Provider Termination

Effective Date of Termination
Provider Information
Practice Address
Termination Detail
Moved out of area
Provider Retired
Provider Death
Other Reason
One file only.
16 MB limit.
Allowed types: gif, jpg, jpeg, png, bmp, eps, tif, pict, psd, txt, rtf, odf, pdf, doc, docx, ppt, pptx, xls, xlsx, xml.