Practice Address Update Please complete the following information to remove current address information for an existing practice and replace with new address information. This is the address that will be listed in the Neighborhood Health Plan of Rhode Island Provider Directory. If the Tax Identification Number (TIN) of your group has changed, please contact Provider Contracting. (Additional language for mailing and billing address)Effective Date* MM slash DD slash YYYY Group/Entity NPI* Group/Entity Name* Group/Entity TIN* Practice Name* Practice NPI (if applicable) Former 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 Former Practice Phone*Former Practice Fax*New 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 New Practice Phone*New Practice Fax*Does this office meet ADA Accessibility requirements?*Does this office meet ADA Accessibility requirements? *YesNoDoes this site offer the following:Handicap Accessible Building*Handicap Accessible Building *YesNoHandicap Parking*Handicap Parking *YesNoHandicap Restroom*Handicap Restroom *YesNoHandicap Accessible Exam Room*Handicap Accessible Exam Room *YesNoDoes this site offer other services or programs for the disabled?Is this site accessible by public transportation?Bus*Bus *YesNoSubway*Subway *YesNoOffice Contact Name* Office Contact Email Address* Provider(s) Impacted by UpdateProvider's Full Name* Provider NPI* Is this location the provider’s primary correspondence address?*Is this location the provider’s primary correspondence address? *YesNoProvider's Full Name Provider NPI Provider's Full Name Provider NPI If additional providers are impacted, please attach a list (Excel or Word) that includes the provider's full name and NPIMax. file size: 200 MB.Details for the person submitting the formName* Title* Phone Number*Email* Date MM slash DD slash YYYY CAPTCHA