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Change a Primary Location

KanCare Provider Enrollment and Changes: Providers must use the Kansas Modular Medicaid System (KMMS) Provider Enrollment Wizard to update their information for any or all of the Medicaid fee-for-service (FFS) and managed-care organization (MCOs) health plans.

Medicare or Ambetter Change a Primary Location

Please use the form below to submit a change to your primary location.

Update for: * Ambetter (Health Insurance Marketplace) Medicare (Allwell / Wellcare)

Group/Facility Name *

Tax ID # *

Group NPI # *

Practitioner First Name *

Practitioner Last Name *

Practitioner NPI

Multiple Practitioners

If multiple practitioners are moving, please attach a spreadsheet with their names and NPI numbers

Old Primary Location Address

Street Address *

Address Line 2

City *

State *

ZIP / Postal Code *

NEW Primary Location Address

Street Address *

Address Line 2

City *

State *

ZIP / Postal Code *

Appointment Phone Number *

Primary Phone Number *

Please enter your office hours below:

Comments

Update Requested By:

First Name *

Last Name *

Contact Email *

Contact Phone *