Remove a 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 Remove a Location

Please use the form below to remove a location from a practitioner or group.

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

Group/Facility Name *

Tax ID # *

Group NPI # *

Practitioner First Name

Practitioner Last Name

Practitioner NPI

Is this location closing completely? Yes No

Delete Location Address

Street Address *

Address Line 2

City *

State *

ZIP / Postal Code *

Location Phone Number *

Comments

Update Requested By:

First Name *

Last Name *

Contact Email *

Contact Phone *