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 Information
Please list your contact information below. By default, all correspondence will be conducted through the individual identified in this section.
First Name Last Name Phone #
Email*
Facility or Ancillary Provider Information
Practice Name*
Practice Address*
Street Address Address Line 2 City State 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 Numbers
Tax ID Number (TIN)*
Facility or Ancillary NPI Number*
Medicare Number
CAQH ID Number
Comments
Please list any additional information that might assist us in reviewing your application.
Name
This field is for validation purposes and should be left unchanged.

An accessible provider network for employers, payors, and their members.

A division of

Contact Information