CMS-10237 MA Provider Table CY 2014

SSA State/County
Code

Name of Physician or
National Provider
Mid-Level Practitioner Identifier (NPI) Number

Specialty

Specialty Code

Contract Type

Provider Street
Address

Provider City

Provider State

Provider Zip Code

Provider Previously
Listed? (Y or N)

Contracted Hospital
Where Privileged

Hospital NPI Number

If PCP, Accepts New
Patients? (Y or N)

Name of Medical
Group Affiliation or
"DC"

Employment Status

Uses CMS MA
Contract Amendment
(Y or N)