Make a Change to an IRS Number or NPI Number

Group/Facility Name *

Old Tax Identification Number (TIN) *

Old Group NPI # *

New Tax Identification Number (TIN) *

New Group NPI # *

Please Attach a Completed W9 *

Comments

Update Requested By

First Name *

Last Name *

Contact Email *

Contact Phone Number *

Date Requested *

This form will send your message to Ambetter from MHS as an email. The email is not encrypted and is not transmitted in a secured format. By communicating with Ambetter from MHS through email, you accept associated risks. Ambetter from MHS does not accept responsibility or liability for any loss or damage arising from the use of email. To ensure the safety of your PHI, please send us a message through the Secure Member or Provider portal.

Group/Facility Name *

Old Group NPI # *

New Group NPI # *

Tax ID # *

Comments

Update Requested By

First Name *

Last Name *

Contact Email *

Contact Phone Number *

Date Requested *

Group/Facility Name *

Tax ID # *

Group NPI # *

IRS Address

Street Address *

Address Line 2

City *

State *

Zip Code *

Please Attach a Completed W9 *

Comments

Update Requested By

First Name *

Last Name *

Contact Email *

Contact Phone Number *

Date Requested *

Provider Updates: Change IRS or NPI Number | Ambetter from MHS Indiana

Make a Change to an IRS Number or NPI Number

Update Requested By

Update Requested By

IRS Address

Update Requested By