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Appendix 4 <br />Medical Group Service Locations <br />Medical Group attests that this Appendix identifies all services and locations covered under this Agreement. <br />IMPORTANT NOTE: Medical Group acknowledges its obligation pursuant to the agreement to promptly <br />report any change in Medical Group's name or Taxpayer Identification Number. Failure to do so may result <br />in denial of claims or incorrect payment. <br />Identify only if a common name and address appears on all Medical Group service location bills <br />that utilize the Medical Grou 's Taxpayer Identification Numbers under the A reement. <br />Practice Name: Kittitas Countv <br />Street Address: 307 W UMPTANUM RD <br />City: ELLENSBURG State:WA Zip: 98926 <br />Taxpayer Identification Number(s) (TIN) 916001349 <br />National Provider ID (NPI): 1063226272 <br />11tEDICAI GROUP LOCATION - List BOTH the'Scivice Location and the Billing Address'for the <br />Service Location' <br />Service Location <br />Billing Address for the Service Location (if <br />different from above) <br />Medical Group Name <br />Medical Group Name <br />Kittitas County <br />Kittitas County <br />Street Address <br />Street Address <br />205 W 5TH AVE STE 1 <br />205 W 5TH AVE STE 1 <br />City <br />City <br />ELLENSBURG <br />ELLENSBURG <br />State and Zip Code <br />State and Zip Code <br />WA 98926 <br />WA 98926 <br />Phone Number <br />Phone Number <br />506 962-7527 <br />506 962-7527 <br />TIN I different rom above <br />National Provider ID PI <br />ADDITIONAL MEDICAL GROUP LOCATIONS - List BOTH the Service Location and the Billing <br />Address for the Service Location <br />Service Location <br />Billing Address for the Service Location (if <br />different from above) <br />Medical Group Name <br />Medical Group Name <br />Street Address <br />Street Address <br />City <br />City <br />State and Zip Code <br />State and Zip Code <br />GenAnid.SMGA. BN. WA. 06.25 - 3 - UnitedNealthcare <br />Confidential and Proprietary <br />