Add a Practice Location to a Current Group Please complete the following information to add a new practice/group location to an existing contracted entity with Neighborhood Health Plan of Rhode Island.Location Open Date* MM slash DD slash YYYY Group/Entity NPI* Group/Entity Name* Group/Entity TIN* Practice Name* Practice NPI (if applicable) Practice Address* Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Practice Phone*Practice Fax*Type of Location* PCP (If this is a PCP or OB/GYN provider location, please complete the required Facility Requirements Form and PCP Participation Questionnaire. Save this form to your desktop, complete, and attach/upload to this form below.) Behavioral Health (If this is a Behavioral Health provider location, please complete the required Facility Requirements Form. Save this form to your desktop, complete, and attach/upload to this form below.) Specialist Facility Attestation* Drop files here or Select files Accepted file types: pdf, Max. file size: 50 MB. Does this office meet ADA Accessibility requirements?* Yes No Does this site offer the following:Handicap Accessible Building* Yes No Handicap Parking* Yes No Handicap Restroom* Yes No Handicap Accessible Exam Room* Yes No Does this site offer other services or programs for the disabled?Is this site accessible by public transportation?Bus* Yes No Subway* Yes No Office Contact Name* Office Contact Email Address* Provider(s) Impacted by UpdateAdditional Provider's Full Name* Additional Provider NPI* Additional Provider's Full Name Additional Provider NPI Additional Provider's Full Name Additional Provider NPI If additional providers are impacted, please attach a list (Excel or Word) that includes the provider's full name and NPI Drop files here or Select files Accepted file types: xls, xlsx, doc, docx, Max. file size: 50 MB. Details for the person submitting the formName* Title* Phone Number*Email* Date MM slash DD slash YYYY CAPTCHA