Date new location will be effective:*
  

List location in Unity Provider Directory? *
   

Name of new location: *
 

Physical address of new location: 
Address: *
 
City: *
 
State: *
 
Zip: *
 
County: *
 
Phone Number: *
  
Fax Number:  
 
Clinic Back Up:
Clinic Manager: *
Name: *
 
Phone: *
  
Fax:  
 
Email: *
  
Contract Name:

Mailing address of new location:
Address:
City:
State:
Zip:

Billing Tax ID Number: *
   
Name on Check: *
 
Billing address for this location:
Address: *
 
City: *
 
State: *
 
Zip: *
 
Phone:   
 
Fax:   
 
Billing Contact:
Name: *
 
Phone:   
 
Fax:   
 
Email:   
 

Facility NPI #s/Taxonomy Codes *
Facility NPI#Service TypeTaxonomy Code 
Add

Which practitioners will be located at this new site? *
PractitionerTax ID Number 
Add

Monday Tuesday Wednesday Thursday Friday Saturday Sunday
Clinic Hours:
Urgent/After Hours:
(If your clinic does not have urgent or after hours, please indicate that by placing "NA" in the box.)

When a patient calls this office and this clinic is closed, who or what will they contact?


If the patient contacts an answering machine, what does the machine direct the patient to do?

* Indicates a required field.