP Code Office Locations Primary Office Address - Number and Street Building/ Box City State ZIP Code Main Telephone Number FAX Number Handicap Access TIN TIN Owner (Appears on SS4 or W-9). Second Office Address - Number and Street Building/ Box City State ZIP Code Main Telephone Number Fax Number Handicap Access TIN TIN Owner (Appears on SS4 or W-9).
Initial Provider Application Network Role PCP Specialist Both Allied Please include all forms and attachments upon return. Provider Information - Please check the box if additional information is attached (Please type or print) Name - Last First Middle (Jr., Sr., etc.)
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