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 AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest 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?* Yes No Are you interested in participating with Medicare Advantage products via Center Care?* Yes No Identification NumbersTax ID Number (TIN)* Facility or Ancillary NPI Number* Medicare Number CAQH ID Number CommentsPlease list any additional information that might assist us in reviewing your application.NameThis field is for validation purposes and should be left unchanged.