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["Providers Full Name","Providers NPI","Tax ID#","State","Practice Name","Payor Name","Enrollment Status","Current Status","Effective Date","Indv ID#","Grp ID#","Note Date","Notes","Symplr Rep","Enroll Type","Practice Address","Practice Address 2","Practice City","Practice Zip Code"]
["P Douglas Cochran, MD",1316026396,"20-0212181","TX","P. Douglas Cochran, MD, PA","Caprock (CapStar)","Participating","Enrollment Complete","2023-05-01","","","2023-05-22","5/22/2023 Rcvd email from Caprock that May roster has been processed and provider is PAR w/ group effective 5/1/2023.  DCannon"]
["P Douglas Cochran, MD",1316026396,"20-0212181","TX","P. Douglas Cochran, MD, PA","Aetna","Participating","Enrollment Complete","2023-05-01","","","2023-05-31","05.31.2023 S/W Ria of Aetna @ 1-800-353-1232. Per rep, provider is showing participating and link under the Group and TIN with an Effective date 05/01/2023. Provider ID 7795370, Payer ID 60054 and Recredentialing date is 05/01/2026. Service location is on file. Call ref#:6149191218. - Danico Gabriel Melendres"]
["P Douglas Cochran, MD",1316026396,"20-0212181","TX","P. Douglas Cochran, MD, PA","IMS","Participating","Enrollment Complete","2023-05-01","","","2023-07-20","7/20/2023 Per email received from IMS/OMNI May delegated roster has been processed and provider is PAR and linked to group effective 5/1/2023.  DCannon"]
["P Douglas Cochran, MD",1316026396,"20-0212181","TX","P. Douglas Cochran, MD, PA","HealthSmart PPO","Participating","Enrollment Complete","2023-05-01","","","2023-11-13","11/13/2023 Per phone conversation with Lee Kinard at Healthsmart provider is PAR and linked to group TIN/location effective 5/1/2023.  DCannon"]
["P Douglas Cochran, MD",1316026396,"20-0212181","TX","P. Douglas Cochran, MD, PA","United Health Care","Participating","Enrollment Complete","2023-05-01","","","2023-09-07","9/7/2023 Per email from UHC May delegated roster has been completed.  Provider is PAR and linked to group TIN/locations effective 5/1/2023.  DCannon"]
["P Douglas Cochran, MD",1316026396,"20-0212181","TX","P. Douglas Cochran, MD, PA","Humana","Participating","Enrollment Complete","2006-12-14","","","2023-09-15","9/15/2023 Per email received from Humana provider is PAR and linked to group TIN/locations effective 12/14/2006.  DCannon"]
["P Douglas Cochran, MD",1316026396,"20-0212181","TX","P. Douglas Cochran, MD, PA","Galaxy Health","Participating","Enrollment Complete","2023-05-01","","","2023-07-24","7/24/2023 Per email received from Galaxy May delegated roster has been processed and provider is PAR and linked to group effective 5/1/2023.  DCannon"]
["P Douglas Cochran, MD",1316026396,"20-0212181","TX","P. Douglas Cochran, MD, PA","Wellmed","Participating","Enrollment Complete","2023-05-01","","","2023-10-13","10/13/2023 Provider is PAR and linked to group TIN effective 5/1/2023.  DCannon"]
["P Douglas Cochran, MD",1316026396,"20-0212181","TX","P. Douglas Cochran, MD, PA","Cigna","Participating","Enrollment Complete","2023-05-01","","","2023-11-03","Received confirmation of update. W202310193478451 MS"]
["Jennifer Lynn Delk-Fikes, APRN-FNP-BC",1386288876,"20-4063608","TX","PE - C Vallie CFNP Limited Partnership","Ambetter","Participating","Enrollment Complete","2022-04-01","","","2022-06-13","6/13/2022 Received April Monthly Validation roster from Superior and provider is PAR and linked effective 4/1/2022.  DCannon"]
["Jennifer Lynn Delk-Fikes, APRN-FNP-BC",1386288876,"20-4063608","TX","PE - C Vallie CFNP Limited Partnership","Scott&White (First Care)","Participating","Enrollment Complete","2021-02-12","","","2021-01-29","1/29/2021 - Rcvd roster from Scott&White (First Care) confirming participation of provider with TIN and location effective dates.  DCannon"]
["Jennifer Lynn Delk-Fikes, APRN-FNP-BC",1386288876,"20-4063608","TX","PE - C Vallie CFNP Limited Partnership","Tricare Prime","Panel Closed","Panel Closed","","","","2021-07-09","7/9/2021 The payor is no longer extending contracts to new groups at this time; however, required to check on-line for future openings of the panel. KFrazier"]
["Jennifer Lynn Delk-Fikes, APRN-FNP-BC",1386288876,"20-4063608","TX","PE - C Vallie CFNP Limited Partnership","Omni PPO","Participating","Enrollment Complete","2021-01-07","","","2021-02-01","02/01/2021 Rcvd email from German Aviles <german.aciles@imsm.net> at IMS/OMNI stating that the monthly delegated roster provider loads for March, April, May and June have been completed.  Provider is PAR and linked to location/TIN effective 1/7/2021. DCannon"]
["Jennifer Lynn Delk-Fikes, APRN-FNP-BC",1386288876,"20-4063608","TX","PE - C Vallie CFNP Limited Partnership","Superior","Participating","Enrollment Complete","2021-02-01","","","2021-02-02","2/2/2021 - Rcvd confirmation from payer that provider is participating and linked to TIN effective 12/1/2020.  DCannon"]
["Jennifer Lynn Delk-Fikes, APRN-FNP-BC",1386288876,"20-4063608","TX","PE - C Vallie CFNP Limited Partnership","Cigna","Participating","Enrollment Complete","2021-03-26","8757188","","2021-04-05","3/30/2021 Received email from discovercigna@information.cigna.com with an approval notice effective 3/26/2021 with assigned provider ID 8757188. KFrazier"]
["Jennifer Lynn Delk-Fikes, APRN-FNP-BC",1386288876,"20-4063608","TX","PE - C Vallie CFNP Limited Partnership","Aetna","Participating","Enrollment Complete","2021-01-07","","","2021-04-18","4/18/2021 Rcvd complete roster from Jamie Roberts <robertsj6@aetna.com> at Aetna listing provider as participating at TIN and locations.  DCannon"]
["Jennifer Lynn Delk-Fikes, APRN-FNP-BC",1386288876,"20-4063608","TX","PE - C Vallie CFNP Limited Partnership","Humana","Participating","Enrollment Complete","2021-09-01","","","2021-11-18","11/18/2021 Rcvd full roster from Humana listing provider as PAR and linked to group TIN/location effective 9/1/2021.  DCannon"]
["Jennifer Lynn Delk-Fikes, APRN-FNP-BC",1386288876,"20-4063608","TX","PE - C Vallie CFNP Limited Partnership","Wellmed","Participating","Enrollment Complete","2022-01-01","","","2023-03-23","3/23/2023 Rcvd roster from UHC w/ all Wellmed participating providers.  Provider is PAR effective 1/1/2022.  DCannon"]
["Jennifer Lynn Delk-Fikes, APRN-FNP-BC",1386288876,"20-4063608","TX","PE - C Vallie CFNP Limited Partnership","Wellcare","Participating","Enrollment Complete","2021-11-01","","","2022-11-15","11/15/2022 Per roster received from Wellcare provider is PAR and linked to group TIN/location effective 11/1/2021.  DCannon"]
["Jennifer Lynn Delk-Fikes, APRN-FNP-BC",1386288876,"20-4063608","TX","PE - C Vallie CFNP Limited Partnership","USA PPO","Participating","Enrollment Complete","2021-01-07","1310973","","2021-03-12","3/12/2021 Per verification on payor website USAMCO.com provider is loaded as participating.  Rcvd Roster LeNetrice Myart with provider numbers and effective dates for providers.  DCannon"]
["Jennifer Lynn Delk-Fikes, APRN-FNP-BC",1386288876,"20-4063608","TX","PE - C Vallie CFNP Limited Partnership","Caprock (CapStar)","Participating","Enrollment Complete","2021-01-07","","","2021-02-03","2/3/2021 - Rcvd confirmation email from payor stating that provider is participating and linked at location and TIN effective 1/7/2021.  DCannon"]
["Jennifer Lynn Delk-Fikes, APRN-FNP-BC",1386288876,"20-4063608","TX","PE - C Vallie CFNP Limited Partnership","TriCare Standard","Participating","Enrollment Complete","2021-01-02","","","2021-03-08","3/8/2021 Upon review of the self-service portal, provider has been added under group certification with an effective date of 1/2/2021. KFrazier"]
["Jennifer Lynn Delk-Fikes, APRN-FNP-BC",1386288876,"20-4063608","TX","PE - C Vallie CFNP Limited Partnership","Multiplan","Participating","Enrollment Complete","2021-01-07","","","2022-07-24","7/24/2022 Per email from Marcie Eckhart-Havens Multiplan July delegated roster has been completed  and provider is PAR and linked to group TIN effective 1/7/2021.  DCannon"]
["Jennifer Lynn Delk-Fikes, APRN-FNP-BC",1386288876,"20-4063608","TX","PE - C Vallie CFNP Limited Partnership","Amerigroup","Participating","Enrollment Complete","2021-01-07","","","2021-08-26","8/26/2021 Rcvd full roster from Joe Rodriguez at Amerigroup listing provider as PAR w/ group TIN and location effective 1/7/2021.  DCannon"]
["Jennifer Lynn Delk-Fikes, APRN-FNP-BC",1386288876,"20-4063608","TX","PE - C Vallie CFNP Limited Partnership","CAQH","Participating","CAQH Reattested","2023-10-05","In-House Quarterly Maintenance","","2023-10-05","10/5/2023 CAQH reviewed/re-attested.  DCannon"]
["Jennifer Lynn Delk-Fikes, APRN-FNP-BC",1386288876,"20-4063608","TX","PE - C Vallie CFNP Limited Partnership","United Health Care","Participating","Enrollment Complete","2021-02-12","7369251","","2021-05-04","5/4/2021 Received a Roster of enrollment status from networkhelp@uhc.com which confirms provider is participating under group Tax ID with Commercial Choice, Community & State, and Medicare effective 2/12/2021 under unique ID 7369251. KFrazier"]
["Jennifer Lynn Delk-Fikes, APRN-FNP-BC",1386288876,"20-4063608","TX","PE - C Vallie CFNP Limited Partnership","IMS","Participating","Enrollment Complete","2021-01-07","","","2021-02-02","2/2/2021 Rcvd confirmation email from German Aviles that providers have been loaded according to the monthly delegation roster.  DCannon"]
["Jennifer Lynn Delk-Fikes, APRN-FNP-BC",1386288876,"20-4063608","TX","PE - C Vallie CFNP Limited Partnership","First Health Coventry","Participating","Enrollment Complete","2021-01-07","","","2023-06-02","06.02.2023 S/W Trina of First Health @ 800-226-5116. Rep advised to call aetna first to see if provider is credentialed with aetna. S/W Chris of Aetna @ 1-800-353-1232. Per rep, provider is showing participating with First Health and link under the Group and TIN with an Effective date 01/07/2021. Provider ID 6764140, Payer ID 60025 and Recredentialing date 01/07/2024. Service location is on file. Call ref#:6149441125. - Danico Gabriel Melendres"]
["Jennifer Lynn Delk-Fikes, APRN-FNP-BC",1386288876,"20-4063608","TX","PE - C Vallie CFNP Limited Partnership","HealthSmart PPO","Participating","Enrollment Complete","2021-01-07","","","2021-04-11","4/11/2021 Rcvd email from HealthSmart <mdipsupport@healthsmart.com> confirming participation of provider under TIN and location effective 1/7/2021.  DCannon"]
["Jennifer Lynn Delk-Fikes, APRN-FNP-BC",1386288876,"20-4063608","TX","PE - C Vallie CFNP Limited Partnership","Galaxy Health","Participating","Enrollment Complete","2021-01-07","","","2021-03-15","3/15/2021 Rcvd email from Michelle Monroe at Galaxy Health confirming provider is participating under TIN and at location effective 1/7/2021.  DCannon"]
["Jennifer Lynn Delk-Fikes, APRN-FNP-BC",1386288876,"20-4063608","TX","PE - C Vallie CFNP Limited Partnership","Triwest VA","In House Enrollment","In House Enrollment","","","","2021-01-14","1/6/2021 MQA Team is working with Representatives at BCBS-TX to ensure all providers are enrolled and loaded to participate with the VACCN network in a timely manner. However, we are currently awaiting a full roster of providers currently participating and will update all records accordingly upon receipt. Kfrazier"]
["C Vallie CFNP Limite","","20-4063608","TX","PE - C Vallie CFNP Limited Partnership","Cigna","Participating","Enrollment Complete","2021-02-24","","","2021-04-05","4/5/2021 Received executed group agreement, which indicates effective 2/24/2021. KFrazier"]
["C Vallie CFNP Limite","","20-4063608","TX","PE - C Vallie CFNP Limited Partnership","Tricare Prime","Panel Closed","Panel Closed","","","","2023-10-20",""]
["Cheryl J. Vallie, APRN-FNP-BC",1417941410,"20-4063608","TX","PE - C Vallie CFNP Limited Partnership","Triwest VA","In House Enrollment","In House Enrollment","","","","2021-01-14","1/6/2021 MQA Team is working with Representatives at BCBS-TX to ensure all providers are enrolled and loaded to participate with the VACCN network in a timely manner. However, we are currently awaiting a full roster of providers currently participating and will update all records accordingly upon receipt. Kfrazier"]
["Cheryl J. Vallie, APRN-FNP-BC",1417941410,"20-4063608","TX","PE - C Vallie CFNP Limited Partnership","IMS","Participating","Enrollment Complete","2021-02-08","","","2021-04-01","4/1/2021 Rcvd confirmation email from German Aviles that providers have been loaded according to the monthly delegation roster.  DCannon"]
["Cheryl J. Vallie, APRN-FNP-BC",1417941410,"20-4063608","TX","PE - C Vallie CFNP Limited Partnership","Superior","Participating","Enrollment Complete","2021-03-01","","","2021-03-09","3/9/2021 Rcvd notification from Delegated payor that provider is participting under TIN and at location effective 3/1/2021.  DCannon"]
["Cheryl J. Vallie, APRN-FNP-BC",1417941410,"20-4063608","TX","PE - C Vallie CFNP Limited Partnership","Wellmed","Participating","Enrollment Complete","2022-01-01","","","2023-03-23","3/23/2023 Rcvd roster from UHC w/ all Wellmed participating providers.  Provider is PAR effective 1/1/2022.  DCannon"]
["Cheryl J. Vallie, APRN-FNP-BC",1417941410,"20-4063608","TX","PE - C Vallie CFNP Limited Partnership","HealthSmart PPO","Participating","Enrollment Complete","2021-02-08","","","2021-04-11","4/11/2021 Rcvd email from HealthSmart <mdipsupport@healthsmart.com> confirming participation of provider under TIN and location effective 2/8/2021.  DCannon"]
["Cheryl J. Vallie, APRN-FNP-BC",1417941410,"20-4063608","TX","PE - C Vallie CFNP Limited Partnership","TriCare Standard","Participating","Enrollment Complete","2020-11-01","","","2020-12-31","12/31/2020 Confirmed provider is certified as a non-netwok provider with group practice. KFrazier"]
["Cheryl J. Vallie, APRN-FNP-BC",1417941410,"20-4063608","TX","PE - C Vallie CFNP Limited Partnership","Galaxy Health","Participating","Enrollment Complete","2021-02-08","","","2021-03-15","3/15/2021 Rcvd email from Michelle Monroe at Galaxy Health confirming provider is participating under TIN and at location effective 02/08/2021.  DCannon"]
["Cheryl J. Vallie, APRN-FNP-BC",1417941410,"20-4063608","TX","PE - C Vallie CFNP Limited Partnership","Aetna","Participating","Enrollment Complete","2009-08-17","","","2021-03-09","3/9/2021 Per \"Comform Par Status\" notes the provider is participating under the group and TIN# effective 8/17/2009, physical location is on file. Provider ID is 7900545.  DCannon"]
["Cheryl J. Vallie, APRN-FNP-BC",1417941410,"20-4063608","TX","PE - C Vallie CFNP Limited Partnership","Tricare Prime","Panel Closed","Panel Closed","","","","2021-07-09","7/9/2021 The payor is no longer extending contracts to new groups at this time; however, required to check on-line for future openings of the panel. KFrazier"]
["Cheryl J. Vallie, APRN-FNP-BC",1417941410,"20-4063608","TX","PE - C Vallie CFNP Limited Partnership","Scott&White (First Care)","Participating","Enrollment Complete","2019-11-01","","","2021-08-30","8/30/2021 Rcvd email from Scott & White (First Care) <SWHPDELEGATION@BSWHealth.org>that provider is PAR and linked to group TIN/locations effective 11/1/2019.  DCannon"]
["Cheryl J. Vallie, APRN-FNP-BC",1417941410,"20-4063608","TX","PE - C Vallie CFNP Limited Partnership","Ambetter","Participating","Enrollment Complete","2022-04-01","","","2022-06-13","6/13/2022 Per roster received from Superior provider is PAR and linked to group delegation roster effective 4/1/2022."]
["Cheryl J. Vallie, APRN-FNP-BC",1417941410,"20-4063608","TX","PE - C Vallie CFNP Limited Partnership","USA PPO","Participating","Enrollment Complete","2021-02-08","","","2021-05-04","5/4/2021  In following up with USAMCO (800-872-3860) I was told that you can confirm participating via the USA MCO website  https://providersearch.usamco.com/hwprovsearch.  Provider is PAR and linked to location/TIN effective 2/8/2021.  DCannon"]
["Cheryl J. Vallie, APRN-FNP-BC",1417941410,"20-4063608","TX","PE - C Vallie CFNP Limited Partnership","CAQH","Participating","CAQH Reattested","2023-10-19","In-House Monthly Maintenance","","2023-10-19","10/19/2023 CAQH reattested.  DCannon"]
["Cheryl J. Vallie, APRN-FNP-BC",1417941410,"20-4063608","TX","PE - C Vallie CFNP Limited Partnership","Caprock (CapStar)","Participating","Enrollment Complete","2021-02-08","","","2021-08-05","8/5/2021 Rcvd email from Caprock Provider Services provider_services_shared.t8@90degreebenefits.com  that providers from April, May and June delegated rosters have been loaded into their systems under requested TINS effective 2/8/2021.  DCannon"]
["Cheryl J. Vallie, APRN-FNP-BC",1417941410,"20-4063608","TX","PE - C Vallie CFNP Limited Partnership","Omni PPO","Participating","Enrollment Complete","2021-02-08","","","2021-04-01","4/1/2021 Rcvd confirmation email from German Aviles that providers have been loaded according to the monthly delegation roster.  DCannon"]
["Cheryl J. Vallie, APRN-FNP-BC",1417941410,"20-4063608","TX","PE - C Vallie CFNP Limited Partnership","Multiplan","Participating","Enrollment Complete","2021-02-08","","","2022-07-24","7/24/2022 Per email from Marcie Eckhart-Havens Multiplan July delegated roster has been completed  and provider is PAR and linked to group TIN effective 2/8/2021.  DCannon"]
["Cheryl J. Vallie, APRN-FNP-BC",1417941410,"20-4063608","TX","PE - C Vallie CFNP Limited Partnership","United Health Care","Participating","Enrollment Complete","2009-10-01","MPIN 2403042","204063608","2020-12-28","12/28/2020 Received email confirmation and report of provider's participation under group with initial effective date of 10/1/2009; however, they are non-par with all Medicare networks (i.e. AARP, Medicare advantage, etc.). KFrazier"]
["Cheryl J. Vallie, APRN-FNP-BC",1417941410,"20-4063608","TX","PE - C Vallie CFNP Limited Partnership","Cigna","Participating","Enrollment Complete","2018-11-22","","","2020-12-23",""]
["Cheryl J. Vallie, APRN-FNP-BC",1417941410,"20-4063608","TX","PE - C Vallie CFNP Limited Partnership","Humana","Participating","Enrollment Complete","2018-08-31","","","2021-03-09","3/9/2021 Per \"Comform Par Status\" notes the provider is participating under the group and TIN# effective 8/31/2018, physical location is on file.  DCannon"]
["Cheryl J. Vallie, APRN-FNP-BC",1417941410,"20-4063608","TX","PE - C Vallie CFNP Limited Partnership","Amerigroup","Participating","Enrollment Complete","2021-02-08","","","2021-08-26","8/26/2021 Rcvd full roster from Joe Rodriguez at Amerigroup listing provider as PAR w/ group TIN and location effective 2/8/2021.  DCannon"]
["Shylesh R Ganta, MD",1811900657,"20-8658501","TX","PE - Shylesh Ganta, MD, PA","First Health Coventry","Participating","Enrollment Complete","2008-09-01","1098298","","2020-03-20","03/20/2020 - Rec'd an email from the payer stating this provider is EFF under this TIN. Email shared provider ID# 1098298 - Stacey Hudak"]
["Shylesh R Ganta, MD",1811900657,"20-8658501","TX","PE - Shylesh Ganta, MD, PA","CAQH","Participating","CAQH Reattested","2023-10-30","11192078","","2023-10-30","10/30/2023 - Updated Primary mail, cred contact, Board  and Re-attestation - Mkhan"]
["Shylesh R Ganta, MD",1811900657,"20-8658501","TX","PE - Shylesh Ganta, MD, PA","Omni PPO","Participating","Enrollment Complete","2007-11-07","1811900657","","2020-06-25",""]
["Shylesh R Ganta, MD",1811900657,"20-8658501","TX","PE - Shylesh Ganta, MD, PA","TriCare Standard","Participating","Enrollment Complete","2007-02-23","1811900657","","2020-05-01","05/01/2020 - Rec'd access to the TIN through the payer portal. The provider IS PAR with this payer/service location - Stacey Hudak"]
["Shylesh R Ganta, MD",1811900657,"20-8658501","TX","PE - Shylesh Ganta, MD, PA","Rail Road Medicare","Participating","Enrollment Complete","2007-11-01","P00663946","DO2096","2020-03-10","03/10/2020 - Found EFF info through payer portal - Stacey Hudak"]
["Shylesh R Ganta, MD",1811900657,"20-8658501","TX","PE - Shylesh Ganta, MD, PA","Caprock (CapStar)","Participating","Enrollment Complete","2019-09-01","1811900657","","2020-09-23","09/23/2020 - rec'd confirmation from the payer that this August 2020 roster was completed. This provider/service location was added to PriMed Agreement - OK to move to completed status. - Stacey Hudak"]
["Shylesh R Ganta, MD",1811900657,"20-8658501","TX","PE - Shylesh Ganta, MD, PA","Cigna","Participating","Enrollment Complete","2010-08-01","1811900657","","2020-04-22","04/22/2020--S/W Anna of Cigna @ 8008824462, provider NPI# is on file for the provider and is participating effective 08/01/2010 under the group and TIN#. Physical location is on file. Call ref# Anna04202020.\ncopied note from spreadsheet-tisha rader"]
["Shylesh R Ganta, MD",1811900657,"20-8658501","TX","PE - Shylesh Ganta, MD, PA","Scott&White (First Care)","Participating","Enrollment Complete","2016-02-01","1811900657","","2020-08-20","08/20/2020 - Rec'd spreadsheet from the payer stating this provider is affiliated with the PRIMED DELEGATED AGREEEMENT under this TIN/Service Location. This provider is networked with: \nFirstCare MyChoice PPO\nFirstCare Select Benefit Network\nHMO Enhanced Benefit Network\nPPO Limited Benefit Network\n- Stacey Hudak"]
["Shylesh R Ganta, MD",1811900657,"20-8658501","TX","PE - Shylesh Ganta, MD, PA","United Health Care","Participating","Enrollment Complete","2020-01-01","1811900657","","2020-08-03","8/3/2020 - Emailed Tracy Diapolo and confirmed this provider is NOT with PriMed. That agreement has dissoled with UHC and the phone rep was incorrect in sharing this information. However, she confirmed the provider has been credentialed directly with UHC and all else is well. - Stacey Hudak"]
["Shylesh R Ganta, MD",1811900657,"20-8658501","TX","PE - Shylesh Ganta, MD, PA","HealthSmart PPO","Participating","Enrollment Complete","2011-02-01","1811900657","","2020-06-10","06/10/2020 - Rec'd email from the payer stating this provider is EFF - Stacey Hudak"]
["Shylesh R Ganta, MD",1811900657,"20-8658501","TX","PE - Shylesh Ganta, MD, PA","Liberty Mutual","Participating","Enrollment Complete","2009-10-23","1811900657","208658501","2020-08-19","Confirmed provider is participating with WIN networks, which includes this payor (list of networks attached). Kimberly Frazier"]
["Shylesh R Ganta, MD",1811900657,"20-8658501","TX","PE - Shylesh Ganta, MD, PA","Wellcare","Participating","Enrollment Complete","2021-11-01","","","2022-12-01","12/1/2022 Per roster received from Wellcare provider is PAR and linked to group TIN/location effective 11/1/2021.  DCannon"]
["Shylesh R Ganta, MD",1811900657,"20-8658501","TX","PE - Shylesh Ganta, MD, PA","Humana","Participating","Enrollment Complete","2011-05-04","","","2021-11-18","11/18/2021 Rcvd full roster from Humana listing provider as PAR and linked to group TIN/location effective 5/4/2011.  DCannon"]
["Shylesh R Ganta, MD",1811900657,"20-8658501","TX","PE - Shylesh Ganta, MD, PA","Triwest VA","In House Enrollment","In House Enrollment","","","","2021-01-14","1/6/2021 MQA Team is working with Representatives at BCBS-TX to ensure all providers are enrolled and loaded to participate with the VACCN network in a timely manner. However, we are currently awaiting a full roster of providers currently participating and will update all records accordingly upon receipt. Kfrazier"]
["Shylesh R Ganta, MD",1811900657,"20-8658501","TX","PE - Shylesh Ganta, MD, PA","Galaxy Health","Participating","Enrollment Complete","2019-09-01","1811900657","","2020-08-24","08/21/2020 - Rec'd email confirmation that this roster was processed and this provider was made effective with the requested eff date of 9-1-2019 - Stacey Hudak"]
["Shylesh R Ganta, MD",1811900657,"20-8658501","TX","PE - Shylesh Ganta, MD, PA","Sedgwick","Participating","Enrollment Complete","2009-10-23","1811900657","208658501","2020-08-19","Confirmed provider is participating with WIN networks, which includes this payor (list of networks attached). Kimberly Frazier"]
["Shylesh R Ganta, MD",1811900657,"20-8658501","TX","PE - Shylesh Ganta, MD, PA","IMS","Participating","Enrollment Complete","2007-11-07","1811900657","","2020-06-22","06/22/2020- Rec'd email from the payer confirming this provider is PAR with this group/service location - Stacey Hudak"]
["Shylesh R Ganta, MD",1811900657,"20-8658501","TX","PE - Shylesh Ganta, MD, PA","Multiplan","Participating","Enrollment Complete","2007-06-01","1811900657","","2020-02-13","02/13/2020 - Rec'd confirmation through payer portal stating this provider is EFF through an INDIVIDUAL CONTRACT as of 6-1-2007. This provider is networked under Multiplan and PHCS - Stacey Hudak"]
["Shylesh R Ganta, MD",1811900657,"20-8658501","TX","PE - Shylesh Ganta, MD, PA","Aetna","Participating","Enrollment Complete","2020-03-01"," 7700212","","2020-07-10","07/10/2020 - moved to completed status per notes in Follow Up Complete  - Stacey Hudak"]
["Shylesh R Ganta, MD",1811900657,"20-8658501","TX","PE - Shylesh Ganta, MD, PA","USA PPO","Participating","Enrollment Complete","2009-10-23","1811900657","208658501","2020-08-19","Confirmed provider is participating with PPO, H&W and WIN networks (list of networks attached). Kimberly Frazier"]
["Shylesh R Ganta, MD",1811900657,"20-8658501","TX","PE - Shylesh Ganta, MD, PA","Boon Chapman","Participating","Enrollment Complete","2007-06-01","1811900657","","2020-10-05","Enrolled thru PHCS"]
["Shylesh R Ganta, MD",1811900657,"20-8658501","TX","PE - Shylesh Ganta, MD, PA","Medicare","Participating","Enrollment Complete","2007-11-01","8F6462","00Y323","2020-03-10","03/10/2020 - signed into PECOS and verified that this provider is linked to this group: SHYLESH GANTA ,MD , PA (group TPAN 00Y323) as of 11-1-2007 - Stacey Hudak"]
["Shylesh R Ganta, MD",1811900657,"20-8658501","TX","PE - Shylesh Ganta, MD, PA","Wellmed","Participating","Enrollment Complete","2022-01-01","","","2023-03-23","3/23/2023 Rcvd roster from UHC w/ all Wellmed participating providers.  Provider is PAR effective 1/1/2022.  DCannon"]
["Sapna Chilka, MD",1790972610,"20-8658501","TX","PE - Shylesh Ganta, MD, PA","Medicare","Participating","Enrollment Complete","2007-11-01","8F6463","00Y323","2020-03-10","03/10/2020 - Confirmed that this provider is EFF through PECOS and assigned to the correct group - Stacey Hudak"]
["Sapna Chilka, MD",1790972610,"20-8658501","TX","PE - Shylesh Ganta, MD, PA","Wellmed","Participating","Enrollment Complete","2022-01-01","","","2023-03-23","3/23/2023 Rcvd roster from UHC w/ all Wellmed participating providers.  Provider is PAR effective 1/1/2022.  DCannon"]
["Sapna Chilka, MD",1790972610,"20-8658501","TX","PE - Shylesh Ganta, MD, PA","Galaxy Health","Participating","Enrollment Complete","2008-04-09","1790972610","","2020-07-17","7/17/2020 - Received a spreadsheet from the payer stating this provider is effective as of 4/9/2008 - Jesriel Segovia"]
["Sapna Chilka, MD",1790972610,"20-8658501","TX","PE - Shylesh Ganta, MD, PA","CAQH","Participating","CAQH Reattested","2023-10-30","12137263","","2023-10-30","10/30/2023 - Updated Primary Mail, cred contant and Re-attested - Mkhan"]
["Sapna Chilka, MD",1790972610,"20-8658501","TX","PE - Shylesh Ganta, MD, PA","Boon Chapman","Participating","Enrollment Complete","2020-03-20","","","2022-07-24","7/24/2022 Per email from Marcie Eckhart-Havens Multiplan July delegated roster has been completed  and provider is PAR and linked to group TIN effective 3/20/2020.   DCannon"]
["Sapna Chilka, MD",1790972610,"20-8658501","TX","PE - Shylesh Ganta, MD, PA","Triwest VA","In House Enrollment","In House Enrollment","","","","2021-01-13","1/6/2021 MQA Team is working with Representatives at BCBS-TX to ensure all providers are enrolled and loaded to participate with the VACCN network in a timely manner. However, we are currently awaiting a full roster of providers currently participating and will update all records accordingly upon receipt. Kfrazier"]
["Sapna Chilka, MD",1790972610,"20-8658501","TX","PE - Shylesh Ganta, MD, PA","IMS","Participating","Enrollment Complete","2008-04-09","1790972610","","2020-06-22","06/22/2020- Rec'd email from the payer confirming this provider is PAR with this group/service location - Stacey Hudak"]
["Sapna Chilka, MD",1790972610,"20-8658501","TX","PE - Shylesh Ganta, MD, PA","TriCare Standard","Participating","Enrollment Complete","2007-11-01","1790972610","","2020-05-01","05/01/2020 - Rec'd access to the TIN through the payer portal and I was able to confirm that this provider is EFF - Stacey Hudak"]
["Sapna Chilka, MD",1790972610,"20-8658501","TX","PE - Shylesh Ganta, MD, PA","Caprock (CapStar)","Participating","Enrollment Complete","2012-03-01","1790972610","","2020-06-02","06/02/2020 - rec'd spreadsheet back from the payer Mary Rodriguez <MRodriguez@caprockhp.com> confirming this provider/service location is EFF with this payer - Stacey Hudak"]
["Sapna Chilka, MD",1790972610,"20-8658501","TX","PE - Shylesh Ganta, MD, PA","Liberty Mutual","Participating","Enrollment Complete","2009-10-23","","","2020-09-09","Confirmed provider is particpating with WIN networks, which includes this payor (list of networks attached). Kimberly Frazier"]
["Sapna Chilka, MD",1790972610,"20-8658501","TX","PE - Shylesh Ganta, MD, PA","Sedgwick","Participating","Enrollment Complete","2009-10-23","","","2020-09-09","Confirmed provider is particpating with WIN networks, which includes this payor (list of networks attached). Kimberly Frazier"]
["Sapna Chilka, MD",1790972610,"20-8658501","TX","PE - Shylesh Ganta, MD, PA","Scott&White (First Care)","Participating","Enrollment Complete","2009-01-01","1790972610","","2020-08-20","08/20/2020 - Rec'd spreadsheet from the payer stating this provider is affiliated with the PRIMED DELEGATED AGREEMENT under this TIN/Service Location. This provider is networked with:\nFirstCare Select Benefit Network\nHMO Enhanced Benefit Network\nMedicare (FC)\n- Stacey HUdak"]
["Sapna Chilka, MD",1790972610,"20-8658501","TX","PE - Shylesh Ganta, MD, PA","Multiplan","Participating","Enrollment Complete","2020-03-20","","","2022-07-24","7/24/2022 Per email from Marcie Eckhart-Havens Multiplan July delegated roster has been completed  and provider is PAR and linked to group TIN effective 3/20/2020.   DCannon"]
["Sapna Chilka, MD",1790972610,"20-8658501","TX","PE - Shylesh Ganta, MD, PA","Cigna","Participating","Enrollment Complete","2010-11-18","1790972610","","2020-04-22","04/22/2020--S/W Rica of Cigna @ 8008824462, provider NPI# is on file for the provider and is participating effective 11/18/2010 under the group and TIN#. Physical location is on file. Call ref# Rica04202020.\ncopied note from spreadsheet-tisha rader"]
["Sapna Chilka, MD",1790972610,"20-8658501","TX","PE - Shylesh Ganta, MD, PA","HealthSmart PPO","Participating","Enrollment Complete","2011-02-01","1790972610","","2020-06-10","06/10/2020 - Rec'd email from the payer stating this provider is EFF - Stacey Hudak"]
["Sapna Chilka, MD",1790972610,"20-8658501","TX","PE - Shylesh Ganta, MD, PA","Rail Road Medicare","Participating","Enrollment Complete","2007-11-01","P00710890","DO2096","2020-08-28","08/28/2020 - moved to completed status after confirming EFF info through payer site - Stacey Hudak"]
["Sapna Chilka, MD",1790972610,"20-8658501","TX","PE - Shylesh Ganta, MD, PA","Aetna","Participating","Enrollment Complete","2010-06-01","1790972610","","2020-03-26","3/26/2020--SW Ali of Aetna @ 800-353-1232. NPI is on file for the provider and is participating effective 6/1/2010 under group and TIN. DIRECT CONTRACT with Aetna. Physical location is on file. Call ref# 5196002602.\ntisha rader"]
["Sapna Chilka, MD",1790972610,"20-8658501","TX","PE - Shylesh Ganta, MD, PA","United Health Care","Participating","Enrollment Complete","2020-01-01","1790972610","","2020-08-03","8/3/2020 - Emailed Tracy Diapolo and confirmed this provider is NOT with PriMed. That agreement has dissoled with UHC and the phone rep was incorrect in sharing this information. However, she confirmed the provider has been credentialed directly with UHC and all else is well. - Stacey Hudak"]
["Sapna Chilka, MD",1790972610,"20-8658501","TX","PE - Shylesh Ganta, MD, PA","First Health Coventry","Participating","Enrollment Complete","2010-12-01","1621807","","2020-02-25","03/20/2020 - Rec'd an email from the payer stating this provider is EFF under this TIN. Email shared provider ID# 1621807 - Stacey Hudak"]
["Sapna Chilka, MD",1790972610,"20-8658501","TX","PE - Shylesh Ganta, MD, PA","USA PPO","Participating","Enrollment Complete","2009-10-23","","","2020-09-09","Confirmed provider is participating with PPO, H&W and WIN networks (list of networks attached). Kimberly Frazier"]
["Sapna Chilka, MD",1790972610,"20-8658501","TX","PE - Shylesh Ganta, MD, PA","Omni PPO","Participating","Enrollment Complete","2008-04-09","1790972610","","2020-06-25",""]
["Sapna Chilka, MD",1790972610,"20-8658501","TX","PE - Shylesh Ganta, MD, PA","Humana","Participating","Enrollment Complete","2011-05-04","1790972610","","2020-09-24","09/24/2020 - moved to completed status after reviewing follow up complete note - Stacey Hudak"]
["Tiffany B Hansen, APRN-FNP-BC",1750794749,"20-8658501","TX","PE - Shylesh Ganta, MD, PA","Aetna","Participating","Enrollment Complete","2020-08-01","6418713","","2020-07-20","07/20/2020 - Rec'd email from the payer stating \"Welcome to the provider network effective 8/1/2020. Your Provider Identification Number (PIN) is: 6418713\" - Stacey HUdak"]
["Tiffany B Hansen, APRN-FNP-BC",1750794749,"20-8658501","TX","PE - Shylesh Ganta, MD, PA","Rail Road Medicare","Participating","Enrollment Complete","2014-06-10","P02417404","DO2096","2020-08-31","08/31/2020 - moved to completed status after reviewing follow up complete note and downloading EFF letter - Stacey Hudak"]
["Tiffany B Hansen, APRN-FNP-BC",1750794749,"20-8658501","TX","PE - Shylesh Ganta, MD, PA","Humana","Participating","Enrollment Complete","2021-09-01","","","2021-11-18","11/18/2021 Rcvd full roster from Humana listing provider as PAR and linked to group TIN/location effective 9/1/2021.  DCannon"]
["Tiffany B Hansen, APRN-FNP-BC",1750794749,"20-8658501","TX","PE - Shylesh Ganta, MD, PA","IMS","Participating","Enrollment Complete","2019-09-01","1750794749","","2020-07-27","07/27/2020 - Rec'd roster response back from the payer regarding 7/15/2020 submission stating that all requested providers/service locations have been added to PriMed agreement - Stacey Hudak"]
["Tiffany B Hansen, APRN-FNP-BC",1750794749,"20-8658501","TX","PE - Shylesh Ganta, MD, PA","Scott&White (First Care)","Participating","Enrollment Complete","2020-09-28","","","2021-01-29","1/29/2021 - Rcvd roster from Scott&White (First Care) confirming participation of provider with TIN and location effective dates.  DCannon"]
["Tiffany B Hansen, APRN-FNP-BC",1750794749,"20-8658501","TX","PE - Shylesh Ganta, MD, PA","Multiplan","Participating","Enrollment Complete","2020-04-03","","","2022-07-24","7/24/2022 Per email from Marcie Eckhart-Havens Multiplan July delegated roster has been completed  and provider is PAR and linked to group TIN effective 4/3/2020.   DCannon"]
["Tiffany B Hansen, APRN-FNP-BC",1750794749,"20-8658501","TX","PE - Shylesh Ganta, MD, PA","Caprock (CapStar)","Participating","Enrollment Complete","2019-09-01","1750794749","","2020-09-23","09/23/2020 - rec'd confirmation from the payer that this August 2020 roster was completed. This provider/service location was added to PriMed Agreement - OK to move to completed status. - Stacey Hudak"]
["Tiffany B Hansen, APRN-FNP-BC",1750794749,"20-8658501","TX","PE - Shylesh Ganta, MD, PA","HealthSmart PPO","Participating","Enrollment Complete","2020-04-03","","","2022-02-26","2/26/2022 Per Healthsmart website provider is PAR and loaded under TIN/location effective 4/3/2020.  DCannon"]
["Tiffany B Hansen, APRN-FNP-BC",1750794749,"20-8658501","TX","PE - Shylesh Ganta, MD, PA","USA PPO","Participating","Enrollment Complete","2021-01-26","1312309","","2021-03-13","3/12/2021 Per verification on payor website USAMCO.com provider is loaded as participating.  Rcvd Roster LeNetrice Myart with provider numbers and effective dates for providers.  DCannon"]
["Tiffany B Hansen, APRN-FNP-BC",1750794749,"20-8658501","TX","PE - Shylesh Ganta, MD, PA","Triwest VA","In House Enrollment","In House Enrollment","","","","2021-01-13","1/6/2021 MQA Team is working with Representatives at BCBS-TX to ensure all providers are enrolled and loaded to participate with the VACCN network in a timely manner. However, we are currently awaiting a full roster of providers currently participating and will update all records immediately upon receipt. KFrazier"]
["Tiffany B Hansen, APRN-FNP-BC",1750794749,"20-8658501","TX","PE - Shylesh Ganta, MD, PA","Cigna","Participating","Enrollment Complete","2020-09-15","5009460","","2020-09-18","09/18/2020 - Your effective date is 09/15/2020. Your provider identification number is 5009460.  - Stacey Hudak"]
["Tiffany B Hansen, APRN-FNP-BC",1750794749,"20-8658501","TX","PE - Shylesh Ganta, MD, PA","Boon Chapman","Participating","Enrollment Complete","2020-04-03","","","2022-07-24","7/24/2022 Per email from Marcie Eckhart-Havens Multiplan July delegated roster has been completed  and provider is PAR and linked to group TIN effective 4/3/2020.   DCannon"]
["Tiffany B Hansen, APRN-FNP-BC",1750794749,"20-8658501","TX","PE - Shylesh Ganta, MD, PA","Medicare","Participating","Enrollment Complete","2014-06-10","363200ZH9T","00Y323","2020-03-10","03/10/2020 - Confimed through PECOS that this provider is linked to the corect group and EFF 6-10-2014 - Stacey Hudak"]
["Tiffany B Hansen, APRN-FNP-BC",1750794749,"20-8658501","TX","PE - Shylesh Ganta, MD, PA","Wellmed","Participating","Enrollment Complete","2022-01-01","","","2023-03-23","3/23/2023 Rcvd roster from UHC w/ all Wellmed participating providers.  Provider is PAR effective 1/1/2022.  DCannon"]
["Tiffany B Hansen, APRN-FNP-BC",1750794749,"20-8658501","TX","PE - Shylesh Ganta, MD, PA","United Health Care","Participating","Enrollment Complete","2019-12-01","1750794749","","2020-07-30","7/30/2020 - moved to completed status after reviewing follow up complete note - Stacey Hudak"]
["Tiffany B Hansen, APRN-FNP-BC",1750794749,"20-8658501","TX","PE - Shylesh Ganta, MD, PA","Galaxy Health","Participating","Enrollment Complete","2019-09-01","1750794749","","2020-08-24","08/21/2020 - Rec'd email confirmation that this roster was processed and this provider was made effective with the requested eff date of 9-1-2019 - Stacey Hudak"]
["Tiffany B Hansen, APRN-FNP-BC",1750794749,"20-8658501","TX","PE - Shylesh Ganta, MD, PA","Omni PPO","Participating","Enrollment Complete","2019-09-01","1750794749","","2020-07-27","IMS completed"]
["Tiffany B Hansen, APRN-FNP-BC",1750794749,"20-8658501","TX","PE - Shylesh Ganta, MD, PA","CAQH","Participating","CAQH Reattested","2023-10-31","12740460","","2023-10-31","10/31/2023 - License, DEA, Board, cred contact and re-attested - rkedare"]
["Tiffany B Hansen, APRN-FNP-BC",1750794749,"20-8658501","TX","PE - Shylesh Ganta, MD, PA","First Health Coventry","Participating","Enrollment Complete","2020-08-01","3524170","","2022-04-05","4/5/2022  Per First Health online provider directory provider is PAR and linked to group/locations  effective 8/1/2020.  DCannon"]
["Leo D Villaroman, MD",1073796330,"26-3413331","TX","PE - Leo Villaroman, MD, PA","CAQH","Participating","CAQH Reattested","2023-10-05","","","2023-10-05","10/5/2023 CAQH reviewed and re-attested.  DCannon"]
["Leo D Villaroman, MD",1073796330,"26-3413331","TX","","CAQH","Participating","CAQH Reattested","2023-10-05","","","2023-10-05","10/5/2023 CAQH reviewed and re-attested.  DCannon"]
["Leo D Villaroman, MD",1073796330,"26-3413331","TX","PE - Leo Villaroman, MD, PA","Amerigroup","In Process","Payor Follow Up","","","","2023-10-20","10/13/2023 Sent follow-up email to Cassandra Dunagon-Smith and Vanessa Christensen at Amerigroup to check status of follow-up request sent on 9/9/2023.  DCannon"]
["Leo D Villaroman, MD",1073796330,"26-3413331","TX","","Amerigroup","In Process","Payor Follow Up","","","","2023-10-20","10/13/2023 Sent follow-up email to Cassandra Dunagon-Smith and Vanessa Christensen at Amerigroup to check status of follow-up request sent on 9/9/2023.  DCannon"]
["Leo D Villaroman, MD",1073796330,"26-3413331","TX","PE - Leo Villaroman, MD, PA","USA PPO","Participating","Enrollment Complete","2023-01-09","","","2023-03-24","3/24/2023 In following up with USAMCO (800-872-3860) I was told that you can confirm participating via the USA MCO website  https://providersearch.usamco.com/hwprovsearch.  Provider is PAR and linked to location/TIN effective 1/9/2023.  DCannon"]
["Leo D Villaroman, MD",1073796330,"26-3413331","TX","","USA PPO","Participating","Enrollment Complete","2023-01-09","","","2023-03-24","3/24/2023 In following up with USAMCO (800-872-3860) I was told that you can confirm participating via the USA MCO website  https://providersearch.usamco.com/hwprovsearch.  Provider is PAR and linked to location/TIN effective 1/9/2023.  DCannon"]
["Leo D Villaroman, MD",1073796330,"26-3413331","TX","PE - Leo Villaroman, MD, PA","Medicare","In Process","Payor Follow Up","","","","2023-11-09","11/9/2023 Per PECOS application is still in process.  Tracking ID # T082320230002396.  DCannon"]
["Leo D Villaroman, MD",1073796330,"26-3413331","TX","","Medicare","In Process","Payor Follow Up","","","","2023-11-09","11/9/2023 Per PECOS application is still in process.  Tracking ID # T082320230002396.  DCannon"]
["Leo D Villaroman, MD",1073796330,"26-3413331","TX","PE - Leo Villaroman, MD, PA","United Health Care","Participating","Enrollment Complete","2023-01-09","","","2023-02-08","2/8/2023 Rcvd email from UHC that January delegated roster provider load has been completed and provider is PAR and linked to group TIN effective 1/9/2023.  MPIN# 003004855.  DCannon"]
["Leo D Villaroman, MD",1073796330,"26-3413331","TX","","United Health Care","Participating","Enrollment Complete","2023-01-09","","","2023-02-08","2/8/2023 Rcvd email from UHC that January delegated roster provider load has been completed and provider is PAR and linked to group TIN effective 1/9/2023.  MPIN# 003004855.  DCannon"]
["Leo D Villaroman, MD",1073796330,"26-3413331","TX","PE - Leo Villaroman, MD, PA","IMS","Participating","Enrollment Complete","2023-01-09","","","2023-01-31","1/31/2023 Per email received from German Aviles at IMS/OMNI monthly delegation roster provider load for December has been completed.  Provider is PAR and linked to group TIN effective 1/9/2023.   DCannon"]
["Leo D Villaroman, MD",1073796330,"26-3413331","TX","","IMS","Participating","Enrollment Complete","2023-01-09","","","2023-01-31","1/31/2023 Per email received from German Aviles at IMS/OMNI monthly delegation roster provider load for December has been completed.  Provider is PAR and linked to group TIN effective 1/9/2023.   DCannon"]
["Leo D Villaroman, MD",1073796330,"26-3413331","TX","PE - Leo Villaroman, MD, PA","Humana","Participating","Enrollment Complete","2023-01-09","","","2023-08-31","8/31/2023 Per email from Marcus Wester at Humana January delegated roster has been completed and provider is PAR effective 1/9/2023.  DCannon"]
["Leo D Villaroman, MD",1073796330,"26-3413331","TX","","Humana","Participating","Enrollment Complete","2023-01-09","","","2023-08-31","8/31/2023 Per email from Marcus Wester at Humana January delegated roster has been completed and provider is PAR effective 1/9/2023.  DCannon"]
["Leo D Villaroman, MD",1073796330,"26-3413331","TX","PE - Leo Villaroman, MD, PA","Omni PPO","Participating","Enrollment Complete","2023-01-09","","","2023-01-31","1/31/2023 Per email received from German Aviles at IMS/OMNI monthly delegation roster provider load for December has been completed.  Provider is PAR and linked to group TIN effective 1/9/2023.   DCannon"]
["Leo D Villaroman, MD",1073796330,"26-3413331","TX","","Omni PPO","Participating","Enrollment Complete","2023-01-09","","","2023-01-31","1/31/2023 Per email received from German Aviles at IMS/OMNI monthly delegation roster provider load for December has been completed.  Provider is PAR and linked to group TIN effective 1/9/2023.   DCannon"]
["Leo D Villaroman, MD",1073796330,"26-3413331","TX","PE - Leo Villaroman, MD, PA","HealthSmart PPO","Participating","Enrollment Complete","2023-01-09","","","2023-02-28","2/28/2023 Per Healthsmart website provider is PAR and loaded under TIN/location effective 1/9/2023.  DCannon"]
["Leo D Villaroman, MD",1073796330,"26-3413331","TX","","HealthSmart PPO","Participating","Enrollment Complete","2023-01-09","","","2023-02-28","2/28/2023 Per Healthsmart website provider is PAR and loaded under TIN/location effective 1/9/2023.  DCannon"]
["Leo D Villaroman, MD",1073796330,"26-3413331","TX","PE - Leo Villaroman, MD, PA","Aetna","Participating","Enrollment Complete","2023-01-09","9762353","","2023-02-16","02.16.2023  Per follow-up note - S/W Ian of Aetna @ 800-353-1232. Per rep, provider is showing participating with an Effective date 01/09/2023 and link under the Group and TIN. Provider ID 9762353, Payer ID 60054 and Recredentialing date 01/09/2026. Service location is on file. Call ref#:6133795635.  DCannon"]
["Leo D Villaroman, MD",1073796330,"26-3413331","TX","","Aetna","Participating","Enrollment Complete","2023-01-09","9762353","","2023-02-16","02.16.2023  Per follow-up note - S/W Ian of Aetna @ 800-353-1232. Per rep, provider is showing participating with an Effective date 01/09/2023 and link under the Group and TIN. Provider ID 9762353, Payer ID 60054 and Recredentialing date 01/09/2026. Service location is on file. Call ref#:6133795635.  DCannon"]
["Leo D Villaroman, MD",1073796330,"26-3413331","TX","PE - Leo Villaroman, MD, PA","TriCare Standard","Participating","Enrollment Complete","2023-04-25","","","2023-06-15","Confirmed provider is loaded. MS"]
["Leo D Villaroman, MD",1073796330,"26-3413331","TX","","TriCare Standard","Participating","Enrollment Complete","2023-04-25","","","2023-06-15","Confirmed provider is loaded. MS"]
["Leo D Villaroman, MD",1073796330,"26-3413331","TX","PE - Leo Villaroman, MD, PA","Cigna","Participating","Enrollment Complete","2023-09-19","","","2023-10-12","Contract has been signed and executed. MS"]
["Leo D Villaroman, MD",1073796330,"26-3413331","TX","","Cigna","Participating","Enrollment Complete","2023-09-19","","","2023-10-12","Contract has been signed and executed. MS"]
["Leo D Villaroman, MD",1073796330,"26-3413331","TX","PE - Leo Villaroman, MD, PA","Boon Chapman","Pending Other Enrollment","Pending Other Enrollment","","","","2023-10-16","10/16/2023 Pending Multiplan enrollment.  DCannon"]
["Leo D Villaroman, MD",1073796330,"26-3413331","TX","","Boon Chapman","Pending Other Enrollment","Pending Other Enrollment","","","","2023-10-16","10/16/2023 Pending Multiplan enrollment.  DCannon"]
["Leo D Villaroman, MD",1073796330,"26-3413331","TX","PE - Leo Villaroman, MD, PA","Scott&White (First Care)","In Process","Application Submitted","","","","2023-11-15","11/15/2023 Delegated roster submitted for a second time advising to only load provider in PPO network and Medicare plans ONLY.  As provider does not want to be loaded in HMO or Medicaid plans.  DCannon"]
["Leo D Villaroman, MD",1073796330,"26-3413331","TX","","Scott&White (First Care)","In Process","Application Submitted","","","","2023-11-15","11/15/2023 Delegated roster submitted for a second time advising to only load provider in PPO network and Medicare plans ONLY.  As provider does not want to be loaded in HMO or Medicaid plans.  DCannon"]
["Leo D Villaroman, MD",1073796330,"26-3413331","TX","PE - Leo Villaroman, MD, PA","Galaxy Health","Participating","Enrollment Complete","2023-01-09","","","2023-03-09","3/9/2023 Per email rcvd from Karen Avalos at Galaxy, January monthly roster has been completed.  Provider is PAR and linked to group effective 1/9/2023.  DCannon"]
["Leo D Villaroman, MD",1073796330,"26-3413331","TX","","Galaxy Health","Participating","Enrollment Complete","2023-01-09","","","2023-03-09","3/9/2023 Per email rcvd from Karen Avalos at Galaxy, January monthly roster has been completed.  Provider is PAR and linked to group effective 1/9/2023.  DCannon"]
["Leo D Villaroman, MD",1073796330,"26-3413331","TX","PE - Leo Villaroman, MD, PA","First Health Coventry","Participating","Enrollment Complete","2023-01-09","","","2023-08-17","8/17/2023 Per First Health web portal provider is PAR and linked to group/location effective 1/9/2023.  PID # 1961903.  DCannon"]
["Leo D Villaroman, MD",1073796330,"26-3413331","TX","","First Health Coventry","Participating","Enrollment Complete","2023-01-09","","","2023-08-17","8/17/2023 Per First Health web portal provider is PAR and linked to group/location effective 1/9/2023.  PID # 1961903.  DCannon"]
["Leo D Villaroman, MD",1073796330,"26-3413331","TX","PE - Leo Villaroman, MD, PA","Caprock (CapStar)","Participating","Enrollment Complete","2023-01-09","","","2023-01-20","1/20/2023 Rcvd email  confirmation from Caprock that provider is PAR and linked to group TIN/locations effective 1/9/2023.  DCannon"]
["Leo D Villaroman, MD",1073796330,"26-3413331","TX","","Caprock (CapStar)","Participating","Enrollment Complete","2023-01-09","","","2023-01-20","1/20/2023 Rcvd email  confirmation from Caprock that provider is PAR and linked to group TIN/locations effective 1/9/2023.  DCannon"]
["Leo D Villaroman, MD",1073796330,"26-3413331","TX","PE - Leo Villaroman, MD, PA","Triwest VA","In House Enrollment","In House Enrollment","","","","2023-01-14",""]
["Leo D Villaroman, MD",1073796330,"26-3413331","TX","","Triwest VA","In House Enrollment","In House Enrollment","","","","2023-01-14",""]
["Leo D Villaroman, MD",1073796330,"26-3413331","TX","PE - Leo Villaroman, MD, PA","Multiplan","In Process","Application Resubmitted","","","","2023-11-20","11/20/2023 Submitted request via Multiplan provider portal to add provider to Multiplan PPO networks.  Service Case # 9394298.  DCannon"]
["Leo D Villaroman, MD",1073796330,"26-3413331","TX","","Multiplan","In Process","Application Resubmitted","","","","2023-11-20","11/20/2023 Submitted request via Multiplan provider portal to add provider to Multiplan PPO networks.  Service Case # 9394298.  DCannon"]
["Carlos Molina, DO",1225277833,"26-3789190","TX","PE - Permian Physician Services","Texas Municipal League","Participating","Enrollment Complete","","","","2023-11-20","participating, please see Alliance notes. MS"]
["Carlos Molina, DO",1225277833,"26-3789190","TX","PE - Permian Physician Services","Superior","Participating","Enrollment Complete","2020-10-01","1225277833","","2020-10-01","10/01/2020 - Rec'd email from the payer stating this provider has been uploaded to the PriMed agreement  - Stacey Hudak"]
["Carlos Molina, DO",1225277833,"26-3789190","TX","PE - Permian Physician Services","Ambetter","Participating","Enrollment Complete","2022-04-01","","","2022-06-13","6/13/2022 Per roster received from Superior provider is PAR and linked to group delegation roster effective 4/1/2022."]
