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Palmetto GBA Corporate
Palmetto GBA Medicare
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Provider Name:
Last Name
First Name
E-mail Address:
Re-enter Email Address :
Phone Number :
Extension :
I am/work for :
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Provider
Billing Service
Clearinghouse
Rendering Physician
PTAN:
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NPI:
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Tax ID:
Line of Business:
Part B West Virginia
Part B Virginia
Part B North Carolina
Part A South Carolina / HHH
Part A North Carolina
Part A Virginia / West Virginia
Part B South Carolina
Railroad Specialty Medicare Administrative Contract (RRB SMAC)
Part A Alabama
Part A Georgia
Part A Tennessee
Part B Alabama
Part B Georgia
Part B Tennessee
Most Recent Medicare
Payment Amount Received
or Access Code:
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Rendering Physician Date Of Birth:
SSN:
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Billing Service/ClearingHouse Name :
Company Address 1 :
Company Address 2 :
Company City :
Company State :
Company Zip Code :
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