Add a Practice Location to an Existing Contract

Contracted providers can use this form to add a location to an existing contract. Please note, if you are affiliated with a third party Delegate Manager, all changes must be made at the request of the Delegate. Contact your Delegate Manager for additional information.

NOTE: Medical Providers and Groups (MD, DO, DC, DPM and Physician Extenders) who want to add a new practice location and are currently credentialed by Superior; or ancillary providers who want to add a new practice location that will operate under the same state license and TIN/NPI combination should contact your Account Management Representative.

Click here to find your Account Management Representative.

To ensure your request is processed timely, please submit using the most recent version of Internet Explorer, Chrome, Safari or FireFox.

Will this new practice location be operating under the same state license as the existing location? * Yes No

Will the new practice location be operating under the same TIN/NPI combination? * Yes No

Enter Name of Practice * Please enter the name that appears on the W9

Enter Provider Tax ID Number * 9 digits, no dashes

Enter Provider NPI Number * 10 digits, no dashes

Practice Location Zip Code *

Notice Mailing Address * Street Address or P.O. Box

City *

State *

Zip Code *

Enter Contract Representative Name *

Contact Representative Email *

Sorry, your request cannot be completed using this form. Please contact your Account Management Representative to add a practice location.