["Carlos Molina, DO",1225277833,"26-3789190","TX","PE - Permian Physician Services","United Health Care","Participating","Enrollment Complete","2020-10-07","1225277833","","2020-10-30","10/30/2020 - Rec'd email from the payer stating \"Good news! We’ve completed the provider/group updates you requested on Oct 7, 2020 12:22:11 PM. Your request was assigned reference number PR-5533577 .\" - Stacey Hudak"]
["Carlos Molina, DO",1225277833,"26-3789190","TX","PE - Permian Physician Services","Gallagher","Panel Closed","Panel Closed","","","","2023-07-24"," We appreciate your interest in joining the Coventry Network.  At this time, our panels are closed, and we are not accepting new applications.  Please check back routinely to stay apprised of our panel status. We will update this site when we are open for new applicants. Gallagher, Hartford, Liberty Mutual, Travelers and Zurich fall under Coventry. Jen Videan"]
["Carlos Molina, DO",1225277833,"26-3789190","TX","PE - Permian Physician Services","Humana","Participating","Enrollment Complete","2017-03-30","1225277833","","2020-09-24","09/24/2020 - moved to completed status after reviewing follow up complete - Stacey Hudak"]
["Carlos Molina, DO",1225277833,"26-3789190","TX","PE - Permian Physician Services","Scott&White (First Care)","Participating","Enrollment Complete","2017-03-13","","","2021-01-29","1/29/2021 - Rcvd roster from Scott&White (First Care) confirming participation of provider with TIN and location effective dates.  DCannon"]
["Carlos Molina, DO",1225277833,"26-3789190","TX","PE - Permian Physician Services","First Health Coventry","Participating","Enrollment Complete","2019-12-13","","","2023-05-02","5/2.2023 Per confirm par status -  Per rep, provider is showing participating with an effective date 12/13/2019 and link under the Group and TIN. Provider ID 2343457.  Service location is on file. Call ref#:610334. DCannon"]
["Carlos Molina, DO",1225277833,"26-3789190","TX","PE - Permian Physician Services","Coventry Workers Comp","Panel Closed","Panel Closed","","","","2023-07-24"," We appreciate your interest in joining the Coventry Network.  At this time, our panels are closed, and we are not accepting new applications.  Please check back routinely to stay apprised of our panel status. We will update this site when we are open for new applicants. Gallagher, Hartford, Liberty Mutual, Travelers and Zurich fall under Coventry. Jen Videan"]
["Carlos Molina, DO",1225277833,"26-3789190","TX","PE - Permian Physician Services","TriCare Standard","Participating","Enrollment Complete","2021-06-03","","","2021-09-14","7/2/2021- S/W Tierra OF TRICARE Standard @ 8004445445, call was transferred to WPS for further assistance, Spoke to Sandra, as per Rep, NPI#is on file for the provider, shows certified Non particpiating under the group and TIN# effective 6/3/2021 under the physical location. Provider ID is 26-3789190-79714-A016. Call ref# Herminia Gilongos"]
["Carlos Molina, DO",1225277833,"26-3789190","TX","PE - Permian Physician Services","Aetna","Participating","Enrollment Complete","2019-12-13","1225277833","","2020-09-24","09/24/2020 - moved to completed status after reviewing follow up complete - Stacey Hudak"]
["Carlos Molina, DO",1225277833,"26-3789190","TX","PE - Permian Physician Services","Medicaid","Participating","Enrollment Complete","","363647401","","2020-10-01","10/01/2020 - Rec'd email from the clinic stating the TPI# only. NO effective date of TMHP group login info was shared. - Stacey Hudak"]
["Carlos Molina, DO",1225277833,"26-3789190","TX","PE - Permian Physician Services","Sedgwick","Pending Other Enrollment","Pending Contracting","","","","2023-11-28","Per Debbie Mason at Sedgwick TIN is not contracted/enrolled. Emailed roster and W9 per her request and she is looking into available contract opportunities. See group enrollment payor line for status/updates. Jen Videan"]
["Carlos Molina, DO",1225277833,"26-3789190","TX","PE - Permian Physician Services","Caprock (CapStar)","Participating","Enrollment Complete","2017-03-30","","","2020-09-14",""]
["Carlos Molina, DO",1225277833,"26-3789190","TX","PE - Permian Physician Services","Medicare","Participating","Enrollment Complete","2016-09-19","535392YTA9","0A3812","2020-09-25","09/25/2020 - Rec'd proof of Medicare enrollment from the clinic. Moved to completed status - stacey Hudak"]
["Carlos Molina, DO",1225277833,"26-3789190","TX","PE - Permian Physician Services","Corvel Healthcare Corp.","In Process","Pending Info/Document","","","","2023-11-21","Per Karina at Corvel, Permian Physician Services is part of SETHS delegated contract. Emailed MQA for assistance. Jen Videan"]
["Carlos Molina, DO",1225277833,"26-3789190","TX","PE - Permian Physician Services","Wellmed","Participating","Enrollment Complete","2022-01-01","","","2023-03-23","3/23/2023 Rcvd roster from UHC w/ all Wellmed participating providers.  Provider is PAR effective 1/1/2022.  DCannon"]
["Carlos Molina, DO",1225277833,"26-3789190","TX","PE - Permian Physician Services","Cigna","Participating","Enrollment Complete","2016-10-28","","","2021-03-08","3/8/2021 Rcvd confirmation from Cigna that provider is now participating under TIN and linked to location effective 10/28/2016.  CPID # 7966637.  DCannon"]
["Carlos Molina, DO",1225277833,"26-3789190","TX","PE - Permian Physician Services","Broadspire Services Inc.","In Process","Pending Info/Document","","","","2023-11-21","Emailed Priscilla and Neerja for status of signed group agreements. Unable to move forward with individual provider until group agreement is in place.  Jen Videan"]
["Carlos Molina, DO",1225277833,"26-3789190","TX","PE - Permian Physician Services","Liberty Mutual","Panel Closed","Panel Closed","","","","2023-07-24"," We appreciate your interest in joining the Coventry Network.  At this time, our panels are closed, and we are not accepting new applications.  Please check back routinely to stay apprised of our panel status. We will update this site when we are open for new applicants. Gallagher, Hartford, Liberty Mutual, Travelers and Zurich fall under Coventry. Jen Videan"]
["Carlos Molina, DO",1225277833,"26-3789190","TX","PE - Permian Physician Services","Alliance WC","Participating","Enrollment Complete","2023-07-21","","","2023-09-01","Per Michelle Killough @ pswca provider effective 07/21/2023. Jen Videan"]
["Carlos Molina, DO",1225277833,"26-3789190","TX","PE - Permian Physician Services","Galaxy Health","Participating","Enrollment Complete","2020-01-01","1225277833","","2020-10-05","10/5/2020 - Rec'd email back from the payer stating this enrollment has been completed - Stacey"]
["Carlos Molina, DO",1225277833,"26-3789190","TX","PE - Permian Physician Services","Hartford","Panel Closed","Panel Closed","","","","2023-07-24"," We appreciate your interest in joining the Coventry Network.  At this time, our panels are closed, and we are not accepting new applications.  Please check back routinely to stay apprised of our panel status. We will update this site when we are open for new applicants. Gallagher, Hartford, Liberty Mutual, Travelers and Zurich fall under Coventry. Jen Videan"]
["Carlos Molina, DO",1225277833,"26-3789190","TX","PE - Permian Physician Services","Texas Mutual","In Process","Application Resubmitted","","","","2023-11-21","Signed contract and required documents emailed to wwtxcontracts@texasmutual.com. Jen Videan"]
["Carlos Molina, DO",1225277833,"26-3789190","TX","PE - Permian Physician Services","USA PPO","Participating","Enrollment Complete","2017-04-03","1225277833","263789190","2020-08-19","Confirmed provider is participating with PPO and H&W networks (list of networks attached). Kimberly Frazier"]
["Carlos Molina, DO",1225277833,"26-3789190","TX","PE - Permian Physician Services","Wellcare","Participating","Enrollment Complete","2021-11-01","","","2022-12-01","12/1/2022 Per roster received from Wellcare provider is PAR and linked to group TIN/location effective 11/1/2021.  DCannon"]
["Carlos Molina, DO",1225277833,"26-3789190","TX","PE - Permian Physician Services","Zurich","Panel Closed","Panel Closed","","","","2023-07-24"," We appreciate your interest in joining the Coventry Network.  At this time, our panels are closed, and we are not accepting new applications.  Please check back routinely to stay apprised of our panel status. We will update this site when we are open for new applicants. Gallagher, Hartford, Liberty Mutual, Travelers and Zurich fall under Coventry. Jen Videan"]
["Carlos Molina, DO",1225277833,"26-3789190","TX","PE - Permian Physician Services","Triwest VA","Participating","Enrollment Complete","2017-08-01","","","2022-10-06","09/28/2022 - Received Permian Physician Services Roster from TriWest VA (Scarlett Abigail,  scarlett_abigail@bcbstx.com); provider listed as participating, effective 08/01/2017 | Priscilla A."]
["Carlos Molina, DO",1225277833,"26-3789190","TX","PE - Permian Physician Services","Travelers WC","Panel Closed","Panel Closed","","","","2023-07-24"," We appreciate your interest in joining the Coventry Network.  At this time, our panels are closed, and we are not accepting new applications.  Please check back routinely to stay apprised of our panel status. We will update this site when we are open for new applicants. Gallagher, Hartford, Liberty Mutual, Travelers and Zurich fall under Coventry. Jen Videan"]
["Carlos Molina, DO",1225277833,"26-3789190","TX","PE - Permian Physician Services","HealthSmart PPO","Participating","Enrollment Complete","2017-03-22","1225277833","","2020-09-23","09/23/2020 - moved to completed status after reviewing follow up complete note - Stacey Hudak"]
["Carlos Molina, DO",1225277833,"26-3789190","TX","PE - Permian Physician Services","Amerigroup","Participating","Enrollment Complete","2020-07-17","04579868","","2021-02-13","2/13/2021 - Verification on payer website Amerigroup.healthsparq.com provider is participating and linked to TIN and location for the following plans CHIP, CHIP-PERINATAL, STAR, STAR-KIDS, STAR-PLUS.  DCannon"]
["Carlos Molina, DO",1225277833,"26-3789190","TX","PE - Permian Physician Services","Multiplan","Participating","Enrollment Complete","2021-09-02","","","2022-07-23","7/23/2022 Per email from Marcie Eckhart-Haven at Multiplan provider is PAR and linked to group TIN effective 9/2/2021.  DCannon"]
["Alyssa Tochterman, MD",1972942209,"26-3789190","TX","PE - Permian Physician Services","Ambetter","Participating","Enrollment Complete","2022-04-01","","","2022-06-13","6/13/2022 Per roster received from Superior provider is PAR and linked to group delegation roster effective 4/1/2022."]
["Alyssa Tochterman, MD",1972942209,"26-3789190","TX","PE - Permian Physician Services","Caprock (CapStar)","Participating","Enrollment Complete","2016-10-26","","","2020-09-14",""]
["Alyssa Tochterman, MD",1972942209,"26-3789190","TX","PE - Permian Physician Services","Corvel Healthcare Corp.","In Process","Pending Info/Document","","","","2023-11-21","Per Karina at Corvel, Permian Physician Services is part of SETHS delegated contract. Emailed MQA for assistance. Jen Videan"]
["Alyssa Tochterman, MD",1972942209,"26-3789190","TX","PE - Permian Physician Services","Medicaid","Participating","Enrollment Complete","","363469301","","2020-10-01","10/01/2020 - Rec'd the TPI# for provider and Permian via email from the clinic contact, but no effective date or group login was provided - Stacey Hudak"]
["Alyssa Tochterman, MD",1972942209,"26-3789190","TX","PE - Permian Physician Services","Alliance WC","Participating","Enrollment Complete","","","","2023-10-02","Per Barry Harris at pswca.org provider is effective 09/22/2023. Jen Videan"]
["Alyssa Tochterman, MD",1972942209,"26-3789190","TX","PE - Permian Physician Services","USA PPO","Participating","Enrollment Complete","2016-10-26","1972942209","263789190","2020-08-19","Confirmed provider is partipating with PPO and H&W networks (list of networks attached). Kimberly Frazier"]
["Alyssa Tochterman, MD",1972942209,"26-3789190","TX","PE - Permian Physician Services","Medicare","Participating","Enrollment Complete","2016-07-19","442715YTA9","0A3812","2020-09-25","09/25/2020 - Rec'd email from this clinic that this provider is EFF with Medicare - Stacey Hudak"]
["Alyssa Tochterman, MD",1972942209,"26-3789190","TX","PE - Permian Physician Services","United Health Care","Participating","Enrollment Complete","2019-11-01","1972942209","","2020-10-02","10/02/2020 - moved to completed status after reviewing follow up complete note - Stacey Hudak"]
["Alyssa Tochterman, MD",1972942209,"26-3789190","TX","PE - Permian Physician Services","Texas Municipal League","Participating","Enrollment Complete","","","","2023-11-20","participating, please see Alliance notes. MS"]
["Alyssa Tochterman, MD",1972942209,"26-3789190","TX","PE - Permian Physician Services","First Health Coventry","Participating","Enrollment Complete","2016-11-01","2939545","","2023-05-02","5/2.2023 Per confirm par status - per rep, provider is showing participating with an effective date 11/1/2016 and link under the Group and TIN. Provider ID 2939545.  Service location is on file. Call ref#:610334. DCannon"]
["Alyssa Tochterman, MD",1972942209,"26-3789190","TX","PE - Permian Physician Services","Multiplan","Participating","Enrollment Complete","2020-07-13","","","2022-07-23","7/23/2022 Per email from Marcie Eckhart-Haven at Multiplan provider is PAR and linked to group TIN effective 7/13/2022.  DCannon"]
["Alyssa Tochterman, MD",1972942209,"26-3789190","TX","PE - Permian Physician Services","Triwest VA","Participating","Enrollment Complete","2017-08-01","","","2022-10-06","09/28/2022 -  Received Permian Physician Services roster from TriWest VA (Scarlett Abigail, Scarlett_Abigail@bcbstx.com); provider listed as participating, eff. 08/01/2017 | Priscilla A."]
["Alyssa Tochterman, MD",1972942209,"26-3789190","TX","PE - Permian Physician Services","Texas Mutual","In Process","Application Resubmitted","","","","2023-11-21","Signed contract and required documents emailed to wwtxcontracts@texasmutual.com. Jen Videan"]
["Alyssa Tochterman, MD",1972942209,"26-3789190","TX","PE - Permian Physician Services","Cigna","Participating","Enrollment Complete","2019-09-01","1972942209","","2020-09-23","09/23/2020 - moved to completed status after reviewing follow up complete note - Stacey Hudak"]
["Alyssa Tochterman, MD",1972942209,"26-3789190","TX","PE - Permian Physician Services","Broadspire Services Inc.","In Process","Pending Info/Document","","","","2023-11-21","Emailed Priscilla and Neerja for status of signed group agreements. Unable to move forward with individual provider until group agreement is in place.  Jen Videan"]
["Alyssa Tochterman, MD",1972942209,"26-3789190","TX","PE - Permian Physician Services","Sedgwick","Pending Other Enrollment","Pending Contracting","","","","2023-11-28","Per Debbie Mason at Sedgwick TIN is not contracted/enrolled. Emailed roster and W9 per her request and she is looking into available contract opportunities. See group enrollment payor line for status/updates. Jen Videan"]
["Alyssa Tochterman, MD",1972942209,"26-3789190","TX","PE - Permian Physician Services","Galaxy Health","Participating","Enrollment Complete","2019-09-01","1972942209","","2020-08-21","08/21/2020 - Rec'd email confirmation that this roster was processed and this provider was made effective with the requested eff date of 9-1-2019 - Stacey Hudak"]
["Alyssa Tochterman, MD",1972942209,"26-3789190","TX","PE - Permian Physician Services","HealthSmart PPO","Participating","Enrollment Complete","2016-10-19","1972942209","","2020-09-23","09/23/2020 - moved to completed status after reviewing follow up completed note - Stacey Hudak"]
["Alyssa Tochterman, MD",1972942209,"26-3789190","TX","PE - Permian Physician Services","Wellcare","Participating","Enrollment Complete","2021-11-01","","","2022-12-01","12/1/2022 Per roster received from Wellcare provider is PAR and linked to group TIN/location effective 11/1/2021.  DCannon"]
["Alyssa Tochterman, MD",1972942209,"26-3789190","TX","PE - Permian Physician Services","Gallagher","Panel Closed","Panel Closed","","","","2023-07-24"," We appreciate your interest in joining the Coventry Network.  At this time, our panels are closed, and we are not accepting new applications.  Please check back routinely to stay apprised of our panel status. We will update this site when we are open for new applicants. Gallagher, Hartford, Liberty Mutual, Travelers and Zurich fall under Coventry. Jen Videan"]
["Alyssa Tochterman, MD",1972942209,"26-3789190","TX","PE - Permian Physician Services","TriCare Standard","Participating","Enrollment Complete","2020-08-04","","","2020-12-22","12/22/2020 Confirmed via self-service portal provider is certified as non-network under Group and Tax ID, as well as location. KFrazier"]
["Alyssa Tochterman, MD",1972942209,"26-3789190","TX","PE - Permian Physician Services","Aetna","Participating","Enrollment Complete","2016-11-01","","","2020-12-04","12/4/2020 - Rcvd completed PRIMED ROSTER back from the payer. This provider is PAR at this service location eff 9/1/2020.  DCannon"]
["Alyssa Tochterman, MD",1972942209,"26-3789190","TX","PE - Permian Physician Services","Amerigroup","Participating","Enrollment Complete","2020-07-14","04223193","","2021-02-13","2/13/2021 - Verification on payer website Amerigroup.healthsparq.com provider is participating and linked to TIN and location for the following plans CHIP, CHIP-PERINATAL, STAR, STAR-KIDS, STAR-PLUS.  DCannon"]
["Alyssa Tochterman, MD",1972942209,"26-3789190","TX","PE - Permian Physician Services","Coventry Workers Comp","Panel Closed","Panel Closed","","","","2023-07-24"," We appreciate your interest in joining the Coventry Network.  At this time, our panels are closed, and we are not accepting new applications.  Please check back routinely to stay apprised of our panel status. We will update this site when we are open for new applicants. Gallagher, Hartford, Liberty Mutual, Travelers and Zurich fall under Coventry. Jen Videan"]
["Alyssa Tochterman, MD",1972942209,"26-3789190","TX","PE - Permian Physician Services","Zurich","Panel Closed","Panel Closed","","","","2023-07-24"," We appreciate your interest in joining the Coventry Network.  At this time, our panels are closed, and we are not accepting new applications.  Please check back routinely to stay apprised of our panel status. We will update this site when we are open for new applicants. Gallagher, Hartford, Liberty Mutual, Travelers and Zurich fall under Coventry. Jen Videan"]
["Alyssa Tochterman, MD",1972942209,"26-3789190","TX","PE - Permian Physician Services","Liberty Mutual","Panel Closed","Panel Closed","","","","2023-07-24"," We appreciate your interest in joining the Coventry Network.  At this time, our panels are closed, and we are not accepting new applications.  Please check back routinely to stay apprised of our panel status. We will update this site when we are open for new applicants. Gallagher, Hartford, Liberty Mutual, Travelers and Zurich fall under Coventry. Jen Videan"]
["Alyssa Tochterman, MD",1972942209,"26-3789190","TX","PE - Permian Physician Services","Humana","Participating","Enrollment Complete","2016-10-26","","","2021-11-18","11/18/2021 Rcvd full roster from Humana listing provider as PAR and linked to group TIN/location effective 10/26/2016.  DCannon"]
["Alyssa Tochterman, MD",1972942209,"26-3789190","TX","PE - Permian Physician Services","Superior","Participating","Enrollment Complete","2020-10-01","1972942209","","2020-10-01","10/01/2020 - Rec'd completed spreadsheet from the payer stating this provider is EFF - Stacey Hudak"]
["Alyssa Tochterman, MD",1972942209,"26-3789190","TX","PE - Permian Physician Services","Travelers WC","Panel Closed","Panel Closed","","","","2023-07-24"," We appreciate your interest in joining the Coventry Network.  At this time, our panels are closed, and we are not accepting new applications.  Please check back routinely to stay apprised of our panel status. We will update this site when we are open for new applicants. Gallagher, Hartford, Liberty Mutual, Travelers and Zurich fall under Coventry. Jen Videan"]
["Alyssa Tochterman, MD",1972942209,"26-3789190","TX","PE - Permian Physician Services","Hartford","Panel Closed","Panel Closed","","","","2023-07-24"," We appreciate your interest in joining the Coventry Network.  At this time, our panels are closed, and we are not accepting new applications.  Please check back routinely to stay apprised of our panel status. We will update this site when we are open for new applicants. Gallagher, Hartford, Liberty Mutual, Travelers and Zurich fall under Coventry. Jen Videan"]
["Alyssa Tochterman, MD",1972942209,"26-3789190","TX","PE - Permian Physician Services","Scott&White (First Care)","Participating","Enrollment Complete","2016-10-19","1972942209","","2020-08-19","08/19/2020 - Rec'd spreadsheet from the payer confirming this provider is linked to this TIN/service location and networked with the following: \nFirstCare MyChoice PPO\nCHIP\nFirstCare Select Benefit Network\nHMO Enhanced Benefit Network\nMedicaid (FC)\nMedicare (FC)\nPPO Limited Benefit Network  - Stacey Hudak"]
["Margaret Merriam, DO",1083867147,"26-3789190","TX","PE - Permian Physician Services","HealthSmart PPO","Participating","Enrollment Complete","2017-05-31","","","2021-04-11","4/11/2021 Rcvd email from HealthSmart <mdipsupport@healthsmart.com> confirming participation of provider under TIN and location effective 5/31/2017.  DCannon"]
["Margaret Merriam, DO",1083867147,"26-3789190","TX","PE - Permian Physician Services","Wellmed","Participating","Enrollment Complete","2022-01-01","","","2023-03-23","3/23/2023 Rcvd roster from UHC w/ all Wellmed participating providers.  Provider is PAR effective 1/1/2022.  DCannon"]
["Margaret Merriam, DO",1083867147,"26-3789190","TX","PE - Permian Physician Services","First Health Coventry","Participating","Enrollment Complete","2021-12-01","","","2023-05-02","5/2.2023 Per confirm par status -  Per rep, provider is showing participating with an effective date 12/1/2021 and link under the Group and TIN. Provider ID 2680644.  Service location is on file. Call ref#:610334. DCannon"]
["Margaret Merriam, DO",1083867147,"26-3789190","TX","PE - Permian Physician Services","Humana","Participating","Enrollment Complete","2017-06-05","","","2021-11-18","11/18/2021 Rcvd full roster from Humana listing provider as PAR and linked to group TIN/location effective 6/5/2017.  DCannon"]
["Margaret Merriam, DO",1083867147,"26-3789190","TX","PE - Permian Physician Services","Ambetter","Participating","Enrollment Complete","2022-06-01","","","2022-06-13","6/13/2022 Per roster received from Superior provider is PAR and linked to group delegation roster effective 6/1/2022."]
["Margaret Merriam, DO",1083867147,"26-3789190","TX","PE - Permian Physician Services","Coventry Workers Comp","Panel Closed","Panel Closed","","","","2023-07-25","We appreciate your interest in joining the Coventry Network.  At this time, our panels are closed, and we are not accepting new applications.  Please check back routinely to stay apprised of our panel status. We will update this site when we are open for new applicants. Gallagher, Hartford, Liberty Mutual, Travelers and Zurich fall under Coventry. Jen Videan"]
["Margaret Merriam, DO",1083867147,"26-3789190","TX","PE - Permian Physician Services","Texas Mutual","In Process","Application Resubmitted","","","","2023-11-28","TSCA and required documents resubmitted to wwtxcontracts@texasmutual.com. Jen Videan"]
["Margaret Merriam, DO",1083867147,"26-3789190","TX","PE - Permian Physician Services","Sedgwick","Pending Other Enrollment","Pending Contracting","","","","2023-11-28","Per Debbie Mason at Sedgwick TIN is not contracted/enrolled. Emailed roster and W9 per her request and she is looking into available contract opportunities. See group enrollment payor line for status/updates. Jen Videan"]
["Margaret Merriam, DO",1083867147,"26-3789190","TX","PE - Permian Physician Services","Superior","Participating","Enrollment Complete","2020-09-01","1083867147","","2020-09-02","09/02/2020 - Rec'd email from the payer stating this provider add to TIN has been completed. Delegated roster has been processed - Stacey Hudak"]
["Margaret Merriam, DO",1083867147,"26-3789190","TX","PE - Permian Physician Services","Amerigroup","Participating","Enrollment Complete","2020-08-05","04727805","","2023-08-17","8/17/2023 Per email from Priscilla Albertine at MQA she received a roster from Amerigroup confirming that provider is PAR and linked to group TIN/location effective 8/5/2020.  DCannon"]
["Margaret Merriam, DO",1083867147,"26-3789190","TX","PE - Permian Physician Services","TriCare Standard","Participating","Enrollment Complete","2021-04-14","","","2021-05-09","5/9/2021 Upon review of the self-service portal, provider has been loaded under group Tax ID and location effective 4/14/2021. KFrazier"]
["Margaret Merriam, DO",1083867147,"26-3789190","TX","PE - Permian Physician Services","Multiplan","Participating","Enrollment Complete","2020-08-05","","","2022-07-23","7/23/2022 Per email from Marcie Eckhart-Haven at Multiplan provider is PAR and linked to group TIN effective 8/5/2020.  DCannon"]
["Margaret Merriam, DO",1083867147,"26-3789190","TX","PE - Permian Physician Services","Aetna","Participating","Enrollment Complete","2021-12-01","","","2023-03-21","3/21/2023 Per email from Priscilla Albertine at MQA provider's correct effective date for TIN 26-3789190 is 12/1/2021.  DCannon"]
["Margaret Merriam, DO",1083867147,"26-3789190","TX","PE - Permian Physician Services","Broadspire Services Inc.","In Process","Pending Info/Document","","","","2023-11-21","Emailed Priscilla and Neerja for status of signed group agreements. Unable to move forward with individual provider until group agreement is in place.  Jen Videan"]
["Margaret Merriam, DO",1083867147,"26-3789190","TX","PE - Permian Physician Services","Gallagher","Panel Closed","Panel Closed","","","","2023-07-25","We appreciate your interest in joining the Coventry Network.  At this time, our panels are closed, and we are not accepting new applications.  Please check back routinely to stay apprised of our panel status. We will update this site when we are open for new applicants. Gallagher, Hartford, Liberty Mutual, Travelers and Zurich fall under Coventry. Jen Videan"]
["Margaret Merriam, DO",1083867147,"26-3789190","TX","PE - Permian Physician Services","Scott&White (First Care)","Participating","Enrollment Complete","2017-10-23","1083867147","","2020-08-19","8/19/2020 - Rec'd email from the payer stating this provider is already affiliated with the PRIMED DELEGATED AGREEMENT and enrolled with this group TIN/Service Location and group NPI# 1124054069 - Stacey Hudak\n\n**Verified this provider is networked with:\nFirstCare MyChoice PPO\nCHIP\nFirstCare Select Benefit Network\nHMO Enhanced Benefit Network\nMedicaid (FC)\nMedicare (FC)\nPPO Limited Benefit Network"]
["Margaret Merriam, DO",1083867147,"26-3789190","TX","PE - Permian Physician Services","USA PPO","Participating","Enrollment Complete","2017-06-08","1083867147","263789190","2020-08-19","Confirmed provider is participating with PPO and H&W networks (list of networks attached). Kimberly Frazier"]
["Margaret Merriam, DO",1083867147,"26-3789190","TX","PE - Permian Physician Services","Travelers WC","Panel Closed","Panel Closed","","","","2023-08-22","08/22/2023  We appreciate your interest in joining the Coventry Network.  At this time, our panels are closed, and we are not accepting new applications.  Please check back routinely to stay apprised of our panel status. We will update this site when we are open for new applicants. Gallagher, Hartford, Liberty Mutual, Travelers and Zurich fall under Coventry. Jen Videan"]
["Margaret Merriam, DO",1083867147,"26-3789190","TX","PE - Permian Physician Services","Hartford","Panel Closed","Panel Closed","","","","2023-07-25","We appreciate your interest in joining the Coventry Network.  At this time, our panels are closed, and we are not accepting new applications.  Please check back routinely to stay apprised of our panel status. We will update this site when we are open for new applicants. Gallagher, Hartford, Liberty Mutual, Travelers and Zurich fall under Coventry. Jen Videan"]
["Margaret Merriam, DO",1083867147,"26-3789190","TX","PE - Permian Physician Services","Zurich","Panel Closed","Panel Closed","","","","2023-07-25","We appreciate your interest in joining the Coventry Network.  At this time, our panels are closed, and we are not accepting new applications.  Please check back routinely to stay apprised of our panel status. We will update this site when we are open for new applicants. Gallagher, Hartford, Liberty Mutual, Travelers and Zurich fall under Coventry. Jen Videan"]
["Margaret Merriam, DO",1083867147,"26-3789190","TX","PE - Permian Physician Services","Galaxy Health","Participating","Enrollment Complete","2019-09-01","1083867147","","2020-08-21","08/21/2020 - Rec'd email confirmation that this roster was processed and this provider was made effective with the requested eff date of 9-1-2019 - Stacey Hudak"]
["Margaret Merriam, DO",1083867147,"26-3789190","TX","PE - Permian Physician Services","Wellcare","Participating","Enrollment Complete","2021-11-01","","","2022-12-01","12/1/2022 Per roster received from Wellcare provider is PAR and linked to group TIN/location effective 11/1/2021.  DCannon"]
["Margaret Merriam, DO",1083867147,"26-3789190","TX","PE - Permian Physician Services","Rail Road Medicare","Participating","Enrollment Complete","2009-03-16","P02539434","DS7320","2020-10-29","10/29/2020 - Rec'd confirmation of effective enrollment from the payer portal - Stacey Hudak"]
["Margaret Merriam, DO",1083867147,"26-3789190","TX","PE - Permian Physician Services","Triwest VA","Participating","Enrollment Complete","2018-01-01","","","2022-10-06","09/28/2022 -  Received Permian Physician Services roster from TriWest VA (Scarlett Abigail, Scarlett_Abigail@bcbstx.com); provider listed as participating, eff. 01/01/2018  |  Priscilla A"]
["Margaret Merriam, DO",1083867147,"26-3789190","TX","PE - Permian Physician Services","Liberty Mutual","Panel Closed","Panel Closed","","","","2023-07-25","We appreciate your interest in joining the Coventry Network.  At this time, our panels are closed, and we are not accepting new applications.  Please check back routinely to stay apprised of our panel status. We will update this site when we are open for new applicants. Gallagher, Hartford, Liberty Mutual, Travelers and Zurich fall under Coventry. Jen Videan"]
["Margaret Merriam, DO",1083867147,"26-3789190","TX","PE - Permian Physician Services","United Health Care","Participating","Enrollment Complete","2019-11-01","1083867147","","2020-10-02","10/02/2020 - moved to completed status after reviewing follow up complete note - Stacey Hudak"]
["Margaret Merriam, DO",1083867147,"26-3789190","TX","PE - Permian Physician Services","Hartford","Panel Closed","Panel Closed","","","","2023-07-25","We appreciate your interest in joining the Coventry Network.  At this time, our panels are closed, and we are not accepting new applications.  Please check back routinely to stay apprised of our panel status. We will update this site when we are open for new applicants. Gallagher, Hartford, Liberty Mutual, Travelers and Zurich fall under Coventry. Jen Videan"]
["Margaret Merriam, DO",1083867147,"26-3789190","TX","PE - Permian Physician Services","Cigna","Participating","Enrollment Complete","2019-09-01","1083867147","","2020-09-23","09/23/2020 - moved to completed status after reviewing follow up complete note - Stacey Hudak"]
["Margaret Merriam, DO",1083867147,"26-3789190","TX","PE - Permian Physician Services","Medicaid","Participating","Enrollment Complete","","367456601","","2020-10-01","10/01/2020 - This clinic has sent me the TPI# only - no group sign on info. Moved to completed status - Stacey Hudak"]
["Margaret Merriam, DO",1083867147,"26-3789190","TX","PE - Permian Physician Services","Medicare","Participating","Enrollment Complete","2017-02-20","560166YTA9","0A3812","2020-09-25","09/25/2020 - moved to completed status after reviewing PECOS EFF info from the clinic - Stacey Hudak"]
["Margaret Merriam, DO",1083867147,"26-3789190","TX","PE - Permian Physician Services","Alliance WC","Participating","Enrollment Complete","2023-07-21","","","2023-09-01","Per Michelle Killough @ pswca provider effective 07/21/2023. Jen Videan"]
["Margaret Merriam, DO",1083867147,"26-3789190","TX","PE - Permian Physician Services","Caprock (CapStar)","Participating","Enrollment Complete","2017-06-05","","","2020-09-14",""]
["Jennifer B Hada-Ondriezek, DNP",1669617981,"26-3789190","TX","PE - Permian Physician Services","Triwest VA","Participating","Enrollment Complete","2015-01-01","","","2022-10-06","09/28/2022 -  Received Permian Physician Services roster from TriWest VA (Scarlett Abigail, Scarlett_Abigail@bcbstx.com); provider listed as participating, eff. 01/01/2015 | Priscilla A"]
["Jennifer B Hada-Ondriezek, DNP",1669617981,"26-3789190","TX","PE - Permian Physician Services","Aetna","Participating","Enrollment Complete","2020-09-16","9363366","","2021-07-01","7/1/2021 Per Aetna roster received from Jamie Roberts provider is PAR and linked to TIN/locations effective 9/16/2020.  DCannon"]
["Jennifer B Hada-Ondriezek, DNP",1669617981,"26-3789190","TX","PE - Permian Physician Services","Medicare","Participating","Enrollment Complete","2021-01-01","1M9244","","2021-04-26","4/26/2021 Per Stacy Salazar she processed provider's enrollment application and assigned PTAN is 1M9244, effective 1/1/2021. KFrazier"]
["Jennifer B Hada-Ondriezek, DNP",1669617981,"26-3789190","TX","PE - Permian Physician Services","Wellmed","Participating","Enrollment Complete","2022-01-01","","","2023-03-23","3/23/2023 Rcvd roster from UHC w/ all Wellmed participating providers.  Provider is PAR effective 1/1/2022.  DCannon"]
["Jennifer B Hada-Ondriezek, DNP",1669617981,"26-3789190","TX","PE - Permian Physician Services","Texas Mutual","In Process","Application Resubmitted","2021-09-01","","","2023-11-22","TSCA and required documents emailed to wwtxcontracts@texasmutual.com. Jen Videan"]
["Jennifer B Hada-Ondriezek, DNP",1669617981,"26-3789190","TX","PE - Permian Physician Services","Medicaid","In House Enrollment","Enrollment Complete","2021-01-01","205286204","","2021-05-05","5/5/2021 Per email received from Stacy Salazar, provider has been approved and assigned TPI 205286204 effective 1/1/2021. KFrazier"]
["Jennifer B Hada-Ondriezek, DNP",1669617981,"26-3789190","TX","PE - Permian Physician Services","Alliance WC","Participating","Enrollment Complete","","","","2023-05-22","Michelle Killough confirmed provider is effective since 2019. MS"]
["Jennifer B Hada-Ondriezek, DNP",1669617981,"26-3789190","TX","PE - Permian Physician Services","Multiplan","Participating","Enrollment Complete","2020-09-17","","","2022-07-23","7/23/2022 Per email from Marcie Eckhart-Haven at Multiplan provider is PAR and linked to group TIN effective  9/17/2021. DCannon"]
["Jennifer B Hada-Ondriezek, DNP",1669617981,"26-3789190","TX","PE - Permian Physician Services","United Health Care","Participating","Enrollment Complete","2019-11-01","","","2021-01-18","1/18/2021 - Per follow-up notes provider NPI# is on file for the provider and is participating effective 11/01/2019 for Commercial Choice, 08/02/2017 for Community and State and 06/01/2020 for Medicare under the group and TIN#.  DCannon"]
["Jennifer B Hada-Ondriezek, DNP",1669617981,"26-3789190","TX","PE - Permian Physician Services","Ambetter","Participating","Enrollment Complete","2022-04-01","","","2022-06-13","6/13/2022 Received April Monthly Validation roster from Superior and provider is PAR and linked effective 4/1/2022.  DCannon"]
["Jennifer B Hada-Ondriezek, DNP",1669617981,"26-3789190","TX","PE - Permian Physician Services","HealthSmart PPO","Participating","Enrollment Complete","2019-09-26","","","2021-04-11","4/11/2021 Rcvd email from HealthSmart <mdipsupport@healthsmart.com> confirming participation of provider under TIN and location effective 9/26/2019.  DCannon"]
["Jennifer B Hada-Ondriezek, DNP",1669617981,"26-3789190","TX","PE - Permian Physician Services","Humana","Participating","Enrollment Complete","2010-07-01","","","2021-07-09","7/9/2021 Called Humana at 800-626-2741 spoke w/ Taylor, call reference # 2000191481297 he confirmed that provider is PAR under TIN and location effective 7/1/2010.  DCannon"]
["Jennifer B Hada-Ondriezek, DNP",1669617981,"26-3789190","TX","PE - Permian Physician Services","Cigna","Participating","Enrollment Complete","2019-09-01","6837080","","2020-12-04","12/4/2020 Rcvd email from Cigna confirming provider is PAR at location.  PID: 6837080; TIN: 263789190\nEffective date: 09/01/2019.  DCannon"]
["Jennifer B Hada-Ondriezek, DNP",1669617981,"26-3789190","TX","PE - Permian Physician Services","Scott&White (First Care)","Participating","Enrollment Complete","2021-03-12","","","2021-04-22","4/22/2021 Rcvd roster from S&W and provider is participating and linked to TIN effective 03/12/2021.  DCannon"]
["Jennifer B Hada-Ondriezek, DNP",1669617981,"26-3789190","TX","PE - Permian Physician Services","Sedgwick","Pending Other Enrollment","Pending Contracting","","","","2023-11-28","Per Debbie Mason at Sedgwick TIN is not contracted/enrolled. Emailed roster and W9 per her request and she is looking into available contract opportunities. See group enrollment payor line for status/updates. Jen Videan"]
["Jennifer B Hada-Ondriezek, DNP",1669617981,"26-3789190","TX","PE - Permian Physician Services","Gallagher","Panel Closed","Panel Closed","","","","2023-07-19","07/18/2023. We appreciate your interest in joining the Coventry Network.  At this time, our panels are closed, and we are not accepting new applications.  Please check back routinely to stay apprised of our panel status. We will update this site when we are open for new applicants. Gallagher, Hartford, Liberty Mutual, Travelers and Zurich fall under Coventry. Jen Videan"]
["Jennifer B Hada-Ondriezek, DNP",1669617981,"26-3789190","TX","PE - Permian Physician Services","Superior","Participating","Enrollment Complete","2021-12-01","","","2021-12-07","12/7/2021 Rcvd email from SuperiorDelegation that November delegation roster has been completed and providers are loaded under appropriate group TIN/locations effective 12/1/2021.  DCannon"]
["Jennifer B Hada-Ondriezek, DNP",1669617981,"26-3789190","TX","PE - Permian Physician Services","USA PPO","Participating","Enrollment Complete","2019-08-30","1138545","","2020-12-17","12/17/2020 Per provider roster from September provider is listed as par at this location effective 8/30/2019.  DCannon"]
["Jennifer B Hada-Ondriezek, DNP",1669617981,"26-3789190","TX","PE - Permian Physician Services","Caprock (CapStar)","Participating","Enrollment Complete","2019-08-26","","","2021-04-09","4/9/2020 Rcvd roster from Mary Rodriguez <mary.rodriguez@90degreebenefits.com> at Caprock listing provider as participating under TIN.  DCannon"]
["Jennifer B Hada-Ondriezek, DNP",1669617981,"26-3789190","TX","PE - Permian Physician Services","TriCare Standard","Participating","Enrollment Complete","","","","2021-09-15","7/2/2021- S/W Tierra OF TRICARE Standard @ 8004445445, call was transferred to WPS for further assistance, Spoke to Sandra, as per Rep, NPI#is on file for the provider, shows certified Non particpiating under the group and TIN# effective 6/1/2021-11/1/2022 under the physical location. Provider ID is 26-3789190-79714-C006. to become a Par provider need to contact PR liason for assistance, Rep do not have the contact info and TAT for the process. Call ref# Herminia Gilongos"]
["Jennifer B Hada-Ondriezek, DNP",1669617981,"26-3789190","TX","PE - Permian Physician Services","First Health Coventry","Participating","Enrollment Complete","2020-09-16","","","2023-05-02","5/2.2023 Per confirm par status.  Per rep, provider is showing participating with an effective date 9/16/2020 and link under the Group and TIN. Provider ID 2099013.  Service location is on file. Call ref#:610334. DCannon"]
["Jennifer B Hada-Ondriezek, DNP",1669617981,"26-3789190","TX","PE - Permian Physician Services","Galaxy Health","Participating","Enrollment Complete","2020-09-17","","","2020-12-14","12/14/2020 - Rcvd email confirmation from Galaxy Health that the November Delegation Roster was completed. DCannon"]
["Jennifer B Hada-Ondriezek, DNP",1669617981,"26-3789190","TX","PE - Permian Physician Services","Wellcare","Participating","Enrollment Complete","2022-04-01","","","2022-07-01","7/1/2022 Received April Monthly Validation roster from Superior and provider is PAR and linked effective 4/1/2022.  DCannon"]
["Jennifer B Hada-Ondriezek, DNP",1669617981,"26-3789190","TX","PE - Permian Physician Services","Amerigroup","Participating","Enrollment Complete","2015-10-29","01449153","","2021-02-13","2/13/2021 - Rcvd complete roster from Amerigroup provider is participating and linked to TIN and location for the following plans STAR - eff 3/1/2012; Medicare - eff 8/1/2012; C-SNP - eff 1/1/2017; Other - eff 1/1/2021, Plus - eff 3/1/2012, Star_Kids - eff 11/1/2016.  DCannon"]
["Stephanie Jean Fitzgerald, MD",1184035313,"26-3789190","TX","PE - Permian Physician Services","Superior","Participating","Enrollment Complete","2020-10-01","1184035313","","2020-10-02","10/02/2020 - Rec'd email from the payer stating this provider has been added to the delegated primed roster - Stacey Hudak"]
["Stephanie Jean Fitzgerald, MD",1184035313,"26-3789190","TX","PE - Permian Physician Services","Caprock (CapStar)","Participating","Enrollment Complete","2020-08-05","","","2021-04-09","4/9/2020 Rcvd roster from Mary Rodriguez <mary.rodriguez@90degreebenefits.com> at Caprock listing provider as participating under TIN.  DCannon"]
["Stephanie Jean Fitzgerald, MD",1184035313,"26-3789190","TX","PE - Permian Physician Services","Amerigroup","Participating","Enrollment Complete","2020-08-05","","","2021-08-26","8/26/2021 Rcvd full roster from Joe Rodriguez at Amerigroup listing provider as PAR w/ group TIN and location effective 8/5/2020.  DCannon"]
["Stephanie Jean Fitzgerald, MD",1184035313,"26-3789190","TX","PE - Permian Physician Services","Wellcare","Participating","Enrollment Complete","2021-11-01","","","2022-11-15","11/15/2022 Per roster received from Wellcare provider is PAR and linked to group TIN/location effective 11/1/2021.  DCannon"]
["Stephanie Jean Fitzgerald, MD",1184035313,"26-3789190","TX","PE - Permian Physician Services","HealthSmart PPO","Participating","Enrollment Complete","2020-08-05","","","2021-12-03","12/3/2021 Per Healthsmart website provider is PAR and loaded under TIN/location effective 8/5/2020.  DCannon"]
["Stephanie Jean Fitzgerald, MD",1184035313,"26-3789190","TX","PE - Permian Physician Services","Medicare","Participating","Enrollment Complete","2020-06-22","1D9600","","2020-10-27","10/27/2020 Upon review of PECOS, provider has been issued PTAN 1D9600 effective 6/22/2020. Kimberly Frazier"]
["Stephanie Jean Fitzgerald, MD",1184035313,"26-3789190","TX","PE - Permian Physician Services","Sedgwick","Pending Other Enrollment","Pending Contracting","","","","2023-11-28","Per Debbie Mason at Sedgwick TIN is not contracted/enrolled. Emailed roster and W9 per her request and she is looking into available contract opportunities. See group enrollment payor line for status/updates. Jen Videan"]
["Stephanie Jean Fitzgerald, MD",1184035313,"26-3789190","TX","PE - Permian Physician Services","Ambetter","Participating","Enrollment Complete","2022-06-01","","","2022-06-13","6/13/2022 Per roster received from Superior provider is PAR and linked to group delegation roster effective 6/1/2022."]
