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city <br />City <br />State and Zip Code <br />State and Zip Code <br />Phone Number <br />Phone Number <br />TIN I different rom above) <br />National Provider ID(NM <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 NPI <br />Gen.Amd.SMGAJ3R WA.06.25 - 6 - United Healthcare <br />Confidential and Proprietary <br />