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Phone Number <br />Phone Number <br />TIN (If dtfferentfrom above <br />National Provider ID P <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 />Phone Number <br />Phone Number <br />TIN (If differentfinom above <br />National Provider ID NP <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 />Phone Number <br />Phone Number <br />TIN (If different.ftom above <br />National Provider ID NP D <br />Gen.Amd.SMGA.BH. WA.06.25 - 4 - UnitedHealthcare <br />Confidential and Proprietary <br />