["Stephanie Jean Fitzgerald, MD",1184035313,"26-3789190","TX","PE - Permian Physician Services","First Health Coventry","Participating","Enrollment Complete","2023-05-28","3133441","","2023-07-25","7/25/2023  Per First Health online provider directory provider is PAR and linked to group/locations  effective 5/28/2023.  DCannon"]
["Stephanie Jean Fitzgerald, MD",1184035313,"26-3789190","TX","PE - Permian Physician Services","Multiplan","Participating","Enrollment Complete","2020-08-05","","","2022-07-23","7/23/2022 Per email from Marcie Eckhart-Haven at Multiplan provider is PAR and linked to group TIN effective 8/5/2020.  DCannon"]
["Stephanie Jean Fitzgerald, MD",1184035313,"26-3789190","TX","PE - Permian Physician Services","Humana","Participating","Enrollment Complete","2021-09-01","","","2021-11-18","11/18/2021 Rcvd full roster from Humana listing provider as PAR and linked to group TIN/location effective 9/1/2021.  DCannon"]
["Stephanie Jean Fitzgerald, MD",1184035313,"26-3789190","TX","PE - Permian Physician Services","TriCare Standard","Participating","Enrollment Complete","2020-06-22","","","2020-10-27","10/27/2020 Confirmed provider is certified as a non-network provider. Kimberly Frazier"]
["Stephanie Jean Fitzgerald, MD",1184035313,"26-3789190","TX","PE - Permian Physician Services","United Health Care","Participating","Enrollment Complete","2020-08-22","1184035313","","2020-10-23","10/23/2020 -Called the payer and spoke with Corrine and was told that this provider HAS BEEN DE-DELEGATED AS OF 6-19-2020 and currently holds a direct contract with UHC. Provider is linked to this TIN as of 8-22-2020. - Stacey Hudak"]
["Stephanie Jean Fitzgerald, MD",1184035313,"26-3789190","TX","PE - Permian Physician Services","Cigna","Participating","Enrollment Complete","2020-08-05","8214651","","2021-04-22","4/22/2021 Rcvd email from Cigna <intake_pdm@cigna.com that provider is participating and linked to TIN and locations.  CPID # 8214651 effective 8/5/2020.  DCannon"]
["Stephanie Jean Fitzgerald, MD",1184035313,"26-3789190","TX","PE - Permian Physician Services","Texas Mutual","Participating","Enrollment Complete","2021-09-01","","","2023-05-10","5/10/2023 Per email rcvd TX Mutual - WorkWell provider is PAR and linked to group effective 9/1/2021.  DCannon"]
["Stephanie Jean Fitzgerald, MD",1184035313,"26-3789190","TX","PE - Permian Physician Services","Scott&White (First Care)","Participating","Enrollment Complete","2021-02-12","","","2021-01-29","1/29/2021 - Rcvd roster from Scott&White (First Care) confirming participation of provider with TIN and location effective dates.  DCannon"]
["Stephanie Jean Fitzgerald, MD",1184035313,"26-3789190","TX","PE - Permian Physician Services","Triwest VA","Participating","Enrollment Complete","2022-10-01","","","2022-10-06","09/28/2022 - Received Permian Physician Services Roster from TriWest VA (Scarlett Abigail,  scarlett_abigail@bcbstx.com); provider listed as participating, effective 10/01/2022 | Priscilla A."]
["Stephanie Jean Fitzgerald, MD",1184035313,"26-3789190","TX","PE - Permian Physician Services","Aetna","Participating","Enrollment Complete","2020-09-01","1184035313","","2020-11-03","11/3/2020 - Rec'd email from the payer confirming this provider is effective with this TIN - Stacey Hudak"]
["Stephanie Jean Fitzgerald, MD",1184035313,"26-3789190","TX","PE - Permian Physician Services","Medicaid","Participating","Enrollment Complete","2020-06-22","378571905","205408201","2020-11-03","11/3/2020 Per email received from Stacy Salazar, provider has been approved and assigned TPI 378571905. Kimberly Frazier"]
["Stephanie Jean Fitzgerald, MD",1184035313,"26-3789190","TX","PE - Permian Physician Services","Wellmed","Participating","Enrollment Complete","2022-01-01","","","2023-03-23","3/23/2023 Rcvd roster from UHC w/ all Wellmed participating providers.  Provider is PAR effective 1/1/2022.  DCannon"]
["Stephanie Jean Fitzgerald, MD",1184035313,"26-3789190","TX","PE - Permian Physician Services","Galaxy Health","Participating","Enrollment Complete","2019-09-01","1184035313","","2020-08-21",""]
["Stephanie Jean Fitzgerald, MD",1184035313,"26-3789190","TX","PE - Permian Physician Services","USA PPO","Participating","Enrollment Complete","2021-01-26","1312291","","2021-03-12","3/12/2021 Per verification on payor website USAMCO.com provider is loaded as participating.  Rcvd Roster LeNetrice Myart with provider numbers and effective dates for providers.  DCannon"]
["Stephanie Jean Fitzgerald, MD",1184035313,"26-3789190","TX","PE - Permian Physician Services","Alliance WC","Participating","Enrollment Complete","2020-12-04","","","2023-05-22","Michelle Killough confirmed provider is effective 12/4/2020. MS"]
["Rahul Dinesh Puri, MD",1306928098,"26-3789190","TX","PE - Permian Physician Services","Wellcare","Participating","Enrollment Complete","2021-11-01","","","2022-12-01","12/1/2022 Per roster received from Wellcare provider is PAR and linked to group TIN/location effective 11/1/2021.  DCannon"]
["Rahul Dinesh Puri, MD",1306928098,"26-3789190","TX","","Wellcare","Participating","Enrollment Complete","2021-11-01","","","2022-12-01","12/1/2022 Per roster received from Wellcare provider is PAR and linked to group TIN/location effective 11/1/2021.  DCannon"]
["Rahul Dinesh Puri, MD",1306928098,"26-3789190","TX","PE - Permian Physician Services","Medicare","Participating","Enrollment Complete","2016-04-01","311323YTA9","0A3812","2020-09-25","09/25/2020 - Rec'd documentation from the clinic that this has been approved through PECOS - Stacey Hudak"]
["Rahul Dinesh Puri, MD",1306928098,"26-3789190","TX","","Medicare","Participating","Enrollment Complete","2016-04-01","311323YTA9","0A3812","2020-09-25","09/25/2020 - Rec'd documentation from the clinic that this has been approved through PECOS - Stacey Hudak"]
["Rahul Dinesh Puri, MD",1306928098,"26-3789190","TX","PE - Permian Physician Services","Aetna","Participating","Enrollment Complete","2016-04-01","1306928098","","2020-07-20","07/20/2020 - moved to completed status after reviewing Follow up Complete note. This provider has a DIRECT contract - Stacey Hudak"]
["Rahul Dinesh Puri, MD",1306928098,"26-3789190","TX","","Aetna","Participating","Enrollment Complete","2016-04-01","1306928098","","2020-07-20","07/20/2020 - moved to completed status after reviewing Follow up Complete note. This provider has a DIRECT contract - Stacey Hudak"]
["Rahul Dinesh Puri, MD",1306928098,"26-3789190","TX","PE - Permian Physician Services","Texas Mutual","Participating","Enrollment Complete","2020-07-02","","","2021-01-23","11/25/2020-Confirmed provider is participating under group Tax ID and practice location. -Elonah Grace B. Gelig"]
["Rahul Dinesh Puri, MD",1306928098,"26-3789190","TX","","Texas Mutual","Participating","Enrollment Complete","2020-07-02","","","2021-01-23","11/25/2020-Confirmed provider is participating under group Tax ID and practice location. -Elonah Grace B. Gelig"]
["Rahul Dinesh Puri, MD",1306928098,"26-3789190","TX","PE - Permian Physician Services","Zurich","Enrollment Stopped","Enrollment Stopped","","","","2021-08-05","8/4/2021 Provider does not see WC patients; therefore, enrollment has stopped. KFrazier"]
["Rahul Dinesh Puri, MD",1306928098,"26-3789190","TX","","Zurich","Enrollment Stopped","Enrollment Stopped","","","","2021-08-05","8/4/2021 Provider does not see WC patients; therefore, enrollment has stopped. KFrazier"]
["Rahul Dinesh Puri, MD",1306928098,"26-3789190","TX","PE - Permian Physician Services","HealthSmart PPO","Participating","Enrollment Complete","2011-11-01","","","2021-04-11","4/11/2021 Rcvd email from HealthSmart <mdipsupport@healthsmart.com> confirming participation of provider under TIN and location effective 11/01/2011.  DCannon"]
["Rahul Dinesh Puri, MD",1306928098,"26-3789190","TX","","HealthSmart PPO","Participating","Enrollment Complete","2011-11-01","","","2021-04-11","4/11/2021 Rcvd email from HealthSmart <mdipsupport@healthsmart.com> confirming participation of provider under TIN and location effective 11/01/2011.  DCannon"]
["Rahul Dinesh Puri, MD",1306928098,"26-3789190","TX","PE - Permian Physician Services","Cigna","Participating","Enrollment Complete","2016-04-01","1306928098","","2020-07-23","07/23/2020 - moved to completed status after reviewing follow up complete status - Stacey Hudak"]
["Rahul Dinesh Puri, MD",1306928098,"26-3789190","TX","","Cigna","Participating","Enrollment Complete","2016-04-01","1306928098","","2020-07-23","07/23/2020 - moved to completed status after reviewing follow up complete status - Stacey Hudak"]
["Rahul Dinesh Puri, MD",1306928098,"26-3789190","TX","PE - Permian Physician Services","Multiplan","Participating","Enrollment Complete","2020-07-13","","","2022-07-23","7/23/2022 Per email from Marcie Eckhart-Haven at Multiplan provider is PAR and linked to group TIN effective 7/13/2022.  DCannon"]
["Rahul Dinesh Puri, MD",1306928098,"26-3789190","TX","","Multiplan","Participating","Enrollment Complete","2020-07-13","","","2022-07-23","7/23/2022 Per email from Marcie Eckhart-Haven at Multiplan provider is PAR and linked to group TIN effective 7/13/2022.  DCannon"]
["Rahul Dinesh Puri, MD",1306928098,"26-3789190","TX","PE - Permian Physician Services","Scott&White (First Care)","Participating","Enrollment Complete","2016-03-30","1306928098","","2020-08-20","8/20/2020 - Rec'd a spreadsheet from the payer stating this provider is affilaited with the PRIMED DELEGATED ROSTER under this TIN/Service Location. This provider is networked with\nFirstCare MyChoice PPO\nCHIP\nFirstCare Select Benefit Network\nHMO Enhanced Benefit Network\nMedicaid (FC)\nMedicare (FC)\nPPO Limited Benefit Network\n- Stacey Hudak"]
["Rahul Dinesh Puri, MD",1306928098,"26-3789190","TX","","Scott&White (First Care)","Participating","Enrollment Complete","2016-03-30","1306928098","","2020-08-20","8/20/2020 - Rec'd a spreadsheet from the payer stating this provider is affilaited with the PRIMED DELEGATED ROSTER under this TIN/Service Location. This provider is networked with\nFirstCare MyChoice PPO\nCHIP\nFirstCare Select Benefit Network\nHMO Enhanced Benefit Network\nMedicaid (FC)\nMedicare (FC)\nPPO Limited Benefit Network\n- Stacey Hudak"]
["Rahul Dinesh Puri, MD",1306928098,"26-3789190","TX","PE - Permian Physician Services","Amerigroup","Participating","Enrollment Complete","2020-07-14","05227920","","2021-02-13","2/13/2021 - Verification on payer website Amerigroup.healthsparq.com provider is participating and linked to TIN and location for the following plans CHIP, CHIP-PERINATAL, STAR, STAR-KIDS, STAR-PLUS.  DCannon"]
["Rahul Dinesh Puri, MD",1306928098,"26-3789190","TX","","Amerigroup","Participating","Enrollment Complete","2020-07-14","05227920","","2021-02-13","2/13/2021 - Verification on payer website Amerigroup.healthsparq.com provider is participating and linked to TIN and location for the following plans CHIP, CHIP-PERINATAL, STAR, STAR-KIDS, STAR-PLUS.  DCannon"]
["Rahul Dinesh Puri, MD",1306928098,"26-3789190","TX","PE - Permian Physician Services","Medicaid","In House Enrollment","In House Enrollment","","","","2021-06-01","6/1/2021 Revalidation required mailing of original, which Chris Dalllaire of practice mailed directly to payor and forwarded us a signed copy for our files. KFrazier"]
["Rahul Dinesh Puri, MD",1306928098,"26-3789190","TX","","Medicaid","In House Enrollment","In House Enrollment","","","","2021-06-01","6/1/2021 Revalidation required mailing of original, which Chris Dalllaire of practice mailed directly to payor and forwarded us a signed copy for our files. KFrazier"]
["Rahul Dinesh Puri, MD",1306928098,"26-3789190","TX","PE - Permian Physician Services","Superior","Participating","Enrollment Complete","2017-01-01","1306928098","","2020-07-14","07/14/2020 - Rec'd email from the payer stating this provider is EFF under PRIMED DELEGATED agreement - Stacey Hudak"]
["Rahul Dinesh Puri, MD",1306928098,"26-3789190","TX","","Superior","Participating","Enrollment Complete","2017-01-01","1306928098","","2020-07-14","07/14/2020 - Rec'd email from the payer stating this provider is EFF under PRIMED DELEGATED agreement - Stacey Hudak"]
["Rahul Dinesh Puri, MD",1306928098,"26-3789190","TX","PE - Permian Physician Services","Ambetter","Participating","Enrollment Complete","2022-06-01","","","2022-06-13","6/13/2022 Per roster received from Superior provider is PAR and linked to group delegation roster effective 6/1/2022."]
["Rahul Dinesh Puri, MD",1306928098,"26-3789190","TX","","Ambetter","Participating","Enrollment Complete","2022-06-01","","","2022-06-13","6/13/2022 Per roster received from Superior provider is PAR and linked to group delegation roster effective 6/1/2022."]
["Rahul Dinesh Puri, MD",1306928098,"26-3789190","TX","PE - Permian Physician Services","Molina","Participating","Enrollment Complete","2020-04-17","1306928098","","2020-09-28","09/28/2020 - moved to completed status after reviewing follow up complete note - Stacey Hudak"]
["Rahul Dinesh Puri, MD",1306928098,"26-3789190","TX","","Molina","Participating","Enrollment Complete","2020-04-17","1306928098","","2020-09-28","09/28/2020 - moved to completed status after reviewing follow up complete note - Stacey Hudak"]
["Rahul Dinesh Puri, MD",1306928098,"26-3789190","TX","PE - Permian Physician Services","Triwest VA","Participating","Enrollment Complete","2016-10-01","","","2022-10-06","09/28/2022 - Received Permian Physician Services Roster from TriWest VA (Scarlett Abigail,  scarlett_abigail@bcbstx.com); provider listed as participating, effective 10/01/2016 | Priscilla A."]
["Rahul Dinesh Puri, MD",1306928098,"26-3789190","TX","","Triwest VA","Participating","Enrollment Complete","2016-10-01","","","2022-10-06","09/28/2022 - Received Permian Physician Services Roster from TriWest VA (Scarlett Abigail,  scarlett_abigail@bcbstx.com); provider listed as participating, effective 10/01/2016 | Priscilla A."]
["Rahul Dinesh Puri, MD",1306928098,"26-3789190","TX","PE - Permian Physician Services","Caprock (CapStar)","Participating","Enrollment Complete","2020-07-14","","","2021-04-09","4/9/2020 Rcvd roster from Mary Rodriguez <mary.rodriguez@90degreebenefits.com> at Caprock listing provider as participating under TIN.  DCannon"]
["Rahul Dinesh Puri, MD",1306928098,"26-3789190","TX","","Caprock (CapStar)","Participating","Enrollment Complete","2020-07-14","","","2021-04-09","4/9/2020 Rcvd roster from Mary Rodriguez <mary.rodriguez@90degreebenefits.com> at Caprock listing provider as participating under TIN.  DCannon"]
["Rahul Dinesh Puri, MD",1306928098,"26-3789190","TX","PE - Permian Physician Services","Galaxy Health","Participating","Enrollment Complete","2019-09-01","1306928098","","2020-08-21","08/21/2020 - Rec'd email confirmation that this roster was processed and this provider was made effective with the requested eff date of 9-1-2019 - Stacey Hudak"]
["Rahul Dinesh Puri, MD",1306928098,"26-3789190","TX","","Galaxy Health","Participating","Enrollment Complete","2019-09-01","1306928098","","2020-08-21","08/21/2020 - Rec'd email confirmation that this roster was processed and this provider was made effective with the requested eff date of 9-1-2019 - Stacey Hudak"]
["Rahul Dinesh Puri, MD",1306928098,"26-3789190","TX","PE - Permian Physician Services","Boon Chapman","Participating","Enrollment Complete","2016-07-07","1306928098","","2020-10-05","Enrolled thru PHCS"]
["Rahul Dinesh Puri, MD",1306928098,"26-3789190","TX","","Boon Chapman","Participating","Enrollment Complete","2016-07-07","1306928098","","2020-10-05","Enrolled thru PHCS"]
["Rahul Dinesh Puri, MD",1306928098,"26-3789190","TX","PE - Permian Physician Services","Medicaid","In House Enrollment","In House Enrollment","","1306928098","1427297134","2021-10-14","10/14/2021 In-House Enrollment. KFrazier"]
["Rahul Dinesh Puri, MD",1306928098,"26-3789190","TX","","Medicaid","In House Enrollment","In House Enrollment","","1306928098","1427297134","2021-10-14","10/14/2021 In-House Enrollment. KFrazier"]
["Rahul Dinesh Puri, MD",1306928098,"26-3789190","TX","PE - Permian Physician Services","Sedgwick","Pending Other Enrollment","Pending Contracting","","1161265","","2023-11-28","Per Debbie Mason at Sedgwick TIN is not contracted/enrolled. Emailed roster and W9 per her request and she is looking into available contract opportunities. See group enrollment payor line for status/updates. Jen Videan"]
["Rahul Dinesh Puri, MD",1306928098,"26-3789190","TX","","Sedgwick","Pending Other Enrollment","Pending Contracting","","1161265","","2023-11-28","Per Debbie Mason at Sedgwick TIN is not contracted/enrolled. Emailed roster and W9 per her request and she is looking into available contract opportunities. See group enrollment payor line for status/updates. Jen Videan"]
["Rahul Dinesh Puri, MD",1306928098,"26-3789190","TX","PE - Permian Physician Services","Wellmed","Participating","Enrollment Complete","2022-01-01","","","2023-03-23","3/23/2023 Rcvd roster from UHC w/ all Wellmed participating providers.  Provider is PAR effective 1/1/2022.  DCannon"]
["Rahul Dinesh Puri, MD",1306928098,"26-3789190","TX","","Wellmed","Participating","Enrollment Complete","2022-01-01","","","2023-03-23","3/23/2023 Rcvd roster from UHC w/ all Wellmed participating providers.  Provider is PAR effective 1/1/2022.  DCannon"]
["Rahul Dinesh Puri, MD",1306928098,"26-3789190","TX","PE - Permian Physician Services","Liberty Mutual","Enrollment Stopped","Enrollment Stopped","","","","2021-08-05","8/4/2021 Provider does not see WC patients; therefore, enrollment has stopped. KFrazier"]
["Rahul Dinesh Puri, MD",1306928098,"26-3789190","TX","","Liberty Mutual","Enrollment Stopped","Enrollment Stopped","","","","2021-08-05","8/4/2021 Provider does not see WC patients; therefore, enrollment has stopped. KFrazier"]
["Rahul Dinesh Puri, MD",1306928098,"26-3789190","TX","PE - Permian Physician Services","Gallagher","Enrollment Stopped","Enrollment Stopped","","272644","2272644","2021-08-05","8/4/2021 Provider does not see WC patients; therefore, enrollment has stopped. KFrazier"]
["Rahul Dinesh Puri, MD",1306928098,"26-3789190","TX","","Gallagher","Enrollment Stopped","Enrollment Stopped","","272644","2272644","2021-08-05","8/4/2021 Provider does not see WC patients; therefore, enrollment has stopped. KFrazier"]
["Rahul Dinesh Puri, MD",1306928098,"26-3789190","TX","PE - Permian Physician Services","First Health Coventry","Participating","Enrollment Complete","","","","2023-07-24","Confirmed enrollment via online directory. MS"]
["Rahul Dinesh Puri, MD",1306928098,"26-3789190","TX","","First Health Coventry","Participating","Enrollment Complete","","","","2023-07-24","Confirmed enrollment via online directory. MS"]
["Rahul Dinesh Puri, MD",1306928098,"26-3789190","TX","PE - Permian Physician Services","United Health Care","Participating","Enrollment Complete","2017-01-17","1306928098","","2020-07-30","7-30-2020 - moved to completed status after reviewing follow up complete note - Stacey Hudak"]
["Rahul Dinesh Puri, MD",1306928098,"26-3789190","TX","","United Health Care","Participating","Enrollment Complete","2017-01-17","1306928098","","2020-07-30","7-30-2020 - moved to completed status after reviewing follow up complete note - Stacey Hudak"]
["Rahul Dinesh Puri, MD",1306928098,"26-3789190","TX","PE - Permian Physician Services","USA PPO","Participating","Enrollment Complete","2016-03-16","1306928098","263789190","2020-08-19","Confirmed provider is participating with PPO and H&W networks (list of networks attached). Kimberly Frazier"]
["Rahul Dinesh Puri, MD",1306928098,"26-3789190","TX","","USA PPO","Participating","Enrollment Complete","2016-03-16","1306928098","263789190","2020-08-19","Confirmed provider is participating with PPO and H&W networks (list of networks attached). Kimberly Frazier"]
["Rahul Dinesh Puri, MD",1306928098,"26-3789190","TX","PE - Permian Physician Services","TriCare Standard","Participating","Enrollment Complete","2021-11-18","","","2021-12-14","12/14/2021 Per tircare portal provider linked to location as of 11/18/2021. Cbankston"]
["Rahul Dinesh Puri, MD",1306928098,"26-3789190","TX","","TriCare Standard","Participating","Enrollment Complete","2021-11-18","","","2021-12-14","12/14/2021 Per tircare portal provider linked to location as of 11/18/2021. Cbankston"]
["Amanda Compton, MD",1679953517,"26-3789190","TX","PE - Permian Physician Services","USA PPO","Participating","Enrollment Complete","2021-04-06","","","2023-05-19","Checked enrollment status via https://providersearch.usamco.com/wintprovsearch . Provider is enrolled with Group Health and Wellness PPO. MS"]
["Amanda Compton, MD",1679953517,"26-3789190","TX","PE - Permian Physician Services","Texas Mutual","Participating","Enrollment Complete","2023-05-01","","","2023-05-10","5/10/2023 Rcvd TX Mutual - WorkWell approval letter.  Provider is PAR and linked to group effective 5/1/2023.  DCannon"]
["Amanda Compton, MD",1679953517,"26-3789190","TX","PE - Permian Physician Services","Galaxy Health","Participating","Enrollment Complete","2022-12-01","","","2023-03-08","3/8/2023  Per email from Karen Avalos at Galaxy delegated roster for December is complete and provider is loaded effective 12/1/2022.  DCannon"]
["Amanda Compton, MD",1679953517,"26-3789190","TX","PE - Permian Physician Services","Superior","Participating","Enrollment Complete","2023-01-01","","",44950,"1/24/2023 Rcvd email from Priscilla Albertine at MQA of confirmation that provider is PAR in Superior Health plan under the group TIN effective 1/1/2023.   DCannon"]
["Amanda Compton, MD",1679953517,"26-3789190","TX","PE - Permian Physician Services","Scott&White (First Care)","Participating","Enrollment Complete","2023-01-15","","","2023-08-08","Per response from hpdelegation@bswhealth.org, Amanda Compton is effective 01/15/2023. Jen Videan"]
["Amanda Compton, MD",1679953517,"26-3789190","TX","PE - Permian Physician Services","Ambetter","Participating","Enrollment Complete","2022-12-01","","","2023-02-28","2/28/2023 Per email received from Priscilla Albertine at MQA she received confirmation from Superior that provider is PAR and linked to group TIN/location effective 12/1/2022.  DCannon"]
["Amanda Compton, MD",1679953517,"26-3789190","TX","PE - Permian Physician Services","Omni PPO","Participating","Enrollment Complete","2022-12-01","","","2023-03-08","3/8/2023 Per email received from German Aviles at IMS/OMNI monthly delegation roster provider load for December has been completed.  Provider is PAR and linked to group TIN effective 12/1/2022.   DCannon"]
["Amanda Compton, MD",1679953517,"26-3789190","TX","PE - Permian Physician Services","HealthSmart PPO","Participating","Enrollment Complete","2022-12-01","","","2023-02-28","2/28/2023 Per Healthsmart website provider is PAR and loaded under TIN/location effective 12/1/2022.  DCannon"]
["Amanda Compton, MD",1679953517,"26-3789190","TX","PE - Permian Physician Services","Sedgwick","Pending Other Enrollment","Pending Contracting","","","","2023-11-28","Per Debbie Mason at Sedgwick TIN is not contracted/enrolled. Emailed roster and W9 per her request and she is looking into available contract opportunities. See group enrollment payor line for status/updates. Jen Videan"]
["Amanda Compton, MD",1679953517,"26-3789190","TX","PE - Permian Physician Services","Caprock (CapStar)","Participating","Enrollment Complete","2022-12-01","","","2022-12-29","12/29/2022 Rcvd email  confirmation from Caprock that provider is PAR and linked to group TIN/locations effective 12/1/2022.  DCannon"]
["Amanda Compton, MD",1679953517,"26-3789190","TX","PE - Permian Physician Services","United Health Care","Participating","Enrollment Complete","2022-12-01","","","2023-02-28","2/28/2023 Rcvd email from UHC that January delegated roster provider load has been completed and provider is PAR and linked to group TIN effective 12/1/2022.  MPIN# 006893323.  DCannon"]
["Amanda Compton, MD",1679953517,"26-3789190","TX","PE - Permian Physician Services","Tricare Prime","Panel Closed","Panel Closed","","","","2022-12-15","12/15/2022 Per Tricare/Humana Military is currently not accepting requests to join the medical surgical network. Will check back soon to see if we are accepting network providers.  DCannon"]
["Amanda Compton, MD",1679953517,"26-3789190","TX","PE - Permian Physician Services","Aetna","Participating","Enrollment Complete","2022-12-01","","","2023-01-18","1.18.2023 S/W Paul of Aetna @ 800-353-1232. Provider is on file and participating. Link under the group and TIN effective 12/1/2022. Location is on file. Provider ID is 6529979. Next recredentialing date is 12/30/2025. Payer# is 60054. Call ref# 6129095229"]
["Amanda Compton, MD",1679953517,"26-3789190","TX","PE - Permian Physician Services","Rail Road Medicare","Participating","Enrollment Complete","2022-12-01","","","2023-05-24",""]
["Amanda Compton, MD",1679953517,"26-3789190","TX","PE - Permian Physician Services","Amerigroup","Participating","Enrollment Complete","2022-12-01","","","2023-02-16","2.16.2023  Per follow-up note - S/W Qjuana of Amerigroup @ 800-454-3730. Provider is on file and participating. Link under the group and TIN effective 12/1/2022. Location is on file. Provider ID is 15255052.   DCannon"]
["Amanda Compton, MD",1679953517,"26-3789190","TX","PE - Permian Physician Services","Boon Chapman","Participating","Enrollment Complete","2022-12-01","","","2023-07-25","7/25/2023 Rcvd email from Jessica Bess at Multiplan with a full roster and provider is PAR w/ group effective 12/1/2022.  DCannon"]
["Amanda Compton, MD",1679953517,"26-3789190","TX","PE - Permian Physician Services","CAQH","Participating","CAQH Reattested","2023-10-31","14304570","",45230,"10/31/2023 - updated Primary mail, cred contact, License and reattested - mkhan"]
["Amanda Compton, MD",1679953517,"26-3789190","TX","PE - Permian Physician Services","CAQH","Participating","CAQH Reattested","2023-10-31","14304570","","2023-10-31","10/31/2023 - updated Primary mail, cred contact, License and reattested - mkhan"]
["Amanda Compton, MD",1679953517,"26-3789190","TX","PE - Permian Physician Services","IMS","Participating","Enrollment Complete","2022-12-01","","","2023-01-05","1/5/2023 Per email received from German Aviles at IMS/OMNI monthly delegation roster provider load for December has been completed.  Provider is PAR and linked to group TIN effective 12/1/2022.   DCannon"]
["Amanda Compton, MD",1679953517,"26-3789190","TX","PE - Permian Physician Services","Triwest VA","In House Enrollment","In House Enrollment","","","","2022-12-15",""]
["Amanda Compton, MD",1679953517,"26-3789190","TX","PE - Permian Physician Services","Humana","Participating","Enrollment Complete","2022-12-01","","","2023-02-25","2/25/2023 Per email received from Vernita Young November delegated roster has been processed and provider is PAR effective 12/1/2022.  DCannon"]
["Amanda Compton, MD",1679953517,"26-3789190","TX","PE - Permian Physician Services","Multiplan","Participating","Enrollment Complete","2022-12-01","","","2023-07-25","7/25/2023 Rcvd email from Jessica Bess at Multiplan with a full roster and provider is PAR w/ group effective 12/1/2022.  DCannon"]
["Amanda Compton, MD",1679953517,"26-3789190","TX","PE - Permian Physician Services","Cigna","Participating","Enrollment Complete","2022-12-01","2149846","","2023-01-31","1/31/2023 Rcvd email from Cigna that provider is PAR and linked to group TIN/location effective 12/1/2022.  PID # 2149846.  DCannon"]
["Amanda Compton, MD",1679953517,"26-3789190","TX","PE - Permian Physician Services","First Health Coventry","Participating","Enrollment Complete","2022-12-01","","","2023-04-06","4/6/2023 Per confirm par status note -  provider is showing participating with an Effective date 12/01/2022 and link under the Group and TIN. Provider ID 3629097, Recredentialing date 12/01/2025. Service location is on file. DCannon"]
["Amanda Compton, MD",1679953517,"26-3789190","TX","PE - Permian Physician Services","Medicare","Participating","Enrollment Complete","2022-12-01","2M8579","0A3812","2022-12-28","12/28/2022 Rcvd copy of Medicare approval letter.  Provider is PAR and linked to group effective 12/1/2022.  PTAN # 2M8579.  DCannon"]
["Amanda Compton, MD",1679953517,"26-3789190","TX","PE - Permian Physician Services","Medicaid","In House Enrollment","In House Enrollment","","","","2022-12-15",""]
["Amanda Compton, MD",1679953517,"26-3789190","TX","PE - Permian Physician Services","Wellcare","Participating","Enrollment Complete","2023-01-01","","","2023-07-26","7/26/2023 Rcvd email from that provider is PAR in Superior Health plan under the group TIN effective 1/1/2023.   DCannon"]
["Ragini Sastry, DO",1942568431,"26-3789190","TX","PE - Permian Physician Services","Omni PPO","Participating","Enrollment Complete","2022-05-09","","","2022-07-05","7/5/2022 Rcvd email from G.Aviles at IMS/OMNI that delegation roster provider load for June has been completed.  Provider is PAR and linked to group effective 5/9/2022.  DCannon"]
["Ragini Sastry, DO",1942568431,"26-3789190","TX","PE - Permian Physician Services","Alliance WC","Enrollment Stopped","Enrollment Denied","","","","2023-10-09","Rcvd denial letter for Dr. Sastry's application. Application has been denied at this time but they will keep information on file for a period of 6 months for review and future consideration. 10/09/2023 Jen Videan"]
["Ragini Sastry, DO",1942568431,"26-3789190","TX","PE - Permian Physician Services","Corvel Healthcare Corp.","In Process","Pending Info/Document","","","","2023-11-21","Per Karina at Corvel, Permian Physician Services is part of SETHS delegated contract. Emailed MQA for assistance. Jen Videan"]
["Ragini Sastry, DO",1942568431,"26-3789190","TX","PE - Permian Physician Services","Gallagher","Panel Closed","Panel Closed","","","","2023-07-24"," We appreciate your interest in joining the Coventry Network.  At this time, our panels are closed, and we are not accepting new applications.  Please check back routinely to stay apprised of our panel status. We will update this site when we are open for new applicants. Gallagher, Hartford, Liberty Mutual, Travelers and Zurich fall under Coventry. Jen Videan"]
["Ragini Sastry, DO",1942568431,"26-3789190","TX","PE - Permian Physician Services","Aetna","Participating","Enrollment Complete","2022-05-09","6410096","","2022-06-08","6/8/2022 Per Aetna provider directory provider is PAR and linked to group TIN/location effective 5/9/2022.   DCannon"]
["Ragini Sastry, DO",1942568431,"26-3789190","TX","PE - Permian Physician Services","Medicaid","In House Enrollment","In House Enrollment","","1942568431","1427297134","2022-05-02","5/2/2022 Per email from Stacy Salazar provider is now PAR in TX Medicaid.  DCannon"]
["Ragini Sastry, DO",1942568431,"26-3789190","TX","PE - Permian Physician Services","Caprock (CapStar)","Participating","Enrollment Complete","2020-01-01","","","2022-10-12","10/12/2022 Per email from Priscilla Albertine she rcvd confirmation from Mary Rodriguez at Caprock that provider is PAR and linked to group TIN/locations effective 1/1/2020.  DCannon"]
["Ragini Sastry, DO",1942568431,"26-3789190","TX","PE - Permian Physician Services","CAQH","Participating","CAQH Reattested","2023-10-30","","","2023-10-30","10/30/2023 Updated Email id, License, credential contact, specialties - rkedar"]
["Ragini Sastry, DO",1942568431,"26-3789190","TX","PE - Permian Physician Services","CAQH","Participating","CAQH Reattested","2023-10-30","","","2023-10-30","10/30/2023 Updated Email id, License, credential contact, specialties - rkedar"]
["Ragini Sastry, DO",1942568431,"26-3789190","TX","PE - Permian Physician Services","Liberty Mutual","Panel Closed","Panel Closed","","","","2023-07-24"," We appreciate your interest in joining the Coventry Network.  At this time, our panels are closed, and we are not accepting new applications.  Please check back routinely to stay apprised of our panel status. We will update this site when we are open for new applicants. Gallagher, Hartford, Liberty Mutual, Travelers and Zurich fall under Coventry. Jen Videan"]
["Ragini Sastry, DO",1942568431,"26-3789190","TX","PE - Permian Physician Services","HealthSmart PPO","Participating","Enrollment Complete","2022-05-09","","","2022-07-14","7/14/2022 Per Healthsmart website provider is PAR and loaded under TIN/location effective 5/9/2022.  DCannon"]
["Ragini Sastry, DO",1942568431,"26-3789190","TX","PE - Permian Physician Services","Hartford","Panel Closed","Panel Closed","","","","2023-07-24"," We appreciate your interest in joining the Coventry Network.  At this time, our panels are closed, and we are not accepting new applications.  Please check back routinely to stay apprised of our panel status. We will update this site when we are open for new applicants. Gallagher, Hartford, Liberty Mutual, Travelers and Zurich fall under Coventry. Jen Videan"]
["Ragini Sastry, DO",1942568431,"26-3789190","TX","PE - Permian Physician Services","Scott&White (First Care)","Participating","Enrollment Complete","2022-06-15","","","2022-06-22","6/22/2022 Per phone conversation with Jennifer Penn at Scott & White provider is PAR and linked to group TIN/location effective 6/15/2022.  DCannon"]
["Ragini Sastry, DO",1942568431,"26-3789190","TX","PE - Permian Physician Services","IMS","Participating","Enrollment Complete","2022-05-09","","","2022-07-05","7/5/2022 Rcvd email from G.Aviles at IMS/OMNI that delegation roster provider load for June has been completed.  Provider is PAR and linked to group effective 5/9/2022.  DCannon"]
["Ragini Sastry, DO",1942568431,"26-3789190","TX","PE - Permian Physician Services","Medicare","Participating","In House Enrollment","2021-12-01","1X1116","0A3812","2021-12-31","12/31/2021 Per PECOS provider is PAR and linked to group/locations.  PTAN# 1X1116 - effective 12/1/2021.  DCannon"]
["Ragini Sastry, DO",1942568431,"26-3789190","TX","PE - Permian Physician Services","Zurich","Panel Closed","Panel Closed","","","","2023-07-24"," We appreciate your interest in joining the Coventry Network.  At this time, our panels are closed, and we are not accepting new applications.  Please check back routinely to stay apprised of our panel status. We will update this site when we are open for new applicants. Gallagher, Hartford, Liberty Mutual, Travelers and Zurich fall under Coventry. Jen Videan"]
["Ragini Sastry, DO",1942568431,"26-3789190","TX","PE - Permian Physician Services","Texas Municipal League","Thru Other Payor","Enrollment Denied","","","","2023-11-20","Please see Alliance notes for details of denied enrollment. MS"]
["Ragini Sastry, DO",1942568431,"26-3789190","TX","PE - Permian Physician Services","Superior","Participating","Enrollment Complete","2022-06-01","","","2022-06-01","6/1/2022 Per roster received from Superior May monthly delegated submission is complete and provider is PAR and linked to group TIN/locations effective  6/1/2022.  DCannon"]
["Ragini Sastry, DO",1942568431,"26-3789190","TX","PE - Permian Physician Services","Sedgwick","Pending Other Enrollment","Pending Contracting","","","","2023-11-28","Per Debbie Mason at Sedgwick TIN is not contracted/enrolled. Emailed roster and W9 per her request and she is looking into available contract opportunities. See group enrollment payor line for status/updates. Jen Videan"]
["Ragini Sastry, DO",1942568431,"26-3789190","TX","PE - Permian Physician Services","Humana","Participating","Enrollment Complete","2022-05-09","","","2022-08-20","8/20/2022 Per email received from Vernita Young July monthly delegated roster is complete and provider is PAR and linked to group TIN/location effective 5/9/2022.  DCannon"]
["Ragini Sastry, DO",1942568431,"26-3789190","TX","PE - Permian Physician Services","United Health Care","Participating","Enrollment Complete","2021-12-01","","","2022-06-08","6/8/2022 Rcvd email that initial delegated provider load has been completed and ALL MQA providers are loaded under delegation with original effective date requested.  Provider is PAR effective 12/1/2022.  DCannon"]
["Ragini Sastry, DO",1942568431,"26-3789190","TX","PE - Permian Physician Services","Cigna","Participating","Enrollment Complete","2021-12-01","0570215","","2022-04-06","4/6/2022 Received email from pdmcogz@cigna.com, provider is eff and linked to group as of 12/1/2021. PID 0570215. Cbankston"]
["Ragini Sastry, DO",1942568431,"26-3789190","TX","PE - Permian Physician Services","Multiplan","Participating","Enrollment Complete","2022-05-09","","","2022-07-23","7/23/3033 Per email from Marcie Eckhart-Haven at Multiplan provider is PAR and linked to group TIN effective 5/9/2022.  DCannon"]
["Ragini Sastry, DO",1942568431,"26-3789190","TX","PE - Permian Physician Services","Broadspire Services Inc.","In Process","Pending Info/Document","","","","2023-11-21","Emailed Priscilla and Neerja for status of signed group agreements. Unable to move forward with individual provider until group agreement is in place.  Jen Videan"]
["Ragini Sastry, DO",1942568431,"26-3789190","TX","PE - Permian Physician Services","Texas Mutual","In Process","Application Resubmitted","","","","2023-11-21","Signed contract and required documents emailed to wwtxcontracts@texasmutual.com. Jen Videan"]
["Ragini Sastry, DO",1942568431,"26-3789190","TX","PE - Permian Physician Services","Coventry Workers Comp","Panel Closed","Panel Closed","","","","2023-07-24"," We appreciate your interest in joining the Coventry Network.  At this time, our panels are closed, and we are not accepting new applications.  Please check back routinely to stay apprised of our panel status. We will update this site when we are open for new applicants. Gallagher, Hartford, Liberty Mutual, Travelers and Zurich fall under Coventry. Jen Videan"]
["Ragini Sastry, DO",1942568431,"26-3789190","TX","PE - Permian Physician Services","First Health Coventry","Participating","Enrollment Complete","2022-05-01","3218967","","2023-05-02","5/2/2023 Per confirm par status note - Per rep, provider is showing participating with an effective date 05/01/2022 and link under the Group and TIN. Provider ID 3218967, No Payer ID and No recredentialing date. Service location is on file. Call ref#:610385.-DCannon"]
["Ragini Sastry, DO",1942568431,"26-3789190","TX","PE - Permian Physician Services","Amerigroup","Participating","Enrollment Complete","2022-05-09","","","2022-09-23","9/23/2022 Per roster received from Joe Rodriguez at Amerigroup provider is PAR and linked to group TIN effective 5/9/2022.  DCannon"]
["Ragini Sastry, DO",1942568431,"26-3789190","TX","PE - Permian Physician Services","Ambetter","Participating","Enrollment Complete","2022-06-01","","","2022-06-13","6/13/2022 Per roster received from Superior provider is PAR and linked to group delegation roster effective 6/1/2022."]
