Terminate/Close a Practice "*" indicates required fields Please complete the following information to close a practice/group.Effective 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*Provider(s) Impacted by UpdateProvider's Full Name* Provider NPI* Provider Specialty at this location*Provider Specialty at this location *PCPSpecialistName of provider assuming panel* Provider NPI* Specialty (Must match the Provider's PCP role)* Provider's Full Name Provider NPI Provider Specialty at this locationProvider Specialty at this locationPCPSpecialistName of provider assuming panel Provider NPI Specialty (Must match the Provider's PCP role) Provider's Full Name Provider NPI Provider Specialty at this locationProvider Specialty at this locationPCPSpecialistName of provider assuming panel Provider NPI Specialty (Must match the Provider's PCP role) 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