Provider Address Change Form Provider Name




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Provider Address Change Form



Provider Name

(please print)


Provider ID Number/Taxonomy Code
Physical Address

(Where services are provided)


(Post office box allowed ONLY as an addition to a street address)




City State ZIP+4


County Phone Number (Include area code)

Mailing/Billing

Address






City State ZIP+4


Phone Number (Include area code)

E-mail Address

Note: Before a change can be made in your provider file, we must have your original signature. A photo copied or stamped signature is unacceptable and the only signature valid for an individual practitioner is their own.

Provider’s Signature Date

Mail this completed form to:
Medicaid Provider Enrollment Unit

Hewlett Packard Enterprise

P.O. Box 8105

Little Rock, AR 72203-8105


DMS-673 Rev. 4/07


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