["Ragini Sastry, DO",1942568431,"26-3789190","TX","PE - Permian Physician Services","Travelers WC","Panel Closed","Panel Closed","","","","2023-07-24"," We appreciate your interest in joining the Coventry Network.  At this time, our panels are closed, and we are not accepting new applications.  Please check back routinely to stay apprised of our panel status. We will update this site when we are open for new applicants. Gallagher, Hartford, Liberty Mutual, Travelers and Zurich fall under Coventry. Jen Videan"]
["Richard Glenn Eby, MD",1598260325,"26-3789190","TX","PE - Permian Physician Services","Superior","Participating","Enrollment Complete","2022-11-01","","","2022-12-08","12/08/2022 Rcvd confirmation email from Superior that October delegation roster has been processed and provider has been loaded to delegation roster and PAR w/ group effective 11/1/2022.  DCannon"]
["Richard Glenn Eby, MD",1598260325,"26-3789190","TX","PE - Permian Physician Services","Travelers WC","Panel Closed","Panel Closed","","","","2023-07-19","07/18/2023. We appreciate your interest in joining the Coventry Network.  At this time, our panels are closed, and we are not accepting new applications.  Please check back routinely to stay apprised of our panel status. We will update this site when we are open for new applicants. Gallagher, Hartford, Liberty Mutual, Travelers and Zurich fall under Coventry. Jen Videan"]
["Richard Glenn Eby, MD",1598260325,"26-3789190","TX","PE - Permian Physician Services","Galaxy Health","Participating","Enrollment Complete","2022-09-26","","","2022-12-31","12/31/2022 Rcvd email from Karen Avalos at Galaxy that delegated roster submission for October has been completed.  Provider is PAR and linked to group TIN effective 9/26/2022.  DCannon"]
["Richard Glenn Eby, MD",1598260325,"26-3789190","TX","PE - Permian Physician Services","Omni PPO","Participating","Enrollment Complete","2022-09-26","","","2022-10-17","10/17/2022 Per email received from German Aviles at IMS/OMNI monthly delegation roster provider load for October has been completed.  Provider is PAR and linked to group TIN effective 9/26/2022.   DCannon"]
["Richard Glenn Eby, MD",1598260325,"26-3789190","TX","PE - Permian Physician Services","Texas Mutual","In Process","Application Resubmitted","","","","2023-11-22","TSCA and documents emailed to wwtxcontracts@texasmutual.com. Jen Videan"]
["Richard Glenn Eby, MD",1598260325,"26-3789190","TX","PE - Permian Physician Services","Multiplan","Participating","Enrollment Complete","2022-09-26","","","2023-07-25","7/25/2023 Rcvd email from Jessica Bess at Multiplan with a full roster and provider is PAR w/ group and location effective 9/26/2022.  DCannon"]
["Richard Glenn Eby, MD",1598260325,"26-3789190","TX","PE - Permian Physician Services","Coventry Workers Comp","Panel Closed","Panel Closed","","","","2023-05-18","Coventry panel is currently closed for new enrollments. MS"]
["Richard Glenn Eby, MD",1598260325,"26-3789190","TX","PE - Permian Physician Services","Triwest VA","In House Enrollment","In House Enrollment","","","","2022-08-23",""]
["Richard Glenn Eby, MD",1598260325,"26-3789190","TX","PE - Permian Physician Services","Amerigroup","Participating","Enrollment Complete","2022-09-26","","","2023-02-01","2/1/2023 Per email response from Amerigroup Provider Relations-Texas provider is PAR and linked to group effective 9/26/2022.  PID# 14643274.  DCannon"]
["Richard Glenn Eby, MD",1598260325,"26-3789190","TX","PE - Permian Physician Services","IMS","Participating","Enrollment Complete","2022-09-26","","","2022-10-17","10/17/2022 Per email received from German Aviles at IMS/OMNI monthly delegation roster provider load for October has been completed.  Provider is PAR and linked to group TIN effective 9/26/2022.   DCannon"]
["Richard Glenn Eby, MD",1598260325,"26-3789190","TX","PE - Permian Physician Services","Corvel Healthcare Corp.","Participating","Enrollment Complete","2022-09-26","","","2023-05-02","05.02.2023  Per follow-up note - S/W Marina of Corvel Healthcare Corp @ 800-872-0820. Per rep, provider is showing PAR and link under the Group and Tax ID with an Effective date 09/26/2022. Provider ID 1341506, Recredentialing date is 09/26/2025. Service location is on file. Call ref#:Marina05022023.-Danico Gabriel Melendres"]
["Richard Glenn Eby, MD",1598260325,"26-3789190","TX","PE - Permian Physician Services","Scott&White (First Care)","Participating","Enrollment Complete","2022-11-14","","","2023-02-09","2/9/2023 Rcvd email from Priscilla Albertine at MQA that provider is PAR and linked to group TIN effective 11/14/2022.  DCannon"]
["Richard Glenn Eby, MD",1598260325,"26-3789190","TX","PE - Permian Physician Services","Aetna","Participating","Enrollment Complete","2023-01-01","","","2023-01-18","1.18.2023 S/W Dan of Aetna @ 800-353-1232. Provider is on file and participating. Link under the group and TIN effective 1/15/2023. Location is on file. Provider ID is 6836243. Next recredentialing date is 12/9/2025. Payer# is 60054. -Kim Monique Fabian\n-"]
["Richard Glenn Eby, MD",1598260325,"26-3789190","TX","PE - Permian Physician Services","Cigna","In Process","Payor Follow Up","","","","2023-11-18","Emailed PSScentral for status update. MS"]
["Richard Glenn Eby, MD",1598260325,"26-3789190","TX","PE - Permian Physician Services","Medicare","Participating","Enrollment Complete","2022-08-01","2G5555","0A3812","2022-09-08","9/8/2022 Per PECOS provider is PAR and linked to group.  PTAN 2G5555 - effective 8/1/2022.  DCannon"]
["Richard Glenn Eby, MD",1598260325,"26-3789190","TX","PE - Permian Physician Services","Tricare Prime","Panel Closed","Panel Closed","","","","2022-10-28","10/28/2022 Per Tricare/Humana Military is currently not accepting requests to join the medical surgical network. Will check back soon to see if we are accepting network providers.  DCannon"]
["Richard Glenn Eby, MD",1598260325,"26-3789190","TX","PE - Permian Physician Services","Sedgwick","Pending Other Enrollment","Pending Contracting","","","","2023-11-28","Per Debbie Mason at Sedgwick TIN is not contracted/enrolled. Emailed roster and W9 per her request and she is looking into available contract opportunities. See group enrollment payor line for status/updates. Jen Videan"]
["Richard Glenn Eby, MD",1598260325,"26-3789190","TX","PE - Permian Physician Services","Texas Municipal League","Participating","Enrollment Complete","","","","2023-11-20","participating, please see Alliance notes. MS"]
["Richard Glenn Eby, MD",1598260325,"26-3789190","TX","PE - Permian Physician Services","Ambetter","Participating","Enrollment Complete","2022-11-01","","","2022-12-29","12/29/2022 Rcvd confirmation email from Superior that October delegation roster has been processed and provider has been loaded to delegation roster and PAR w/ group effective 11/1/2022.  DCannon"]
["Richard Glenn Eby, MD",1598260325,"26-3789190","TX","PE - Permian Physician Services","Humana","Participating","Enrollment Complete","2022-09-26","","","2023-02-17","2/17/2023 Per email received from Priscilla Albertine at MQA she received confirmation from Humana that provider is PAR and linked to group TIN/location effective 9/26/2022.  DCannon"]
["Richard Glenn Eby, MD",1598260325,"26-3789190","TX","PE - Permian Physician Services","Wellcare","Participating","Enrollment Complete","2022-11-01","","","2022-12-29","12/29/2022 Rcvd confirmation email from Superior that October delegation roster has been processed and provider has been loaded to delegation roster and PAR w/ group effective 11/1/2022.  DCannon"]
["Richard Glenn Eby, MD",1598260325,"26-3789190","TX","PE - Permian Physician Services","USA PPO","Participating","Enrollment Complete","2022-09-26","","","2023-03-24","3/24/2023 In following up with USAMCO (800-872-3860) I was told that you can confirm participating via the USA MCO website  https://providersearch.usamco.com/hwprovsearch.  Provider is PAR and linked to location/TIN effective 9/26/2022.  DCannon"]
["Richard Glenn Eby, MD",1598260325,"26-3789190","TX","PE - Permian Physician Services","Alliance WC","Participating","Enrollment Complete","2023-06-02","","","2023-06-14","Rep emailed and confirmed participation. MS"]
["Richard Glenn Eby, MD",1598260325,"26-3789190","TX","PE - Permian Physician Services","First Health Coventry","Participating","Enrollment Complete","2022-11-01","","","2023-02-09","2/9/2023 Rcvd email from Priscilla Albertine at MQA with confirmation that provider is PAR and linked to group TIN/location effective 11/1/2022.  DCannon"]
["Richard Glenn Eby, MD",1598260325,"26-3789190","TX","PE - Permian Physician Services","CAQH","Participating","CAQH Reattested","2023-10-27","","","2023-10-27","10/27/2023 - Updated License, Cred Contact, Primary Mail, no any affiliation data available and Re attested - Mkhan"]
["Richard Glenn Eby, MD",1598260325,"26-3789190","TX","PE - Permian Physician Services","CAQH","Participating","CAQH Reattested","2023-10-27","","","2023-10-27","10/27/2023 - Updated License, Cred Contact, Primary Mail, no any affiliation data available and Re attested - Mkhan"]
["Richard Glenn Eby, MD",1598260325,"26-3789190","TX","PE - Permian Physician Services","Caprock (CapStar)","Participating","Enrollment Complete","2022-09-26","","","2022-12-29","12/29/2022 Rcvd email  confirmation from Caprock that provider is PAR and linked to group TIN/locations effective 9/26/2022.  DCannon"]
["Richard Glenn Eby, MD",1598260325,"26-3789190","TX","PE - Permian Physician Services","Liberty Mutual","Panel Closed","Panel Closed","","","","2023-07-19","07/18/2023. We appreciate your interest in joining the Coventry Network.  At this time, our panels are closed, and we are not accepting new applications.  Please check back routinely to stay apprised of our panel status. We will update this site when we are open for new applicants. Gallagher, Hartford, Liberty Mutual, Travelers and Zurich fall under Coventry. Jen Videan"]
["Richard Glenn Eby, MD",1598260325,"26-3789190","TX","PE - Permian Physician Services","Broadspire Services Inc.","In Process","Pending Info/Document","","","","2023-11-21","Emailed Priscilla and Neerja for status of signed group agreements. Unable to move forward with individual provider until group agreement is in place.  Jen Videan"]
["Richard Glenn Eby, MD",1598260325,"26-3789190","TX","PE - Permian Physician Services","Zurich","Panel Closed","Panel Closed","","","","2023-07-19","07/18/2023. We appreciate your interest in joining the Coventry Network.  At this time, our panels are closed, and we are not accepting new applications.  Please check back routinely to stay apprised of our panel status. We will update this site when we are open for new applicants. Gallagher, Hartford, Liberty Mutual, Travelers and Zurich fall under Coventry. Jen Videan"]
["Richard Glenn Eby, MD",1598260325,"26-3789190","TX","PE - Permian Physician Services","HealthSmart PPO","Participating","Enrollment Complete","2022-09-26","","","2022-11-28","11/28/2022 Per Healthsmart website provider is PAR and loaded under TIN/location effective 9/26/2022.  DCannon"]
["Richard Glenn Eby, MD",1598260325,"26-3789190","TX","PE - Permian Physician Services","United Health Care","Participating","Enrollment Complete","2022-09-26","","","2023-09-05","9/2/2023 Per email from UHC provider is PAR and linked to group TIN/location effective 9/26/2022.  DCannon"]
["Richard Glenn Eby, MD",1598260325,"26-3789190","TX","PE - Permian Physician Services","Hartford","Panel Closed","Panel Closed","","","","2023-07-19","07/18/2023. We appreciate your interest in joining the Coventry Network.  At this time, our panels are closed, and we are not accepting new applications.  Please check back routinely to stay apprised of our panel status. We will update this site when we are open for new applicants. Gallagher, Hartford, Liberty Mutual, Travelers and Zurich fall under Coventry. Jen Videan"]
["Richard Glenn Eby, MD",1598260325,"26-3789190","TX","PE - Permian Physician Services","Gallagher","Panel Closed","Panel Closed","","","","2023-07-19","07/18/2023. We appreciate your interest in joining the Coventry Network.  At this time, our panels are closed, and we are not accepting new applications.  Please check back routinely to stay apprised of our panel status. We will update this site when we are open for new applicants. Gallagher, Hartford, Liberty Mutual, Travelers and Zurich fall under Coventry. Jen Videan"]
["Richard Glenn Eby, MD",1598260325,"26-3789190","TX","PE - Permian Physician Services","Medicaid","Participating","Enrollment Complete","2022-08-01","","","2023-07-12","Per Neris at TMHP Ticket# 46628797000 Dr. Eby is par and linked to Permian Physician Practice effective 08/01/2022. TPI# 406528603. Jen Videan"]
["Richard Glenn Eby, MD",1598260325,"26-3789190","TX","PE - Permian Physician Services","TriCare Standard","Participating","Enrollment Complete","2022-09-19","","","2022-10-28","10/28/2022 Per Tricare/Humana Military portal provider is PAR and linked to group TIN/location effective 9/19/2022.  DCannon"]
["Suhail Sami Daye, MD",1639251481,"26-3789190","TX","PE - Permian Physician Services","Ambetter","Participating","Enrollment Complete","2023-06-01","","","2023-07-17","7/17/2023 Rcvd email from Superior that provider is PAR and linked to group delegated roster effective 6/1/2023.  DCannon"]
["Suhail Sami Daye, MD",1639251481,"26-3789190","TX","PE - Permian Physician Services","Wellmed","Participating","Enrollment Complete","2023-05-08","","","2023-10-13","10/13/2023 Provider is PAR and linked to group TIN effective 5/8/2023.    DCannon"]
["Suhail Sami Daye, MD",1639251481,"26-3789190","TX","PE - Permian Physician Services","Gallagher","Panel Closed","Panel Closed","","","","2023-05-15","Confirmed with rep that provider will need to be active with Coventry prior to submitting the request to join Gallagher. I've saved the enrollment instructions in the Gallagher file. MS"]
["Suhail Sami Daye, MD",1639251481,"26-3789190","TX","PE - Permian Physician Services","Texas Municipal League","Thru Other Payor","Thru Other Payor","","","","2023-11-20","Please see Alliance payor lines for status updates. MS"]
["Suhail Sami Daye, MD",1639251481,"26-3789190","TX","PE - Permian Physician Services","Broadspire Services Inc.","In Process","Pending Info/Document","","","","2023-11-21","Emailed Priscilla and Neerja for status of signed group agreements. Unable to move forward with individual provider until group agreement is in place.  Jen Videan"]
["Suhail Sami Daye, MD",1639251481,"26-3789190","TX","PE - Permian Physician Services","Medicare","Participating","Enrollment Complete","2023-03-01","2S7645","0A3812","2023-05-04","5/4/2023 Rcvd Medicare approval letter.  Provider is PAR and linked to group/locations effective 3/1/2023.  PTAN# 2S7645.  DCannon"]
["Suhail Sami Daye, MD",1639251481,"26-3789190","TX","PE - Permian Physician Services","USA PPO","Participating","Enrollment Complete","2023-05-08","","","2023-08-23","8/23/2023 In following up with USAMCO (800-872-3860) I was told that you can confirm participating via the USA MCO website  https://providersearch.usamco.com/hwprovsearch.  Provider is PAR and linked to location/TIN effective 5/8/2023.  DCannon"]
["Suhail Sami Daye, MD",1639251481,"26-3789190","TX","PE - Permian Physician Services","Cigna","Participating","Enrollment Complete","2014-05-28","2761782","","2023-05-02","5.2.2023 Per confirm par status note - Per rep, provider is showing credentialed and in network under the TIN with an effective date 05/28/2014. Provider ID 2761782. Recredentialing date 10/13/2025. Service location is on file. Call ref#:AndrewJ04262023. DCannon"]
["Suhail Sami Daye, MD",1639251481,"26-3789190","TX","PE - Permian Physician Services","IMS","Participating","Enrollment Complete","2023-05-08","","","2023-07-19","7/19/2023 Per email received from IMS/OMNI May delegated roster has been processed and provider is PAR and linked to group effective 5/8/2023.  DCannon"]
["Suhail Sami Daye, MD",1639251481,"26-3789190","TX","PE - Permian Physician Services","TriCare Standard","Participating","Enrollment Complete","2023-04-25","","","2023-05-04","5/4/2023 Rcvd Tricare approval letter, provider is Tricare certified w/ group TIN effective 4/25/2023.  DCannon"]
["Suhail Sami Daye, MD",1639251481,"26-3789190","TX","PE - Permian Physician Services","Multiplan","Participating","Enrollment Complete","2017-06-12","","","2023-06-01","6/01/2023 S/W Latuya of MultiPlan @ 1-800-950-7040.Per rep, Provider NPI# 1639251481 is on file for the provider and is participating, effective 6-12-2017 under the group and TIN# 26-3789190. PIN: 12424933. Physical location is on file. Next credentialing is not required. no payer ID. Call ref# 8813120. - Jherimiah Medina"]
["Suhail Sami Daye, MD",1639251481,"26-3789190","TX","PE - Permian Physician Services","Wellcare","Participating","Enrollment Complete","2023-06-01","","","2023-07-17","7/17/2023 Rcvd email from Superior that provider is PAR and linked to group delegated roster effective 6/1/2023.  DCannon"]
["Suhail Sami Daye, MD",1639251481,"26-3789190","TX","PE - Permian Physician Services","CAQH","Participating","CAQH Reattested","2023-10-04","","","2023-10-04","10/04/2023 - Updated Primary mail, Practice Location, Cred contact, Insurance  and Re-attested - Mkhan"]
["Suhail Sami Daye, MD",1639251481,"26-3789190","TX","PE - Permian Physician Services","Medicaid","In House Enrollment","In House Enrollment","","","","2023-05-22",""]
["Suhail Sami Daye, MD",1639251481,"26-3789190","TX","PE - Permian Physician Services","Triwest VA","In House Enrollment","In House Enrollment","","","","2023-04-19",""]
["Suhail Sami Daye, MD",1639251481,"26-3789190","TX","PE - Permian Physician Services","Scott&White (First Care)","Participating","Enrollment Complete","2023-06-15","","","2023-08-08","Per response from hpdelegation@bswhealth.org, Dr. Daye  is effective 06/15/2023. Jen Videan"]
["Suhail Sami Daye, MD",1639251481,"26-3789190","TX","PE - Permian Physician Services","Aetna","Participating","Enrollment Complete","2015-12-15","5930358","","2023-05-02","5.2.2023 Per confirm par status note - Per rep, provider is showing participating with an effective date 12/15/2015 and link under the Group and TIN. Provider ID 5930358, Recredentialing date 01/29/2024. Service location is on file. Call ref#:6144015874.  DCannon"]
["Suhail Sami Daye, MD",1639251481,"26-3789190","TX","PE - Permian Physician Services","Humana","Participating","Enrollment Complete","2023-05-08","","","2023-09-27","9/27/2023 Per email response from Marcus Wester at Humana May delegated roster has bee completed.  Provider is PAR and linked to group/location effective 5/8/2023.  DCannon"]
["Suhail Sami Daye, MD",1639251481,"26-3789190","TX","PE - Permian Physician Services","First Health Coventry","Participating","Enrollment Complete","2023-05-01","2288286","","2023-09-20","09.20.2023 S/W Britney of First Health @ 800-226-5116. Per rep, provider is in network with First Health and linked to the group and TIN# effective 05/01/2023. No recredentialing date available. PIN: 2288286. Servicing location is on file. No payer# available. Call ref# 760669. - Willie Ravas"]
["Suhail Sami Daye, MD",1639251481,"26-3789190","TX","PE - Permian Physician Services","Hartford","Panel Closed","Panel Closed","","","","2023-07-24"," We appreciate your interest in joining the Coventry Network.  At this time, our panels are closed, and we are not accepting new applications.  Please check back routinely to stay apprised of our panel status. We will update this site when we are open for new applicants. Gallagher, Hartford, Liberty Mutual, Travelers and Zurich fall under Coventry. Jen Videan"]
["Suhail Sami Daye, MD",1639251481,"26-3789190","TX","PE - Permian Physician Services","Travelers WC","Panel Closed","Panel Closed","","","","2023-05-10","Pending Coventry Enrollment. MS"]
["Suhail Sami Daye, MD",1639251481,"26-3789190","TX","PE - Permian Physician Services","Amerigroup","Participating","Enrollment Complete","2019-08-30","","","2023-08-17","8/17/2023 Per email from Priscilla Albertine at MQA she received a roster from Amerigroup confirming that provider is PAR and linked to group TIN/location effective 8/30/2019.  DCannon"]
["Suhail Sami Daye, MD",1639251481,"26-3789190","TX","PE - Permian Physician Services","Molina","In Process","Application Submitted","","","","2023-11-20","11/20/2023 Emailed change of information form to Molina Healthcare to add prover to group TIN/location.  DCannon"]
["Suhail Sami Daye, MD",1639251481,"26-3789190","TX","PE - Permian Physician Services","HealthSmart PPO","Participating","Enrollment Complete","2023-05-08","","","2023-07-21","7/21/2023 Per Healthsmart website provider is PAR and loaded under TIN/location effective 5/8/2023.  DCannon"]
["Suhail Sami Daye, MD",1639251481,"26-3789190","TX","PE - Permian Physician Services","Superior","Participating","Enrollment Complete","2023-06-01","","","2023-07-17","7/17/2023 Rcvd email from Superior that provider is PAR and linked to group delegated roster effective 6/1/2023.  DCannon"]
["Suhail Sami Daye, MD",1639251481,"26-3789190","TX","PE - Permian Physician Services","Caprock (CapStar)","Participating","Enrollment Complete","2023-05-08","","","2023-05-22","5/22/2023 Rcvd email from Caprock that May roster has been processed and provider is PAR w/ group effective 5/8/2023.  DCannon"]
["Suhail Sami Daye, MD",1639251481,"26-3789190","TX","PE - Permian Physician Services","Liberty Mutual","Panel Closed","Panel Closed","","","","2023-05-18","Pending Coventry Enrollment. MS"]
["Suhail Sami Daye, MD",1639251481,"26-3789190","TX","PE - Permian Physician Services","Corvel Healthcare Corp.","In Process","Pending Info/Document","","","","2023-11-21","Per Karina at Corvel, Permian Physician Services is part of SETHS delegated contract. Emailed MQA for assistance. Jen Videan"]
["Suhail Sami Daye, MD",1639251481,"26-3789190","TX","PE - Permian Physician Services","Rail Road Medicare","Participating","Enrollment Complete","2023-03-01","Q00516358","DS7320","2023-07-19","7/19/2023 Rcvd RR Medicare approval letter.   PTAN # Q00516358 - effective 3/1/2023.  DCannon"]
["Suhail Sami Daye, MD",1639251481,"26-3789190","TX","PE - Permian Physician Services","Alliance WC","Participating","Enrollment Complete","2023-07-21","","","2023-08-15","Per Michelle Killough at michelle.killough@pswca.org, Dr. Daye is par effective 07/21/2023. Jen Videan"]
["Suhail Sami Daye, MD",1639251481,"26-3789190","TX","PE - Permian Physician Services","Galaxy Health","Participating","Enrollment Complete","2023-05-08","","","2023-07-20","7/20/2023 Per email received from Galaxy May delegated roster has been processed and provider is PAR and linked to group effective 5/8/2023.  DCannon"]
["Suhail Sami Daye, MD",1639251481,"26-3789190","TX","PE - Permian Physician Services","Zurich","Panel Closed","Panel Closed","","","","2023-05-18","Pending Coventry Enrollment. MS"]
["Suhail Sami Daye, MD",1639251481,"26-3789190","TX","PE - Permian Physician Services","Texas Mutual","Panel Closed","Panel Closed","","","","2023-06-05","Per email dated 05/15/2023 from Matt Gorman at Texas Mutual (mgorman@texasmutual.com) Permian Physician Services contract is handled through Coventry. Coventry panel is closed. \nJen Videan"]
["Suhail Sami Daye, MD",1639251481,"26-3789190","TX","PE - Permian Physician Services","Boon Chapman","Participating","Enrollment Complete","2017-06-12","","","2023-07-26","7/26/2023 Rcvd email from Jessica Bess at Multiplan with a full roster and provider is PAR w/ group and location effective 6/2/2017.  DCannon"]
["Suhail Sami Daye, MD",1639251481,"26-3789190","TX","PE - Permian Physician Services","United Health Care","Participating","Enrollment Complete","2023-05-08","001060728","","2023-08-23","8/23/2023 Rcvd email from UHC that May delegated roster provider load has been completed and provider is PAR and linked to group TIN effective 5/8/2023.  MPIN# 001060728.  DCannon"]
["Suhail Sami Daye, MD",1639251481,"26-3789190","TX","PE - Permian Physician Services","Sedgwick","Pending Other Enrollment","Pending Contracting","","","","2023-11-28","Per Debbie Mason at Sedgwick TIN is not contracted/enrolled. Emailed roster and W9 per her request and she is looking into available contract opportunities. See group enrollment payor line for status/updates. Jen Videan"]
["Suhail Sami Daye, MD",1639251481,"26-3789190","TX","PE - Permian Physician Services","Tricare Prime","Panel Closed","Panel Closed","","","","2023-04-25","4/25/2023 Per Humana Military web portal Humana Military is currently not accepting requests to join the medical surgical network. We apologize for the inconvenience, but we hope you check back soon to see if we are accepting network providers.  DCannon"]
["Suhail Sami Daye, MD",1639251481,"26-3789190","TX","PE - Permian Physician Services","Coventry Workers Comp","Panel Closed","Panel Closed","","","","2023-05-22","Coventry Panel is closed. MS"]
["Suhail Sami Daye, MD",1639251481,"26-3789190","TX","PE - Permian Physician Services","Omni PPO","Participating","Enrollment Complete","2023-05-08","","","2023-07-19","7/19/2023 Per email received from IMS/OMNI May delegated roster has been processed and provider is PAR and linked to group effective 5/8/2023.  DCannon"]
["Rand E Waddingham, M.D.",1730181389,"26-3789190","TX","PE - Permian Physician Services","Medicare","Participating","Enrollment Complete","2021-01-01","1M9652","","2021-04-27","4/26/2021 Per email confirmation received from Stacy Salazar, provider has been assigned PTAN 1M9652 under group effective 1/1/2021. KFrazier"]
["Rand E Waddingham, M.D.",1730181389,"26-3789190","TX","","Medicare","Participating","Enrollment Complete","2021-01-01","1M9652","","2021-04-27","4/26/2021 Per email confirmation received from Stacy Salazar, provider has been assigned PTAN 1M9652 under group effective 1/1/2021. KFrazier"]
["Rand E Waddingham, M.D.",1730181389,"26-3789190","TX","PE - Permian Physician Services","Superior","Participating","Enrollment Complete","2020-10-01","1730181389","","2020-10-02","10/02/2020 - rec'd email from the payer confirming this provider has been added to the primed delegation - Stacey Hudak"]
["Rand E Waddingham, M.D.",1730181389,"26-3789190","TX","","Superior","Participating","Enrollment Complete","2020-10-01","1730181389","","2020-10-02","10/02/2020 - rec'd email from the payer confirming this provider has been added to the primed delegation - Stacey Hudak"]
["Rand E Waddingham, M.D.",1730181389,"26-3789190","TX","PE - Permian Physician Services","HealthSmart PPO","Participating","Enrollment Complete","2002-04-01","","","2021-04-11","4/11/2021 Rcvd email from HealthSmart <mdipsupport@healthsmart.com> confirming participation of provider under TIN and location effective 4/1/2002.  DCannon"]
["Rand E Waddingham, M.D.",1730181389,"26-3789190","TX","","HealthSmart PPO","Participating","Enrollment Complete","2002-04-01","","","2021-04-11","4/11/2021 Rcvd email from HealthSmart <mdipsupport@healthsmart.com> confirming participation of provider under TIN and location effective 4/1/2002.  DCannon"]
["Rand E Waddingham, M.D.",1730181389,"26-3789190","TX","PE - Permian Physician Services","Triwest VA","Participating","Enrollment Complete","2022-08-01","","","2022-10-06","09/28/2022 -  Received Permian Physician Services roster from TriWest VA (Scarlett Abigail, Scarlett_Abigail@bcbstx.com); provider listed as participating, eff. 08/01/2022 | Priscilla A."]
["Rand E Waddingham, M.D.",1730181389,"26-3789190","TX","","Triwest VA","Participating","Enrollment Complete","2022-08-01","","","2022-10-06","09/28/2022 -  Received Permian Physician Services roster from TriWest VA (Scarlett Abigail, Scarlett_Abigail@bcbstx.com); provider listed as participating, eff. 08/01/2022 | Priscilla A."]
["Rand E Waddingham, M.D.",1730181389,"26-3789190","TX","PE - Permian Physician Services","Gallagher","Panel Closed","Panel Closed","","","","2023-07-25","We appreciate your interest in joining the Coventry Network.  At this time, our panels are closed, and we are not accepting new applications.  Please check back routinely to stay apprised of our panel status. We will update this site when we are open for new applicants. Gallagher, Hartford, Liberty Mutual, Travelers and Zurich fall under Coventry. Jen Videan"]
["Rand E Waddingham, M.D.",1730181389,"26-3789190","TX","","Gallagher","Panel Closed","Panel Closed","","","","2023-07-25","We appreciate your interest in joining the Coventry Network.  At this time, our panels are closed, and we are not accepting new applications.  Please check back routinely to stay apprised of our panel status. We will update this site when we are open for new applicants. Gallagher, Hartford, Liberty Mutual, Travelers and Zurich fall under Coventry. Jen Videan"]
["Rand E Waddingham, M.D.",1730181389,"26-3789190","TX","PE - Permian Physician Services","Coventry Workers Comp","Panel Closed","Panel Closed","","","","2023-07-25","We appreciate your interest in joining the Coventry Network.  At this time, our panels are closed, and we are not accepting new applications.  Please check back routinely to stay apprised of our panel status. We will update this site when we are open for new applicants. Gallagher, Hartford, Liberty Mutual, Travelers and Zurich fall under Coventry. Jen Videan"]
["Rand E Waddingham, M.D.",1730181389,"26-3789190","TX","","Coventry Workers Comp","Panel Closed","Panel Closed","","","","2023-07-25","We appreciate your interest in joining the Coventry Network.  At this time, our panels are closed, and we are not accepting new applications.  Please check back routinely to stay apprised of our panel status. We will update this site when we are open for new applicants. Gallagher, Hartford, Liberty Mutual, Travelers and Zurich fall under Coventry. Jen Videan"]
["Rand E Waddingham, M.D.",1730181389,"26-3789190","TX","PE - Permian Physician Services","Hartford","Panel Closed","Panel Closed","","","","2023-07-25","We appreciate your interest in joining the Coventry Network.  At this time, our panels are closed, and we are not accepting new applications.  Please check back routinely to stay apprised of our panel status. We will update this site when we are open for new applicants. Gallagher, Hartford, Liberty Mutual, Travelers and Zurich fall under Coventry. Jen Videan"]
["Rand E Waddingham, M.D.",1730181389,"26-3789190","TX","","Hartford","Panel Closed","Panel Closed","","","","2023-07-25","We appreciate your interest in joining the Coventry Network.  At this time, our panels are closed, and we are not accepting new applications.  Please check back routinely to stay apprised of our panel status. We will update this site when we are open for new applicants. Gallagher, Hartford, Liberty Mutual, Travelers and Zurich fall under Coventry. Jen Videan"]
["Rand E Waddingham, M.D.",1730181389,"26-3789190","TX","PE - Permian Physician Services","Wellmed","Participating","Enrollment Complete","2022-01-12","","","2023-03-23","3/23/2023 Rcvd roster from UHC w/ all Wellmed participating providers.  Provider is PAR effective 1/1/2022.  DCannon"]
["Rand E Waddingham, M.D.",1730181389,"26-3789190","TX","","Wellmed","Participating","Enrollment Complete","2022-01-12","","","2023-03-23","3/23/2023 Rcvd roster from UHC w/ all Wellmed participating providers.  Provider is PAR effective 1/1/2022.  DCannon"]
["Rand E Waddingham, M.D.",1730181389,"26-3789190","TX","PE - Permian Physician Services","Wellcare","Participating","Enrollment Complete","2021-11-01","","","2022-12-01","12/1/2022 Per roster received from Wellcare provider is PAR and linked to group TIN/location effective 11/1/2021.  DCannon"]
["Rand E Waddingham, M.D.",1730181389,"26-3789190","TX","","Wellcare","Participating","Enrollment Complete","2021-11-01","","","2022-12-01","12/1/2022 Per roster received from Wellcare provider is PAR and linked to group TIN/location effective 11/1/2021.  DCannon"]
["Rand E Waddingham, M.D.",1730181389,"26-3789190","TX","PE - Permian Physician Services","Sedgwick","Pending Other Enrollment","Pending Contracting","","","","2023-11-28","Per Debbie Mason at Sedgwick TIN is not contracted/enrolled. Emailed roster and W9 per her request and she is looking into available contract opportunities. See group enrollment payor line for status/updates. Jen Videan"]
["Rand E Waddingham, M.D.",1730181389,"26-3789190","TX","","Sedgwick","Pending Other Enrollment","Pending Contracting","","","","2023-11-28","Per Debbie Mason at Sedgwick TIN is not contracted/enrolled. Emailed roster and W9 per her request and she is looking into available contract opportunities. See group enrollment payor line for status/updates. Jen Videan"]
["Rand E Waddingham, M.D.",1730181389,"26-3789190","TX","PE - Permian Physician Services","Multiplan","Participating","Enrollment Complete","2021-09-02","","","2022-07-23","7/23/2022 Per email from Marcie Eckhart-Haven at Multiplan provider is PAR and linked to group TIN effective 9/2/2021.  DCannon"]
["Rand E Waddingham, M.D.",1730181389,"26-3789190","TX","","Multiplan","Participating","Enrollment Complete","2021-09-02","","","2022-07-23","7/23/2022 Per email from Marcie Eckhart-Haven at Multiplan provider is PAR and linked to group TIN effective 9/2/2021.  DCannon"]
["Rand E Waddingham, M.D.",1730181389,"26-3789190","TX","PE - Permian Physician Services","TriCare Standard","Participating","Enrollment Complete","","","","2021-09-15","9/15/2021 Per non network portal, provider is certified under this location. Cbankston"]
["Rand E Waddingham, M.D.",1730181389,"26-3789190","TX","","TriCare Standard","Participating","Enrollment Complete","","","","2021-09-15","9/15/2021 Per non network portal, provider is certified under this location. Cbankston"]
["Rand E Waddingham, M.D.",1730181389,"26-3789190","TX","PE - Permian Physician Services","Broadspire Services Inc.","In Process","Pending Info/Document","","","","2023-11-21","Emailed Priscilla and Neerja for status of signed group agreements. Unable to move forward with individual provider until group agreement is in place.  Jen Videan"]
["Rand E Waddingham, M.D.",1730181389,"26-3789190","TX","","Broadspire Services Inc.","In Process","Pending Info/Document","","","","2023-11-21","Emailed Priscilla and Neerja for status of signed group agreements. Unable to move forward with individual provider until group agreement is in place.  Jen Videan"]
["Rand E Waddingham, M.D.",1730181389,"26-3789190","TX","PE - Permian Physician Services","USA PPO","Participating","Enrollment Complete","2021-01-26","547155","","2021-03-12","3/12/2021 Per verification on payor website USAMCO.com provider is loaded as participating.  Rcvd Roster LeNetrice Myart with provider numbers and effective dates for providers.  DCannon"]
["Rand E Waddingham, M.D.",1730181389,"26-3789190","TX","","USA PPO","Participating","Enrollment Complete","2021-01-26","547155","","2021-03-12","3/12/2021 Per verification on payor website USAMCO.com provider is loaded as participating.  Rcvd Roster LeNetrice Myart with provider numbers and effective dates for providers.  DCannon"]
["Rand E Waddingham, M.D.",1730181389,"26-3789190","TX","PE - Permian Physician Services","Medicaid","Participating","Enrollment Complete","2021-01-01","137280711","205408201","2021-04-14","4/14/2021 Rcvd TMHP Approval letter from Stacy Salazar that provider has been linked to Permian Physician Services TMHP group #.  TPI # 137280711 effective 1/1/2021"]
["Rand E Waddingham, M.D.",1730181389,"26-3789190","TX","","Medicaid","Participating","Enrollment Complete","2021-01-01","137280711","205408201","2021-04-14","4/14/2021 Rcvd TMHP Approval letter from Stacy Salazar that provider has been linked to Permian Physician Services TMHP group #.  TPI # 137280711 effective 1/1/2021"]
["Rand E Waddingham, M.D.",1730181389,"26-3789190","TX","PE - Permian Physician Services","Galaxy Health","Participating","Enrollment Complete","2019-09-01","1730181389","","2020-08-21","08/21/2020 - Rec'd email confirmation that this roster was processed and this provider was made effective with the requested eff date of 9-1-2019 - Stacey Hudak"]
["Rand E Waddingham, M.D.",1730181389,"26-3789190","TX","","Galaxy Health","Participating","Enrollment Complete","2019-09-01","1730181389","","2020-08-21","08/21/2020 - Rec'd email confirmation that this roster was processed and this provider was made effective with the requested eff date of 9-1-2019 - Stacey Hudak"]
["Rand E Waddingham, M.D.",1730181389,"26-3789190","TX","PE - Permian Physician Services","Caprock (CapStar)","Participating","Enrollment Complete","2019-09-01","","","2021-04-09","4/9/2020 Rcvd roster from Mary Rodriguez <mary.rodriguez@90degreebenefits.com> at Caprock listing provider as participating under TIN.  DCannon"]
["Rand E Waddingham, M.D.",1730181389,"26-3789190","TX","","Caprock (CapStar)","Participating","Enrollment Complete","2019-09-01","","","2021-04-09","4/9/2020 Rcvd roster from Mary Rodriguez <mary.rodriguez@90degreebenefits.com> at Caprock listing provider as participating under TIN.  DCannon"]
["Rand E Waddingham, M.D.",1730181389,"26-3789190","TX","PE - Permian Physician Services","Zurich","Panel Closed","Panel Closed","","","","2023-07-25","We appreciate your interest in joining the Coventry Network.  At this time, our panels are closed, and we are not accepting new applications.  Please check back routinely to stay apprised of our panel status. We will update this site when we are open for new applicants. Gallagher, Hartford, Liberty Mutual, Travelers and Zurich fall under Coventry. Jen Videan"]
["Rand E Waddingham, M.D.",1730181389,"26-3789190","TX","","Zurich","Panel Closed","Panel Closed","","","","2023-07-25","We appreciate your interest in joining the Coventry Network.  At this time, our panels are closed, and we are not accepting new applications.  Please check back routinely to stay apprised of our panel status. We will update this site when we are open for new applicants. Gallagher, Hartford, Liberty Mutual, Travelers and Zurich fall under Coventry. Jen Videan"]
["Rand E Waddingham, M.D.",1730181389,"26-3789190","TX","PE - Permian Physician Services","Ambetter","Participating","Enrollment Complete","2022-04-01","","","2022-06-13","6/13/2022 Per roster received from Superior provider is PAR and linked to group delegation roster effective 4/1/2022."]
["Rand E Waddingham, M.D.",1730181389,"26-3789190","TX","","Ambetter","Participating","Enrollment Complete","2022-04-01","","","2022-06-13","6/13/2022 Per roster received from Superior provider is PAR and linked to group delegation roster effective 4/1/2022."]
["Rand E Waddingham, M.D.",1730181389,"26-3789190","TX","PE - Permian Physician Services","Texas Municipal League","Participating","Enrollment Complete","2023-11-03","","","2023-11-20","Enrollment through Alliance WC. Rcvd approval ltr. Provider effective 11/03/2023. See Alliance WC payor line. Jen Videan"]
["Rand E Waddingham, M.D.",1730181389,"26-3789190","TX","","Texas Municipal League","Participating","Enrollment Complete","2023-11-03","","","2023-11-20","Enrollment through Alliance WC. Rcvd approval ltr. Provider effective 11/03/2023. See Alliance WC payor line. Jen Videan"]
["Rand E Waddingham, M.D.",1730181389,"26-3789190","TX","PE - Permian Physician Services","Liberty Mutual","Panel Closed","Panel Closed","","","","2023-07-19","07/18/2023. We appreciate your interest in joining the Coventry Network.  At this time, our panels are closed, and we are not accepting new applications.  Please check back routinely to stay apprised of our panel status. We will update this site when we are open for new applicants. Gallagher, Hartford, Liberty Mutual, Travelers and Zurich fall under Coventry. Jen Videan"]
["Rand E Waddingham, M.D.",1730181389,"26-3789190","TX","","Liberty Mutual","Panel Closed","Panel Closed","","","","2023-07-19","07/18/2023. We appreciate your interest in joining the Coventry Network.  At this time, our panels are closed, and we are not accepting new applications.  Please check back routinely to stay apprised of our panel status. We will update this site when we are open for new applicants. Gallagher, Hartford, Liberty Mutual, Travelers and Zurich fall under Coventry. Jen Videan"]
["Rand E Waddingham, M.D.",1730181389,"26-3789190","TX","PE - Permian Physician Services","Alliance WC","Participating","Enrollment Complete","2023-11-03","","","2023-11-27","Per barry.harris@pswca.org, Dr. Rand Waddingham enrollment has been completed for Andrew Family Medicine and Permian Physician Services. Effective 11-03-23. Jen Videan"]
["Rand E Waddingham, M.D.",1730181389,"26-3789190","TX","","Alliance WC","Participating","Enrollment Complete","2023-11-03","","","2023-11-27","Per barry.harris@pswca.org, Dr. Rand Waddingham enrollment has been completed for Andrew Family Medicine and Permian Physician Services. Effective 11-03-23. Jen Videan"]
["Rand E Waddingham, M.D.",1730181389,"26-3789190","TX","PE - Permian Physician Services","Travelers WC","Panel Closed","Panel Closed","","","","2023-07-25","We appreciate your interest in joining the Coventry Network.  At this time, our panels are closed, and we are not accepting new applications.  Please check back routinely to stay apprised of our panel status. We will update this site when we are open for new applicants. Gallagher, Hartford, Liberty Mutual, Travelers and Zurich fall under Coventry. Jen Videan"]
["Rand E Waddingham, M.D.",1730181389,"26-3789190","TX","","Travelers WC","Panel Closed","Panel Closed","","","","2023-07-25","We appreciate your interest in joining the Coventry Network.  At this time, our panels are closed, and we are not accepting new applications.  Please check back routinely to stay apprised of our panel status. We will update this site when we are open for new applicants. Gallagher, Hartford, Liberty Mutual, Travelers and Zurich fall under Coventry. Jen Videan"]
["Rand E Waddingham, M.D.",1730181389,"26-3789190","TX","PE - Permian Physician Services","United Health Care","Participating","Enrollment Complete","2022-01-12","001199099","","2022-02-09","2/9/2022 Received email from united_healthcare_provider_operations@uhc.com, provider/group updates are complete. PID 001199099. Reference number PR-6309606. Sent email to network services requesting eff date. Cbankston"]
["Rand E Waddingham, M.D.",1730181389,"26-3789190","TX","","United Health Care","Participating","Enrollment Complete","2022-01-12","001199099","","2022-02-09","2/9/2022 Received email from united_healthcare_provider_operations@uhc.com, provider/group updates are complete. PID 001199099. Reference number PR-6309606. Sent email to network services requesting eff date. Cbankston"]
["Rand E Waddingham, M.D.",1730181389,"26-3789190","TX","PE - Permian Physician Services","Scott&White (First Care)","Participating","Enrollment Complete","2020-07-14","","","2021-08-26","8/26/2021 Rcvd roster from Scott & White/First Care, provider is listed as PAR under group TIN/location effective 7/14/2020.  DCannon"]
["Rand E Waddingham, M.D.",1730181389,"26-3789190","TX","","Scott&White (First Care)","Participating","Enrollment Complete","2020-07-14","","","2021-08-26","8/26/2021 Rcvd roster from Scott & White/First Care, provider is listed as PAR under group TIN/location effective 7/14/2020.  DCannon"]
["Rand E Waddingham, M.D.",1730181389,"26-3789190","TX","PE - Permian Physician Services","Humana","Participating","Enrollment Complete","2021-09-01","","","2021-11-18","11/18/2021 Rcvd full roster from Humana listing provider as PAR and linked to group TIN/location effective 9/1/2021.  DCannon"]
["Rand E Waddingham, M.D.",1730181389,"26-3789190","TX","","Humana","Participating","Enrollment Complete","2021-09-01","","","2021-11-18","11/18/2021 Rcvd full roster from Humana listing provider as PAR and linked to group TIN/location effective 9/1/2021.  DCannon"]
["Rand E Waddingham, M.D.",1730181389,"26-3789190","TX","PE - Permian Physician Services","Cigna","Participating","Enrollment Complete","2020-01-01","6384931","","2020-11-24","11/24/2020 - Rcvd confirmation email that provider is linked to group eff 1/1/2020 PID # 6384931.  DCannon"]
["Rand E Waddingham, M.D.",1730181389,"26-3789190","TX","","Cigna","Participating","Enrollment Complete","2020-01-01","6384931","","2020-11-24","11/24/2020 - Rcvd confirmation email that provider is linked to group eff 1/1/2020 PID # 6384931.  DCannon"]
["Rand E Waddingham, M.D.",1730181389,"26-3789190","TX","PE - Permian Physician Services","Amerigroup","Participating","Enrollment Complete","2012-03-01","","","2021-02-13","2/13/2021 - Rcvd complete roster from Amerigroup provider is participating and linked to TIN and location for the following plans STAR - eff 3/1/2012, MEDICARE - eff 8/1/2012, C-SNP - eff 1/1/2017, OTHER - eff 1/1/2021, OTHER - eff 1/1/2020,  PLUS - eff 3/1/2012, Star_Kids - eff 11/1/2016.  DCannon"]
["Rand E Waddingham, M.D.",1730181389,"26-3789190","TX","","Amerigroup","Participating","Enrollment Complete","2012-03-01","","","2021-02-13","2/13/2021 - Rcvd complete roster from Amerigroup provider is participating and linked to TIN and location for the following plans STAR - eff 3/1/2012, MEDICARE - eff 8/1/2012, C-SNP - eff 1/1/2017, OTHER - eff 1/1/2021, OTHER - eff 1/1/2020,  PLUS - eff 3/1/2012, Star_Kids - eff 11/1/2016.  DCannon"]
["Rand E Waddingham, M.D.",1730181389,"26-3789190","TX","PE - Permian Physician Services","Texas Mutual","In Process","Application Submitted","","","","2023-11-22","TSCA and required documents emailed to wwtxcontracts@texasmutual.com. Jen Videan"]
["Rand E Waddingham, M.D.",1730181389,"26-3789190","TX","","Texas Mutual","In Process","Application Submitted","","","","2023-11-22","TSCA and required documents emailed to wwtxcontracts@texasmutual.com. Jen Videan"]
["Frank O McGehee, IV, MD",1134151756,"27-0950535","TX","PE - McGehee Medical, PA","Humana","Participating","Enrollment Complete","2011-03-01","1134151756","","2020-07-15","7/15/2020 - Received email spreadsheet from the payor confirming that this provider is EFF at this service location and PAR with the PRIMED DELEGATED agreement - Pam Porter"]
["Frank O McGehee, IV, MD",1134151756,"27-0950535","TX","","Humana","Participating","Enrollment Complete","2011-03-01","1134151756","","2020-07-15","7/15/2020 - Received email spreadsheet from the payor confirming that this provider is EFF at this service location and PAR with the PRIMED DELEGATED agreement - Pam Porter"]
["Frank O McGehee, IV, MD",1134151756,"27-0950535","TX","PE - McGehee Medical, PA","Boon Chapman","Enrollment Stopped","Enrollment Stopped","","","","2023-09-25","9/25/2023 Per email from Priscilla Albertine at MQA provider does not wish to enroll in Multiplan.  Therefore, enrollment for Boon Chapman will be stopped at this time.  DCannon"]
["Frank O McGehee, IV, MD",1134151756,"27-0950535","TX","","Boon Chapman","Enrollment Stopped","Enrollment Stopped","","","","2023-09-25","9/25/2023 Per email from Priscilla Albertine at MQA provider does not wish to enroll in Multiplan.  Therefore, enrollment for Boon Chapman will be stopped at this time.  DCannon"]
["Frank O McGehee, IV, MD",1134151756,"27-0950535","TX","PE - McGehee Medical, PA","United Health Care","Participating","Enrollment Complete","2015-12-14","2748091","","2020-07-30","7/30/2020 - moved to completed status after reviewing follow up complete note - Stacey Hudak"]
["Frank O McGehee, IV, MD",1134151756,"27-0950535","TX","","United Health Care","Participating","Enrollment Complete","2015-12-14","2748091","","2020-07-30","7/30/2020 - moved to completed status after reviewing follow up complete note - Stacey Hudak"]
["Frank O McGehee, IV, MD",1134151756,"27-0950535","TX","PE - McGehee Medical, PA","Scott&White (First Care)","Participating","Enrollment Complete","2016-02-01","1134151756","","2020-04-16","04/16/2020 - Rec'd spreadsheet from payer indiciating this provider is EFF with PPPO & Medicare products under the PRIMED DELEGATED agreement under this TIN/Service location - Stacey Hudak"]
["Frank O McGehee, IV, MD",1134151756,"27-0950535","TX","","Scott&White (First Care)","Participating","Enrollment Complete","2016-02-01","1134151756","","2020-04-16","04/16/2020 - Rec'd spreadsheet from payer indiciating this provider is EFF with PPPO & Medicare products under the PRIMED DELEGATED agreement under this TIN/Service location - Stacey Hudak"]
["Frank O McGehee, IV, MD",1134151756,"27-0950535","TX","PE - McGehee Medical, PA","Galaxy Health","Participating","Enrollment Complete","2010-04-16","1619213386","","2020-07-17","7/17/2020- Received a spreadsheet from the payer stating this provider is effective as of 4/16/2010. – Jerha Gayorgor"]
["Frank O McGehee, IV, MD",1134151756,"27-0950535","TX","","Galaxy Health","Participating","Enrollment Complete","2010-04-16","1619213386","","2020-07-17","7/17/2020- Received a spreadsheet from the payer stating this provider is effective as of 4/16/2010. – Jerha Gayorgor"]
["Frank O McGehee, IV, MD",1134151756,"27-0950535","TX","PE - McGehee Medical, PA","Aetna","Participating","Enrollment Complete","2009-05-15","1134151756","","2020-04-23","04/23/2020--S/W Ed of Aetna @ 8003531232, provider NPI is on file for the provider and participating effective 05/15/09 under the group and TIN. Delegated with Primed Health Network. Physical location is on file. Provider ID# 9485308. Call ref# 5235876865. \ncopied note from spreadsheet-tisha rader"]
["Frank O McGehee, IV, MD",1134151756,"27-0950535","TX","","Aetna","Participating","Enrollment Complete","2009-05-15","1134151756","","2020-04-23","04/23/2020--S/W Ed of Aetna @ 8003531232, provider NPI is on file for the provider and participating effective 05/15/09 under the group and TIN. Delegated with Primed Health Network. Physical location is on file. Provider ID# 9485308. Call ref# 5235876865. \ncopied note from spreadsheet-tisha rader"]
["Frank O McGehee, IV, MD",1134151756,"27-0950535","TX","PE - McGehee Medical, PA","HealthSmart PPO","Participating","Enrollment Complete","2011-02-01","1134151756","","2020-06-04","06/04/2020 - moved to completed status after getting email from payer that this provider is EFF - Stacey Hudak"]
["Frank O McGehee, IV, MD",1134151756,"27-0950535","TX","","HealthSmart PPO","Participating","Enrollment Complete","2011-02-01","1134151756","","2020-06-04","06/04/2020 - moved to completed status after getting email from payer that this provider is EFF - Stacey Hudak"]
["Frank O McGehee, IV, MD",1134151756,"27-0950535","TX","PE - McGehee Medical, PA","IMS","Participating","Enrollment Complete","2010-02-01","1134151756","","2020-06-22","06/22/2020- Rec'd email from the payer confirming this provider is PAR with this group/service location - Stacey Hudak"]
["Frank O McGehee, IV, MD",1134151756,"27-0950535","TX","","IMS","Participating","Enrollment Complete","2010-02-01","1134151756","","2020-06-22","06/22/2020- Rec'd email from the payer confirming this provider is PAR with this group/service location - Stacey Hudak"]
["Frank O McGehee, IV, MD",1134151756,"27-0950535","TX","PE - McGehee Medical, PA","First Health Coventry","Participating","Enrollment Complete","2020-02-01","1609797","","2020-03-20","03/02/2020 - Rec'd email fromt he payer confirming that this provider is effective with this payer under provider ID# 1609797 - Stacey Hudak"]
["Frank O McGehee, IV, MD",1134151756,"27-0950535","TX","","First Health Coventry","Participating","Enrollment Complete","2020-02-01","1609797","","2020-03-20","03/02/2020 - Rec'd email fromt he payer confirming that this provider is effective with this payer under provider ID# 1609797 - Stacey Hudak"]
["Stephanie D Crawford, FNP",1265081616,"27-4061759","TX","PE - Permian Cardiology Inc.","Amerigroup","Participating","Enrollment Complete","2022-12-19","","","2023-02-16","2.16.2023 Per follow-up note - S/W Qjuana of Amerigroup @ 800-454-3730. Provider is on file and participating. Link under the group and TIN effective 12/19/2022. Location is on file. Provider ID is 15465202.   DCannon"]
["Stephanie D Crawford, FNP",1265081616,"27-4061759","TX","PE - Permian Cardiology Inc.","Triwest VA","In House Enrollment","In House Enrollment","","","","2022-11-21",""]
["Stephanie D Crawford, FNP",1265081616,"27-4061759","TX","PE - Permian Cardiology Inc.","Medicaid","Participating","Enrollment Complete","2022-08-07","","","2023-08-21","Stephanie Crawford  Medicaid par effective 08/07/22. Jen Videan"]
["Stephanie D Crawford, FNP",1265081616,"27-4061759","TX","PE - Permian Cardiology Inc.","First Health Coventry","Participating","Enrollment Complete","","3641811","","2023-07-24","Confirmed enrollment via online directory. MS"]
["Stephanie D Crawford, FNP",1265081616,"27-4061759","TX","PE - Permian Cardiology Inc.","USA PPO","Participating","Enrollment Complete","2022-12-19","","","2023-03-24","3/24/2023 In following up with USAMCO (800-872-3860) I was told that you can confirm participating via the USA MCO website  https://providersearch.usamco.com/hwprovsearch.  Provider is PAR and linked to location/TIN effective 12/19/2022.  DCannon"]
["Stephanie D Crawford, FNP",1265081616,"27-4061759","TX","PE - Permian Cardiology Inc.","Tricare Prime","Panel Closed","Panel Closed","","","","2022-11-28","11/28/2022 Tricare Prime panel is closed and currently not accepting requests to join the network.  DCannon"]
["Stephanie D Crawford, FNP",1265081616,"27-4061759","TX","PE - Permian Cardiology Inc.","Boon Chapman","Participating","Enrollment Complete","2022-12-19","","","2023-07-26","7/26/2023 Rcvd email from Jessica Bess at Multiplan with a full roster and provider is PAR w/ group and location effective 12/19/2022.  DCannon"]
["Stephanie D Crawford, FNP",1265081616,"27-4061759","TX","PE - Permian Cardiology Inc.","Ambetter","Participating","Enrollment Complete","2023-02-01","","","2023-03-23","3/23/2023 Rcvd email Superior w/ confirmation from that provider is PAR and linked to group effective 2/1/2023.  DCannon"]
