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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 tdentification Number. Failure to do so may result <br />in denial of claims or incorrect payment. <br />BILLTNC ADDRESS <br />Identiff only if a common name and address appears on all Medical Group service location bills <br />utilize the Medical S Identification Num under the <br />Practice Name: Kittitas County <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 1063226272 <br />UnitedHealthcare <br />Confidential and Proprie tary <br />3 <br />Nrl <br />MEDICAL GROUP LOCATION - List BOTH the Service Location and the Billing Address for the <br />Service Location <br />Service Location Billing Address for the Service Location (if <br />different from above) <br />Medical Group Name Medical Group Name <br />Kittitas County Kittitas County <br />Street Address Street Address <br />205 W 5TH AVE STE 1 205 W 5TH AVE STE 1 <br />City Citv <br />ELLENSBURG ELLENSBURG <br />State and Zin Code State and Zip Code <br />wA 98926 wA 98926 <br />Phone Number Phone Number <br />(s06) 962-7s27 (s0$ 962-7s27 <br />TIN (Ifdifferent from tbove) <br />National Provider ID (NPD <br />ADDITIONAL MEDICAL GROUP LOCATIONS - List BOTH the Service Location and the Billing <br />Address for the Service Location <br />Service Location Billing Address for the Service Location (if <br />different from above) <br />Medical Group Name Medical Group Name <br />Street Address Street Address <br />Citv Citv <br />State and Zip Code State and Zip Code <br />G e n.Amd. S MG A. B H. WA.0 6. 2 5