Transcription of Kansas Medical Assistance Program - kmap-state …
1 Street:City/State/Zip+4: Phone #Fax #Street:City/State/Zip+4: Phone #Fax #Street:City/State/Zip+4: Phone #Fax #It is very important our files remain up-to-date and current. Notify us of any changes to your address, phone number, and tax ID or Social Security number within 30 days to avoid the inactivation of your provider number. You can mail this information to us at the address above or fax it to 785-266-6112. Please include a copy of this Date: / /HOME OFFICEMAIL TOPAY TOKMAP Provider UpdateKansas Medical Assistance Program P O Box 3571 Topeka, KS 66601-3571 Provider 1-800-933-6593 Beneficiary 1-800-766-9012 Phone #Fax #Street:City/State/Zip+4:Phone #Fax #EMAIL ADDRESS:NPI:Taxonomy:Provider ID:TAX ID:Contact Name:Phone Number:Authorized Signature:Date:This form can be faxed to 785-266-6112 or mailed to kmap Attn: Provider Enrollment, Box 3571, Topeka KS INFORMATION:If you have any questions, contact the Provider Enrollment department at 785-274-5914 between 8:00 and 4:30 , Central Standard PROVIDER IDENTIFIER (PLEASE ATTACH NOTIFICATION FROM NPPES.)
2 SERVICE LOCATIONNPIU pdated 01/2013