["Stephanie D Crawford, FNP",1265081616,"27-4061759","TX","PE - Permian Cardiology Inc.","TriCare Standard","Participating","Enrollment Complete","2022-11-28","","","2022-12-28","12/28/2022  Per Humana Military/Tricare portal, provider is provider is PAR and linked to group effective 11/28/2022. DCannon"]
["Stephanie D Crawford, FNP",1265081616,"27-4061759","TX","PE - Permian Cardiology Inc.","Medicare","Participating","Enrollment Complete","2019-12-01","902816","TXB115966","2022-11-28","11/28/2022 Per PECOS provider is PAR and linked to group effective 12/1/2019.  PTAN # 902816.  DCannon"]
["Stephanie D Crawford, FNP",1265081616,"27-4061759","TX","PE - Permian Cardiology Inc.","Cigna","In Process","Payor Follow Up","","","","2023-11-18","Emailed PSScentral for status inquiry. MS"]
["Stephanie D Crawford, FNP",1265081616,"27-4061759","TX","PE - Permian Cardiology Inc.","United Health Care","Participating","Enrollment Complete","2022-12-19","","","2023-02-08","2/8/2023 Rcvd email from UHC that January delegated roster provider load has been completed and provider is PAR and linked to group TIN effective 12/19/2022.  MPIN# 007288273.  DCannon"]
["Stephanie D Crawford, FNP",1265081616,"27-4061759","TX","PE - Permian Cardiology Inc.","Scott&White (First Care)","Participating","Enrollment Complete","2023-02-14","","","2023-08-24","8/24/2023 Per email rcvd from Scott & White provider is PAR and linked to group TIN/location effective 2/14/2023.  DCannon"]
["Stephanie D Crawford, FNP",1265081616,"27-4061759","TX","PE - Permian Cardiology Inc.","Wellmed","Participating","Enrollment Complete","2022-12-19","","","2023-03-23","3/23/2023 Rcvd roster from UHC w/ all Wellmed participating providers.  Provider is PAR effective 12/19/2022.  DCannon"]
["Stephanie D Crawford, FNP",1265081616,"27-4061759","TX","PE - Permian Cardiology Inc.","Wellcare","Participating","Enrollment Complete","2023-02-01","","","2023-03-23","3/23/2023 Rcvd email Superior w/ confirmation from that provider is PAR and linked to group effective 2/1/2023.  DCannon"]
["Stephanie D Crawford, FNP",1265081616,"27-4061759","TX","PE - Permian Cardiology Inc.","Humana","Participating","Enrollment Complete","2022-12-19","","","2023-08-31","8/31/2023 Per email from Marcus Wester at Humana January delegated roster has been completed and provider is PAR effective 12/19/2022.  DCannon"]
["Stephanie D Crawford, FNP",1265081616,"27-4061759","TX","PE - Permian Cardiology Inc.","Aetna","Participating","Enrollment Complete","2023-01-09","6492054","","2023-04-03","04.03.2023 S/W Julie of Aetna @ 800-353-1232. Per rep, provider is showing participating with an Effective date 01/09/2023 and link under Group and TIN. Provider ID 6492054, Payer ID 60054 and Recredentialing date 12/16/2025. Service location is on file. Call ref#:6140925184. -Danico Gabriel Melendres"]
["Stephanie D Crawford, FNP",1265081616,"27-4061759","TX","PE - Permian Cardiology Inc.","Rail Road Medicare","Participating","Enrollment Complete","2019-12-01","Q00373156","DS1746","2022-11-28","11/28/2022 Rcvd RR Medicare approval letter.  PTAN # Q00373156 - effective 12/1/2019.  DCannon"]
["Stephanie D Crawford, FNP",1265081616,"27-4061759","TX","PE - Permian Cardiology Inc.","Superior","Participating","Enrollment Complete","2023-02-01","","","2023-02-09","2/9/2023 Rcvd confirmation email from Superior that January delegation roster has been processed and provider has been loaded to delegation roster and PAR w/ group effective 2/1/2023.  DCannon"]
["Stephanie D Crawford, FNP",1265081616,"27-4061759","TX","PE - Permian Cardiology Inc.","Caprock (CapStar)","Participating","Enrollment Complete","2022-12-19","","","2023-01-20","1/20/2023 Rcvd email  confirmation from Caprock that provider is PAR and linked to group TIN/locations effective 12/19/2022.  DCannon"]
["Stephanie D Crawford, FNP",1265081616,"27-4061759","TX","PE - Permian Cardiology Inc.","Multiplan","Participating","Enrollment Complete","2022-12-19","","","2023-06-21","Rcvd effective date of 12/19/2022 from jessica.bess@MultiPlan.com.\nJen Videan"]
["Stephanie D Crawford, FNP",1265081616,"27-4061759","TX","PE - Permian Cardiology Inc.","HealthSmart PPO","Participating","Enrollment Complete","2022-12-19","","","2023-02-28","2/28/2023 Per Healthsmart website provider is PAR and loaded under TIN/location effective 12/19/2022.  DCannon"]
["Stephanie D Crawford, FNP",1265081616,"27-4061759","TX","PE - Permian Cardiology Inc.","Omni PPO","Participating","Enrollment Complete","2022-12-19","","","2023-01-31","1/31/2023 Per email received from German Aviles at IMS/OMNI monthly delegation roster provider load for December has been completed.  Provider is PAR and linked to group TIN effective 11/28/2022.   DCannon"]
["Stephanie D Crawford, FNP",1265081616,"27-4061759","TX","PE - Permian Cardiology Inc.","Galaxy Health","Participating","Enrollment Complete","2022-12-19","","","2023-03-09","3/9/2023 Per email rcvd from Karen Avalos at Galaxy, January monthly roster has been completed.  Provider is PAR and linked to group effective 12/19/2022.  DCannon"]
["Jose A Suarez, MD",1669470332,"27-4061759","TX","PE - Permian Cardiology Inc.","Cigna","In Process","Payor Receipt Validated","","","","2023-11-07","Received receipt from payor. Ref 13506945. MS"]
["Jose A Suarez, MD",1669470332,"27-4061759","TX","","Cigna","In Process","Payor Receipt Validated","","","","2023-11-07","Received receipt from payor. Ref 13506945. MS"]
["Jose A Suarez, MD",1669470332,"27-4061759","TX","PE - Permian Cardiology Inc.","Galaxy Health","Participating","Enrollment Complete","2023-06-01","","","2023-07-20","7/20/2023 Per email received from Galaxy June delegated roster has been processed and provider is PAR and linked to group effective 6/1/2023.  DCannon"]
["Jose A Suarez, MD",1669470332,"27-4061759","TX","","Galaxy Health","Participating","Enrollment Complete","2023-06-01","","","2023-07-20","7/20/2023 Per email received from Galaxy June delegated roster has been processed and provider is PAR and linked to group effective 6/1/2023.  DCannon"]
["Jose A Suarez, MD",1669470332,"27-4061759","TX","PE - Permian Cardiology Inc.","Tricare Prime","Panel Closed","Panel Closed","","","","2023-04-25","4/25/2023 Per Humana Military web portal Humana Military is currently not accepting requests to join the medical surgical network. We apologize for the inconvenience, but we hope you check back soon to see if we are accepting network providers.  DCannon"]
["Jose A Suarez, MD",1669470332,"27-4061759","TX","","Tricare Prime","Panel Closed","Panel Closed","","","","2023-04-25","4/25/2023 Per Humana Military web portal Humana Military is currently not accepting requests to join the medical surgical network. We apologize for the inconvenience, but we hope you check back soon to see if we are accepting network providers.  DCannon"]
["Jose A Suarez, MD",1669470332,"27-4061759","TX","PE - Permian Cardiology Inc.","United Health Care","Participating","Enrollment Complete","2023-06-01","2419969","","2023-07-20","7/20/2023 Rcvd email confirmation that provider is PAR and linked to group effective 6/1/2023.  MPIN# 2419969.  DCannon"]
["Jose A Suarez, MD",1669470332,"27-4061759","TX","","United Health Care","Participating","Enrollment Complete","2023-06-01","2419969","","2023-07-20","7/20/2023 Rcvd email confirmation that provider is PAR and linked to group effective 6/1/2023.  MPIN# 2419969.  DCannon"]
["Jose A Suarez, MD",1669470332,"27-4061759","TX","PE - Permian Cardiology Inc.","Ambetter","Participating","Enrollment Complete","2023-08-01","","","2023-08-15","8/15/2023 Rcvd confirmation email from Superior that February delegation roster has been processed and provider has been loaded to delegation roster and PAR w/ group effective 8/1/2023.  DCannon"]
["Jose A Suarez, MD",1669470332,"27-4061759","TX","","Ambetter","Participating","Enrollment Complete","2023-08-01","","","2023-08-15","8/15/2023 Rcvd confirmation email from Superior that February delegation roster has been processed and provider has been loaded to delegation roster and PAR w/ group effective 8/1/2023.  DCannon"]
["Jose A Suarez, MD",1669470332,"27-4061759","TX","PE - Permian Cardiology Inc.","Rail Road Medicare","Participating","Enrollment Complete","2023-05-01","","","2023-05-24",""]
["Jose A Suarez, MD",1669470332,"27-4061759","TX","","Rail Road Medicare","Participating","Enrollment Complete","2023-05-01","","","2023-05-24",""]
["Jose A Suarez, MD",1669470332,"27-4061759","TX","PE - Permian Cardiology Inc.","Medicare","Participating","Enrollment Complete","2023-05-01","2S7046","TXB115966","2023-04-28","4/28/2023 Rcvd Medicare approval letter.  Provider is PAR and linked to group/location effective 5/1/2023.  PTAN# 2S7046.  DCannon"]
["Jose A Suarez, MD",1669470332,"27-4061759","TX","","Medicare","Participating","Enrollment Complete","2023-05-01","2S7046","TXB115966","2023-04-28","4/28/2023 Rcvd Medicare approval letter.  Provider is PAR and linked to group/location effective 5/1/2023.  PTAN# 2S7046.  DCannon"]
["Jose A Suarez, MD",1669470332,"27-4061759","TX","PE - Permian Cardiology Inc.","Caprock (CapStar)","Participating","Enrollment Complete","2023-06-01","","","2023-07-26","7/26/2023 Rcvd email  confirmation from Caprock that provider is PAR and linked to group TIN/locations effective 6/1/2023.  DCannon"]
["Jose A Suarez, MD",1669470332,"27-4061759","TX","","Caprock (CapStar)","Participating","Enrollment Complete","2023-06-01","","","2023-07-26","7/26/2023 Rcvd email  confirmation from Caprock that provider is PAR and linked to group TIN/locations effective 6/1/2023.  DCannon"]
["Jose A Suarez, MD",1669470332,"27-4061759","TX","PE - Permian Cardiology Inc.","CAQH","Participating","CAQH Reattested","2023-10-04","","","2023-10-04","10/04/2023 - updated and uploaded Board , Practice Location, credential contact, Insurance and Re-attested - Mkhan"]
["Jose A Suarez, MD",1669470332,"27-4061759","TX","","CAQH","Participating","CAQH Reattested","2023-10-04","","","2023-10-04","10/04/2023 - updated and uploaded Board , Practice Location, credential contact, Insurance and Re-attested - Mkhan"]
["Jose A Suarez, MD",1669470332,"27-4061759","TX","PE - Permian Cardiology Inc.","HealthSmart PPO","In Process","Payor Follow Up","","","","2023-11-14","11/14/2023 Per Healthsmart provider portal provider is still not loaded under group TIN.  Per phone conversation with Lee Kinard at Healthsmart provider portal should be updated  by 11/27/2023.  Will allow more time, check back in 2 weeks.   DCannon"]
["Jose A Suarez, MD",1669470332,"27-4061759","TX","","HealthSmart PPO","In Process","Payor Follow Up","","","","2023-11-14","11/14/2023 Per Healthsmart provider portal provider is still not loaded under group TIN.  Per phone conversation with Lee Kinard at Healthsmart provider portal should be updated  by 11/27/2023.  Will allow more time, check back in 2 weeks.   DCannon"]
["Jose A Suarez, MD",1669470332,"27-4061759","TX","PE - Permian Cardiology Inc.","Scott&White (First Care)","Participating","Enrollment Complete","2023-07-20","","","2023-08-24","8/24/2023 Per email rcvd from Scott & White provider is PAR and linked to group TIN/location effective 7/20/2023.  DCannon"]
["Jose A Suarez, MD",1669470332,"27-4061759","TX","","Scott&White (First Care)","Participating","Enrollment Complete","2023-07-20","","","2023-08-24","8/24/2023 Per email rcvd from Scott & White provider is PAR and linked to group TIN/location effective 7/20/2023.  DCannon"]
["Jose A Suarez, MD",1669470332,"27-4061759","TX","PE - Permian Cardiology Inc.","IMS","Participating","Enrollment Complete","2023-06-01","","","2023-07-18","7/18/2023 Per email received from IMS/OMNI June delegated roster has been processed and provider is PAR and linked to group effective 6/1/2023.  DCannon"]
["Jose A Suarez, MD",1669470332,"27-4061759","TX","","IMS","Participating","Enrollment Complete","2023-06-01","","","2023-07-18","7/18/2023 Per email received from IMS/OMNI June delegated roster has been processed and provider is PAR and linked to group effective 6/1/2023.  DCannon"]
["Jose A Suarez, MD",1669470332,"27-4061759","TX","PE - Permian Cardiology Inc.","Triwest VA","In House Enrollment","In House Enrollment","","","","2023-04-19",""]
["Jose A Suarez, MD",1669470332,"27-4061759","TX","","Triwest VA","In House Enrollment","In House Enrollment","","","","2023-04-19",""]
["Jose A Suarez, MD",1669470332,"27-4061759","TX","PE - Permian Cardiology Inc.","Multiplan","Participating","Enrollment Complete","2023-06-01","","","2023-07-25","7/25/2023 Rcvd email confirmation from Jessica Bess at Multiplan that June roster has been processed and provider is PAR w/ group effective 6/1/2023.  DCannon"]
["Jose A Suarez, MD",1669470332,"27-4061759","TX","","Multiplan","Participating","Enrollment Complete","2023-06-01","","","2023-07-25","7/25/2023 Rcvd email confirmation from Jessica Bess at Multiplan that June roster has been processed and provider is PAR w/ group effective 6/1/2023.  DCannon"]
["Jose A Suarez, MD",1669470332,"27-4061759","TX","PE - Permian Cardiology Inc.","Boon Chapman","Participating","Enrollment Complete","2023-06-01","","","2023-07-25","7/25/2023 Rcvd email confirmation from Jessica Bess at Multiplan that June roster has been processed and provider is PAR w/ group effective 6/1/2023.  DCannon"]
["Jose A Suarez, MD",1669470332,"27-4061759","TX","","Boon Chapman","Participating","Enrollment Complete","2023-06-01","","","2023-07-25","7/25/2023 Rcvd email confirmation from Jessica Bess at Multiplan that June roster has been processed and provider is PAR w/ group effective 6/1/2023.  DCannon"]
["Jose A Suarez, MD",1669470332,"27-4061759","TX","PE - Permian Cardiology Inc.","Humana","Participating","Enrollment Complete","2023-06-01","","","2023-10-27","10/27/2023 Per email received from Humana provider is PAR and linked to group TIN/locations effective 6/1/2023.  DCannon"]
["Jose A Suarez, MD",1669470332,"27-4061759","TX","","Humana","Participating","Enrollment Complete","2023-06-01","","","2023-10-27","10/27/2023 Per email received from Humana provider is PAR and linked to group TIN/locations effective 6/1/2023.  DCannon"]
["Jose A Suarez, MD",1669470332,"27-4061759","TX","PE - Permian Cardiology Inc.","Amerigroup","Participating","Enrollment Complete","2023-06-01","","","2023-10-18","10/18/2023 Per email received from Jessica Bess at  Multiplan provider is PAR with Amerigroup and linked to group TIN/locations thru Multiplan enrollment effective 6/1/2023.  DCannon"]
["Jose A Suarez, MD",1669470332,"27-4061759","TX","","Amerigroup","Participating","Enrollment Complete","2023-06-01","","","2023-10-18","10/18/2023 Per email received from Jessica Bess at  Multiplan provider is PAR with Amerigroup and linked to group TIN/locations thru Multiplan enrollment effective 6/1/2023.  DCannon"]
["Jose A Suarez, MD",1669470332,"27-4061759","TX","PE - Permian Cardiology Inc.","Wellcare","Participating","Enrollment Complete","2023-08-01","","","2023-08-15","8/15/2023 Rcvd confirmation email from Superior that February delegation roster has been processed and provider has been loaded to delegation roster and PAR w/ group effective 8/1/2023.  DCannon"]
["Jose A Suarez, MD",1669470332,"27-4061759","TX","","Wellcare","Participating","Enrollment Complete","2023-08-01","","","2023-08-15","8/15/2023 Rcvd confirmation email from Superior that February delegation roster has been processed and provider has been loaded to delegation roster and PAR w/ group effective 8/1/2023.  DCannon"]
["Jose A Suarez, MD",1669470332,"27-4061759","TX","PE - Permian Cardiology Inc.","First Health Coventry","Participating","Enrollment Complete","2023-06-01","","","2023-07-26","07.27.2023 S/W Bridgett of First Health @800-226-5116. Per rep, provider is showing participating and link under the Group and TIN with an Effective date 06/01/2023. Provider ID 1910887. Service location is on file. Call ref#:709557. - Danico Gabriel Melendres"]
["Jose A Suarez, MD",1669470332,"27-4061759","TX","","First Health Coventry","Participating","Enrollment Complete","2023-06-01","","","2023-07-26","07.27.2023 S/W Bridgett of First Health @800-226-5116. Per rep, provider is showing participating and link under the Group and TIN with an Effective date 06/01/2023. Provider ID 1910887. Service location is on file. Call ref#:709557. - Danico Gabriel Melendres"]
["Jose A Suarez, MD",1669470332,"27-4061759","TX","PE - Permian Cardiology Inc.","TriCare Standard","Participating","Enrollment Complete","2023-04-23","","","2023-05-24","Confirmed via HM portal. MS"]
["Jose A Suarez, MD",1669470332,"27-4061759","TX","","TriCare Standard","Participating","Enrollment Complete","2023-04-23","","","2023-05-24","Confirmed via HM portal. MS"]
["Jose A Suarez, MD",1669470332,"27-4061759","TX","PE - Permian Cardiology Inc.","Medicaid","Participating","Enrollment Complete","2023-05-01","","","2023-08-02","Rcvd approval letter from TMHP. Jen Videan"]
["Jose A Suarez, MD",1669470332,"27-4061759","TX","","Medicaid","Participating","Enrollment Complete","2023-05-01","","","2023-08-02","Rcvd approval letter from TMHP. Jen Videan"]
["Jose A Suarez, MD",1669470332,"27-4061759","TX","PE - Permian Cardiology Inc.","Wellmed","Participating","Enrollment Complete","2023-06-01","","","2023-07-26","7/26/2023 Per email received from UHC provider is PAR and linked to group/TIN effective 6/1/2023.  DCannon"]
["Jose A Suarez, MD",1669470332,"27-4061759","TX","","Wellmed","Participating","Enrollment Complete","2023-06-01","","","2023-07-26","7/26/2023 Per email received from UHC provider is PAR and linked to group/TIN effective 6/1/2023.  DCannon"]
["Jose A Suarez, MD",1669470332,"27-4061759","TX","PE - Permian Cardiology Inc.","Superior","Participating","Enrollment Complete","2023-08-01","","","2023-08-15","8/15/2023 Rcvd confirmation email from Superior that February delegation roster has been processed and provider has been loaded to delegation roster and PAR w/ group effective 8/1/2023.  DCannon"]
["Jose A Suarez, MD",1669470332,"27-4061759","TX","","Superior","Participating","Enrollment Complete","2023-08-01","","","2023-08-15","8/15/2023 Rcvd confirmation email from Superior that February delegation roster has been processed and provider has been loaded to delegation roster and PAR w/ group effective 8/1/2023.  DCannon"]
["Jose A Suarez, MD",1669470332,"27-4061759","TX","PE - Permian Cardiology Inc.","Omni PPO","Participating","Enrollment Complete","2023-06-01","","","2023-07-18","7/18/2023 Per email received from IMS/OMNI June delegated roster has been processed and provider is PAR and linked to group effective 6/1/2023.  DCannon"]
["Jose A Suarez, MD",1669470332,"27-4061759","TX","","Omni PPO","Participating","Enrollment Complete","2023-06-01","","","2023-07-18","7/18/2023 Per email received from IMS/OMNI June delegated roster has been processed and provider is PAR and linked to group effective 6/1/2023.  DCannon"]
["Jose A Suarez, MD",1669470332,"27-4061759","TX","PE - Permian Cardiology Inc.","Aetna","Participating","Enrollment Complete","2023-10-02","","","2023-06-09","Received welcome letter. attached. MS"]
["Jose A Suarez, MD",1669470332,"27-4061759","TX","","Aetna","Participating","Enrollment Complete","2023-10-02","","","2023-06-09","Received welcome letter. attached. MS"]
["Jose A Suarez, MD",1669470332,"27-4061759","TX","PE - Permian Cardiology Inc.","USA PPO","Participating","Enrollment Complete","2023-06-01","","","2023-08-23","8/23/2023 In following up with USAMCO (800-872-3860) I was told that you can confirm participating via the USA MCO website  https://providersearch.usamco.com/hwprovsearch.  Provider is PAR and linked to location/TIN effective 6/1/2023.  DCannon"]
["Jose A Suarez, MD",1669470332,"27-4061759","TX","","USA PPO","Participating","Enrollment Complete","2023-06-01","","","2023-08-23","8/23/2023 In following up with USAMCO (800-872-3860) I was told that you can confirm participating via the USA MCO website  https://providersearch.usamco.com/hwprovsearch.  Provider is PAR and linked to location/TIN effective 6/1/2023.  DCannon"]
["Whitney E Wyers, APRN-FNP-BC",1972003119,"27-4061759","TX","PE - Permian Cardiology Inc.","Aetna","Participating","Enrollment Complete","2023-08-24","6859498","","2023-08-04","Received confirmation email, which is saved to provider file. MS"]
["Whitney E Wyers, APRN-FNP-BC",1972003119,"27-4061759","TX","PE - Permian Cardiology Inc.","BCBSTX","In House Enrollment","In House Enrollment","","","","2023-08-15",""]
["Whitney E Wyers, APRN-FNP-BC",1972003119,"27-4061759","TX","PE - Permian Cardiology Inc.","IMS","Participating","Enrollment Complete","2023-09-08","","","2023-10-09","10/9/2023 Per email received from G. Aviles at IMS/OMNI September delegation roster has been completed.  Provider is PAR and linked to group/location effective 9/8/2023.  DCannon"]
["Whitney E Wyers, APRN-FNP-BC",1972003119,"27-4061759","TX","PE - Permian Cardiology Inc.","Ambetter","Participating","Enrollment Complete","2023-10-01","","","2023-10-16","10/16/2023 Rcvd email from Superior that provider is PAR and linked to group TIN/location effective 10/1/2023.  DCannon"]
["Whitney E Wyers, APRN-FNP-BC",1972003119,"27-4061759","TX","PE - Permian Cardiology Inc.","Tricare Prime","Panel Closed","Panel Closed","","","",45155,""]
["Whitney E Wyers, APRN-FNP-BC",1972003119,"27-4061759","TX","PE - Permian Cardiology Inc.","HealthSmart PPO","In Process","Payor Follow Up","","","","2023-11-14","11/14/2023 Per Healthsmart provider portal provider is still not loaded under group TIN.  Per phone conversation with Lee Kinard at Healthsmart provider portal should be updated  by 11/27/2023.  Will allow more time, check back in 2 weeks.   DCannon"]
["Whitney E Wyers, APRN-FNP-BC",1972003119,"27-4061759","TX","PE - Permian Cardiology Inc.","Wellmed","Participating","Enrollment Complete","2023-09-08","","","2023-09-28","9/28/2023 Rcvd email confirmation from UHC that September delegated roster has been completed.  Provider is PAR and linked to group/location effective 9/8/2023.  DCannon"]
["Whitney E Wyers, APRN-FNP-BC",1972003119,"27-4061759","TX","PE - Permian Cardiology Inc.","Superior","Participating","Enrollment Complete","2023-10-01","","","2023-10-16","10/16/2023 Rcvd email from Superior that provider is PAR and linked to group TIN/location effective 10/1/2023.  DCannon"]
["Whitney E Wyers, APRN-FNP-BC",1972003119,"27-4061759","TX","PE - Permian Cardiology Inc.","Scott&White (First Care)","Participating","Payor Follow Up","2023-10-15","","","2023-10-12","10/12/2023 Per email received from Scott & White provider is PAR and linked to group TIN/locations effective 10/15/2023.  DCannon"]
["Whitney E Wyers, APRN-FNP-BC",1972003119,"27-4061759","TX","PE - Permian Cardiology Inc.","Caprock (CapStar)","Participating","Enrollment Complete","2023-09-08","","","2023-09-27","9/27/2023 Rcvd email confirmation from Caprock that the September roster has been completed.  Provider is PAR and linked to group/location effective 9/8/2023.  DCannon"]
["Whitney E Wyers, APRN-FNP-BC",1972003119,"27-4061759","TX","PE - Permian Cardiology Inc.","Medicaid","In Process","Add Info Submitted","","","","2023-11-28","11/28/2023 Rcvd TMHP deficiency notice requesting copy of RN License.  Uploaded current of RN License via TMHP web portal. \n DCannon"]
["Whitney E Wyers, APRN-FNP-BC",1972003119,"27-4061759","TX","PE - Permian Cardiology Inc.","Boon Chapman","Participating","Enrollment Complete","2023-09-08","","","2023-10-12","10/12/2023 Per email received from Jessica Bess at  Multiplan provider is PAR and linked to group TIN/locations effective 9/8/2023.  DCannon"]
["Whitney E Wyers, APRN-FNP-BC",1972003119,"27-4061759","TX","PE - Permian Cardiology Inc.","Humana","In Process","Payor Follow Up","","","","2023-11-17","11/17/2023 Sent follow-up email to Marcus Wester at Humana to check status of September monthly delegated roster submission.  Provider Add - CO16127988, Provider Changes - CO-16128096,  Provider Terms - CO-16128221.  DCannon"]
["Whitney E Wyers, APRN-FNP-BC",1972003119,"27-4061759","TX","PE - Permian Cardiology Inc.","First Health Coventry","Participating","Enrollment Complete","","3143820","","2023-11-16","Confirmed enrollment via the payor directory. MS"]
["Whitney E Wyers, APRN-FNP-BC",1972003119,"27-4061759","TX","PE - Permian Cardiology Inc.","Galaxy Health","Participating","Enrollment Complete","2023-09-08","","","2023-10-11","10/11/2023 Per email received from Galaxy September delegated roster has been processed and provider is PAR and linked to group/location effective 9/8/2023.  DCannon"]
["Whitney E Wyers, APRN-FNP-BC",1972003119,"27-4061759","TX","PE - Permian Cardiology Inc.","Wellcare","Participating","Enrollment Complete","2023-10-01","","","2023-11-03","11/3/2023 Rcvd email from Superior that provider is PAR and linked to group TIN/location effective 10/1/2023.  DCannon"]
["Whitney E Wyers, APRN-FNP-BC",1972003119,"27-4061759","TX","PE - Permian Cardiology Inc.","Medicare","Participating","Enrollment Complete","2023-11-13","6C5573","","2023-11-03","Received welcome letter. MS"]
["Whitney E Wyers, APRN-FNP-BC",1972003119,"27-4061759","TX","PE - Permian Cardiology Inc.","Triwest VA","In House Enrollment","In House Enrollment","","","","2023-08-15",""]
["Whitney E Wyers, APRN-FNP-BC",1972003119,"27-4061759","TX","PE - Permian Cardiology Inc.","TriCare Standard","Participating","Enrollment Complete","2023-08-10","","","2023-08-24","Provider is linked to location effective 8/10. MS"]
["Whitney E Wyers, APRN-FNP-BC",1972003119,"27-4061759","TX","PE - Permian Cardiology Inc.","Cigna","Participating","Enrollment Complete","2023-10-05","","","2023-10-06","Received confirmation email. MS"]
["Whitney E Wyers, APRN-FNP-BC",1972003119,"27-4061759","TX","PE - Permian Cardiology Inc.","Multiplan","Participating","Enrollment Complete","2023-09-08","","","2023-10-12","10/12/2023 Per email received from Jessica Bess at  Multiplan provider is PAR and linked to group TIN/locations effective 9/8/2023.  DCannon"]
["Whitney E Wyers, APRN-FNP-BC",1972003119,"27-4061759","TX","PE - Permian Cardiology Inc.","USA PPO","In Process","Payor Follow Up","","","","2023-11-27","11/27/2023 Per USA PPO provider portal provider is still not loaded under new locations.  Will allow more time, check back in 2 weeks.  \nDCannon"]
["Whitney E Wyers, APRN-FNP-BC",1972003119,"27-4061759","TX","PE - Permian Cardiology Inc.","CAQH","Participating","CAQH Reattested","2023-10-30","","","2023-10-30","10/30/2023 - Updated license cred contact billing address and re-attested - rkedare"]
["Whitney E Wyers, APRN-FNP-BC",1972003119,"27-4061759","TX","PE - Permian Cardiology Inc.","Rail Road Medicare","Participating","Enrollment Complete","2023-11-13","Q00602404","","2023-11-16","Received confirmation. MS"]
["Whitney E Wyers, APRN-FNP-BC",1972003119,"27-4061759","TX","PE - Permian Cardiology Inc.","United Health Care","Participating","Enrollment Complete","2023-09-08","006787417","","2023-09-28","9/28/2023 Rcvd email confirmation from UHC that September delegated roster has been completed.  Provider is PAR and linked to group/location effective 9/8/2023.  DCannon"]
["Whitney E Wyers, APRN-FNP-BC",1972003119,"27-4061759","TX","PE - Permian Cardiology Inc.","Amerigroup","In Process","Payor Follow Up","","","","2023-10-27","10/27/2023 Sent follow-up email to Amerigroup to check status of September delegated roster submission.  DCannon"]
["Whitney E Wyers, APRN-FNP-BC",1972003119,"27-4061759","TX","PE - Permian Cardiology Inc.","Omni PPO","Participating","Enrollment Complete","2023-09-08","","","2023-10-09","10/9/2023 Per email received from G. Aviles at IMS/OMNI September delegation roster has been completed.  Provider is PAR and linked to group/location effective 9/8/2023.  DCannon"]
["James H Barnett, MD",1356484497,"27-4061759","TX","PE - Permian Cardiology Inc.","Caprock (CapStar)","Participating","Enrollment Complete","2012-03-01","1356484497","","",""]
["James H Barnett, MD",1356484497,"27-4061759","TX","","Caprock (CapStar)","Participating","Enrollment Complete","2012-03-01","1356484497","","",""]
["James H Barnett, MD",1356484497,"27-4061759","TX","PE - Permian Cardiology Inc.","Medicaid","Participating","Enrollment Complete","2021-10-06","136698110","356723201","2021-11-03","11/3/2021 Per TMHP website provider's revalidation has been completed effective 10/06/2021 with the next revalidation date being 11/23/2023.  DCannon"]
["James H Barnett, MD",1356484497,"27-4061759","TX","","Medicaid","Participating","Enrollment Complete","2021-10-06","136698110","356723201","2021-11-03","11/3/2021 Per TMHP website provider's revalidation has been completed effective 10/06/2021 with the next revalidation date being 11/23/2023.  DCannon"]
["James H Barnett, MD",1356484497,"27-4061759","TX","PE - Permian Cardiology Inc.","Amerigroup","Participating","Enrollment Complete","2019-07-30","1356484497","","2020-03-17","03/17/2020 - Rec'd an email from the payer contaning a spreadsheet showing this service location as effective - Stacey Hudak"]
["James H Barnett, MD",1356484497,"27-4061759","TX","","Amerigroup","Participating","Enrollment Complete","2019-07-30","1356484497","","2020-03-17","03/17/2020 - Rec'd an email from the payer contaning a spreadsheet showing this service location as effective - Stacey Hudak"]
["James H Barnett, MD",1356484497,"27-4061759","TX","PE - Permian Cardiology Inc.","Wellmed","Participating","Enrollment Complete","2022-01-01","","","2023-03-23","3/23/2023 Rcvd roster from UHC w/ all Wellmed participating providers.  Provider is PAR effective 1/1/2022.  DCannon"]
["James H Barnett, MD",1356484497,"27-4061759","TX","","Wellmed","Participating","Enrollment Complete","2022-01-01","","","2023-03-23","3/23/2023 Rcvd roster from UHC w/ all Wellmed participating providers.  Provider is PAR effective 1/1/2022.  DCannon"]
["James H Barnett, MD",1356484497,"27-4061759","TX","PE - Permian Cardiology Inc.","Humana","Participating","Enrollment Complete","2012-11-09","","","2021-11-18","11/18/2021 Rcvd full roster from Humana listing provider as PAR and linked to group TIN/location effective 11/9/2012.  DCannon"]
["James H Barnett, MD",1356484497,"27-4061759","TX","","Humana","Participating","Enrollment Complete","2012-11-09","","","2021-11-18","11/18/2021 Rcvd full roster from Humana listing provider as PAR and linked to group TIN/location effective 11/9/2012.  DCannon"]
["James H Barnett, MD",1356484497,"27-4061759","TX","PE - Permian Cardiology Inc.","HealthSmart PPO","Participating","Enrollment Complete","2011-02-01","1356484497","","2020-06-05","06/05/2020 - Rec'd email from the payer stating this provider is EFF -S tacey Hudak"]
["James H Barnett, MD",1356484497,"27-4061759","TX","","HealthSmart PPO","Participating","Enrollment Complete","2011-02-01","1356484497","","2020-06-05","06/05/2020 - Rec'd email from the payer stating this provider is EFF -S tacey Hudak"]
["James H Barnett, MD",1356484497,"27-4061759","TX","PE - Permian Cardiology Inc.","Liberty Mutual","Participating","Enrollment Complete","2010-12-29","1356484497","274061759","2020-08-19","Confirmed provider is participating with WIN network in which this payor is included (list of networks attached). Kimberly Frazier"]
["James H Barnett, MD",1356484497,"27-4061759","TX","","Liberty Mutual","Participating","Enrollment Complete","2010-12-29","1356484497","274061759","2020-08-19","Confirmed provider is participating with WIN network in which this payor is included (list of networks attached). Kimberly Frazier"]
["James H Barnett, MD",1356484497,"27-4061759","TX","PE - Permian Cardiology Inc.","Sedgwick","Participating","Enrollment Complete","2010-12-29","1356484497","274061759","2020-08-19","Confirmed provider is participating with WIN network in which this payor is included (list of networks attached). Kimberly Frazier"]
["James H Barnett, MD",1356484497,"27-4061759","TX","","Sedgwick","Participating","Enrollment Complete","2010-12-29","1356484497","274061759","2020-08-19","Confirmed provider is participating with WIN network in which this payor is included (list of networks attached). Kimberly Frazier"]
["James H Barnett, MD",1356484497,"27-4061759","TX","PE - Permian Cardiology Inc.","Superior","Participating","Enrollment Complete","2019-10-01","1356484497","","2020-07-14","07/14/2020 - Rec'd email from the payer stating this provider is EFF under PRIMED DELEGATED agreement - Stacey Hudak"]
["James H Barnett, MD",1356484497,"27-4061759","TX","","Superior","Participating","Enrollment Complete","2019-10-01","1356484497","","2020-07-14","07/14/2020 - Rec'd email from the payer stating this provider is EFF under PRIMED DELEGATED agreement - Stacey Hudak"]
["James H Barnett, MD",1356484497,"27-4061759","TX","PE - Permian Cardiology Inc.","Omni PPO","Participating","Enrollment Complete","2010-12-29","1356484497","","2020-06-29","06/29/2020 - confirmed that IMS is effective, therefore this enrollment is also effective - Stacey Hudak"]
["James H Barnett, MD",1356484497,"27-4061759","TX","","Omni PPO","Participating","Enrollment Complete","2010-12-29","1356484497","","2020-06-29","06/29/2020 - confirmed that IMS is effective, therefore this enrollment is also effective - Stacey Hudak"]
["James H Barnett, MD",1356484497,"27-4061759","TX","PE - Permian Cardiology Inc.","USA PPO","Participating","Enrollment Complete","2010-12-29","1356484497","274061759","2020-08-19","Confirmed provider is participating with PPO, H&W and WIN networks (list of networks attached). Kimberly Frazier"]
["James H Barnett, MD",1356484497,"27-4061759","TX","","USA PPO","Participating","Enrollment Complete","2010-12-29","1356484497","274061759","2020-08-19","Confirmed provider is participating with PPO, H&W and WIN networks (list of networks attached). Kimberly Frazier"]
["James H Barnett, MD",1356484497,"27-4061759","TX","PE - Permian Cardiology Inc.","CAQH","Participating","CAQH Reattested","2023-10-02","12124562","","2023-10-02","10/02/2023 - Updated License, DEA and board and re-attested - rkedare"]
["James H Barnett, MD",1356484497,"27-4061759","TX","","CAQH","Participating","CAQH Reattested","2023-10-02","12124562","","2023-10-02","10/02/2023 - Updated License, DEA and board and re-attested - rkedare"]
["James H Barnett, MD",1356484497,"27-4061759","TX","PE - Permian Cardiology Inc.","Cigna","Participating","Enrollment Complete","2010-08-01","1356484497","","2020-08-26","08/26/2020 - Moved to completed status after reviewing Follow UP Complete note - Stacey Hudak"]
["James H Barnett, MD",1356484497,"27-4061759","TX","","Cigna","Participating","Enrollment Complete","2010-08-01","1356484497","","2020-08-26","08/26/2020 - Moved to completed status after reviewing Follow UP Complete note - Stacey Hudak"]
["James H Barnett, MD",1356484497,"27-4061759","TX","PE - Permian Cardiology Inc.","Boon Chapman","Participating","Enrollment Complete","2015-03-24","","","2021-08-06","8/6/2021 Boon Chapman falls under the Multiplan umbrella, received roster from Multiplan provider is listed on roster under TIN/location as PAR effective 3/24/2015.  DCannon"]
["James H Barnett, MD",1356484497,"27-4061759","TX","","Boon Chapman","Participating","Enrollment Complete","2015-03-24","","","2021-08-06","8/6/2021 Boon Chapman falls under the Multiplan umbrella, received roster from Multiplan provider is listed on roster under TIN/location as PAR effective 3/24/2015.  DCannon"]
["James H Barnett, MD",1356484497,"27-4061759","TX","PE - Permian Cardiology Inc.","First Health Coventry","Participating","Enrollment Complete","2023-02-01","3649611","","2023-03-08","03.06.2023 Per follow-up note - Provider is in network and linked under the TIN effective 02/01/2023. Next recredentialing is every 3 yrs from the effective date. Provider ID# 3649611. Physical location is on file.  DCannon"]
["James H Barnett, MD",1356484497,"27-4061759","TX","","First Health Coventry","Participating","Enrollment Complete","2023-02-01","3649611","","2023-03-08","03.06.2023 Per follow-up note - Provider is in network and linked under the TIN effective 02/01/2023. Next recredentialing is every 3 yrs from the effective date. Provider ID# 3649611. Physical location is on file.  DCannon"]
["James H Barnett, MD",1356484497,"27-4061759","TX","PE - Permian Cardiology Inc.","TriCare Standard","Participating","Enrollment Complete","2011-01-01","1356484497","","2020-03-10","03/10/2020 - Signed onto payer portal and found this provider is linked to the group at this service location. Please note that this TIN is OUT OF NETWORK and the payer is not currently accepting new in network groups at this time. Due to this, credentialing is not required - Stacey Hudak"]
["James H Barnett, MD",1356484497,"27-4061759","TX","","TriCare Standard","Participating","Enrollment Complete","2011-01-01","1356484497","","2020-03-10","03/10/2020 - Signed onto payer portal and found this provider is linked to the group at this service location. Please note that this TIN is OUT OF NETWORK and the payer is not currently accepting new in network groups at this time. Due to this, credentialing is not required - Stacey Hudak"]
["James H Barnett, MD",1356484497,"27-4061759","TX","PE - Permian Cardiology Inc.","Rail Road Medicare","Participating","Enrollment Complete","2011-01-27"," P01470034"," DS1746","2020-04-22","04/22/2020 -verified EFF info though payer site - Stacey Hudak"]
["James H Barnett, MD",1356484497,"27-4061759","TX","","Rail Road Medicare","Participating","Enrollment Complete","2011-01-27"," P01470034"," DS1746","2020-04-22","04/22/2020 -verified EFF info though payer site - Stacey Hudak"]
["James H Barnett, MD",1356484497,"27-4061759","TX","PE - Permian Cardiology Inc.","Scott&White (First Care)","Participating","Enrollment Complete","2019-07-29","1356484497","","2020-08-19","08/29/2020 - Rec'd spreadsheet back from the payer confirming that this provider is affiliated with the delegated PRIMED AGREEMENT under this TIN/Service Location. This provider is networked with: \nFirstCare MyChoice PPO\nCHIP\nFirstCare Select Benefit Network\nHMO Enhanced Benefit Network\nMedicaid (FC)\nPPO Limited Benefit Network\n- Stacey Hudak"]
["James H Barnett, MD",1356484497,"27-4061759","TX","","Scott&White (First Care)","Participating","Enrollment Complete","2019-07-29","1356484497","","2020-08-19","08/29/2020 - Rec'd spreadsheet back from the payer confirming that this provider is affiliated with the delegated PRIMED AGREEMENT under this TIN/Service Location. This provider is networked with: \nFirstCare MyChoice PPO\nCHIP\nFirstCare Select Benefit Network\nHMO Enhanced Benefit Network\nMedicaid (FC)\nPPO Limited Benefit Network\n- Stacey Hudak"]
["James H Barnett, MD",1356484497,"27-4061759","TX","PE - Permian Cardiology Inc.","United Health Care","Participating","Enrollment Complete","2020-01-01","1356484497","","2020-08-31","08/31/2020 - moved to completed status after reviewing follow up complete status - Stacey Hudak"]
["James H Barnett, MD",1356484497,"27-4061759","TX","","United Health Care","Participating","Enrollment Complete","2020-01-01","1356484497","","2020-08-31","08/31/2020 - moved to completed status after reviewing follow up complete status - Stacey Hudak"]
["James H Barnett, MD",1356484497,"27-4061759","TX","PE - Permian Cardiology Inc.","Ambetter","Participating","Enrollment Complete","2022-06-01","","","2022-06-13","6/13/2022 Per roster received from Superior provider is PAR and linked to group delegation roster effective 6/1/2022."]
["James H Barnett, MD",1356484497,"27-4061759","TX","","Ambetter","Participating","Enrollment Complete","2022-06-01","","","2022-06-13","6/13/2022 Per roster received from Superior provider is PAR and linked to group delegation roster effective 6/1/2022."]
["James H Barnett, MD",1356484497,"27-4061759","TX","PE - Permian Cardiology Inc.","IMS","Participating","Enrollment Complete","2010-12-29","1356484497","","2020-06-22","06/22/2020- Rec'd email from the payer confirming this provider is PAR with this group/service location - Stacey Hudak"]
["James H Barnett, MD",1356484497,"27-4061759","TX","","IMS","Participating","Enrollment Complete","2010-12-29","1356484497","","2020-06-22","06/22/2020- Rec'd email from the payer confirming this provider is PAR with this group/service location - Stacey Hudak"]
["James H Barnett, MD",1356484497,"27-4061759","TX","PE - Permian Cardiology Inc.","Multiplan","Participating","Enrollment Complete","2015-03-24","1356484497","","2020-02-12","02/12/2020 - Rec'd confirmation through payer portal: Provider: James Barnett \nNetwork: MPI\nNetwork Participation effective:3/24/2015\nContract Source Group contract through: DELEGATED PARTY: West Texas Physicians Alliance - Stacey Hudak"]
["James H Barnett, MD",1356484497,"27-4061759","TX","","Multiplan","Participating","Enrollment Complete","2015-03-24","1356484497","","2020-02-12","02/12/2020 - Rec'd confirmation through payer portal: Provider: James Barnett \nNetwork: MPI\nNetwork Participation effective:3/24/2015\nContract Source Group contract through: DELEGATED PARTY: West Texas Physicians Alliance - Stacey Hudak"]
["James H Barnett, MD",1356484497,"27-4061759","TX","PE - Permian Cardiology Inc.","Galaxy Health","Participating","Enrollment Complete","1998-07-23","1356484497","","2020-07-20","7/20/2020- Received a spreadsheet from the payer stating this provider is effective as of 7/23/1998. – Jerha Gayorgor"]
["James H Barnett, MD",1356484497,"27-4061759","TX","","Galaxy Health","Participating","Enrollment Complete","1998-07-23","1356484497","","2020-07-20","7/20/2020- Received a spreadsheet from the payer stating this provider is effective as of 7/23/1998. – Jerha Gayorgor"]
["James H Barnett, MD",1356484497,"27-4061759","TX","PE - Permian Cardiology Inc.","Aetna","Participating","Enrollment Complete","2020-08-01","1356484497","","2020-09-22","09/22/2020 - Rec'd completed PRIMED ROSTER back from the payer. This provider is PAR at this service location - Stacey Hudak"]
["James H Barnett, MD",1356484497,"27-4061759","TX","","Aetna","Participating","Enrollment Complete","2020-08-01","1356484497","","2020-09-22","09/22/2020 - Rec'd completed PRIMED ROSTER back from the payer. This provider is PAR at this service location - Stacey Hudak"]
["James H Barnett, MD",1356484497,"27-4061759","TX","PE - Permian Cardiology Inc.","Triwest VA","Facility Enrollment","Facility Enrollment","","","","2022-10-17","10/17/2022 - Received roster from Scarlett; provider status: \"No Action.  TIN is CCN participating under own DCN.\""]
["James H Barnett, MD",1356484497,"27-4061759","TX","","Triwest VA","Facility Enrollment","Facility Enrollment","","","","2022-10-17","10/17/2022 - Received roster from Scarlett; provider status: \"No Action.  TIN is CCN participating under own DCN.\""]
["James H Barnett, MD",1356484497,"27-4061759","TX","PE - Permian Cardiology Inc.","Medicare","Participating","Enrollment Complete","2011-01-27"," TXB118608","TXB115966","2020-04-22","04/22/2020 - there hasnt been any assistance fromt he group. I was able to access the providers PECOS account and confirm provider is EFF and linked to this group EFF 1-27-2011 - Stacey Hudak"]
["James H Barnett, MD",1356484497,"27-4061759","TX","","Medicare","Participating","Enrollment Complete","2011-01-27"," TXB118608","TXB115966","2020-04-22","04/22/2020 - there hasnt been any assistance fromt he group. I was able to access the providers PECOS account and confirm provider is EFF and linked to this group EFF 1-27-2011 - Stacey Hudak"]
["Marcy L Askins, FNP-C",1831441385,"27-4061759","TX","PE - Permian Cardiology Inc.","Amerigroup","Participating","Enrollment Complete","2023-05-08","","","2023-10-18","10/18/2023 Per email received from Jessica Bess at  Multiplan provider is PAR with Amerigroup and linked to group TIN/locations thru Multiplan enrollment effective 5/8/2023.  DCannon"]
["Marcy L Askins, FNP-C",1831441385,"27-4061759","TX","PE - Permian Cardiology Inc.","Omni PPO","Participating","Enrollment Complete","2023-05-08","","","2023-07-20","7/20/2023 Per email received from IMS/OMNI May delegated roster has been processed and provider is PAR and linked to group effective 5/8/2023.  DCannon"]
["Marcy L Askins, FNP-C",1831441385,"27-4061759","TX","PE - Permian Cardiology Inc.","United Health Care","Participating","Enrollment Complete","2023-05-08","","","2023-09-05","9/5/2023 Per email from UHC - May monthly delegated roster has been completed.   Provider is PAR and linked to group TIN/location effective 5/8/2023.  DCannon"]
["Marcy L Askins, FNP-C",1831441385,"27-4061759","TX","PE - Permian Cardiology Inc.","Tricare Prime","Panel Closed","Panel Closed","","","","2023-05-10","5/10/2023 Tricare Prime panel is closed and currently not accepting requests to join the network.  DCannon"]
["Marcy L Askins, FNP-C",1831441385,"27-4061759","TX","PE - Permian Cardiology Inc.","Superior","Participating","Enrollment Complete","2023-11-01","","","2023-11-06","11/6/2023 Rcvd email from Superior that provider is PAR and linked to group TIN/location effective 11/1/2023.  DCannon"]
["Marcy L Askins, FNP-C",1831441385,"27-4061759","TX","PE - Permian Cardiology Inc.","Boon Chapman","Participating","Enrollment Complete","2023-05-01","","","2023-07-25","7/25/2023 Rcvd email from Jessica Bess at Multiplan with a full roster and provider is PAR w/ group effective 5/1/2023.  DCannon"]
["Marcy L Askins, FNP-C",1831441385,"27-4061759","TX","PE - Permian Cardiology Inc.","BCBSTX","In House Enrollment","In House Enrollment","","","","2023-05-10",""]
["Marcy L Askins, FNP-C",1831441385,"27-4061759","TX","PE - Permian Cardiology Inc.","HealthSmart PPO","In Process","Payor Follow Up","","","","2023-11-14","11/14/2023 Per Healthsmart provider portal provider is still not loaded under group TIN.  Per phone conversation with Lee Kinard at Healthsmart provider portal should be updated  by 11/27/2023.  Will allow more time, check back in 2 weeks.   DCannon"]
["Marcy L Askins, FNP-C",1831441385,"27-4061759","TX","PE - Permian Cardiology Inc.","Rail Road Medicare","Participating","Enrollment Complete","2017-08-01","","","2023-05-10","5/10/2023 Rcvd RR Medicare approval letter.  Provider is PAR effective 8/1/2017.  PTAN# P02386969.  DCannon"]
["Marcy L Askins, FNP-C",1831441385,"27-4061759","TX","PE - Permian Cardiology Inc.","USA PPO","In Process","Payor Follow Up","","","","2023-11-27","11/27/2023 Per USA PPO provider portal provider is still not loaded under new locations.  Will allow more time, check back in 2 weeks.  \nDCannon"]
["Marcy L Askins, FNP-C",1831441385,"27-4061759","TX","PE - Permian Cardiology Inc.","Aetna","Participating","Enrollment Complete","2023-05-08","4810470","","2023-09-19","09.19.2023 S/W Abby of Aetna @ 1-800-353-1232. Per rep, provider is in network with Aetna for the state of TX and participating under the group and TIN# effective 05/08/2023. PIN: 4810470. Physical location is on file. No next recredentialing date available. Payer# 60054. Call ref# 6163772542. - Willie Ravas"]
["Marcy L Askins, FNP-C",1831441385,"27-4061759","TX","PE - Permian Cardiology Inc.","Cigna","Participating","Enrollment Complete","2023-09-21","6920089","","2023-10-19","10.17.2023 S/W Wyn of Cigna @ 1-800-882-4462. Per rep, Per rep, Provider is in network with Cigna and linked to the group and TIN# effective 09/21/2023. Next recredentialing date is on 09/21/2026. PIN: 6920089. Servicing location is on file. No payer# available. Call ref# Wyn10172023. - Willie Ravas"]
["Marcy L Askins, FNP-C",1831441385,"27-4061759","TX","PE - Permian Cardiology Inc.","Medicare","Participating","Enrollment Complete","2017-08-01","460057ZGML","TXB115966","2023-05-10","5/10/2023 Per PECOS provider is PAR and linked to group effective 8/1/2017.  PTAN # 460057ZGML.  DCannon"]
["Marcy L Askins, FNP-C",1831441385,"27-4061759","TX","PE - Permian Cardiology Inc.","Wellmed","Participating","Enrollment Complete","2023-05-08","","","2023-09-19","9/19/2023  Provider is PAR and linked to group/locations effective 5/8/2023.  DCannon"]
["Marcy L Askins, FNP-C",1831441385,"27-4061759","TX","PE - Permian Cardiology Inc.","Humana","Participating","Enrollment Complete","2023-05-08","","","2023-09-15","9/15/2023 Per email received from Humana provider is PAR and linked to group TIN/locations effective 5/8/2023.  DCannon"]
["Marcy L Askins, FNP-C",1831441385,"27-4061759","TX","PE - Permian Cardiology Inc.","Scott&White (First Care)","Participating","Enrollment Complete","2023-05-08","","","2023-08-17","8/17/2023 Received email from Scott & White HPDELEGATION@BSWHealth.org that provider load from May has been completed and provider is PAR effective 5/8/2023.  DCannon"]
["Marcy L Askins, FNP-C",1831441385,"27-4061759","TX","PE - Permian Cardiology Inc.","First Health Coventry","Participating","Enrollment Complete","2023-05-01"," 2868832","","2023-10-19","10.17.2023 S/W Bridgette of First Health @ 800-226-5116. Per rep, provider is showing as participating and link under the Group and TIN with an Effective date 05/01/2023. Provider ID 2868832. Service location is on file. Call ref#:788770.-Danico Gabriel Melendres"]
["Marcy L Askins, FNP-C",1831441385,"27-4061759","TX","PE - Permian Cardiology Inc.","Multiplan","Participating","Enrollment Complete","2023-05-01","","","2023-07-25","7/25/2023 Rcvd email from Jessica Bess at Multiplan with a full roster and provider is PAR w/ group effective 5/1/2023.  DCannon"]
["Marcy L Askins, FNP-C",1831441385,"27-4061759","TX","PE - Permian Cardiology Inc.","CAQH","Participating","CAQH Reattested","2023-10-04","12631837","","2023-10-09","10/9/2023 CAQH profile reviewed & re-attested by provider.  DCannon"]
["Marcy L Askins, FNP-C",1831441385,"27-4061759","TX","PE - Permian Cardiology Inc.","IMS","Participating","Enrollment Complete","2023-05-08","","","2023-07-20","7/20/2023 Per email received from IMS/OMNI May delegated roster has been processed and provider is PAR and linked to group effective 5/8/2023.  DCannon"]
["Marcy L Askins, FNP-C",1831441385,"27-4061759","TX","PE - Permian Cardiology Inc.","Ambetter","Participating","Enrollment Complete","2023-11-01","","","2023-11-06","11/6/2023 Rcvd email from Superior that provider is PAR and linked to group TIN/location effective 11/1/2023.  DCannon"]
["Marcy L Askins, FNP-C",1831441385,"27-4061759","TX","PE - Permian Cardiology Inc.","Galaxy Health","Participating","Enrollment Complete","2023-05-08","","","2023-07-20","7/20/2023 Per email received from Galaxy May delegated roster has been processed and provider is PAR and linked to group effective 5/8/2023.  DCannon"]
["Marcy L Askins, FNP-C",1831441385,"27-4061759","TX","PE - Permian Cardiology Inc.","Triwest VA","In House Enrollment","In House Enrollment","","","","2023-05-10",""]
["Marcy L Askins, FNP-C",1831441385,"27-4061759","TX","PE - Permian Cardiology Inc.","Wellcare","Participating","Enrollment Complete","2023-11-01","","","2023-11-06","11/6/2023 Rcvd email from Superior that provider is PAR and linked to group TIN/location effective 11/1/2023.  DCannon"]
["Marcy L Askins, FNP-C",1831441385,"27-4061759","TX","PE - Permian Cardiology Inc.","Caprock (CapStar)","Participating","Enrollment Complete","2023-05-08","","","2023-05-22","5/22/2023 Rcvd email from Caprock that May roster has been processed and provider is PAR w/ group effective 5/8/2023.  DCannon"]
["Marcy L Askins, FNP-C",1831441385,"27-4061759","TX","PE - Permian Cardiology Inc.","TriCare Standard","Participating","Enrollment Complete","2023-05-15","","","2023-05-24","Confirmed via HM portal. MS"]
["Leela K Lella, MD",1306162557,"27-4061759","TX","PE - Permian Cardiology Inc.","Triwest VA","Facility Enrollment","Facility Enrollment","","","","2022-10-17","10/17/2022 - Received roster from Scarlett; provider status: \"No Action.  TIN is CCN participating under own DCN.\""]
["Leela K Lella, MD",1306162557,"27-4061759","TX","PE - Permian Cardiology Inc.","Superior","Participating","Enrollment Complete","2019-10-01","1306162557","","2020-07-14","07/14/2020 - Rec'd email from the payer stating this provider is EFF under PRIMED DELEGATED agreement - Stacey Hudak"]
["Leela K Lella, MD",1306162557,"27-4061759","TX","PE - Permian Cardiology Inc.","First Health Coventry","Participating","Enrollment Complete","2023-03-01","","","2023-07-27","07.27.2023 S/W Bridgett of First Health @800-226-5116. Per rep, provider is showing participating and link under the Group and TIN with an Effective date 03/01/2023. Provider ID 3077661. Service location is on file. Call ref#:709557. - Danico Gabriel Melendres"]
["Leela K Lella, MD",1306162557,"27-4061759","TX","PE - Permian Cardiology Inc.","Humana","Participating","Enrollment Complete","2020-01-01","1306162557","","2020-08-31","08/31/2020 - moved to completed status after reviewing follow up complete status - Stacey Hudak"]
["Leela K Lella, MD",1306162557,"27-4061759","TX","PE - Permian Cardiology Inc.","Wellcare","Participating","Enrollment Complete","2021-11-01","","","2022-12-01","12/1/2022 Per roster received from Wellcare provider is PAR and linked to group TIN/location effective 11/1/2021.  DCannon"]
["Leela K Lella, MD",1306162557,"27-4061759","TX","PE - Permian Cardiology Inc.","TriCare Standard","Participating","Enrollment Complete","2014-01-01","1306162557","","2020-03-10","03/10/2020 - rec'd email back through portal and found that the payer is not currently accepting new in network groups at this time. Due to this, credentialing is not required and this can be marked complete to the furthest degree at this time. - Stacey Hudak"]
["Leela K Lella, MD",1306162557,"27-4061759","TX","PE - Permian Cardiology Inc.","CAQH","Participating","CAQH Reattested","2023-10-31","","","2023-10-31","10/31/2023 - CAQH Re-attested updated and uploaded, DEA, license, board, and Liability documents - dkonar"]
["Leela K Lella, MD",1306162557,"27-4061759","TX","PE - Permian Cardiology Inc.","Amerigroup","In Process","Application Submitted","","1306162557","","2023-10-13","10/13/2023 Delegated roster submitted.  DCannon"]
["Leela K Lella, MD",1306162557,"27-4061759","TX","PE - Permian Cardiology Inc.","Ambetter","Participating","Enrollment Complete","2022-06-01","","","2022-06-13","6/13/2022 Per roster received from Superior provider is PAR and linked to group delegation roster effective 6/1/2022."]
