Facility and Ancillary Providers All fields with an asterisk (*) MUST be completed Upon submission of this form, we will review and be in touch with you regarding next steps. Contact InformationPlease list your contact information below. By default, all correspondence will be conducted through the individual identified in this section.First NameLast NamePhone #Email* Facility or Ancillary Provider InformationPractice Name*Practice Address* Street Address Address Line 2 City State AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific ZIP Code County*Practice Phone*Affiliations (if applicable)(i.e. PHO/IPA/Healthcare System) Are you interested in participating with KY Medicaid Managed Care via Center Care?*YesNoAre you interested in participating with Medicare Advantage products via Center Care?*YesNoIdentification NumbersTax ID Number (TIN)*Facility or Ancillary NPI Number*Medicare NumberCAQH ID NumberCommentsPlease list any additional information that might assist us in reviewing your application.EmailThis field is for validation purposes and should be left unchanged.