["Leela K Lella, MD",1306162557,"27-4061759","TX","PE - Permian Cardiology Inc.","Cigna","Participating","Enrollment Complete","2019-06-03","1306162557","","2020-09-24","09/24/2020 - moved to completed status after reviewing follow up complete notes - Stacey Hudak"]
["Leela K Lella, MD",1306162557,"27-4061759","TX","PE - Permian Cardiology Inc.","Galaxy Health","Participating","Enrollment Complete","2018-10-15","1306162557","","2020-07-17","07/17/2020 Received a spreadsheet from the payer stating this provider is effective as of 10/15/2018. – Archie Candiasan"]
["Leela K Lella, MD",1306162557,"27-4061759","TX","PE - Permian Cardiology Inc.","Aetna","Participating","Enrollment Complete","2020-03-13","1306162557","","2020-03-24","3/24/2020--S/W Cris of Aetna @ 18003531232, provider NPI# is on file for the provider and is participating effective 03/13/2020 under the group and TIN#. Physical location is on file. DIRECT CONTRACT---Call ref# 5192774121.\ntisha rader"]
["Leela K Lella, MD",1306162557,"27-4061759","TX","PE - Permian Cardiology Inc.","HealthSmart PPO","Participating","Enrollment Complete","2018-06-19","1306162557","","2020-06-05","06/05/2020 - Rec'd email from the payer stating this provider is EFF -Stacey Hudak"]
["Leela K Lella, MD",1306162557,"27-4061759","TX","PE - Permian Cardiology Inc.","Medicare","Participating","Enrollment Complete","2014-07-28","356720ZGML","TXB115966","2020-05-14","05/14/2020 - Rec'd welcome letter from the clinic and was able to moved to complete status - Stacey Hudak"]
["Leela K Lella, MD",1306162557,"27-4061759","TX","PE - Permian Cardiology Inc.","Rail Road Medicare","Participating","Enrollment Complete","2014-07-28","P01476166","DS1746","2020-05-14","05/14/2020 - Rec'd proof of medicare enrollment and was able to confirm EFF RR through payer site - Stacey Hudak"]
["Leela K Lella, MD",1306162557,"27-4061759","TX","PE - Permian Cardiology Inc.","Wellmed","Participating","Enrollment Complete","2022-01-01","","","2023-03-23","3/23/2023 Rcvd roster from UHC w/ all Wellmed participating providers.  Provider is PAR effective 1/1/2022.  DCannon"]
["Leela K Lella, MD",1306162557,"27-4061759","TX","PE - Permian Cardiology Inc.","IMS","Participating","Enrollment Complete","2018-10-15","1306162557","","2020-06-22","06/22/2020- Rec'd email from the payer confirming this provider is PAR with this group/service location - Stacey Hudak"]
["Leela K Lella, MD",1306162557,"27-4061759","TX","PE - Permian Cardiology Inc.","Caprock (CapStar)","Participating","Enrollment Complete","2020-03-01","1306162557","","2020-06-02","06/02/2020 - rec'd spreadsheet back from the payer Mary Rodriguez <MRodriguez@caprockhp.com> confirming this provider/service location is EFF with this payer - Stacey Hudak"]
["Leela K Lella, MD",1306162557,"27-4061759","TX","PE - Permian Cardiology Inc.","Boon Chapman","Participating","Enrollment Complete","2018-06-19","","","2021-08-06","8/6/2021 Boon Chapman falls under the Multiplan umbrella, received roster from Multiplan provider is listed on roster under TIN/location as PAR effective 6/19/2018.  DCannon"]
["Leela K Lella, MD",1306162557,"27-4061759","TX","PE - Permian Cardiology Inc.","Medicaid","Participating","Enrollment Complete","2014-07-28","388410801","356723201","2023-11-01","Rcvd TMHP revalidation approval letter. Provider effective 07/28/2014. Jen Videan"]
["Leela K Lella, MD",1306162557,"27-4061759","TX","PE - Permian Cardiology Inc.","USA PPO","Participating","Enrollment Complete","2018-10-15","1306162557","274061759","2020-08-21","Confirmed provider is participating with PPO and H&W networks (list of networks attached). Kimberly Frazier"]
["Leela K Lella, MD",1306162557,"27-4061759","TX","PE - Permian Cardiology Inc.","Omni PPO","Participating","Enrollment Complete","2018-10-15","1306162557","","2020-06-29","06/29/2020 - confirmed that IMS is effective, therefore this is also participating - Stacey Hudak"]
["Leela K Lella, MD",1306162557,"27-4061759","TX","PE - Permian Cardiology Inc.","Scott&White (First Care)","Participating","Enrollment Complete","2019-07-29","1306162557","","2020-08-19","8/19/2020 - Rec'd spreadsheet from the payer stating this provider is affiliated with the PRIMED DELEGATED AGREEMENT under this TIN/Service location. This provider is networked with: \nFirstCare MyChoice PPO\nCHIP\nFirstCare Select Benefit Network\nHMO Enhanced Benefit Network\nMedicaid (FC)\nMedicare (FC)\nPPO Limited Benefit Network\n- Stacey Hudak"]
["Leela K Lella, MD",1306162557,"27-4061759","TX","PE - Permian Cardiology Inc.","Multiplan","Participating","Enrollment Complete","2018-06-19","1306162557","","2020-02-12","02/12/2020 - Rec'd confirmation through payer portal stating : Provider:Leela Lella\nNetwork: MPI\nNetwork Participation effective:6/19/2018\nContract Source Group contract through DELEGATED PARTY: West Texas Physicians Alliance - Stacey Hudak"]
["Leela K Lella, MD",1306162557,"27-4061759","TX","PE - Permian Cardiology Inc.","United Health Care","Participating","Enrollment Complete","2019-11-01","1306162557","","2020-08-31","08/31/2020 - moved to completed status after reviewing follow up completed note - Stacey Hudak"]
["Christopher Ryan Vela, PA",1366728909,"27-4061759","TX","PE - Permian Cardiology Inc.","Cigna","Participating","Enrollment Complete","2023-10-25","4158006","","2023-11-01","Received confirmation email. Provider is effective 10/25/23. MS"]
["Christopher Ryan Vela, PA",1366728909,"27-4061759","TX","PE - Permian Cardiology Inc.","Triwest VA","In House Enrollment","In House Enrollment","","","","2023-05-15",""]
["Christopher Ryan Vela, PA",1366728909,"27-4061759","TX","PE - Permian Cardiology Inc.","First Health Coventry","Participating","Enrollment Complete","2023-05-30","","","2023-07-25","7/25/2023  Per First Health online provider directory provider is PAR and linked to group/locations  effective 5/30/2023.  DCannon"]
["Christopher Ryan Vela, PA",1366728909,"27-4061759","TX","PE - Permian Cardiology Inc.","Medicare","Participating","Enrollment Complete","2014-12-21","TXB115966","","2023-09-19","Provider is showing linked to Permian Cardiology. MS"]
["Christopher Ryan Vela, PA",1366728909,"27-4061759","TX","PE - Permian Cardiology Inc.","CAQH","Participating","CAQH Reattested","2023-10-06","","","2023-10-06","10/6/202. CAQH reviewed and re-attested.  Updated practice location and insurance.  Uploaded current COI.  DCannon"]
["Christopher Ryan Vela, PA",1366728909,"27-4061759","TX","PE - Permian Cardiology Inc.","HealthSmart PPO","Participating","Enrollment Complete","2023-02-01","","","2023-09-15","9/15/2023 Per Healthsmart website provider is PAR and loaded under TIN/location effective 2/1/2023.  DCannon"]
["Christopher Ryan Vela, PA",1366728909,"27-4061759","TX","PE - Permian Cardiology Inc.","Scott&White (First Care)","Participating","Enrollment Complete","2023-07-05","","","2023-08-17","8/17/2023 Received email from Scott & White HPDELEGATION@BSWHealth.org that provider load from May has been completed and provider is PAR effective 7/5/2023.  DCannon"]
["Christopher Ryan Vela, PA",1366728909,"27-4061759","TX","PE - Permian Cardiology Inc.","Wellmed","Participating","Enrollment Complete","2023-07-05","","","2023-09-07","9/7/2023 Per email response from UHC June delegated roster is provider load is complete.  Provider is PAR and linked to group TIN/location effective 7/5/2023.  DCannon"]
["Christopher Ryan Vela, PA",1366728909,"27-4061759","TX","PE - Permian Cardiology Inc.","Ambetter","Participating","Enrollment Complete","2023-08-01","","","2023-08-15","8/15/2023 Rcvd confirmation email from Superior that February delegation roster has been processed and provider has been loaded to delegation roster and PAR w/ group effective 8/1/2023.  DCannon"]
["Christopher Ryan Vela, PA",1366728909,"27-4061759","TX","PE - Permian Cardiology Inc.","Superior","Participating","Enrollment Complete","2023-08-01","","","2023-08-15","8/15/2023 Rcvd confirmation email from Superior that February delegation roster has been processed and provider has been loaded to delegation roster and PAR w/ group effective 8/1/2023.  DCannon"]
["Christopher Ryan Vela, PA",1366728909,"27-4061759","TX","PE - Permian Cardiology Inc.","Humana","Participating","Enrollment Complete","2023-05-30","","","2023-09-15","9/15/2023 Per email received from Humana provider is PAR and linked to group TIN/locations effective 5/30/2023.  DCannon"]
["Christopher Ryan Vela, PA",1366728909,"27-4061759","TX","PE - Permian Cardiology Inc.","Boon Chapman","Participating","Enrollment Complete","2023-02-01","","","2023-07-25","7/25/2023 Rcvd email from Jessica Bess at Multiplan with a full roster and provider is PAR w/ group effective 2/1/2023.  DCannon"]
["Christopher Ryan Vela, PA",1366728909,"27-4061759","TX","PE - Permian Cardiology Inc.","Amerigroup","Participating","Enrollment Complete","2023-07-05","","","2023-10-18","10/18/2023 Per email received from Jessica Bess at  Multiplan provider is PAR with Amerigroup and linked to group TIN/locations thru Multiplan enrollment effective 7/5/2023.  DCannon"]
["Christopher Ryan Vela, PA",1366728909,"27-4061759","TX","PE - Permian Cardiology Inc.","TriCare Standard","In Process","Application Resubmitted","","","","2023-11-16","Rep stated the provider needs to be recertified. This application has been submitted. MS"]
["Christopher Ryan Vela, PA",1366728909,"27-4061759","TX","PE - Permian Cardiology Inc.","Tricare Prime","Panel Closed","Panel Closed","","","","2023-05-15","5/15/2023 Tricare Prime panel is closed and currently not accepting requests to join the network.  DCannon"]
["Christopher Ryan Vela, PA",1366728909,"27-4061759","TX","PE - Permian Cardiology Inc.","Caprock (CapStar)","Participating","Enrollment Complete","2023-02-01","","","2023-05-22","5/22/2023 Rcvd email from Caprock that May roster has been processed and provider is PAR w/ group effective 2/1/2023.  DCannon"]
["Christopher Ryan Vela, PA",1366728909,"27-4061759","TX","PE - Permian Cardiology Inc.","IMS","Participating","Enrollment Complete","2023-05-30","","","2023-07-18","7/18/2023 Per email received from IMS/OMNI June delegated roster has been processed and provider is PAR and linked to group effective 5/30/2023.  DCannon"]
["Christopher Ryan Vela, PA",1366728909,"27-4061759","TX","PE - Permian Cardiology Inc.","Wellcare","Participating","Enrollment Complete","2023-08-01","","","2023-08-15","8/15/2023 Rcvd confirmation email from Superior that February delegation roster has been processed and provider has been loaded to delegation roster and PAR w/ group effective 8/1/2023.  DCannon"]
["Christopher Ryan Vela, PA",1366728909,"27-4061759","TX","PE - Permian Cardiology Inc.","USA PPO","In Process","Payor Follow Up","","","","2023-11-27","11/27/2023 Per USA PPO provider portal provider is still not loaded under new locations.  Will allow more time, check back in 2 weeks.  \nDCannon"]
["Christopher Ryan Vela, PA",1366728909,"27-4061759","TX","PE - Permian Cardiology Inc.","Rail Road Medicare","Participating","Enrollment Complete","2014-12-21","Q00581247","","2023-10-19","Received enrollment confirmation. MS"]
["Christopher Ryan Vela, PA",1366728909,"27-4061759","TX","PE - Permian Cardiology Inc.","Aetna","Participating","Enrollment Complete","2023-07-05","8143656","","2023-06-14","6/14/2023 received confirmation email from Aetna that provider is PAR and linked to group TIN/location effective 7/5/2023.  PID # 8143656.  MS"]
["Christopher Ryan Vela, PA",1366728909,"27-4061759","TX","PE - Permian Cardiology Inc.","Omni PPO","Participating","Enrollment Complete","2023-05-30","","","2023-07-18","7/18/2023 Per email received from IMS/OMNI June delegated roster has been processed and provider is PAR and linked to group effective 5/30/2023.  DCannon"]
["Christopher Ryan Vela, PA",1366728909,"27-4061759","TX","PE - Permian Cardiology Inc.","Multiplan","Participating","Enrollment Complete","2023-02-01","","","2023-07-25","7/25/2023 Rcvd email from Jessica Bess at Multiplan with a full roster and provider is PAR w/ group effective 2/1/2023.  DCannon"]
["Christopher Ryan Vela, PA",1366728909,"27-4061759","TX","PE - Permian Cardiology Inc.","Galaxy Health","Participating","Enrollment Complete","2023-05-08","","","2023-07-20","7/20/2023 Per email received from Galaxy May delegated roster has been processed and provider is PAR and linked to group effective 5/8/2023.  DCannon"]
["Christopher Ryan Vela, PA",1366728909,"27-4061759","TX","PE - Permian Cardiology Inc.","United Health Care","Participating","Enrollment Complete","2023-07-05","003444403","","2023-08-21","8/21/2023 Per email from UHC provider is PAR and linked to group TIN/location effective 7/5/2023.  DCannon"]
["Christopher Ryan Vela, PA",1366728909,"27-4061759","TX","PE - Permian Cardiology Inc.","Medicaid","In Process","Application Submitted","","","","2023-11-16","11/16/2023 App submitted online via TMHP web portal.  Request # 20369786.  DCannon"]
["Evbu O Enakpene, MD",1972816189,"27-4061759","TX","PE - Permian Cardiology Inc.","Omni PPO","Participating","Enrollment Complete","2019-02-28","1972816189","","2020-06-29","06/29/2020 - confirmed IMS is par - therefore this enrollment is also effective - Stacey Hudak"]
["Evbu O Enakpene, MD",1972816189,"27-4061759","TX","","Omni PPO","Participating","Enrollment Complete","2019-02-28","1972816189","","2020-06-29","06/29/2020 - confirmed IMS is par - therefore this enrollment is also effective - Stacey Hudak"]
["Evbu O Enakpene, MD",1972816189,"27-4061759","TX","PE - Permian Cardiology Inc.","IMS","Participating","Enrollment Complete","2018-02-28","1972816189","","2020-06-22","06/22/2020- Rec'd email from the payer confirming this provider is PAR with this group/service location - Stacey Hudak"]
["Evbu O Enakpene, MD",1972816189,"27-4061759","TX","","IMS","Participating","Enrollment Complete","2018-02-28","1972816189","","2020-06-22","06/22/2020- Rec'd email from the payer confirming this provider is PAR with this group/service location - Stacey Hudak"]
["Evbu O Enakpene, MD",1972816189,"27-4061759","TX","PE - Permian Cardiology Inc.","HealthSmart PPO","Participating","Enrollment Complete","2018-02-28","1972816189","","2020-06-05","06/05/2020  - Rec'd email from the payer stating this provider is EFF - Stacey Hudak"]
["Evbu O Enakpene, MD",1972816189,"27-4061759","TX","","HealthSmart PPO","Participating","Enrollment Complete","2018-02-28","1972816189","","2020-06-05","06/05/2020  - Rec'd email from the payer stating this provider is EFF - Stacey Hudak"]
["Evbu O Enakpene, MD",1972816189,"27-4061759","TX","PE - Permian Cardiology Inc.","Ambetter","Participating","Enrollment Complete","2022-06-01","","","2022-06-13","6/13/2022 Per roster received from Superior provider is PAR and linked to group delegation roster effective 6/1/2022."]
["Evbu O Enakpene, MD",1972816189,"27-4061759","TX","","Ambetter","Participating","Enrollment Complete","2022-06-01","","","2022-06-13","6/13/2022 Per roster received from Superior provider is PAR and linked to group delegation roster effective 6/1/2022."]
["Evbu O Enakpene, MD",1972816189,"27-4061759","TX","PE - Permian Cardiology Inc.","Scott&White (First Care)","Participating","Enrollment Complete","2019-07-29","1972816189","","2020-08-19","08/19/2020 - Rec'd response from the payer stating this provider is affiliated with the PRIMED DELEGATED AGREEMENT under this TIN/Service Location. This provider is networked with: \nFirstCare MyChoice PPO\nCHIP\nFirstCare Select Benefit Network\nHMO Enhanced Benefit Network\nMedicaid (FC)\nMedicare (FC)\nPPO Limited Benefit Network\n- Stacey Hudak"]
["Evbu O Enakpene, MD",1972816189,"27-4061759","TX","","Scott&White (First Care)","Participating","Enrollment Complete","2019-07-29","1972816189","","2020-08-19","08/19/2020 - Rec'd response from the payer stating this provider is affiliated with the PRIMED DELEGATED AGREEMENT under this TIN/Service Location. This provider is networked with: \nFirstCare MyChoice PPO\nCHIP\nFirstCare Select Benefit Network\nHMO Enhanced Benefit Network\nMedicaid (FC)\nMedicare (FC)\nPPO Limited Benefit Network\n- Stacey Hudak"]
["Evbu O Enakpene, MD",1972816189,"27-4061759","TX","PE - Permian Cardiology Inc.","Rail Road Medicare","Participating","Enrollment Complete","2017-09-01"," P02260538","DS1746","2020-10-09","10/9/2020 - double checked the PTAN and found it was reveresed in the payer line. Found working/effective RRMCRPTAN and updated payer line - Stacey Hudak"]
["Evbu O Enakpene, MD",1972816189,"27-4061759","TX","","Rail Road Medicare","Participating","Enrollment Complete","2017-09-01"," P02260538","DS1746","2020-10-09","10/9/2020 - double checked the PTAN and found it was reveresed in the payer line. Found working/effective RRMCRPTAN and updated payer line - Stacey Hudak"]
["Evbu O Enakpene, MD",1972816189,"27-4061759","TX","PE - Permian Cardiology Inc.","Amerigroup","Participating","Enrollment Complete","2019-07-30","1972816189","","2020-03-18","03/18/2020 - Rec'd confirmation from the payer via spreadsheet stating this provider is EFF with Amerigroup through Texas True Care - Stacey Hudak"]
["Evbu O Enakpene, MD",1972816189,"27-4061759","TX","","Amerigroup","Participating","Enrollment Complete","2019-07-30","1972816189","","2020-03-18","03/18/2020 - Rec'd confirmation from the payer via spreadsheet stating this provider is EFF with Amerigroup through Texas True Care - Stacey Hudak"]
["Evbu O Enakpene, MD",1972816189,"27-4061759","TX","PE - Permian Cardiology Inc.","Galaxy Health","Participating","Enrollment Complete","2018-02-28","1972816189","","2020-07-17","7/17/20- Received a spreadsheet from the payer stating this provider is effective as of 2/28/2018. – Jerha Gayorgor"]
["Evbu O Enakpene, MD",1972816189,"27-4061759","TX","","Galaxy Health","Participating","Enrollment Complete","2018-02-28","1972816189","","2020-07-17","7/17/20- Received a spreadsheet from the payer stating this provider is effective as of 2/28/2018. – Jerha Gayorgor"]
["Evbu O Enakpene, MD",1972816189,"27-4061759","TX","PE - Permian Cardiology Inc.","USA PPO","Participating","Enrollment Complete","2018-08-29","","","2020-09-09","Confirmed provider is participating with PPO and H&W networks (list of networks attached). Kimberly Frazier"]
["Evbu O Enakpene, MD",1972816189,"27-4061759","TX","","USA PPO","Participating","Enrollment Complete","2018-08-29","","","2020-09-09","Confirmed provider is participating with PPO and H&W networks (list of networks attached). Kimberly Frazier"]
["Evbu O Enakpene, MD",1972816189,"27-4061759","TX","PE - Permian Cardiology Inc.","Humana","Participating","Enrollment Complete","2012-11-09","","","2021-11-18","11/18/2021 Rcvd full roster from Humana listing provider as PAR and linked to group TIN/location effective 11/9/2012.  DCannon"]
["Evbu O Enakpene, MD",1972816189,"27-4061759","TX","","Humana","Participating","Enrollment Complete","2012-11-09","","","2021-11-18","11/18/2021 Rcvd full roster from Humana listing provider as PAR and linked to group TIN/location effective 11/9/2012.  DCannon"]
["Evbu O Enakpene, MD",1972816189,"27-4061759","TX","PE - Permian Cardiology Inc.","Triwest VA","Facility Enrollment","Facility Enrollment","","","","2022-10-17","10/17/2022 - Received roster from Scarlett; provider status: \"No Action.  TIN is CCN participating under own DCN.\""]
["Evbu O Enakpene, MD",1972816189,"27-4061759","TX","","Triwest VA","Facility Enrollment","Facility Enrollment","","","","2022-10-17","10/17/2022 - Received roster from Scarlett; provider status: \"No Action.  TIN is CCN participating under own DCN.\""]
["Evbu O Enakpene, MD",1972816189,"27-4061759","TX","PE - Permian Cardiology Inc.","Caprock (CapStar)","Participating","Enrollment Complete","2020-03-01","1972816189","","",""]
["Evbu O Enakpene, MD",1972816189,"27-4061759","TX","","Caprock (CapStar)","Participating","Enrollment Complete","2020-03-01","1972816189","","",""]
["Evbu O Enakpene, MD",1972816189,"27-4061759","TX","PE - Permian Cardiology Inc.","Superior","Participating","Enrollment Complete","2019-10-01","1972816189","","2020-07-14","07/14/2020 - Rec'd email from the payer stating this provider is EFF under PRIMED DELEGATED agreement - Stacey Hudak"]
["Evbu O Enakpene, MD",1972816189,"27-4061759","TX","","Superior","Participating","Enrollment Complete","2019-10-01","1972816189","","2020-07-14","07/14/2020 - Rec'd email from the payer stating this provider is EFF under PRIMED DELEGATED agreement - Stacey Hudak"]
["Evbu O Enakpene, MD",1972816189,"27-4061759","TX","PE - Permian Cardiology Inc.","Aetna","Participating","Enrollment Complete","2018-03-16","6064784","","2020-03-24","3/24/2020--S/W Ian of Aetna @ 800-872-3862, rep advised to call 8003531232. Called 8003531232 and S/W Julia, provider NPI is on file for the provider and participating effective 03/16/18 under the group and TIN. Physical location is on file. Direct contract. Provider ID# 6064784. Call ref# 5192386272.\ntisha rader"]
["Evbu O Enakpene, MD",1972816189,"27-4061759","TX","","Aetna","Participating","Enrollment Complete","2018-03-16","6064784","","2020-03-24","3/24/2020--S/W Ian of Aetna @ 800-872-3862, rep advised to call 8003531232. Called 8003531232 and S/W Julia, provider NPI is on file for the provider and participating effective 03/16/18 under the group and TIN. Physical location is on file. Direct contract. Provider ID# 6064784. Call ref# 5192386272.\ntisha rader"]
["Evbu O Enakpene, MD",1972816189,"27-4061759","TX","PE - Permian Cardiology Inc.","Wellmed","Participating","Enrollment Complete","2022-01-01","","","2023-03-23","3/23/2023 Rcvd roster from UHC w/ all Wellmed participating providers.  Provider is PAR effective 1/1/2022.  DCannon"]
["Evbu O Enakpene, MD",1972816189,"27-4061759","TX","","Wellmed","Participating","Enrollment Complete","2022-01-01","","","2023-03-23","3/23/2023 Rcvd roster from UHC w/ all Wellmed participating providers.  Provider is PAR effective 1/1/2022.  DCannon"]
["Evbu O Enakpene, MD",1972816189,"27-4061759","TX","PE - Permian Cardiology Inc.","Cigna","Participating","Enrollment Complete","2019-06-04","1972816189","","2020-08-26","08/26/2020 - moved to completed status after reviewing followup complete note - Stacey Hudak"]
["Evbu O Enakpene, MD",1972816189,"27-4061759","TX","","Cigna","Participating","Enrollment Complete","2019-06-04","1972816189","","2020-08-26","08/26/2020 - moved to completed status after reviewing followup complete note - Stacey Hudak"]
["Evbu O Enakpene, MD",1972816189,"27-4061759","TX","PE - Permian Cardiology Inc.","Medicare","Participating","Enrollment Complete","2017-09-01","593197ZGML","TXB115966","2020-03-25","03/25/2020 - Signed into PECOS under provider account and confirmed that this provider is EFF with this group - Stacey Hudaki"]
["Evbu O Enakpene, MD",1972816189,"27-4061759","TX","","Medicare","Participating","Enrollment Complete","2017-09-01","593197ZGML","TXB115966","2020-03-25","03/25/2020 - Signed into PECOS under provider account and confirmed that this provider is EFF with this group - Stacey Hudaki"]
["Evbu O Enakpene, MD",1972816189,"27-4061759","TX","PE - Permian Cardiology Inc.","Boon Chapman","Participating","Enrollment Complete","2018-01-30","","","2021-08-06",""]
["Evbu O Enakpene, MD",1972816189,"27-4061759","TX","","Boon Chapman","Participating","Enrollment Complete","2018-01-30","","","2021-08-06",""]
["Evbu O Enakpene, MD",1972816189,"27-4061759","TX","PE - Permian Cardiology Inc.","CAQH","Participating","CAQH Reattested","2023-10-04","14113335","","2023-10-04","10/04/2023 - Updated board, Billing address and re-attested - rkedare"]
["Evbu O Enakpene, MD",1972816189,"27-4061759","TX","","CAQH","Participating","CAQH Reattested","2023-10-04","14113335","","2023-10-04","10/04/2023 - Updated board, Billing address and re-attested - rkedare"]
["Evbu O Enakpene, MD",1972816189,"27-4061759","TX","PE - Permian Cardiology Inc.","Medicaid","Participating","Enrollment Complete","","381744701","356723201","2020-01-29","01/29/2020 - was able to confirm provider enrollment through payer portal. Provider is linked the following plans: TRADITIONAL MEDICAID, Amerigroup - MRSA West, Amerigroup Texas, Inc. - MRSA West - Stacey Hudak"]
["Evbu O Enakpene, MD",1972816189,"27-4061759","TX","","Medicaid","Participating","Enrollment Complete","","381744701","356723201","2020-01-29","01/29/2020 - was able to confirm provider enrollment through payer portal. Provider is linked the following plans: TRADITIONAL MEDICAID, Amerigroup - MRSA West, Amerigroup Texas, Inc. - MRSA West - Stacey Hudak"]
["Evbu O Enakpene, MD",1972816189,"27-4061759","TX","PE - Permian Cardiology Inc.","Wellcare","Participating","Enrollment Complete","2021-11-01","","","2022-11-15","11/15/2022 Per roster received from Wellcare provider is PAR and linked to group TIN/location effective 11/1/2021.  DCannon"]
["Evbu O Enakpene, MD",1972816189,"27-4061759","TX","","Wellcare","Participating","Enrollment Complete","2021-11-01","","","2022-11-15","11/15/2022 Per roster received from Wellcare provider is PAR and linked to group TIN/location effective 11/1/2021.  DCannon"]
["Evbu O Enakpene, MD",1972816189,"27-4061759","TX","PE - Permian Cardiology Inc.","United Health Care","Participating","Enrollment Complete","2019-08-01","6555230","","2020-07-30","7/30/2020 - moved to completed status after reviewing follow up complete note - Stacey Hudak"]
["Evbu O Enakpene, MD",1972816189,"27-4061759","TX","","United Health Care","Participating","Enrollment Complete","2019-08-01","6555230","","2020-07-30","7/30/2020 - moved to completed status after reviewing follow up complete note - Stacey Hudak"]
["Evbu O Enakpene, MD",1972816189,"27-4061759","TX","PE - Permian Cardiology Inc.","Multiplan","Participating","Enrollment Complete","2018-01-30","1972816189","","2020-02-12","02/12/2020 - rec'd confirmation from the payer stating \" Provider:Evbu Enakpene \nNetwork: MPI\nNetwork Participation effective:1/30/2018\nContract Source Group contract through DELEGATED PARTY: West Texas Physicians Alliance\" - Stacey Hudak"]
["Evbu O Enakpene, MD",1972816189,"27-4061759","TX","","Multiplan","Participating","Enrollment Complete","2018-01-30","1972816189","","2020-02-12","02/12/2020 - rec'd confirmation from the payer stating \" Provider:Evbu Enakpene \nNetwork: MPI\nNetwork Participation effective:1/30/2018\nContract Source Group contract through DELEGATED PARTY: West Texas Physicians Alliance\" - Stacey Hudak"]
["Evbu O Enakpene, MD",1972816189,"27-4061759","TX","PE - Permian Cardiology Inc.","TriCare Standard","Participating","Enrollment Complete","2017-09-01","1972816189","","2020-03-10","03/10/2020 - Signed onto payer portal and found this provider is linked to the group at this service location. Please note that this TIN is OUT OF NETWORK and the payer is not currently accepting new in network groups at this time. Due to this, credentialing is not required - Stacey Hudak"]
["Evbu O Enakpene, MD",1972816189,"27-4061759","TX","","TriCare Standard","Participating","Enrollment Complete","2017-09-01","1972816189","","2020-03-10","03/10/2020 - Signed onto payer portal and found this provider is linked to the group at this service location. Please note that this TIN is OUT OF NETWORK and the payer is not currently accepting new in network groups at this time. Due to this, credentialing is not required - Stacey Hudak"]
["Evbu O Enakpene, MD",1972816189,"27-4061759","TX","PE - Permian Cardiology Inc.","First Health Coventry","Participating","Enrollment Complete","2023-03-01","","","2023-07-26","07.26.2023 S/W Stacy of First Health @800-226-5116. Per rep, provider is showing participating and link under the Group and TIN with an Effective date 03/01/2023. Provider ID 3658746. Service location is on file. Call ref#:708923. - Danico Gabriel Melendres"]
["Evbu O Enakpene, MD",1972816189,"27-4061759","TX","","First Health Coventry","Participating","Enrollment Complete","2023-03-01","","","2023-07-26","07.26.2023 S/W Stacy of First Health @800-226-5116. Per rep, provider is showing participating and link under the Group and TIN with an Effective date 03/01/2023. Provider ID 3658746. Service location is on file. Call ref#:708923. - Danico Gabriel Melendres"]
["Joseph M Damiani, MD",1093821274,"39-9526391","TX","PE - Joseph Damiani","CAQH","Participating","CAQH Reattested","2023-10-05","","","2023-10-05","10/5/2023 CAQH reviewed and re-attested.  DCannon"]
["Joseph M Damiani, MD",1093821274,"39-9526391","TX","PE - Joseph Damiani","Cigna","Participating","Enrollment Complete","2014-10-08","1093821274","","2020-08-26","08/26/2020 - moved to completed status after reviewing follow up complete note - Stacey Hudak"]
["Joseph M Damiani, MD",1093821274,"39-9526391","TX","PE - Joseph Damiani","Sedgwick","Participating","Enrollment Complete","2021-01-26","","","2021-05-06",""]
["Joseph M Damiani, MD",1093821274,"39-9526391","TX","PE - Joseph Damiani","Medicare","Participating","Enrollment Complete","2008-12-01","613616","613616 (provider and group in one enrollment)","2020-07-06","07/06/2020 - was able to obtain PECOS login and sign in to verify - Provider Medicare ID# 613616 EFF 12-1-2008 at service location of 2407 W Louisiana Ave - Stacey Hudak"]
["Joseph M Damiani, MD",1093821274,"39-9526391","TX","PE - Joseph Damiani","Humana","Participating","Enrollment Complete","2021-09-01","","","2021-11-18","11/18/2021 Rcvd full roster from Humana listing provider as PAR and linked to group TIN/location effective 9/1/2021.  DCannon"]
["Joseph M Damiani, MD",1093821274,"39-9526391","TX","PE - Joseph Damiani","First Health Coventry","Participating","Enrollment Complete","2016-07-01","1093821274","","2020-07-10","07/10/2020 - moved to completed status per notes in Follow Up Complete  - Stacey Hudak"]
["Joseph M Damiani, MD",1093821274,"39-9526391","TX","PE - Joseph Damiani","Gallagher","Participating","Enrollment Complete","2018-10-01","","","2021-01-25","1/25/2021 - Rcvd email from payer confirming participating under tax ID and at location effectice 10/1/2018.  DCannon"]
["Joseph M Damiani, MD",1093821274,"39-9526391","TX","PE - Joseph Damiani","USA PPO","Participating","Enrollment Complete","2021-01-26","1242855","","2021-03-12","3/12/2021 Per verification on payor website USAMCO.com provider is loaded as participating.  Rcvd Roster LeNetrice Myart with provider numbers and effective dates for providers.  DCannon"]
["Joseph M Damiani, MD",1093821274,"39-9526391","TX","PE - Joseph Damiani","IMS","Participating","Enrollment Complete","2014-10-31","1093821274","","2020-07-01","07/01/2020 - Rec'd confirmation email from the payer stating this provider is EFF - Stacey Hudak"]
["Joseph M Damiani, MD",1093821274,"39-9526391","TX","PE - Joseph Damiani","Multiplan","Participating","Enrollment Complete","2016-01-01","1093821274","PPONEXTSCRVS51A38LO","2020-07-06","07/06/2020 - Rec'd email from the payer stating this provider is EFF - \"Thank you for contacting our Service Department at MultiPlan. Here is the following information we have on file for Damiani, Joseph:\n\nNetwork:  Beech St\nNetwork Participation effective: 01/01/2016 Contract Source Group contract through: PPONEXTSCRVS51A38LO\" - Stacey Hudak"]
["Joseph M Damiani, MD",1093821274,"39-9526391","TX","PE - Joseph Damiani","Galaxy Health","Participating","Enrollment Complete","2019-09-01","1093821274","","2020-08-24","08/21/2020 - Rec'd email confirmation that this roster was processed and this provider was made effective with the requested eff date of 9-1-2019 - Stacey Hudak"]
["Joseph M Damiani, MD",1093821274,"39-9526391","TX","PE - Joseph Damiani","Wellmed","Participating","Enrollment Complete","2022-01-01","","","2023-03-23","3/23/2023 Rcvd roster from UHC w/ all Wellmed participating providers.  Provider is PAR effective 1/1/2022.  DCannon"]
["Joseph M Damiani, MD",1093821274,"39-9526391","TX","PE - Joseph Damiani","Omni PPO","Participating","Enrollment Complete","2014-10-31","1093821274","","2020-07-01","07/01/2020 - Rec'd confirmation that IMS is effective, therefore this payer is also - Stacey Hudak"]
["Joseph M Damiani, MD",1093821274,"39-9526391","TX","PE - Joseph Damiani","Boon Chapman","Participating","Enrollment Complete","2016-01-01","","","2021-08-06","8/6/2021 Boon Chapman falls under the Multiplan umbrella, received roster from Multiplan provider is listed on roster under TIN/location as PAR effective 1/1/2016.  DCannon"]
["Joseph M Damiani, MD",1093821274,"39-9526391","TX","PE - Joseph Damiani","Zurich","Participating","Enrollment Complete","2019-07-24","","","2020-09-10","9/10/2020 Confirmed provider is participating with Coventry Integrated Network under delegation with location on file. Kimberly Frazier"]
["Joseph M Damiani, MD",1093821274,"39-9526391","TX","PE - Joseph Damiani","United Health Care","Participating","Enrollment Complete","2015-09-01","1093821274","","2020-08-31","08/31/2020 - moved to completed status after reviewing follow up complete note - Stacey Hudak"]
["Joseph M Damiani, MD",1093821274,"39-9526391","TX","PE - Joseph Damiani","Liberty Mutual","Participating","Enrollment Complete","2018-10-01","","","2021-01-25","1/25/2021 - Rcvd email from payer confirming participating under tax ID and at location effectice 10/1/2018.  DCannon"]
["Joseph M Damiani, MD",1093821274,"39-9526391","TX","PE - Joseph Damiani","Scott&White (First Care)","Participating","Enrollment Complete","2020-09-28","","","2021-01-29","1/29/2021 - Rcvd roster from Scott&White (First Care) confirming participation of provider with TIN and location effective dates.  DCannon"]
["Joseph M Damiani, MD",1093821274,"39-9526391","TX","PE - Joseph Damiani","Wellcare","Participating","Enrollment Complete","2021-11-01","","","2022-11-15","11/15/2022 Per roster received from Wellcare provider is PAR and linked to group TIN/location effective 11/1/2021.  DCannon"]
["Joseph M Damiani, MD",1093821274,"39-9526391","TX","PE - Joseph Damiani","Texas Mutual","Participating","Enrollment Complete","2020-06-03","","","2021-01-23","11/25/2020-Confirmed provider is participating under group Tax ID and practice location. Rafael Calixtro"]
["Joseph M Damiani, MD",1093821274,"39-9526391","TX","PE - Joseph Damiani","Aetna","Participating","Enrollment Complete","2014-11-15","1093821274","","2020-09-22","09/22/2020 - Rec'd completed PRIMED ROSTER back from the payer. This provider is PAR at this service location - Stacey Hudak"]
["Joseph M Damiani, MD",1093821274,"39-9526391","TX","PE - Joseph Damiani","HealthSmart PPO","Participating","Enrollment Complete","2014-10-31","1093821274","","2020-07-01","07/01/2020 - Rec'd email confirmation from the payer that this provider is EFF - Stacey Hudak"]
["Alim M Ladha, MD",1093935975,"45-3020135","TX","PE - Alim M. Ladha, MD","Scott&White (First Care)","Participating","Enrollment Complete","2018-01-01","1093935975","","2020-04-16","04/16/2020 - Rec'd email from the payer to confirm that this provider is effective with this TIN & service location under PRIMED DELEGATED group with PPO Products only - Stacey Hudak"]
["Alim M Ladha, MD",1093935975,"45-3020135","TX","PE - Alim M. Ladha, MD","Medicare","Participating","Enrollment Complete","2011-09-04","TXB140169","TXB140168","2020-03-10","03/10/2020 - Was able to confirm provider is linked to the group Basin Neurosurgical And Spine Associates EFF 9-4-2011 and in good standing through PECOS - Stacey Hudak"]
["Alim M Ladha, MD",1093935975,"45-3020135","TX","PE - Alim M. Ladha, MD","Humana","Participating","Enrollment Complete","2021-09-01","","","2021-11-18","11/18/2021 Rcvd full roster from Humana listing provider as PAR and linked to group TIN/location effective 9/1/2021.  DCannon"]
["Alim M Ladha, MD",1093935975,"45-3020135","TX","PE - Alim M. Ladha, MD","Galaxy Health","Participating","Enrollment Complete","2014-11-04","1093935975","","2020-07-16","7/16/2020 - Rec'd email from the payer that contains a spreadsheet showing the providers effective date - Stacey Hudak"]
["Alim M Ladha, MD",1093935975,"45-3020135","TX","PE - Alim M. Ladha, MD","Wellcare","Participating","Enrollment Complete","2021-11-01","","","2022-12-01","12/1/2022 Per roster received from Wellcare provider is PAR and linked to group TIN/location effective 11/1/2021.  DCannon"]
["Alim M Ladha, MD",1093935975,"45-3020135","TX","PE - Alim M. Ladha, MD","Ambetter","Participating","Enrollment Complete","2022-04-01","","","2022-06-13","6/13/2022 Per roster received from Superior provider is PAR and linked to group delegation roster effective 4/1/2022."]
["Alim M Ladha, MD",1093935975,"45-3020135","TX","PE - Alim M. Ladha, MD","CAQH","Participating","In House Enrollment","2020-06-11","12334676","","2020-06-11","06/11/2020 - Provider did not supply CAQH login. Provider will maintain this info in-house - Stacey Hudak"]
["Alim M Ladha, MD",1093935975,"45-3020135","TX","PE - Alim M. Ladha, MD","Superior","Participating","Enrollment Complete","2012-09-01","1093935975","","2020-07-14","07/14/2020 - Rec'd email from the payer stating this provider is EFF with this TIN under PRIMED DELEGATED agreement - Stacey Hudak"]
["Alim M Ladha, MD",1093935975,"45-3020135","TX","PE - Alim M. Ladha, MD","Cigna","Terminated","Terminated","2021-02-17","1093935975","","2021-07-09","7/9/2021 Per Rep Joe, the payor received a written request to terminate the provider's participation in December, 2020, and he was officially terminated with the networks as of 2/17/2021. Notice to payor was received by kbakas@echd.org. Emailed this information to MQA for clarification if they wish for us to initiate new enrollment and pending response. KFrazier"]
["Alim M Ladha, MD",1093935975,"45-3020135","TX","PE - Alim M. Ladha, MD","HealthSmart PPO","Participating","Enrollment Complete","2012-09-26","1093935975","","2020-06-04","06/04/2020 - Rec'd email from the payer stating this provider is EFF - Stacey Hudak"]
["Alim M Ladha, MD",1093935975,"45-3020135","TX","PE - Alim M. Ladha, MD","Wellmed","Participating","Enrollment Complete","2020-06-01","","","2023-03-23","3/23/2023 Rcvd roster from UHC w/ all Wellmed participating providers.  Provider is PAR effective 6/1/2020.  DCannon"]
["Alim M Ladha, MD",1093935975,"45-3020135","TX","PE - Alim M. Ladha, MD","Caprock (CapStar)","Participating","Enrollment Complete","2020-03-01","1093935975","","",""]
["Alim M Ladha, MD",1093935975,"45-3020135","TX","PE - Alim M. Ladha, MD","Aetna","Participating","Enrollment Complete","2012-04-15","1093935975","","2021-04-20","4/20/2021 Received email response from Rep Jamie Roberts at RobertsJ6@aetna.com confirming provider was under another IPA delegation with same Tax ID that terminated in December, 2020. Therefore, she has reinstated the provider's participation under the MQA delegation with an effective date of 12/9/2020. KFrazier"]
["Alim M Ladha, MD",1093935975,"45-3020135","TX","PE - Alim M. Ladha, MD","Amerigroup","Participating","Enrollment Complete","2012-09-26","01676266","","2021-02-13","2/13/2021 - Rcvd complete roster from Amerigroup provider is participating and linked to TIN and location for the following plans  Medicare - eff 9/26/2012; C-SNP - eff 1/1/2017; Other - eff 1/1/2021. DCannon"]
["Alim M Ladha, MD",1093935975,"45-3020135","TX","PE - Alim M. Ladha, MD","Cigna","Participating","Enrollment Complete","2021-06-01","6313275","","2021-09-13","9/13/2021 Received email from pdmcogz@cigna.com, Their  records indicate that your provider was credentialed as of 06/01/21 under the below tax ID with assigned provider ID 6313275. Cbankston"]
["Alim M Ladha, MD",1093935975,"45-3020135","TX","PE - Alim M. Ladha, MD","IMS","Participating","Enrollment Complete","2012-02-02","1093935975","","2020-06-22","06/22/2020- Rec'd email from the payer confirming this provider is PAR with this group/service location - Stacey Hudak"]
["Alim M Ladha, MD",1093935975,"45-3020135","TX","PE - Alim M. Ladha, MD","Boon Chapman","Enrollment Stopped","Enrollment Stopped","","","","2023-10-16","10/16/2023 Provider is not enrolled in Multiplan, therefore, provider is not enrolled in Boon Chapman.  DCannon"]
["Alim M Ladha, MD",1093935975,"45-3020135","TX","PE - Alim M. Ladha, MD","United Health Care","Participating","Enrollment Complete","2017-09-09","3517020","","2020-07-30","7/30/2020 - moved to completed status after reviewing follow up complete note - Stacey Hudak"]
["Ryan S Rowland, MD",1740542034,"46-0950925","TX","PE - Urgent Orthopedic Specialists, PLLC","USA PPO","Participating","Enrollment Complete","2018-07-31","1740542034","460950925","2020-08-18","Confirmed provider is participating with PPO and H&W networks (list of networks attached). Kimberly Frazier"]
["Ryan S Rowland, MD",1740542034,"46-0950925","TX","PE - Urgent Orthopedic Specialists, PLLC","Scott&White (First Care)","Participating","Enrollment Complete","2018-09-20","1740542034","","2020-08-20","08/20/2020 - Rec'd emailed spreadsheet from the payer stating this provider is affiliated with the PRIMED DELEGATED AGREEMENT under this TIN/Service location. This provider is networked with:\nFirstCare MyChoice PPO\nCHIP\nFirstCare Select Benefit Network\nHMO Enhanced Benefit Network\nMedicaid (FC)\nMedicare (FC)\nPPO Limited Benefit Network\n- Stacey Hudak"]
["Ryan S Rowland, MD",1740542034,"46-0950925","TX","PE - Urgent Orthopedic Specialists, PLLC","Ambetter","Participating","Enrollment Complete","2022-06-01","","","2022-06-13","6/13/2022 Per roster received from Superior provider is PAR and linked to group delegation roster effective 6/1/2022."]
["Ryan S Rowland, MD",1740542034,"46-0950925","TX","PE - Urgent Orthopedic Specialists, PLLC","HealthSmart PPO","Participating","Enrollment Complete","2018-07-27","1740542034","","2020-06-10","06/10/2020 - Rec'd email from the payer stating provider is EFF - Stacey Hudak"]
["Ryan S Rowland, MD",1740542034,"46-0950925","TX","PE - Urgent Orthopedic Specialists, PLLC","Amerigroup","Participating","Enrollment Complete","2018-07-31","1740542034","","2020-03-20","03/20/2020 - Rec'd email from the payer (Multiplan/Texas True Choice)  stating this provider is EFF at this service location with Amerigroup - Stacey Hudak"]
["Ryan S Rowland, MD",1740542034,"46-0950925","TX","PE - Urgent Orthopedic Specialists, PLLC","Humana","Participating","Enrollment Complete","2017-05-01","","","2021-11-18","11/18/2021 Rcvd full roster from Humana listing provider as PAR and linked to group TIN/location effective 5/1/2017.  DCannon"]
["Ryan S Rowland, MD",1740542034,"46-0950925","TX","PE - Urgent Orthopedic Specialists, PLLC","Superior","Participating","Enrollment Complete","2018-09-01","1740542034","","2020-07-14","07/14/2020 - Rec'd email from the payer stating this provider is EFF under PRIMED DELEGATED agreement - Stacey Hudak"]
["Ryan S Rowland, MD",1740542034,"46-0950925","TX","PE - Urgent Orthopedic Specialists, PLLC","Galaxy Health","Participating","Enrollment Complete","2019-09-01","1740542034","","2020-08-24","08/21/2020 - Rec'd email confirmation that this roster was processed and this provider was made effective with the requested eff date of 9-1-2019 - Stacey Hudak"]
["Ryan S Rowland, MD",1740542034,"46-0950925","TX","PE - Urgent Orthopedic Specialists, PLLC","CAQH","Participating","CAQH Reattested","2023-10-27","","","2023-10-27","10/27/2023 CAQH Sweep"]
["Ryan S Rowland, MD",1740542034,"46-0950925","TX","PE - Urgent Orthopedic Specialists, PLLC","IMS","Participating","Enrollment Complete","2018-07-24","1740542034","","2020-06-22","06/22/2020- Rec'd email from the payer confirming this provider is PAR with this group/service location - Stacey Hudak"]
["Ryan S Rowland, MD",1740542034,"46-0950925","TX","PE - Urgent Orthopedic Specialists, PLLC","Caprock (CapStar)","Participating","Enrollment Complete","2018-07-24","1740542034","","2020-06-02","06/02/2020 - rec'd spreadsheet back from the payer Mary Rodriguez <MRodriguez@caprockhp.com> confirming this provider/service location is EFF with this payer - Stacey Hudak"]
["Ryan S Rowland, MD",1740542034,"46-0950925","TX","PE - Urgent Orthopedic Specialists, PLLC","Multiplan","Participating","Enrollment Complete","2018-08-16","1740542034","","2020-09-08","09/08/2020 - Found response from the payer stating \"Thank you for contacting our Service Department at MultiPlan. Here is the following information we have on file for Multiple providers listed below:\n\nNetwork: Beech St, MPI, & PHCS\nNetwork Participation effective: Please see below\nContract Source Group contract through: Please see below\nRyan S Rowland, MD NPI: 1740542034 – \n5026 – West Texas Physicians Alliance –  Beech St Eff Date 07/11/2018\n23655 – West Texas Physicians Alliance –  MPI Eff Date 08/16/2018\n52669 – West Texas Physicians Alliance – PHCS Eff Date 08/16/2018\" - Stacey Hudak"]
["Ryan S Rowland, MD",1740542034,"46-0950925","TX","PE - Urgent Orthopedic Specialists, PLLC","Wellmed","Participating","Enrollment Complete","2022-01-01","","","2023-03-23","3/23/2023 Rcvd roster from UHC w/ all Wellmed participating providers.  Provider is PAR effective 1/1/2022.  DCannon"]
["Ryan S Rowland, MD",1740542034,"46-0950925","TX","PE - Urgent Orthopedic Specialists, PLLC","United Health Care","Participating","Enrollment Complete","2018-07-24","1740542034","","2020-08-31","08/31/2020 - moved to completed status after reviewing follow up complete note from 8/28/2020 - Stacey Hudak"]
["Ryan S Rowland, MD",1740542034,"46-0950925","TX","PE - Urgent Orthopedic Specialists, PLLC","Triwest VA","Participating","Enrollment Complete","2022-08-01","","","2022-11-14","11/14/22 Per Scarlett Abigail, provider effective from 8/1/22"]
["Ryan S Rowland, MD",1740542034,"46-0950925","TX","PE - Urgent Orthopedic Specialists, PLLC","First Health Coventry","Participating","Enrollment Complete","2018-08-01","3165726","","2020-03-20","03/20/2020 - Recd email from the payer stating this provider is effective under PID# 3165726  - Stacey Hudak"]
["Ryan S Rowland, MD",1740542034,"46-0950925","TX","PE - Urgent Orthopedic Specialists, PLLC","Omni PPO","Participating","Enrollment Complete","2018-07-24","1740542034","","2020-06-26","06/26/2020 - EFF IF IMS IS EFF - Stacey Hudak"]
["Ryan S Rowland, MD",1740542034,"46-0950925","TX","PE - Urgent Orthopedic Specialists, PLLC","Aetna","Participating","Enrollment Complete","2018-08-01","1740542034","","2020-04-23","04/23/2020--S/W Kim of Aetna @ 800-353-1232. Per rep the Provider is on file, linked & participating under the GRP & TIN effective 8/1/2018. Physical Location is on file. Provider ID #6404238. Call ref # 5234162545\ncopied note from spreadsheet-tisha rader"]
["Pamela F Doughty, PA",1346807278,"46-0950925","TX","PE - Urgent Orthopedic Specialists, PLLC","Ambetter","Participating","Enrollment Complete","2022-06-01","","","2022-06-13","6/13/2022 Per roster received from Superior provider is PAR and linked to group delegation roster effective 6/1/2022."]
["Pamela F Doughty, PA",1346807278,"46-0950925","TX","PE - Urgent Orthopedic Specialists, PLLC","Galaxy Health","Participating","Enrollment Complete","2019-09-01","1346807278","","2020-08-24","08/21/2020 - Rec'd email confirmation that this roster was processed and this provider was made effective with the requested eff date of 9-1-2019 - Stacey Hudak"]
["Pamela F Doughty, PA",1346807278,"46-0950925","TX","PE - Urgent Orthopedic Specialists, PLLC","Caprock (CapStar)","Participating","Enrollment Complete","2019-09-01","1346807278","","2020-09-23","09/23/2020 - rec'd confirmation from the payer that this August 2020 roster was completed. This provider/service location was added to PriMed Agreement - OK to move to completed status. - Stacey Hudak"]
["Pamela F Doughty, PA",1346807278,"46-0950925","TX","PE - Urgent Orthopedic Specialists, PLLC","United Health Care","Participating","Enrollment Complete","2020-05-20","1346807278","","2020-08-31","08/31/2020 - moved to completed status after reviewing follow up completed status - Stacey Hudak"]
["Pamela F Doughty, PA",1346807278,"46-0950925","TX","PE - Urgent Orthopedic Specialists, PLLC","CAQH","Participating","CAQH Reattested","2023-10-27","","","2023-10-27","10/27/2023 CAQH Sweep"]
["Pamela F Doughty, PA",1346807278,"46-0950925","TX","PE - Urgent Orthopedic Specialists, PLLC","Superior","Participating","Enrollment Complete","2020-08-01","1346807278","","2020-08-06","8/6/2020 - Rec'd an email from the payer stating this provider was added to their database EFF: 8-1-2020 after receiving/processing the July roster - Stacey Hudak"]
["Pamela F Doughty, PA",1346807278,"46-0950925","TX","PE - Urgent Orthopedic Specialists, PLLC","Wellmed","Participating","Enrollment Complete","2022-01-01","","","2023-03-23","3/23/2023 Rcvd roster from UHC w/ all Wellmed participating providers.  Provider is PAR effective 1/1/2022.  DCannon"]
["Pamela F Doughty, PA",1346807278,"46-0950925","TX","PE - Urgent Orthopedic Specialists, PLLC","Multiplan","Participating","Enrollment Complete","2020-05-13","1346807278","","2020-09-08","09/08/2020 - Rec'd email response from the payer stating \" Network: Beech St, MPI, & PHCS\nNetwork Participation effective: Please see below\nContract Source Group contract through: Please see below:\n\nPamela F Doughty, PA NPI: 1346807278\n5026 – West Texas Physicians Alliance –Beech St Eff Date 05/06/2020\n23655 – West Texas Physicians Alliance – MPI Eff Date 05/13/2020\n52669 – West Texas Physicians Alliance – PHCS Eff Date 05/13/2020\"\n- Stacey Hudak"]
["Pamela F Doughty, PA",1346807278,"46-0950925","TX","PE - Urgent Orthopedic Specialists, PLLC","Medicaid","Participating","In House Enrollment","2020-01-05","412587401","325373401","2020-08-13","8/13/2020 - rec'd effective letter from the clinic. HOwever, this is not a payer that they asked Symplr to maintain. Created a payer line to house effective info if needed by another payer for enrollment - Stacey Hudak"]
["Pamela F Doughty, PA",1346807278,"46-0950925","TX","PE - Urgent Orthopedic Specialists, PLLC","Scott&White (First Care)","Participating","Enrollment Complete","2020-09-28","","","2021-01-29","1/29/2021 - Rcvd roster from Scott&White (First Care) confirming participation of provider with TIN and location effective dates.  DCannon"]
["Pamela F Doughty, PA",1346807278,"46-0950925","TX","PE - Urgent Orthopedic Specialists, PLLC","First Health Coventry","Participating","Enrollment Complete","2020-09-01","","","2020-12-10","12/10/2020 - Per First Health provider is active and linked to practice location effective 9/1/2020.  DCannon"]
["Pamela F Doughty, PA",1346807278,"46-0950925","TX","PE - Urgent Orthopedic Specialists, PLLC","Humana","Participating","Enrollment Complete","2017-05-01","","","2021-11-18","11/18/2021 Rcvd full roster from Humana listing provider as PAR and linked to group TIN/location effective 5/1/2017.  DCannon"]
["Pamela F Doughty, PA",1346807278,"46-0950925","TX","PE - Urgent Orthopedic Specialists, PLLC","USA PPO","Participating","Enrollment Complete","2021-01-26","1312287","","2021-03-12","3/12/2021 Per verification on payor website USAMCO.com provider is loaded as participating.  Rcvd Roster LeNetrice Myart with provider numbers and effective dates for providers.  DCannon"]
["Pamela F Doughty, PA",1346807278,"46-0950925","TX","PE - Urgent Orthopedic Specialists, PLLC","Wellcare","Participating","Enrollment Complete","2021-11-01","","","2022-11-15","11/15/2022 Per roster received from Wellcare provider is PAR and linked to group TIN/location effective 11/1/2021.  DCannon"]
["Pamela F Doughty, PA",1346807278,"46-0950925","TX","PE - Urgent Orthopedic Specialists, PLLC","IMS","Participating","Enrollment Complete","2019-09-01","1346807278","","2020-07-27","07/27/2020 - Rec'd roster response back from the payer regarding 7/15/2020 submission stating that all requested providers/service locations have been added to PriMed agreement - Stacey Hudak"]
["Pamela F Doughty, PA",1346807278,"46-0950925","TX","PE - Urgent Orthopedic Specialists, PLLC","HealthSmart PPO","Participating","Enrollment Complete","2020-05-06","13725946","","2020-07-21","07/21/2020 - rec'd email with a spreadsheet from the payer stating this provider/TIN/service location are all PAR with WEST TEXAS PHYSICIANS ALLIANCE Delegated - Stacey Hudak"]
["Pamela F Doughty, PA",1346807278,"46-0950925","TX","PE - Urgent Orthopedic Specialists, PLLC","Triwest VA","In House Enrollment","In House Enrollment","","","","2021-01-13","01/06/2021 - MQA Team is working with Representatives at BCBS-TX to ensure all providers are enrolled and loaded to participate with the VACCN network in a timely manner. However, we are currently awaiting a full roster of providers currently participating and will update all records accordingly upon receipt. Kfrazier"]
["Pamela F Doughty, PA",1346807278,"46-0950925","TX","PE - Urgent Orthopedic Specialists, PLLC","Amerigroup","Participating","Enrollment Complete","2020-04-15","","","2021-08-26","8/26/2021 Rcvd full roster from Joe Rodriguez at Amerigroup listing provider as PAR w/ group TIN and location effective 4/15/2020.  DCannon"]
["Pamela F Doughty, PA",1346807278,"46-0950925","TX","PE - Urgent Orthopedic Specialists, PLLC","Aetna","Participating","Enrollment Complete","2020-09-01","1346807278","","2020-11-07","11/6/2020 Received email from ProviderCommunications@aetna.cpe.messages2.com confirming provider is now participating under group Tax ID effective 9/1/2020 and assigned PIN number 6962996. Kimberly Frazier"]
["William Gage Liesman, MD",1144665233,"46-0950925","TX","PE - Urgent Orthopedic Specialists, PLLC","HealthSmart PPO","Participating","Enrollment Complete","2019-09-26","1144665233","","2020-06-10","06/10/2020 - Rec'd email from the payer stating this provider is EFF - Stacey Hudak"]
["William Gage Liesman, MD",1144665233,"46-0950925","TX","PE - Urgent Orthopedic Specialists, PLLC","Caprock (CapStar)","Participating","Enrollment Complete","2019-08-26","","","2020-09-14",""]
["William Gage Liesman, MD",1144665233,"46-0950925","TX","PE - Urgent Orthopedic Specialists, PLLC","Omni PPO","Participating","Enrollment Complete","2019-08-26","1144665233","","2020-06-26",""]
["William Gage Liesman, MD",1144665233,"46-0950925","TX","PE - Urgent Orthopedic Specialists, PLLC","Wellcare","Participating","Enrollment Complete","2021-11-01","","","2022-12-01","12/1/2022 Per roster received from Wellcare provider is PAR and linked to group TIN/location effective 11/1/2021.  DCannon"]
["William Gage Liesman, MD",1144665233,"46-0950925","TX","PE - Urgent Orthopedic Specialists, PLLC","Galaxy Health","Participating","Enrollment Complete","2019-09-01","1144665233","","2020-08-24","08/21/2020 - Rec'd email confirmation that this roster was processed and this provider was made effective with the requested eff date of 9-1-2019 - Stacey Hudak"]
["William Gage Liesman, MD",1144665233,"46-0950925","TX","PE - Urgent Orthopedic Specialists, PLLC","Triwest VA","Participating","Enrollment Complete","2022-08-01","","","2022-11-14","11/14/22 Per Scarlett Abigail, provider effective 8/1/22"]
["William Gage Liesman, MD",1144665233,"46-0950925","TX","PE - Urgent Orthopedic Specialists, PLLC","Medicare","Participating","In House Enrollment","2019-09-01","842726","270548","2020-06-29","06/29/2020 - Rec'd a copy of the Medicare EFF letter for our records to support other payer enrollment. Medicare enrollment will be maintained in-house (not my Symplr) - Stacey Hudak"]
["William Gage Liesman, MD",1144665233,"46-0950925","TX","PE - Urgent Orthopedic Specialists, PLLC","Multiplan","Participating","Enrollment Complete","2019-09-01","1144665233","","2020-09-08","09/08/2020 - Rec'd email from the payer stating:\n\"Network: Beech St, MPI, & PHCS\nNetwork Participation effective: Please see below\nContract Source Group contract through: Please see below\n\nW Gage Liesman, MD NPI: 1144665233\n5026 – West Texas Physicians Alliance – Eff Date 09/01/2019\n23655 – West Texas Physicians Alliance – Eff Date 09/01/2019\n52669 – West Texas Physicians Alliance – Eff Date 09/01/2019\" - Stacey Hudak"]
["William Gage Liesman, MD",1144665233,"46-0950925","TX","PE - Urgent Orthopedic Specialists, PLLC","Ambetter","Participating","Enrollment Complete","2022-06-01","","","2022-06-13","6/13/2022 Per roster received from Superior provider is PAR and linked to group delegation roster effective 6/1/2022."]
["William Gage Liesman, MD",1144665233,"46-0950925","TX","PE - Urgent Orthopedic Specialists, PLLC","Scott&White (First Care)","Participating","Enrollment Complete","2019-09-30","1144665233","","2020-08-20","08/20/2020 - rec'd email from the payer stating this provider is affilliated with the PRIMED DELEGATED AGREEMENT under this TIN/Service Location. \nThis provider is networked with:\nFirstCare MyChoice PPO\nCHIP\nFirstCare Select Benefit Network\nHMO Enhanced Benefit Network\nMedicaid (FC)\nMedicare (FC)\nPPO Limited Benefit Network\n- Stacey Hudak"]
["William Gage Liesman, MD",1144665233,"46-0950925","TX","PE - Urgent Orthopedic Specialists, PLLC","CAQH","Participating","CAQH Reattested","2023-10-27","","","2023-10-27","10/27/2023 CAQH Sweep"]
["William Gage Liesman, MD",1144665233,"46-0950925","TX","PE - Urgent Orthopedic Specialists, PLLC","First Health Coventry","Participating","Enrollment Complete","2019-08-01","1144665233","","2020-06-12","06/12/2020 - Rec'd email from the payer stating this provider is EFF - PID# 3303866 - Stacey Hudak"]
["William Gage Liesman, MD",1144665233,"46-0950925","TX","PE - Urgent Orthopedic Specialists, PLLC","USA PPO","Participating","Enrollment Complete","2019-08-30","1144665233","460950925","2020-08-18","Confirmed provider is participating with PPO and H&W networks (list of networks attached). Kimberly Frazier"]
["William Gage Liesman, MD",1144665233,"46-0950925","TX","PE - Urgent Orthopedic Specialists, PLLC","Amerigroup","Participating","Enrollment Complete","2020-04-15","","","2021-02-13","2/13/2021 - Rcvd complete roster from Amerigroup provider is participating and linked to TIN and location for the following plans STAR, CHIP_PERINATAL, STAR_PLUS, CHIP.  DCannon"]
["William Gage Liesman, MD",1144665233,"46-0950925","TX","PE - Urgent Orthopedic Specialists, PLLC","United Health Care","Participating","Enrollment Complete","2020-01-01","1144665233","","2020-08-31","08/31/2020 - moved to completed status after reviewing August follow up complete note - Stacey Hudak"]
["William Gage Liesman, MD",1144665233,"46-0950925","TX","PE - Urgent Orthopedic Specialists, PLLC","Aetna","Participating","Enrollment Complete","2020-09-01","6694913","","2020-11-24","11/24/2020 - Per f/u report provider NPI# is on file for the provider is linked and is participating effective 09/01/2020 under the group and TIN#. Provider ID 6694913. Group ID 4907135.  DCannon"]
["William Gage Liesman, MD",1144665233,"46-0950925","TX","PE - Urgent Orthopedic Specialists, PLLC","IMS","Participating","Enrollment Complete","2019-08-26","1144665233","","2020-06-22","06/22/2020- Rec'd email from the payer confirming this provider is PAR with this group/service location - Stacey Hudak"]
["William Gage Liesman, MD",1144665233,"46-0950925","TX","PE - Urgent Orthopedic Specialists, PLLC","Wellmed","Participating","Enrollment Complete","2020-06-01","","","2023-03-23","3/23/2023 Rcvd roster from UHC w/ all Wellmed participating providers.  Provider is PAR effective 6/1/2020.  DCannon"]
["William Gage Liesman, MD",1144665233,"46-0950925","TX","PE - Urgent Orthopedic Specialists, PLLC","Medicaid","Participating","In House Enrollment","2019-09-01","404183201","","2020-06-29","06/29/2020 - client supplied us with copy of MEDICAID EFF letter for other payer enrollments, if needed. Symplr does not need to maintain this enrollment.  Stacey Hudak"]
["William Gage Liesman, MD",1144665233,"46-0950925","TX","PE - Urgent Orthopedic Specialists, PLLC","Humana","Participating","Enrollment Complete","2017-05-01","","","2021-11-18","11/18/2021 Rcvd full roster from Humana listing provider as PAR and linked to group TIN/location effective 5/1/2017.  DCannon"]
["William Gage Liesman, MD",1144665233,"46-0950925","TX","PE - Urgent Orthopedic Specialists, PLLC","Superior","Participating","Enrollment Complete","2019-10-01","1144665233","","2020-07-14","07/14/2020 - Rec'd email from the payer stating this provider is EFF under PRIMED DELEGATED agreement - Stacey Hudak"]
["Jordan Elizabeth Friday, NP",1215575576,"46-0950925","TX","PE - Urgent Orthopedic Specialists, PLLC","Scott&White (First Care)","Participating","Enrollment Complete","2020-09-28","","","2021-01-29","1/29/2021 - Rcvd roster from Scott&White (First Care) confirming participation of provider with TIN and location effective dates.  DCannon"]
["Jordan Elizabeth Friday, NP",1215575576,"46-0950925","TX","PE - Urgent Orthopedic Specialists, PLLC","Multiplan","Participating","Enrollment Complete","2020-06-10","1215575576","","2020-09-08","09/08/2020 - Rec'd email from the payer confirming this provider is EFF:\n\"Network: Beech St, MPI, & PHCS\nNetwork Participation effective: Please see below\nContract Source Group contract through: Please see below\n\nJordan Elizabeth Friday, NP NPI: 1215575576\n5026 – West Texas Physicians Alliance – Beech St Eff Date 05/06/2020\n23655 – West Texas Physicians Alliance – MPI Eff Date 06/10/2020\n52669 – West Texas Physicians Alliance – PHCS Eff Date 06/10/2020\" - Stacey Hudak"]
["Jordan Elizabeth Friday, NP",1215575576,"46-0950925","TX","PE - Urgent Orthopedic Specialists, PLLC","Caprock (CapStar)","Participating","Enrollment Complete","2019-09-01","1215575576","","2020-09-23","09/23/2020 - rec'd confirmation from the payer that this August 2020 roster was completed. This provider/service location was added to PriMed Agreement - OK to move to completed status. - Stacey Hudak"]
["Jordan Elizabeth Friday, NP",1215575576,"46-0950925","TX","PE - Urgent Orthopedic Specialists, PLLC","USA PPO","Participating","Enrollment Complete","2021-01-26","1312302","","2021-03-12","3/12/2021 Per verification on payor website USAMCO.com provider is loaded as participating.  Rcvd Roster LeNetrice Myart with provider numbers and effective dates for providers.  DCannon"]
["Jordan Elizabeth Friday, NP",1215575576,"46-0950925","TX","PE - Urgent Orthopedic Specialists, PLLC","Wellcare","Participating","Enrollment Complete","2021-11-01","","","2022-12-01","12/1/2022 Per roster received from Wellcare provider is PAR and linked to group TIN/location effective 11/1/2021.  DCannon"]
["Jordan Elizabeth Friday, NP",1215575576,"46-0950925","TX","PE - Urgent Orthopedic Specialists, PLLC","Aetna","Participating","Enrollment Complete","2020-09-01","1215575576","","2020-11-07","11/6/2020 Received email from ProviderCommunications@aetna.cpe.messages2.com confirming provider's participation under group Tax ID effective 9/1/2020 and assigned PIN number 6314133. Kimberly Frazier"]
["Jordan Elizabeth Friday, NP",1215575576,"46-0950925","TX","PE - Urgent Orthopedic Specialists, PLLC","Humana","Participating","Enrollment Complete","2017-05-01","","","2021-11-18","11/18/2021 Rcvd full roster from Humana listing provider as PAR and linked to group TIN/location effective 5/1/2017.  DCannon"]
["Jordan Elizabeth Friday, NP",1215575576,"46-0950925","TX","PE - Urgent Orthopedic Specialists, PLLC","IMS","Participating","Enrollment Complete","2019-09-01","1215575576","","2020-07-27","07/27/2020 - Rec'd roster response back from the payer regarding 7/15/2020 submission stating that all requested providers/service locations have been added to PriMed agreement - Stacey Hudak"]
["Jordan Elizabeth Friday, NP",1215575576,"46-0950925","TX","PE - Urgent Orthopedic Specialists, PLLC","Superior","Participating","Enrollment Complete","2020-08-01","1215575576","","2020-08-06","8/6/2020 - Rec'd an email from the payer stating this provider was added to their database EFF: 8-1-2020 after receiving/processing the July roster - Stacey Hudak"]
["Jordan Elizabeth Friday, NP",1215575576,"46-0950925","TX","PE - Urgent Orthopedic Specialists, PLLC","Amerigroup","Participating","Enrollment Complete","2020-04-15","","","2021-08-26","8/26/2021 Rcvd full roster from Joe Rodriguez at Amerigroup listing provider as PAR w/ group TIN and location effective 4/15/2020.  DCannon"]
["Jordan Elizabeth Friday, NP",1215575576,"46-0950925","TX","PE - Urgent Orthopedic Specialists, PLLC","Omni PPO","Participating","Enrollment Complete","2019-09-01","1215575576","","2020-07-27","IMS approved"]
["Jordan Elizabeth Friday, NP",1215575576,"46-0950925","TX","PE - Urgent Orthopedic Specialists, PLLC","United Health Care","Participating","Enrollment Complete","2021-12-15","7406945","","2022-04-05","4/5/2022 Per email from UHC at networkhelp@uhc.com provider is PAR and linked to group TIN/location effective 12/15/2021.  MPIN # 7406945.  DCannon"]
["Jordan Elizabeth Friday, NP",1215575576,"46-0950925","TX","PE - Urgent Orthopedic Specialists, PLLC","CAQH","Participating","CAQH Reattested","2023-10-06","14594087","","2023-06-05","6/5/2023- CAQH Reattested by Data Services - kavello"]
["Jordan Elizabeth Friday, NP",1215575576,"46-0950925","TX","","CAQH","Participating","CAQH Reattested","2023-10-06","14594087","","2023-06-05","6/5/2023- CAQH Reattested by Data Services - kavello"]
["Jordan Elizabeth Friday, NP",1215575576,"46-0950925","TX","PE - Urgent Orthopedic Specialists, PLLC","CAQH","Participating","CAQH Reattested","2023-10-06","14594087","","2023-10-06","10/06/2023 CAQH Reattested"]
["Jordan Elizabeth Friday, NP",1215575576,"46-0950925","TX","","CAQH","Participating","CAQH Reattested","2023-10-06","14594087","","2023-10-06","10/06/2023 CAQH Reattested"]
["Jordan Elizabeth Friday, NP",1215575576,"46-0950925","TX","PE - Urgent Orthopedic Specialists, PLLC","Triwest VA","In House Enrollment","In House Enrollment","","","","2021-01-13","1/6/2021 MQA Team is working with Representatives at BCBS-TX to ensure all providers are enrolled and loaded to participate with the VACCN network in a timely manner. However, we are currently awaiting a full roster of providers currently participating and will update all records accordingly upon receipt. Kfrazier"]
["Jordan Elizabeth Friday, NP",1215575576,"46-0950925","TX","PE - Urgent Orthopedic Specialists, PLLC","HealthSmart PPO","Participating","Enrollment Complete","2020-05-06","13727511","","2020-07-21","07/21/2020 - Rec'd emailed spreadsheet from the payer stating this provider/service location/TIN are EFF under WEST TEXAS PHYSICIANS ALLIANCE Delegated agreement - Stacey Hudak"]
["Jordan Elizabeth Friday, NP",1215575576,"46-0950925","TX","PE - Urgent Orthopedic Specialists, PLLC","First Health Coventry","Participating","Enrollment Complete","2020-12-01","","","2021-01-18","1/18/2021 - Per follow-up notes provider is now on file and participating under group, location and TIN effective 12/1/2020 PID # 3406971.  DCannon"]
["Jordan Elizabeth Friday, NP",1215575576,"46-0950925","TX","PE - Urgent Orthopedic Specialists, PLLC","Galaxy Health","Participating","Enrollment Complete","2019-09-01","1215575576","","2020-08-24","08/21/2020 - Rec'd email confirmation that this roster was processed and this provider was made effective with the requested eff date of 9-1-2019 - Stacey Hudak"]
["Jordan Elizabeth Friday, NP",1215575576,"46-0950925","TX","PE - Urgent Orthopedic Specialists, PLLC","Ambetter","Participating","Enrollment Complete","2022-06-01","","","2022-06-13","6/13/2022 Per roster received from Superior provider is PAR and linked to group delegation roster effective 6/1/2022."]
["Urgent Orthopedic Specialists, PLLC",1215271929,"46-0950925","TX","PE - Urgent Orthopedic Specialists, PLLC","Multiplan","Participating","Enrollment Complete","","","","2020-10-08","This group has a contract through multiplan tied to WEST TEXAS PHYSICAL ALLIANCE."]
["Urgent Orthopedic Specialists, PLLC",1215271929,"46-0950925","TX","PE - Urgent Orthopedic Specialists, PLLC","Tricare Prime","Panel Closed","Panel Closed","","","","2023-09-27","9/27/2023 Humana Military is currently not accepting requests to join the medical surgical network. We apologize for the inconvenience, but we hope you check back soon to see if we are accepting network providers."]
["Urgent Orthopedic Specialists, PLLC",1215271929,"46-0950925","TX","PE - Urgent Orthopedic Specialists, PLLC","Aetna","Participating","Enrollment Complete","","","","2020-10-08","This group has a DIRECT contract with Aetna."]
["Brandon H Rayne, PA",1912482209,"46-0950925","TX","PE - Urgent Orthopedic Specialists, PLLC","Liberty Mutual","Panel Closed","Panel Closed","","","","2023-08-28","08/28/2023. We appreciate your interest in joining the Coventry Network.  At this time, our panels are closed, and we are not accepting new applications.  Please check back routinely to stay apprised of our panel status. We will update this site when we are open for new applicants. Gallagher, Hartford, Liberty Mutual, Travelers and Zurich fall under Coventry. Jen Videan"]
["Brandon H Rayne, PA",1912482209,"46-0950925","TX","PE - Urgent Orthopedic Specialists, PLLC","Rail Road Medicare","Participating","Enrollment Complete","2021-11-04","P02689897","","2023-10-23","Confirmed RR MCR enrollment. MS"]
["Brandon H Rayne, PA",1912482209,"46-0950925","TX","PE - Urgent Orthopedic Specialists, PLLC","United Health Care","Participating","Enrollment Complete","2023-09-08","008166599","","2023-10-27","10/27/2023 Received email confirmation from Priscilla Albertine and UHC that effective date has been corrected to 9/8/2023.  DCannon"]
["Brandon H Rayne, PA",1912482209,"46-0950925","TX","PE - Urgent Orthopedic Specialists, PLLC","Medicaid","In Process","Pending Info/Document","","","","2023-11-16","We are unable to access Urgent Orthopedic Specialists via TMHP. Emailed MQA for username and password assistance. Jen Videan"]
["Brandon H Rayne, PA",1912482209,"46-0950925","TX","PE - Urgent Orthopedic Specialists, PLLC","TriCare Standard","Participating","Enrollment Complete","2022-12-20","","","2023-10-30","Was finally given access to the group TIN. This provider was already enrolled with the group. MS"]
["Brandon H Rayne, PA",1912482209,"46-0950925","TX","PE - Urgent Orthopedic Specialists, PLLC","CAQH","Participating","CAQH Reattested","2023-08-24","","","2023-08-24","8/24/2023- CAQH Sweep completed -kavello"]
["Brandon H Rayne, PA",1912482209,"46-0950925","TX","PE - Urgent Orthopedic Specialists, PLLC","Caprock (CapStar)","Participating","Enrollment Complete","2023-09-08","","","2023-09-28","9/27/2023 Rcvd email confirmation from Caprock that the September roster has been completed.  Provider is PAR and linked to group/location effective 9/8/2023.  DCannon"]
["Brandon H Rayne, PA",1912482209,"46-0950925","TX","PE - Urgent Orthopedic Specialists, PLLC","Medicare","Participating","Enrollment Complete","2021-11-04","1Z9417","","2023-10-12","Confirmed via PECOS the provider is enrolled and active under this TIN. MS"]
["Brandon H Rayne, PA",1912482209,"46-0950925","TX","PE - Urgent Orthopedic Specialists, PLLC","Texas Municipal League","Participating","Enrollment Complete","2023-11-03","","","2023-11-20","Enrollment through Alliance WC. Rcvd approval ltr. Effective 11/03/2023. See Alliance WC payor line. Jen Videan"]
["Brandon H Rayne, PA",1912482209,"46-0950925","TX","PE - Urgent Orthopedic Specialists, PLLC","Tricare Prime","Panel Closed","Panel Closed","","","","2023-09-01","Panel is closed for medical surgical providers per Tricare rep. MS"]
["Brandon H Rayne, PA",1912482209,"46-0950925","TX","PE - Urgent Orthopedic Specialists, PLLC","Amerigroup","In Process","Payor Follow Up","","","","2023-10-27","10/27/2023 Sent follow-up email to Amerigroup to check status of September delegated roster submission.  DCannon"]
["Brandon H Rayne, PA",1912482209,"46-0950925","TX","PE - Urgent Orthopedic Specialists, PLLC","Corvel Healthcare Corp.","In Process","Payor Follow Up","","","","2023-11-22","Per Karina Garcia at Corvel please allow up to 180 days for processing. Still within time frame...allow more time. Jen Videan"]
["Brandon H Rayne, PA",1912482209,"46-0950925","TX","PE - Urgent Orthopedic Specialists, PLLC","Broadspire Services Inc.","In Process","Pending Info/Document","","","","2023-11-21","Emailed Priscilla and Neerja for status of signed group agreements. Unable to move forward with individual provider until group agreement is in place.  Jen Videan"]
["Brandon H Rayne, PA",1912482209,"46-0950925","TX","PE - Urgent Orthopedic Specialists, PLLC","Galaxy Health","Participating","Enrollment Complete","2023-09-08","","","2023-10-11","10/11/2023 Per email received from Galaxy September delegated roster has been processed and provider is PAR and linked to group/location effective 9/8/2023.  DCannon"]
["Brandon H Rayne, PA",1912482209,"46-0950925","TX","PE - Urgent Orthopedic Specialists, PLLC","Cigna","Participating","Enrollment Complete","2023-11-08","4813053","","2023-11-14","Received confirmation email. MS"]
["Brandon H Rayne, PA",1912482209,"46-0950925","TX","PE - Urgent Orthopedic Specialists, PLLC","Sedgwick","In Process","Payor Follow Up","","","","2023-11-27","Per Sedgwick, your providers’ credentialing has been received & is currently under review at this time. Jen Videan"]
["Brandon H Rayne, PA",1912482209,"46-0950925","TX","PE - Urgent Orthopedic Specialists, PLLC","Wellmed","Participating","Enrollment Complete","2023-09-08","","","2023-09-28","9/28/2023 Rcvd email confirmation from UHC that September delegated roster has been completed.  Provider is PAR and linked to group/location effective 9/8/2023.  DCannon"]
["Brandon H Rayne, PA",1912482209,"46-0950925","TX","PE - Urgent Orthopedic Specialists, PLLC","Alliance WC","Participating","Enrollment Complete","2023-11-03","","","2023-11-20","Rcvd approval ltr. Provider effective 11/03/2023. Jen Videan"]
["Brandon H Rayne, PA",1912482209,"46-0950925","TX","PE - Urgent Orthopedic Specialists, PLLC","Omni PPO","Participating","Enrollment Complete","2023-09-08","","","2023-10-09","10/9/2023 Per email received from G. Aviles at IMS/OMNI September delegation roster has been completed.  Provider is PAR and linked to group/location effective 9/8/2023.  DCannon"]
["Brandon H Rayne, PA",1912482209,"46-0950925","TX","PE - Urgent Orthopedic Specialists, PLLC","Zurich","Panel Closed","Panel Closed","","","","2023-08-28","08/28/2023. We appreciate your interest in joining the Coventry Network.  At this time, our panels are closed, and we are not accepting new applications.  Please check back routinely to stay apprised of our panel status. We will update this site when we are open for new applicants. Gallagher, Hartford, Liberty Mutual, Travelers and Zurich fall under Coventry. Jen Videan"]
["Brandon H Rayne, PA",1912482209,"46-0950925","TX","PE - Urgent Orthopedic Specialists, PLLC","Travelers WC","Panel Closed","Panel Closed","","","","2023-08-28","08/28/2023. We appreciate your interest in joining the Coventry Network.  At this time, our panels are closed, and we are not accepting new applications.  Please check back routinely to stay apprised of our panel status. We will update this site when we are open for new applicants. Gallagher, Hartford, Liberty Mutual, Travelers and Zurich fall under Coventry. Jen Videan"]
["Brandon H Rayne, PA",1912482209,"46-0950925","TX","PE - Urgent Orthopedic Specialists, PLLC","IMS","Participating","Enrollment Complete","2023-09-08","","","2023-10-09","10/9/2023 Per email received from G. Aviles at IMS/OMNI September delegation roster has been completed.  Provider is PAR and linked to group/location effective 9/8/2023.  DCannon"]
["Brandon H Rayne, PA",1912482209,"46-0950925","TX","PE - Urgent Orthopedic Specialists, PLLC","Gallagher","Panel Closed","Panel Closed","","","","2023-08-28","08/28/2023. We appreciate your interest in joining the Coventry Network.  At this time, our panels are closed, and we are not accepting new applications.  Please check back routinely to stay apprised of our panel status. We will update this site when we are open for new applicants. Gallagher, Hartford, Liberty Mutual, Travelers and Zurich fall under Coventry. Jen Videan"]
["Brandon H Rayne, PA",1912482209,"46-0950925","TX","PE - Urgent Orthopedic Specialists, PLLC","USA PPO","In Process","Payor Follow Up","","","","2023-11-27","11/27/2023 Per USA PPO provider portal provider is still not loaded under new locations.  Will allow more time, check back in 2 weeks.  \nDCannon"]
["Brandon H Rayne, PA",1912482209,"46-0950925","TX","PE - Urgent Orthopedic Specialists, PLLC","Texas Mutual","Participating","Enrollment Complete","2023-11-01","","","2023-11-14","Approval Ltr rcvd. Provider effective 11/01/2023. Jen Videan"]
["Brandon H Rayne, PA",1912482209,"46-0950925","TX","PE - Urgent Orthopedic Specialists, PLLC","Ambetter","Participating","Enrollment Complete","2023-10-01","","","2023-10-16","10/16/2023 Rcvd email from Superior that provider is PAR and linked to group TIN/location effective 10/1/2023.  DCannon"]
["Brandon H Rayne, PA",1912482209,"46-0950925","TX","PE - Urgent Orthopedic Specialists, PLLC","Coventry Workers Comp","Panel Closed","Panel Closed","","","","2023-08-28","08/28/2023. We appreciate your interest in joining the Coventry Network.  At this time, our panels are closed, and we are not accepting new applications.  Please check back routinely to stay apprised of our panel status. We will update this site when we are open for new applicants. Gallagher, Hartford, Liberty Mutual, Travelers and Zurich fall under Coventry. Jen Videan"]
["Brandon H Rayne, PA",1912482209,"46-0950925","TX","PE - Urgent Orthopedic Specialists, PLLC","First Health Coventry","Participating","Enrollment Complete","2023-09-08","3746084","","2023-11-20","11/20/2023 S/W Sam of First Health @ 800-226-5116, per rep provider is showing participating and link under the Group and TIN with an Effective date 9/8/2023. Provider ID 3746084. Physical locations are on file. Call ref#:773026. - DCannon"]
["Brandon H Rayne, PA",1912482209,"46-0950925","TX","PE - Urgent Orthopedic Specialists, PLLC","Superior","Participating","Enrollment Complete","2023-10-01","","","2023-10-16","10/16/2023 Rcvd email from Superior that provider is PAR and linked to group TIN/location effective 10/1/2023.  DCannon"]
["Abbie Estes, PA",1952088411,"46-0950925","TX","PE - Urgent Orthopedic Specialists, PLLC","IMS","Participating","Enrollment Complete","2023-09-08","","","2023-10-09","10/9/2023 Per email received from G. Aviles at IMS/OMNI September delegation roster has been completed.  Provider is PAR and linked to group/location effective 9/8/2023.  DCannon"]
["Abbie Estes, PA",1952088411,"46-0950925","TX","PE - Urgent Orthopedic Specialists, PLLC","Superior","Participating","Enrollment Complete","2023-10-01","","","2023-10-16","10/16/2023 Rcvd email from Superior that provider is PAR and linked to group TIN/location effective 10/1/2023.  DCannon"]
["Abbie Estes, PA",1952088411,"46-0950925","TX","PE - Urgent Orthopedic Specialists, PLLC","Corvel Healthcare Corp.","In Process","Payor Follow Up","","","","2023-11-22","Per Karina Garcia at Corvel please allow up to 180 days for processing. Still within time frame...allow more time. Jen Videan"]
["Abbie Estes, PA",1952088411,"46-0950925","TX","PE - Urgent Orthopedic Specialists, PLLC","Rail Road Medicare","In Process","Payor Follow Up","","","","2023-11-01","RR MCR was unable to enroll at this time, I will resubmit the app within 30 days. MS"]
["Abbie Estes, PA",1952088411,"46-0950925","TX","PE - Urgent Orthopedic Specialists, PLLC","Coventry Workers Comp","Panel Closed","Panel Closed","","","","2023-08-08","08/08/2023. We appreciate your interest in joining the Coventry Network.  At this time, our panels are closed, and we are not accepting new applications.  Please check back routinely to stay apprised of our panel status. We will update this site when we are open for new applicants. Jen Videan"]
["Abbie Estes, PA",1952088411,"46-0950925","TX","PE - Urgent Orthopedic Specialists, PLLC","Zurich","Panel Closed","Panel Closed","","","","2023-08-16"," 08/16/2023 We appreciate your interest in joining the Coventry Network.  At this time, our panels are closed, and we are not accepting new applications.  Please check back routinely to stay apprised of our panel status. We will update this site when we are open for new applicants. Gallagher, Hartford, Liberty Mutual, Travelers and Zurich fall under Coventry. Jen Videan"]
["Abbie Estes, PA",1952088411,"46-0950925","TX","PE - Urgent Orthopedic Specialists, PLLC","Scott&White (First Care)","Participating","Enrollment Complete","2023-10-15","","","2023-10-12","10/12/2023 Per email received from Scott & White provider is PAR and linked to group TIN/locations effective 10/15/2023.  DCannon"]
["Abbie Estes, PA",1952088411,"46-0950925","TX","PE - Urgent Orthopedic Specialists, PLLC","Broadspire Services Inc.","In Process","Pending Info/Document","","","","2023-11-21","Emailed Priscilla and Neerja for status of signed group agreements. Unable to move forward with individual provider until group agreement is in place.  Jen Videan"]
["Abbie Estes, PA",1952088411,"46-0950925","TX","PE - Urgent Orthopedic Specialists, PLLC","Wellmed","Participating","Enrollment Complete","2023-09-08","","","2023-09-28","9/28/2023 Rcvd email confirmation from UHC that September delegated roster has been completed.  Provider is PAR and linked to group/location effective 9/8/2023.  DCannon"]
["Abbie Estes, PA",1952088411,"46-0950925","TX","PE - Urgent Orthopedic Specialists, PLLC","Medicare","Participating","Enrollment Complete","2023-07-10","6B7813","","2023-10-24","Received welcome letter. MS"]
["Abbie Estes, PA",1952088411,"46-0950925","TX","PE - Urgent Orthopedic Specialists, PLLC","Tricare Prime","Panel Closed","Panel Closed","","","","2023-08-17","Unfortunately, at this time the network is closed. Humana Military thanks you for your interest in joining the TRICARE East Region network to provide care for our beneficiaries. At this time, we are not currently expanding our network based on your specialty and location within the East Region. Please understand that every market is different based on the beneficiary population and the types of services needed in a particular location. Thank you again for your inquiry.   You can monitor the link below for network opening status.    Join the TRICARE East network (humanamilitary.com)   Humana Military is currently not accepting requests to join the medical surgical network. We apologize for the inconvenience, but we hope you check back soon to see if we are accepting network providers."]
["Abbie Estes, PA",1952088411,"46-0950925","TX","PE - Urgent Orthopedic Specialists, PLLC","Omni PPO","Participating","Enrollment Complete","2023-09-08","","","2023-10-09","10/9/2023 Per email received from G. Aviles at IMS/OMNI September delegation roster has been completed.  Provider is PAR and linked to group/location effective 9/8/2023.  DCannon"]
["Abbie Estes, PA",1952088411,"46-0950925","TX","PE - Urgent Orthopedic Specialists, PLLC","BCBSTX","In House Enrollment","In House Enrollment","","","","2023-08-15",""]
["Abbie Estes, PA",1952088411,"46-0950925","TX","PE - Urgent Orthopedic Specialists, PLLC","USA PPO","In Process","Payor Follow Up","","","","2023-11-27","11/27/2023 Per USA PPO provider portal provider is still not loaded under new locations.  Will allow more time, check back in 2 weeks.  \nDCannon"]
["Abbie Estes, PA",1952088411,"46-0950925","TX","PE - Urgent Orthopedic Specialists, PLLC","Aetna","Participating","Enrollment Complete","2023-09-18","","","2023-08-29","Received confirmation email. The email did not include providers PIN#, so I've reached back out to Aetna to get that. I will update Cactus once received. MS"]
["Abbie Estes, PA",1952088411,"46-0950925","TX","PE - Urgent Orthopedic Specialists, PLLC","Alliance WC","Participating","Enrollment Complete","2023-09-22","","","2023-09-27","Rcvd approval letter from Barry Harris at barry.harris@pswca.org. Provider effective 09/22/2023. Jen Videan"]
["Abbie Estes, PA",1952088411,"46-0950925","TX","PE - Urgent Orthopedic Specialists, PLLC","Amerigroup","In Process","Payor Follow Up","","","","2023-11-06","11/6/2023 Per email received from Cassandra Dunagon delegated roster for September is still in process.  DCannon"]
["Abbie Estes, PA",1952088411,"46-0950925","TX","PE - Urgent Orthopedic Specialists, PLLC","Liberty Mutual","Panel Closed","Panel Closed","","","","2023-08-08","08/08/2023. We appreciate your interest in joining the Coventry Network.  At this time, our panels are closed, and we are not accepting new applications.  Please check back routinely to stay apprised of our panel status. We will update this site when we are open for new applicants. Gallagher, Hartford, Liberty Mutual, Travelers and Zurich fall under Coventry. Jen Videan"]
["Abbie Estes, PA",1952088411,"46-0950925","TX","PE - Urgent Orthopedic Specialists, PLLC","Travelers WC","Panel Closed","Panel Closed","","","","2023-08-08","08/08/2023. We appreciate your interest in joining the Coventry Network.  At this time, our panels are closed, and we are not accepting new applications.  Please check back routinely to stay apprised of our panel status. We will update this site when we are open for new applicants. Gallagher, Hartford, Liberty Mutual, Travelers and Zurich fall under Coventry. Jen Videan"]
["Abbie Estes, PA",1952088411,"46-0950925","TX","PE - Urgent Orthopedic Specialists, PLLC","CAQH","Participating","CAQH Reattested","2023-08-11","","","2023-08-11","8/11/2023- CAQH Sweep completed - kavello"]
["Abbie Estes, PA",1952088411,"46-0950925","TX","PE - Urgent Orthopedic Specialists, PLLC","Caprock (CapStar)","Participating","Enrollment Complete","2023-09-08","","","2023-09-27","9/27/2023 Rcvd email confirmation from Caprock that the September roster has been completed.  Provider is PAR and linked to group/location effective 9/8/2023.  DCannon"]
["Abbie Estes, PA",1952088411,"46-0950925","TX","PE - Urgent Orthopedic Specialists, PLLC","Medicaid","In Process","Pending Info/Document","","","","2023-11-16","We are unable to access Urgent Orthopedic Specialists via TMHP. Emailed MQA for username and password assistance. Jen Videan"]
["Abbie Estes, PA",1952088411,"46-0950925","TX","PE - Urgent Orthopedic Specialists, PLLC","Ambetter","Participating","Enrollment Complete","2023-10-01","","","2023-10-16","10/16/2023 Rcvd email from Superior that provider is PAR and linked to group TIN/location effective 10/1/2023.  DCannon"]
["Abbie Estes, PA",1952088411,"46-0950925","TX","PE - Urgent Orthopedic Specialists, PLLC","TriCare Standard","In Process","Application Submitted","","","","2023-11-05","Application submitted via online portal. MS"]
["Abbie Estes, PA",1952088411,"46-0950925","TX","PE - Urgent Orthopedic Specialists, PLLC","Gallagher","Panel Closed","Panel Closed","","","","2023-08-08","08/08/2023. We appreciate your interest in joining the Coventry Network.  At this time, our panels are closed, and we are not accepting new applications.  Please check back routinely to stay apprised of our panel status. We will update this site when we are open for new applicants. Gallagher, Hartford, Liberty Mutual, Travelers and Zurich fall under Coventry. Jen Videan"]
["Abbie Estes, PA",1952088411,"46-0950925","TX","PE - Urgent Orthopedic Specialists, PLLC","Texas Municipal League","Participating","Enrollment Complete","","","","2023-11-20","participating, please see Alliance WC for current notes. MS"]
["Abbie Estes, PA",1952088411,"46-0950925","TX","PE - Urgent Orthopedic Specialists, PLLC","Boon Chapman","Enrollment Stopped","Enrollment Stopped","","","","2023-10-20","10/20/2023 Must be enrolled in Multiplan in order to be enrolled in Boon Chapman.  Multiplan was not chosen as a payor to enroll with on the payor list submitted.  DCannon"]
["Abbie Estes, PA",1952088411,"46-0950925","TX","PE - Urgent Orthopedic Specialists, PLLC","Texas Mutual","Participating","Enrollment Complete","2023-09-01","","","2023-09-05","Rcvd approval letter from Dee Dee Johnson at Texas Mutual. Effective 09/01/2023. Jen Videan"]
["Abbie Estes, PA",1952088411,"46-0950925","TX","PE - Urgent Orthopedic Specialists, PLLC","First Health Coventry","Participating","Enrollment Complete","2023-09-02","3746308","","2023-11-20","11/20/2023 S/W James of First Health @ 800-226-5116, per rep provider is showing participating and link under the Group and TIN with an Effective date 9/8/2023. Provider ID 3746308. Physical locations are on file. Call ref#:773110. - DCannon"]
["Abbie Estes, PA",1952088411,"46-0950925","TX","PE - Urgent Orthopedic Specialists, PLLC","Sedgwick","In Process","Payor Follow Up","","","","2023-11-27","Per Sedgwick, your providers’ credentialing has been received & is currently under review at this time. Jen Videan"]
["Abbie Estes, PA",1952088411,"46-0950925","TX","PE - Urgent Orthopedic Specialists, PLLC","United Health Care","Participating","Enrollment Complete","2023-09-08","008868311","","2023-10-27","10/27/2023 Received email confirmation from Priscilla Albertine and UHC that effective date has been corrected to 9/8/2023.  DCannon"]
["Abbie Estes, PA",1952088411,"46-0950925","TX","PE - Urgent Orthopedic Specialists, PLLC","Galaxy Health","Participating","Enrollment Complete","2023-09-08","","","2023-10-11","10/11/2023 Per email received from Galaxy September delegated roster has been processed and provider is PAR and linked to group/location effective 9/8/2023.  DCannon"]
["Donald W Floyd, MD",1942216122,"46-0950925","TX","PE - Urgent Orthopedic Specialists, PLLC","Omni PPO","Participating","Enrollment Complete","2012-10-01","1942216122","","2020-06-25",""]
["Donald W Floyd, MD",1942216122,"46-0950925","TX","PE - Urgent Orthopedic Specialists, PLLC","First Health Coventry","Participating","Enrollment Complete","2013-09-01","1907709","","2020-03-20","03/20/2020 - Rec'd email from the payer stating this provider is EFF under PID# 1907709 - Stacey Hudak"]
["Donald W Floyd, MD",1942216122,"46-0950925","TX","PE - Urgent Orthopedic Specialists, PLLC","USA PPO","Participating","Enrollment Complete","2013-11-01","1942216122","460950925","2020-08-19","Confirmed provider is participating with PPO and H&W networks (list of networks attached). Kimberly Frazier"]
["Donald W Floyd, MD",1942216122,"46-0950925","TX","PE - Urgent Orthopedic Specialists, PLLC","Scott&White (First Care)","Participating","Enrollment Complete","2019-03-20","1942216122","","2020-08-19","08/19/2020 - Rec'd spreadsheet confirmation from the payer stating this provider is linked to the PRIMED DELEGATED CONTRACT with this TIN/Service Location and networked with the following: \nCHIP\nFirstCare Select Benefit Network\nHMO Enhanced Benefit Network\nMedicaid (FC)\nMedicare (FC)\nPPO Limited Benefit Network\n- Stacey Hudak"]
["Donald W Floyd, MD",1942216122,"46-0950925","TX","PE - Urgent Orthopedic Specialists, PLLC","United Health Care","Participating","Enrollment Complete","2016-12-26","1942216122","","2020-07-30","7/30/2020 - moved to completed status after reviewing follow up complete note - Stacey Hudak"]
["Donald W Floyd, MD",1942216122,"46-0950925","TX","PE - Urgent Orthopedic Specialists, PLLC","CAQH","Participating","CAQH Reattested","2023-10-27","","","2023-10-27","10/27/2023 CAQH sweep"]
["Donald W Floyd, MD",1942216122,"46-0950925","TX","PE - Urgent Orthopedic Specialists, PLLC","Aetna","Participating","Enrollment Complete","2013-12-23","1942216122","","2020-04-23","04/23/2020--S/W Kim of Aetna @ 800-353-1232. Per rep the Provider is on file, linked & participating under the GRP & TIN effective 4/1/2013. Physical Location is on file. Provider ID #4403094. Call ref # 5234162545\ncopied note from spreadsheet-tisha rader"]
["Donald W Floyd, MD",1942216122,"46-0950925","TX","PE - Urgent Orthopedic Specialists, PLLC","Galaxy Health","Participating","Enrollment Complete","2013-11-01","1942216122","","2020-07-17","7/17/2020- Received a spreadsheet from the payer stating this provider is effective as of  11/1/2013. – Elonah Grace B. Gelig"]
["Donald W Floyd, MD",1942216122,"46-0950925","TX","PE - Urgent Orthopedic Specialists, PLLC","Ambetter","Participating","Enrollment Complete","2022-06-01","","","2022-06-13","6/13/2022 Per roster received from Superior provider is PAR and linked to group delegation roster effective 6/1/2022."]
["Donald W Floyd, MD",1942216122,"46-0950925","TX","PE - Urgent Orthopedic Specialists, PLLC","Wellcare","Participating","Enrollment Complete","2021-11-01","","","2022-11-15","11/15/2022 Per roster received from Wellcare provider is PAR and linked to group TIN/location effective 11/1/2021.  DCannon"]
["Donald W Floyd, MD",1942216122,"46-0950925","TX","PE - Urgent Orthopedic Specialists, PLLC","Amerigroup","Participating","Enrollment Complete","2013-12-23","02033035","","2021-02-13","2/13/2021 - Rcvd complete roster from Amerigroup provider is participating and linked to TIN and location for the following plans STAR - eff 7/2/2014; Medicare - eff 7/2/2014; C-SNP - eff 1/1/2017; Other - eff 1/1/2021, Plus - eff 7/2/2014, Star_Kids - eff 11/1/2016.  DCannon"]
["Donald W Floyd, MD",1942216122,"46-0950925","TX","PE - Urgent Orthopedic Specialists, PLLC","Wellmed","Participating","Enrollment Complete","2022-01-01","","","2023-03-23","3/23/2023 Rcvd roster from UHC w/ all Wellmed participating providers.  Provider is PAR effective 1/1/2022.  DCannon"]
["Donald W Floyd, MD",1942216122,"46-0950925","TX","PE - Urgent Orthopedic Specialists, PLLC","Caprock (CapStar)","Participating","Enrollment Complete","2012-10-01","1942216122","","2020-06-02","06/02/2020 - rec'd spreadsheet back from the payer Mary Rodriguez <MRodriguez@caprockhp.com> confirming this provider/service location is EFF with this payer - Stacey Hudak"]
["Donald W Floyd, MD",1942216122,"46-0950925","TX","PE - Urgent Orthopedic Specialists, PLLC","Triwest VA","Participating","Enrollment Complete","2022-08-01","","","2022-11-11","11/11/22 Provider confirmed effective from 8/1/22 by Scarlett Abigail on 10/17/22"]
["Donald W Floyd, MD",1942216122,"46-0950925","TX","PE - Urgent Orthopedic Specialists, PLLC","HealthSmart PPO","Participating","Enrollment Complete","2019-07-18","1942216122","","2020-06-10","06/10/2020 - Rec'd email from the payer stating this provider is EFF - Stacey Hudak"]
["Donald W Floyd, MD",1942216122,"46-0950925","TX","PE - Urgent Orthopedic Specialists, PLLC","Humana","Participating","Enrollment Complete","2017-05-01","","","2021-11-18","11/18/2021 Rcvd full roster from Humana listing provider as PAR and linked to group TIN/location effective 5/1/2017.  DCannon"]
["Donald W Floyd, MD",1942216122,"46-0950925","TX","PE - Urgent Orthopedic Specialists, PLLC","Superior","Participating","Enrollment Complete","2016-11-01","1942216122","","2020-07-14","07/14/2020 - Rec'd email from the payer stating this provider is EFF under PRIMED DELEGATED agreement - Stacey Hudak"]
["Donald W Floyd, MD",1942216122,"46-0950925","TX","PE - Urgent Orthopedic Specialists, PLLC","IMS","Participating","Enrollment Complete","2012-10-01","1942216122","","2020-06-22","06/22/2020- Rec'd email from the payer confirming this provider is PAR with this group/service location - Stacey Hudak"]
["Stephen P Dodd, PA-C",1598976011,"46-0950925","TX","PE - Urgent Orthopedic Specialists, PLLC","TriCare Standard","Participating","Enrollment Complete","2013-11-01","1598976011","","2020-09-04","09/04/2020 - Rec'd access to this providers profile through the payer site and was able to confirm that this provider is linked to this TIN as non network under the proper service location - Stacey Hudak"]
["Stephen P Dodd, PA-C",1598976011,"46-0950925","TX","PE - Urgent Orthopedic Specialists, PLLC","Omni PPO","Participating","Enrollment Complete","2017-05-01","1598976011","","2020-06-25",""]
["Stephen P Dodd, PA-C",1598976011,"46-0950925","TX","PE - Urgent Orthopedic Specialists, PLLC","Medicare","In House Enrollment","In House Enrollment","2013-10-01","322577YN4B","","2021-04-27","4/27/2021 Received provider's approval notice with assigned PTAN 322577YN4B and effective date of 10/1/2013. KFrazier"]
["Stephen P Dodd, PA-C",1598976011,"46-0950925","TX","PE - Urgent Orthopedic Specialists, PLLC","IMS","Participating","Enrollment Complete","2017-05-01","1598976011","","2020-06-22","06/22/2020- Rec'd email from the payer confirming this provider is PAR with this group/service location - Stacey Hudak"]
["Stephen P Dodd, PA-C",1598976011,"46-0950925","TX","PE - Urgent Orthopedic Specialists, PLLC","Wellmed","Participating","Enrollment Complete","2022-01-01","","","2023-03-23","3/23/2023 Rcvd roster from UHC w/ all Wellmed participating providers.  Provider is PAR effective 1/1/2022.  DCannon"]
["Stephen P Dodd, PA-C",1598976011,"46-0950925","TX","PE - Urgent Orthopedic Specialists, PLLC","Cigna","Participating","Enrollment Complete","2013-11-01","1598976011","","2020-04-22","04/22/2020--S/W Rica of Cigna @ 8008824462, provider NPI# is on file for the provider and is participating effective 11/01/2013 under the group and TIN#. Physical location is on file. Call ref# Rica04202020.\ncopied note from spreadsheet-tisha rader"]
["Stephen P Dodd, PA-C",1598976011,"46-0950925","TX","PE - Urgent Orthopedic Specialists, PLLC","Triwest VA","In House Enrollment","In House Enrollment","","","","2021-01-13","1/6/2021 MQA Team is working with Representatives at BCBS-TX to ensure all providers are enrolled and loaded to participate with the VACCN network in a timely manner. However, we are currently awaiting a full roster of providers currently participating and will update all records accordingly upon receipt. Kfrazier"]
["Stephen P Dodd, PA-C",1598976011,"46-0950925","TX","PE - Urgent Orthopedic Specialists, PLLC","Gallagher","Participating","Enrollment Complete","2014-07-01","1112323","","2020-08-17","Provider is particpating with WC Network effective 7/1/2014, which is under the Aetna delegation. Kim Frazier"]
["Stephen P Dodd, PA-C",1598976011,"46-0950925","TX","PE - Urgent Orthopedic Specialists, PLLC","Texas Mutual","Participating","Enrollment Complete","2020-06-01","","","2020-10-06","10/6/2020 Received recredentialing approval notice and forwarded to Client for their files. Kimberly Frazier"]
["Stephen P Dodd, PA-C",1598976011,"46-0950925","TX","PE - Urgent Orthopedic Specialists, PLLC","Sedgwick","Participating","Enrollment Complete","2014-07-29","","","2021-05-06","5/6/2021  In following up with USAMCO (800-872-3860) I was told that you can confirm participating via the USA MCO website  https://providersearch.usamco.com/hwprovsearch.  Provider is PAR and linked to location/TIN effective 7/29/2014.  DCannon"]
["Stephen P Dodd, PA-C",1598976011,"46-0950925","TX","PE - Urgent Orthopedic Specialists, PLLC","CAQH","Participating","CAQH Reattested","2023-10-04","","","2023-10-04","10/04/2023 - Updated Primary Mail, Cred contact, License, Bord and Re-attested - Mkhan"]
["Stephen P Dodd, PA-C",1598976011,"46-0950925","TX","PE - Urgent Orthopedic Specialists, PLLC","Galaxy Health","Participating","Enrollment Complete","2014-07-29","1598976011","","2020-07-17","7/17/2020 - Received a spreadsheet from the payer stating this provider is effective as of 7/29/2014 - Jesriel Segovia"]
["Stephen P Dodd, PA-C",1598976011,"46-0950925","TX","PE - Urgent Orthopedic Specialists, PLLC","Liberty Mutual","Participating","Enrollment Complete","2018-10-01","","","2021-01-25","1/25/2021 - Rcvd email from payer confirming participating under tax ID and at location effectice 10/1/2018.  DCannon"]
["Stephen P Dodd, PA-C",1598976011,"46-0950925","TX","PE - Urgent Orthopedic Specialists, PLLC","Caprock (CapStar)","Participating","Enrollment Complete","2014-08-01","1598976011","","2020-06-02","06/02/2020 - rec'd spreadsheet back from the payer Mary Rodriguez <MRodriguez@caprockhp.com> confirming this provider/service location is EFF with this payer - Stacey Hudak"]
["Stephen P Dodd, PA-C",1598976011,"46-0950925","TX","PE - Urgent Orthopedic Specialists, PLLC","Zurich","Participating","Enrollment Complete","2015-09-12","","","2020-09-10","Confirmed provider is participating with Coventry Integrated Network under delegation with location on file. Kimberly Frazier"]
["Stephen P Dodd, PA-C",1598976011,"46-0950925","TX","PE - Urgent Orthopedic Specialists, PLLC","Amerigroup","Participating","Enrollment Complete","2015-10-07","02821997","","2021-02-13","2/13/2021 - Rcvd complete roster from Amerigroup provider is participating and linked to TIN and location for the following plans STAR - eff 10/7/2015; CHIP - eff 10/7/2015; CHIP-PERINATE - eff 10/7/2015, PLUS - eff 10/7/2015, Star_Kids - eff 11/1/2016.  DCannon"]
["Stephen P Dodd, PA-C",1598976011,"46-0950925","TX","PE - Urgent Orthopedic Specialists, PLLC","USA PPO","Participating","Enrollment Complete","2014-07-29","1598976011","46-0950925","2020-08-26","Confirmed provider is participating with PPO and H&W networks (list of networks attached). Kimberly Frazier"]
["Stephen P Dodd, PA-C",1598976011,"46-0950925","TX","PE - Urgent Orthopedic Specialists, PLLC","Superior","Participating","Enrollment Complete","2017-01-01","1598976011","","2020-07-14","07/14/2020 - Rec'd email from the payer stating this provider is EFF with this TIN under PRIMED DELEGATED agreement - Stacey Hudak"]
["Stephen P Dodd, PA-C",1598976011,"46-0950925","TX","PE - Urgent Orthopedic Specialists, PLLC","HealthSmart PPO","Participating","Enrollment Complete","2016-04-25","10152248","","2020-07-24","07/24/2020 - Found this provider/service location/TIN are effective on a spreadsheet provided by the payer. Provider is linked to PRIMED ROSTER - Stacey Hudak"]
["Stephen P Dodd, PA-C",1598976011,"46-0950925","TX","PE - Urgent Orthopedic Specialists, PLLC","United Health Care","Participating","Enrollment Complete","2020-01-01","1598976011","","2020-07-29","7-29-2020 - moved to completed status after reviewing follow up complete status - Stacey Hudak"]
["Stephen P Dodd, PA-C",1598976011,"46-0950925","TX","PE - Urgent Orthopedic Specialists, PLLC","Humana","Participating","Enrollment Complete","2017-05-01","1598976011","","2020-08-31","08/31/2020 - moved to completed status afer reviewing follow up complete note - under PRIMED - Stacey Hudak"]
["Stephen P Dodd, PA-C",1598976011,"46-0950925","TX","PE - Urgent Orthopedic Specialists, PLLC","Multiplan","Participating","Enrollment Complete","2015-04-16","1598976011","West Texas Physicians Alliance","2020-09-08","09/08/2020 - Rec'd response from the payer stating \"\n\nNetwork: Beech St, MPI, & PHCS\nNetwork Participation effective: Please see below\nContract Source Group contract through: Please see below\n\nStephen P Dodd, PA-C NPI: 1598976011\n5026 – West Texas Physicians Alliance – Beech St Eff Date 09/01/2009\n23655 – West Texas Physicians Alliance – MPI Eff Date 04/16/2015\n52669 – West Texas Physicians Alliance – PHCS Eff Date 01/21/2015\nAlso has an individual agreement under that TIN – Eff Date 08/07/2014\"\n\n- Stacey Hudak"]
["Stephen P Dodd, PA-C",1598976011,"46-0950925","TX","PE - Urgent Orthopedic Specialists, PLLC","Aetna","Participating","Enrollment Complete","2013-04-01","1598976011","","2020-04-15","04/15/2020 - Rec'd message from the follow up \"S/W Anna of Aetna @ 8003531232, provider NPI is on file for the provider and participating effective 04/01/13 under thre group and TIN with Direct contract. Physical location is on file. Call ref# 5225879870. \" - stacey Hudak"]
["Stephen P Dodd, PA-C",1598976011,"46-0950925","TX","PE - Urgent Orthopedic Specialists, PLLC","First Health Coventry","Participating","Enrollment Complete","2013-11-01","1112323","","2020-03-20","03/20/2020 - Rec'd email from the payer confirming that this provider is EFF under PID# 1112323 - Stacey Hudak"]
["Stephen P Dodd, PA-C",1598976011,"46-0950925","TX","PE - Urgent Orthopedic Specialists, PLLC","Rail Road Medicare","Participating","Enrollment Complete","2013-10-01","P01290248","DU2795","2021-08-03","8/3/2021 Rcvd RR Medicare PTAN instantly after applying via RR Medicare website.  PTAN # P01290248 effective 10/1/2013.  DCannon"]
["Stephen P Dodd, PA-C",1598976011,"46-0950925","TX","PE - Urgent Orthopedic Specialists, PLLC","Ambetter","Participating","Enrollment Complete","2022-06-01","","","2022-06-13","6/13/2022 Per roster received from Superior provider is PAR and linked to group delegation roster effective 6/1/2022."]
["Bhuvana Balasekaran, MD",1770564080,"46-1602172","TX","PE - Bhuvana Balasekaran, MD PA","Caprock (CapStar)","Participating","Enrollment Complete","2013-01-24","1770564080","","2020-06-02","06/02/2020 - rec'd spreadsheet back from the payer Mary Rodriguez <MRodriguez@caprockhp.com> confirming this provider/service location is EFF with this payer - Stacey Hudak"]
["Bhuvana Balasekaran, MD",1770564080,"46-1602172","TX","PE - Bhuvana Balasekaran, MD PA","TriCare Standard","Participating","Enrollment Complete","2013-08-30","1770564080","","2020-09-09","09/09/2020 - reviewed previous note and moved to completed status - Stacey Hudak"]
["Bhuvana Balasekaran, MD",1770564080,"46-1602172","TX","PE - Bhuvana Balasekaran, MD PA","Wellmed","Participating","Enrollment Complete","2022-01-01","","","2023-03-23","3/23/2023 Rcvd roster from UHC w/ all Wellmed participating providers.  Provider is PAR effective 1/1/2022.  DCannon"]
["Bhuvana Balasekaran, MD",1770564080,"46-1602172","TX","PE - Bhuvana Balasekaran, MD PA","Medicare","Participating","Enrollment Complete","2013-04-01","279443YQ43","279442","2020-04-20","04/20/2020 - Rec'd EFF medicare information through PECOS. Provider is linked to group TIN - Stacey Hudak"]
["Bhuvana Balasekaran, MD",1770564080,"46-1602172","TX","PE - Bhuvana Balasekaran, MD PA","Boon Chapman","Participating","Enrollment Complete","2008-12-10","12705210","","2022-02-24","2/224/2022 - Per follow-up note on 2/18/2022 - Provider NPI# is on file for the provider and participating effective 12/10/2008 under the group and TIN#. Provider ID#  12705210. Physical location is on file. Call ref# 7919804 -Marielle Pacheco"]
["Bhuvana Balasekaran, MD",1770564080,"46-1602172","TX","PE - Bhuvana Balasekaran, MD PA","HealthSmart PPO","Participating","Enrollment Complete","2011-02-01","1770564080","","2020-06-04","06/04/2020 - Rec'd email from the payer stating this provider is EFF - Stacey Hudak"]
["Bhuvana Balasekaran, MD",1770564080,"46-1602172","TX","PE - Bhuvana Balasekaran, MD PA","IMS","Participating","Enrollment Complete","2013-01-24","1770564080","","2020-06-22","06/22/2020- Rec'd email from the payer confirming this provider is PAR with this group/service location - Stacey Hudak"]
["Bhuvana Balasekaran, MD",1770564080,"46-1602172","TX","PE - Bhuvana Balasekaran, MD PA","Aetna","Participating","Enrollment Complete","2005-07-01","1770564080","","2020-04-23","4/23/2020--S/W Ed of Aetna @ 8003531232, provider NPI is on file for the provider and participating effective 07/01/05 under the group and TIN. Delegated with Primed Health Network. Physical location is on file. Provider ID# 7329328. Call ref# 5235876865. \ncopied note from spreadsheet-tisha rader"]
["Bhuvana Balasekaran, MD",1770564080,"46-1602172","TX","PE - Bhuvana Balasekaran, MD PA","United Health Care","Participating","Enrollment Complete","2017-11-30","2153983","","2020-07-30","7/30/2020 - moved to completed status after reviewing follow up complete note - Stacey Hudak"]
["Bhuvana Balasekaran, MD",1770564080,"46-1602172","TX","PE - Bhuvana Balasekaran, MD PA","Cigna","Participating","Enrollment Complete","2013-03-01","1770564080","","2020-04-21","04/21/2020--S/W Francis of Cigna @ 8008824462, provider NPI is on file for the provider and participating effective 03/01/13 under the group and TIN with direct contract. Physical location is on file. Provider ID#6815546. Call ref# FRANCIS0421.\n--copied note from spreadsheet-tisha rader"]
["Bhuvana Balasekaran, MD",1770564080,"46-1602172","TX","PE - Bhuvana Balasekaran, MD PA","CAQH","In House Enrollment","In House Enrollment","2020-09-01","10572925","","2022-12-01","12/1/2022 Per email received from Priscilla Albertine at MQA, CAQH maintenance is maintained by the provider's office manager.  DCannon"]
["Bhuvana Balasekaran, MD",1770564080,"46-1602172","TX","PE - Bhuvana Balasekaran, MD PA","Rail Road Medicare","Participating","Enrollment Complete","2013-04-01"," P01188488"," DT8096","2020-04-22","04/22/2020 - Verified proivder is EFF thorugh payer payer site - Stacey Hudak"]
["Bhuvana Balasekaran, MD",1770564080,"46-1602172","TX","PE - Bhuvana Balasekaran, MD PA","Multiplan","Participating","Enrollment Complete","2008-12-10","12705210","","2022-02-24","2/24/2022 Per follow-up note on 2/18/2022 -   Provider NPI# is on file for the provider and participating effective 12/10/2008 under the group and TIN#. Provider ID#  12705210. Physical location is on file. Call ref# 7919804 -DCannon"]
["Bhuvana Balasekaran, MD",1770564080,"46-1602172","TX","PE - Bhuvana Balasekaran, MD PA","Humana","Participating","Enrollment Complete","2021-09-01","","","2021-11-18","11/18/2021 Rcvd full roster from Humana listing provider as PAR and linked to group TIN/location effective 9/1/2021.  DCannon"]
["Bethany M Wood, PA",1225283963,"46-3131679","TX","PE - Midland Texas Orthopedic Group Inc","USA PPO","Participating","Enrollment Complete","2023-05-01","","","2023-05-19","Checked enrollment status via https://providersearch.usamco.com/wintprovsearch . Provider is enrolled with Group Health and Wellness PPO. MS"]
["Bethany M Wood, PA",1225283963,"46-3131679","TX","PE - Midland Texas Orthopedic Group Inc","Texas Municipal League","Participating","Enrollment Complete","2023-05-19","","","2023-07-18","Michelle Killough confirmed provider is effective 5/19/2023. MS See Alliance for enrollment note updates."]
["Bethany M Wood, PA",1225283963,"46-3131679","TX","PE - Midland Texas Orthopedic Group Inc","Medicaid","Participating","Enrollment Complete","2023-05-01","","","2023-08-02","Rcvd approval letter from TMHP. Jen Videan"]
["Bethany M Wood, PA",1225283963,"46-3131679","TX","PE - Midland Texas Orthopedic Group Inc","Sedgwick","In Process","Pending Contracting","","","","2023-11-20","Emailed ProviderData@Careworks.com to see if group has a direct contract with Sedgwick. Jen Videan"]
["Bethany M Wood, PA",1225283963,"46-3131679","TX","PE - Midland Texas Orthopedic Group Inc","Amerigroup","Participating","Enrollment Complete","2023-04-14","","","2023-10-19","10/19/2023 Per email received from Jessica Bess at  Multiplan provider is PAR with Amerigroup and linked to group TIN/locations thru Multiplan enrollment effective 4/14/2023.  DCannon"]
["Bethany M Wood, PA",1225283963,"46-3131679","TX","PE - Midland Texas Orthopedic Group Inc","Omni PPO","Participating","Enrollment Complete","2023-04-14","","","2023-07-26","7/26/2023 Per email received from IMS/OMNI February delegated roster has been processed and provider is PAR and linked to group effective 4/14/2023.  DCannon"]
["Bethany M Wood, PA",1225283963,"46-3131679","TX","PE - Midland Texas Orthopedic Group Inc","Corvel Healthcare Corp.","Participating","Enrollment Complete","2023-04-14","","","2023-07-12","Received confirmation email from rep. MS"]
["Bethany M Wood, PA",1225283963,"46-3131679","TX","PE - Midland Texas Orthopedic Group Inc","Galaxy Health","Participating","Enrollment Complete","2023-04-14","","","2023-07-20","7/20/2023 Per email received from Galaxy April  delegated roster has been processed and provider is PAR and linked to group effective 4/14/2023.  DCannon"]
["Bethany M Wood, PA",1225283963,"46-3131679","TX","PE - Midland Texas Orthopedic Group Inc","HealthSmart PPO","In Process","Payor Follow Up","","","","2023-11-14","11/14/2023 Per Healthsmart provider portal provider is still not loaded under group TIN.  Per phone conversation with Lee Kinard at Healthsmart provider portal should be updated  by 11/27/2023.  Will allow more time, check back in 2 weeks.   DCannon"]
["Bethany M Wood, PA",1225283963,"46-3131679","TX","PE - Midland Texas Orthopedic Group Inc","Zurich","Panel Closed","Panel Closed","","","","2023-04-26","4/26/2023 Per the Coventry website - We appreciate your interest in joining the Coventry Network.  At this time, our panels are closed, and we are not accepting new applications.  Please check back routinely to stay apprised of our panel status. We will update this site when we are open for new applicants.   The following payers fall under Coventry - Travelers, Liberty Health, Hartford, WorkWell-TX, Zurich.    DCannon"]
["Bethany M Wood, PA",1225283963,"46-3131679","TX","PE - Midland Texas Orthopedic Group Inc","Aetna","Participating","Enrollment Complete","2023-04-14","","","2023-05-31","05.31.2023 S/W Anthony of Aetna @ 1-800-353-1232. Per rep, provider is showing participating and link under the Group and TIN with an Effective date 04/14/2023. Provider ID 9850849, Payer ID 60054 and Recredentialing date is not required due to provider is delegated. Service location is on file. Call ref#:6149186847. - Danico Gabriel Melendres"]
["Bethany M Wood, PA",1225283963,"46-3131679","TX","PE - Midland Texas Orthopedic Group Inc","Superior","Participating","Enrollment Complete","2023-05-01","","","2023-07-25","7/25/2023 Rcvd confirmation email from Superior that April delegation roster has been processed and provider has been loaded to delegation roster and PAR w/ group effective 5/1/2023.  DCannon"]
["Bethany M Wood, PA",1225283963,"46-3131679","TX","PE - Midland Texas Orthopedic Group Inc","Broadspire Services Inc.","In Process","Pending Info/Document","","","","2023-11-21","Emailed Priscilla and Neerja for status of signed group agreements. Unable to move forward with individual provider until group agreement is in place.  Jen Videan"]
["Bethany M Wood, PA",1225283963,"46-3131679","TX","PE - Midland Texas Orthopedic Group Inc","Liberty Mutual","Panel Closed","Panel Closed","","","","2023-04-26","4/26/2023 Per the Coventry website - We appreciate your interest in joining the Coventry Network.  At this time, our panels are closed, and we are not accepting new applications.  Please check back routinely to stay apprised of our panel status. We will update this site when we are open for new applicants.   The following payers fall under Coventry - Travelers, Liberty Health, Hartford, , Zurich.    DCannon"]
["Bethany M Wood, PA",1225283963,"46-3131679","TX","PE - Midland Texas Orthopedic Group Inc","Wellmed","Thru Other Payor","Pending Other Enrollment","","","","2023-11-17","11/17/2023 Pending UHC enrollment.  DCannon"]
["Bethany M Wood, PA",1225283963,"46-3131679","TX","PE - Midland Texas Orthopedic Group Inc","Coventry Workers Comp","Panel Closed","Panel Closed","","","","2023-04-26","4/26/2023 Per the Coventry website - We appreciate your interest in joining the Coventry Network.  At this time, our panels are closed, and we are not accepting new applications.  Please check back routinely to stay apprised of our panel status. We will update this site when we are open for new applicants.   The following payers fall under Coventry - Travelers, Liberty Health, Hartford, WorkWell-TX, Zurich.    DCannon"]
["Bethany M Wood, PA",1225283963,"46-3131679","TX","PE - Midland Texas Orthopedic Group Inc","TriCare Standard","Participating","Enrollment Complete","2023-04-25","","","2023-10-19","Received enrollment confirmation. MS"]
["Bethany M Wood, PA",1225283963,"46-3131679","TX","PE - Midland Texas Orthopedic Group Inc","Rail Road Medicare","Participating","Enrollment Complete","2023-05-01","","","2023-08-21","Received confirmation. MS"]
["Bethany M Wood, PA",1225283963,"46-3131679","TX","PE - Midland Texas Orthopedic Group Inc","Alliance WC","Participating","Enrollment Complete","2023-05-19","","","2023-05-22","Michelle Killough confirmed provider is effective 5/19/2023. MS"]
["Bethany M Wood, PA",1225283963,"46-3131679","TX","PE - Midland Texas Orthopedic Group Inc","Medicare","Participating","Enrollment Complete","2023-05-01","2T0202","","2023-05-10","5/10/2023 Rcvd Medicare approval letter.  PTAN # 2T0202 - effective 5/1/2023.   DCannon"]
["Bethany M Wood, PA",1225283963,"46-3131679","TX","PE - Midland Texas Orthopedic Group Inc","Cigna","Participating","Enrollment Complete","2023-07-01","","","2023-09-15","Received confirmation email with effective date. MS"]
["Bethany M Wood, PA",1225283963,"46-3131679","TX","PE - Midland Texas Orthopedic Group Inc","Humana","Participating","Enrollment Complete","2023-04-14","","","2023-09-19","9/19/2023 - Received email that delegation roster has been completed.  Provider is PAR and linked to group TIN/location effective 4/14/2023.  DCannon"]
["Bethany M Wood, PA",1225283963,"46-3131679","TX","PE - Midland Texas Orthopedic Group Inc","CAQH","Participating","CAQH Reattested","2023-10-30","","","2023-10-30","10/30/2023 - CAQH Re-attested, updated and uploaded, DEA and License documents - dkonar"]
["Bethany M Wood, PA",1225283963,"46-3131679","TX","PE - Midland Texas Orthopedic Group Inc","United Health Care","Participating","Enrollment Complete","2023-05-01","003614004","","2023-11-15","11/15/2023 Per email received from UHC provider is PAR and linked to group TIN effective 5/1/2023.  MPIN# 003614004.  DCannon"]
["Bethany M Wood, PA",1225283963,"46-3131679","TX","PE - Midland Texas Orthopedic Group Inc","Gallagher","Panel Closed","Panel Closed","","","","2023-04-26","4/26/2023 Pending First Health enrollment.  DCannon\n07/18/2023. We appreciate your interest in joining the Coventry Network.  At this time, our panels are closed, and we are not accepting new applications.  Please check back routinely to stay apprised of our panel status. We will update this site when we are open for new applicants. Gallagher, Hartford, Liberty Mutual, Travelers and Zurich fall under Coventry. Jen Videan"]
["Bethany M Wood, PA",1225283963,"46-3131679","TX","PE - Midland Texas Orthopedic Group Inc","Tricare Prime","Panel Closed","Panel Closed","","","","2023-04-25","4/25/2023 Per Humana Military web portal Humana Military is currently not accepting requests to join the medical surgical network. We apologize for the inconvenience, but we hope you check back soon to see if we are accepting network providers.  DCannon"]
["Bethany M Wood, PA",1225283963,"46-3131679","TX","PE - Midland Texas Orthopedic Group Inc","Texas Mutual","Participating","Enrollment Complete","2023-08-01","","","2023-08-08","Rcvd approval letter. Effective 08/01/2023. Jen Videan"]
["Bethany M Wood, PA",1225283963,"46-3131679","TX","PE - Midland Texas Orthopedic Group Inc","Multiplan","Participating","Enrollment Complete","2023-04-14","","","2023-06-21","Rcvd effective date of 4/14/2023 from jessica.bess@MultiPlan.com.\nJen Videan"]
["Bethany M Wood, PA",1225283963,"46-3131679","TX","PE - Midland Texas Orthopedic Group Inc","IMS","Participating","Enrollment Complete","2023-04-14","","","2023-07-26","7/26/2023 Per email received from IMS/OMNI April delegated roster has been processed and provider is PAR and linked to group effective 4/14/2023.  DCannon"]
["Bethany M Wood, PA",1225283963,"46-3131679","TX","PE - Midland Texas Orthopedic Group Inc","Caprock (CapStar)","Participating","Enrollment Complete","2023-04-14","","","2023-10-13","10/13/2023 Rcvd email  confirmation from Caprock that provider is PAR and linked to group TIN/locations effective 4/14/2023.  DCannon"]
["Bethany M Wood, PA",1225283963,"46-3131679","TX","PE - Midland Texas Orthopedic Group Inc","Triwest VA","In House Enrollment","In House Enrollment","","","","2023-04-18",""]
["Bethany M Wood, PA",1225283963,"46-3131679","TX","PE - Midland Texas Orthopedic Group Inc","Scott&White (First Care)","Participating","Enrollment Complete","2023-04-14","","","2023-08-17","8/17/2023 Received email from Scott & White HPDELEGATION@BSWHealth.org that provider load from April has been completed and provider is PAR effective 4/14/2023.  DCannon"]
["Bethany M Wood, PA",1225283963,"46-3131679","TX","PE - Midland Texas Orthopedic Group Inc","Boon Chapman","Participating","Enrollment Complete","2023-04-14","","","2023-07-25","7/25/2023 Rcvd email from Jessica Bess at Multiplan with a full roster and provider is PAR w/ group effective 4/14/2023.  DCannon"]
["Bethany M Wood, PA",1225283963,"46-3131679","TX","PE - Midland Texas Orthopedic Group Inc","Wellcare","Participating","Enrollment Complete","2023-05-01","","","2023-07-25","7/25/2023 Rcvd confirmation email from Superior that April delegation roster has been processed and provider has been loaded to delegation roster and PAR w/ group effective 5/1/2023.  DCannon"]
["Bethany M Wood, PA",1225283963,"46-3131679","TX","PE - Midland Texas Orthopedic Group Inc","Ambetter","Participating","Enrollment Complete","2023-05-01","","","2023-07-25","7/25/2023 Rcvd confirmation email from Superior that April delegation roster has been processed and provider has been loaded to delegation roster and PAR w/ group effective 5/1/2023.  DCannon"]
["Bethany M Wood, PA",1225283963,"46-3131679","TX","PE - Midland Texas Orthopedic Group Inc","Hartford","Panel Closed","Panel Closed","","","","2023-04-26","4/26/2023 Per the Coventry website - We appreciate your interest in joining the Coventry Network.  At this time, our panels are closed, and we are not accepting new applications.  Please check back routinely to stay apprised of our panel status. We will update this site when we are open for new applicants.   The following payers fall under Coventry - Travelers, Liberty Health, Hartford, WorkWell-TX, Zurich.    DCannon"]
["Bethany M Wood, PA",1225283963,"46-3131679","TX","PE - Midland Texas Orthopedic Group Inc","Travelers WC","Panel Closed","Panel Closed","","","","2023-04-26","4/26/2023 Per the Coventry website - We appreciate your interest in joining the Coventry Network.  At this time, our panels are closed, and we are not accepting new applications.  Please check back routinely to stay apprised of our panel status. We will update this site when we are open for new applicants.   The following payers fall under Coventry - Travelers, Liberty Health, Hartford, WorkWell-TX, Zurich.    DCannon"]
["John W Mathewson, MD",1588857874,"46-3131679","TX","PE - Midland Texas Orthopedic Group Inc","Medicare","Participating","Enrollment Complete","2019-03-01","774291","320497","2021-09-10","9/10/2021 Received written revalidation approval for provider under provider PTAN 774291. KFrazier"]
["John W Mathewson, MD",1588857874,"46-3131679","TX","PE - Midland Texas Orthopedic Group Inc","Ambetter","Participating","Enrollment Complete","2022-04-01","","","2022-06-13","6/13/2022 Per roster received from Superior provider is PAR and linked to group delegation roster effective 4/1/2022."]
["John W Mathewson, MD",1588857874,"46-3131679","TX","PE - Midland Texas Orthopedic Group Inc","Wellmed","Participating","Enrollment Complete","2022-01-01","","","2023-03-23","3/23/2023 Rcvd roster from UHC w/ all Wellmed participating providers.  Provider is PAR effective 1/1/2022.  DCannon"]
["John W Mathewson, MD",1588857874,"46-3131679","TX","PE - Midland Texas Orthopedic Group Inc","Multiplan","Participating","Enrollment Complete","2020-05-21","1588857874","","2020-09-23","09/23/2020 - moved to completed status after reviewing the follow up completed status - Stacey Hudak"]
["John W Mathewson, MD",1588857874,"46-3131679","TX","PE - Midland Texas Orthopedic Group Inc","Caprock (CapStar)","Participating","Enrollment Complete","2019-04-04","1588857874","","2020-06-02","06/02/2020 - rec'd spreadsheet back from the payer Mary Rodriguez <MRodriguez@caprockhp.com> confirming this provider/service location is EFF with this payer - Stacey Hudak"]
["John W Mathewson, MD",1588857874,"46-3131679","TX","PE - Midland Texas Orthopedic Group Inc","CAQH","Participating","CAQH Reattested","2023-09-27","","","2023-06-05","6/5/2023- CAQH Reattested by Data Services - kavello"]
["John W Mathewson, MD",1588857874,"46-3131679","TX","","CAQH","Participating","CAQH Reattested","2023-09-27","","","2023-06-05","6/5/2023- CAQH Reattested by Data Services - kavello"]
["John W Mathewson, MD",1588857874,"46-3131679","TX","PE - Midland Texas Orthopedic Group Inc","CAQH","Participating","CAQH Reattested","2023-09-27","","","2023-09-27","9/27/2023 CAQH Reattested License updated by DS team wthompson"]
["John W Mathewson, MD",1588857874,"46-3131679","TX","","CAQH","Participating","CAQH Reattested","2023-09-27","","","2023-09-27","9/27/2023 CAQH Reattested License updated by DS team wthompson"]
["John W Mathewson, MD",1588857874,"46-3131679","TX","PE - Midland Texas Orthopedic Group Inc","Omni PPO","Participating","Enrollment Complete","2019-05-21","1588857874","","2020-06-25",""]
["John W Mathewson, MD",1588857874,"46-3131679","TX","PE - Midland Texas Orthopedic Group Inc","Medicaid","Participating","Enrollment Complete","","380896603","331090601","2020-07-15","07/15/2020 - logged into TMHP and found that this provider is EFF - TPI 380896603 - Stacey Hudak"]
["John W Mathewson, MD",1588857874,"46-3131679","TX","PE - Midland Texas Orthopedic Group Inc","Zurich","Participating","Enrollment Complete","2019-05-31","","","2021-08-06","8/6/2021 Moved to enrollment complete per notes from First Health/Coventry. Provider is effective 5/31/2019. Kfrazier"]
["John W Mathewson, MD",1588857874,"46-3131679","TX","PE - Midland Texas Orthopedic Group Inc","Cigna","Participating","Enrollment Complete","2019-04-04","1588857874","","2020-02-20","02/20/2020 - Had the follow up team call CIgna to verify provider enrollment with this TIN. They were advised that this provider is EFF as of 4-4-2019 under a DIRECT CONTRACT at this service location."]
["John W Mathewson, MD",1588857874,"46-3131679","TX","PE - Midland Texas Orthopedic Group Inc","Aetna","Participating","Enrollment Complete","2019-05-21","1588857874","","2020-02-03","02/03/2020 - Rec'd confirmation from the payer that this provider is EFF 6-1-2019 under a DIRECT CONTRACT with this payer. This service location is on file and linked to the provider. -Stacey Hudak"]
["John W Mathewson, MD",1588857874,"46-3131679","TX","PE - Midland Texas Orthopedic Group Inc","Sedgwick","Participating","Enrollment Complete","2019-05-31","","","2021-01-26","1/26/2021 - Per follow-up notes provider is par with TIN and location effective 5/31/2019.  DCannon"]
["John W Mathewson, MD",1588857874,"46-3131679","TX","PE - Midland Texas Orthopedic Group Inc","Liberty Mutual","Participating","Enrollment Complete","2019-11-01","","","2021-01-27","1/27/2021 - Per follow-up notes provider is on file and participating at location and under TIN effective 11/1/2019.  DCannon"]
["John W Mathewson, MD",1588857874,"46-3131679","TX","PE - Midland Texas Orthopedic Group Inc","Superior","Participating","Enrollment Complete","2019-09-01","1588857874","","2020-02-10","02/10/2020 - Rec'd confirmation from payer that this provider is EFF at 5615 Deauville, Ste 220 through a DELEGATED PAYER (Permian Basin Healthcare Network) and linked to the following products: STAR, HEALTH FOSTER CARE, STAR, STAR PLUS, CHIP RSA,\nSTAR KIDS, CHIP, CHIP PERINATE, also EXCHANGE (exchange only since 1-1-2014; non par) All other products are PAR since 9-1-2019. - Stacey Hudak"]
["John W Mathewson, MD",1588857874,"46-3131679","TX","PE - Midland Texas Orthopedic Group Inc","First Health Coventry","Participating","Enrollment Complete","2019-05-01","2650428","","2020-03-20","03/20/2020 - Rec'd email from the payer stating this provider is EFF under PID# 2650428 - Stacey Hudak"]
["John W Mathewson, MD",1588857874,"46-3131679","TX","PE - Midland Texas Orthopedic Group Inc","Triwest VA","Participating","Enrollment Complete","2022-08-01","","","2022-11-14","11/14/22 Per Scarlett Abigail, provider effective 8/1/22"]
["John W Mathewson, MD",1588857874,"46-3131679","TX","PE - Midland Texas Orthopedic Group Inc","Boon Chapman","Participating","Enrollment Complete","2020-05-01","","","2021-08-06","8/6/2021 Boon Chapman falls under the Multiplan umbrella, received roster from Multiplan provider is listed on roster under TIN/location as PAR effective 3/6/2019.  DCannon"]
["John W Mathewson, MD",1588857874,"46-3131679","TX","PE - Midland Texas Orthopedic Group Inc","Rail Road Medicare","Participating","Enrollment Complete","2019-03-01","P02232681","DU5783","2020-02-21","02/12/2020 - Found effective info through payer site stating provider is PAR with group PTAN:  DU5783 EFF 3-1-2019. - Stacey Hudak"]
["John W Mathewson, MD",1588857874,"46-3131679","TX","PE - Midland Texas Orthopedic Group Inc","Gallagher","Participating","Enrollment Complete","2019-05-31","","","2021-08-06","8/6/2021 Moved to enrollment complete per notes from First Health/Coventry. Provider is effective 5/31/2019. Kfrazier"]
["John W Mathewson, MD",1588857874,"46-3131679","TX","PE - Midland Texas Orthopedic Group Inc","Humana","Participating","Enrollment Complete","2020-01-01","1588857874","","2020-07-19","7/19/2020 - Received email spreadsheet from the payor confirming that this provider is EFF at this service location and PAR with the PRIMED DELEGATED agreement - Pam Porter"]
["John W Mathewson, MD",1588857874,"46-3131679","TX","PE - Midland Texas Orthopedic Group Inc","USA PPO","Participating","Enrollment Complete","2019-05-31","1588857874","463131679","2020-08-18","Confirmed provider is participating with PPO and H&W networks (list of networks attached). Kimberly Frazier"]
["John W Mathewson, MD",1588857874,"46-3131679","TX","PE - Midland Texas Orthopedic Group Inc","Texas Mutual","Participating","Enrollment Complete","2019-05-01","","","2020-09-04","Provider is participating under group Tax ID and correct location. Kimberly Frazier"]
["John W Mathewson, MD",1588857874,"46-3131679","TX","PE - Midland Texas Orthopedic Group Inc","IMS","Participating","Enrollment Complete","2019-05-21","1588857874","","2020-06-22","06/22/2020- Rec'd email from the payer confirming this provider is PAR with this group/service location - Stacey Hudak"]
["John W Mathewson, MD",1588857874,"46-3131679","TX","PE - Midland Texas Orthopedic Group Inc","United Health Care","Participating","Enrollment Complete","2019-11-01","1588857874","","2020-08-31","08/31/2020 - moved to completed status after reviewing follow up complete note - Stacey Hudak"]
["John W Mathewson, MD",1588857874,"46-3131679","TX","PE - Midland Texas Orthopedic Group Inc","Galaxy Health","Participating","Enrollment Complete","2019-04-04","1588857874","","2020-07-10","07/10/2020 - updated payer line to enrollment complete status instead of \"Delegated status\" for report running purposes - Stacey Hudak"]
["John W Mathewson, MD",1588857874,"46-3131679","TX","PE - Midland Texas Orthopedic Group Inc","Wellcare","Participating","Enrollment Complete","2021-11-01","","","2022-12-01","12/1/2022 Per roster received from Wellcare provider is PAR and linked to group TIN/location effective 11/1/2021.  DCannon"]
["John W Mathewson, MD",1588857874,"46-3131679","TX","PE - Midland Texas Orthopedic Group Inc","Amerigroup","Participating","Enrollment Complete","2021-02-12","1588857874","","2023-09-20","9/20/2023 Per email from Amerigroup provider is PAR and linked to group TIN effective 2/12/2021.  DCannon"]
["John W Mathewson, MD",1588857874,"46-3131679","TX","PE - Midland Texas Orthopedic Group Inc","Scott&White (First Care)","Participating","Enrollment Complete","2019-05-31","1588857874","","2020-08-19","8/19/2020 - Rec'd spreadsheet from the payer confirming this provider is linked to the PRIMED DELEGATED AGREEMENT under this TIN/Service Location. This provider is networked with:\nFirstCare MyChoice PPO\nCHIP\nHMO Enhanced Benefit Network\nMedicaid (FC)\nMedicare (FC)\nPPO Limited Benefit Network\n- Stacey Hudak"]
["John W Mathewson, MD",1588857874,"46-3131679","TX","PE - Midland Texas Orthopedic Group Inc","HealthSmart PPO","Participating","Enrollment Complete","2019-05-31","1588857874","","2020-06-05","06/05/2020 - Rec'd email from the payer stating this provider is EFF - Stacey Hudak"]
["John W Mathewson, MD",1588857874,"46-3131679","TX","PE - Midland Texas Orthopedic Group Inc","TriCare Standard","Participating","Enrollment Complete","2019-04-19","1588857874","","2020-03-03","03/03/2020 - Rec'd confirmation of provider enrollment through payer portal. Provider is linked to group at this service location - Stacey Hudak"]
["Kristin L Rettig, PA-C",1164778767,"46-3131679","TX","PE - Midland Texas Orthopedic Group Inc","Medicare","Participating","Enrollment Complete","2019-02-18","779243","320497","2020-01-30","01/30/2020 - Found this provider is linked to Midland Texas Ortho (group PTAN 320497 and Employer ID# 1346681061) as of 2-18-2019. MAURENE.MCDANIEL@MIDLANDHEALTH.ORG  is the contact person - Stacey Hudak"]
["Kristin L Rettig, PA-C",1164778767,"46-3131679","TX","PE - Midland Texas Orthopedic Group Inc","Galaxy Health","Participating","Enrollment Complete","2019-05-21","1164778767","","2020-07-17","07/17/2020 Received a spreadsheet from the payer stating this provider is effective as of 5/21/2019. – Archie Candiasan"]
["Kristin L Rettig, PA-C",1164778767,"46-3131679","TX","PE - Midland Texas Orthopedic Group Inc","Cigna","Participating","Enrollment Complete","2019-03-06","1164778767","","2020-02-20","02/20/2020 - Had the follow up team call CIgna to verify provider enrollment with this TIN. They were advised that this provider is EFF as of 3-6-2019 at this service location. They also said this provider IS DELEGATED; but could not say who the delegated company is. - Stacey Hudak"]
["Kristin L Rettig, PA-C",1164778767,"46-3131679","TX","PE - Midland Texas Orthopedic Group Inc","Ambetter","Participating","Enrollment Complete","2022-04-01","","","2022-06-13","6/13/2022 Per roster received from Superior provider is PAR and linked to group delegation roster effective 4/1/2022."]
["Kristin L Rettig, PA-C",1164778767,"46-3131679","TX","PE - Midland Texas Orthopedic Group Inc","Amerigroup","Participating","Enrollment Complete","2021-02-12","1164778767","","2023-09-20","9/20/2023 Per email received from Amerigroup provider is PAR and linked to group TIN effective 2/12/2021.  DCannon"]
["Kristin L Rettig, PA-C",1164778767,"46-3131679","TX","PE - Midland Texas Orthopedic Group Inc","IMS","Participating","Enrollment Complete","2019-05-21","1164778767","","2020-06-22","06/22/2020- Rec'd email from the payer confirming this provider is PAR with this group/service location - Stacey Hudak"]
["Kristin L Rettig, PA-C",1164778767,"46-3131679","TX","PE - Midland Texas Orthopedic Group Inc","CAQH","Participating","CAQH Reattested","2023-10-27","","","2023-10-27","10/27/2023 - updated  license DEA and re-attested - rkedare"]
["Kristin L Rettig, PA-C",1164778767,"46-3131679","TX","PE - Midland Texas Orthopedic Group Inc","Wellmed","Participating","Enrollment Complete","2022-01-01","","","2023-03-23","3/23/2023 Rcvd roster from UHC w/ all Wellmed participating providers.  Provider is PAR effective 1/1/2022.  DCannon"]
["Kristin L Rettig, PA-C",1164778767,"46-3131679","TX","PE - Midland Texas Orthopedic Group Inc","Wellcare","Participating","Enrollment Complete","2021-11-01","","","2022-12-01","12/1/2022 Per roster received from Wellcare provider is PAR and linked to group TIN/location effective 11/1/2021.  DCannon"]
["Kristin L Rettig, PA-C",1164778767,"46-3131679","TX","PE - Midland Texas Orthopedic Group Inc","Caprock (CapStar)","Participating","Enrollment Complete","2019-05-21","1164778767","","2020-06-02","06/02/2020 - rec'd spreadsheet back from the payer Mary Rodriguez <MRodriguez@caprockhp.com> confirming this provider/service location is EFF with this payer - Stacey Hudak"]
["Kristin L Rettig, PA-C",1164778767,"46-3131679","TX","PE - Midland Texas Orthopedic Group Inc","Zurich","Participating","Enrollment Complete","2014-01-01","","","2021-08-06","8/6/2021 Moved to enrollment complete per notes from First Health/Coventry. Provider is effective 1/1/2014. Kfrazier"]
["Kristin L Rettig, PA-C",1164778767,"46-3131679","TX","PE - Midland Texas Orthopedic Group Inc","Medicaid","Participating","Enrollment Complete","2019-02-18","362149203","331090601","2020-02-25","02/25/2020 - Rec'd deficiency from the payer stating this provider was already enrolled with this group TPI, eventhough this provider is not showing under group portal. Asked the clinic to send over welcome letter from this payer and they did. Updated payer line with effective info - Stacey Hudak"]
["Kristin L Rettig, PA-C",1164778767,"46-3131679","TX","PE - Midland Texas Orthopedic Group Inc","Texas Mutual","Participating","Enrollment Complete","2019-05-01","","","2020-08-05","8/5/2020- Per email response received from  Texas Mutual on  8/4/2020, provider NPI# is on file for the provider and is participating effective 5/1/2019 under the group and TIN#. Physical location is on file. - Elonah Grace B. Gelig"]
["Kristin L Rettig, PA-C",1164778767,"46-3131679","TX","PE - Midland Texas Orthopedic Group Inc","First Health Coventry","Participating","Enrollment Complete","2019-05-01","3039403","","2020-03-20","03/20/2020 - Rec'd email from the payer stating this provider is EFF under PID# 3039403 - Stacey Hudak"]
["Kristin L Rettig, PA-C",1164778767,"46-3131679","TX","PE - Midland Texas Orthopedic Group Inc","Triwest VA","Participating","Enrollment Complete","2022-08-01","","","2022-11-14","11/14/22 Per Scarlett Abigail, provider effective 8/1/22"]
["Kristin L Rettig, PA-C",1164778767,"46-3131679","TX","PE - Midland Texas Orthopedic Group Inc","Humana","Participating","Enrollment Complete","2020-01-01","1164778767","","2020-07-19","7/19/2020 - Received email spreadsheet from the payor confirming that this provider is EFF at this service location and PAR with the PRIMED DELEGATED agreement - Pam Porter"]
["Kristin L Rettig, PA-C",1164778767,"46-3131679","TX","PE - Midland Texas Orthopedic Group Inc","Superior","Participating","Enrollment Complete","2020-04-13","","","2020-10-02","10/2/2020 - Rec'd response from the payer stating \"•\tProviders marked as \" Delegated Contract With SHP” have an active delegated contract with another entity by the same NPI & TIN through Superior Health Plan. Please note that these providers will not be accepted as part of your Delegated Opt-in. \" \nWe cannot add this provider to the PriMed delegation, as they are already with another delegated group- Stacey Hudak"]
["Kristin L Rettig, PA-C",1164778767,"46-3131679","TX","PE - Midland Texas Orthopedic Group Inc","HealthSmart PPO","Participating","Enrollment Complete","2019-05-31","1164778767","","2020-06-05","06/05/2020 - Rec'd email from the payer stating this provider is EFF - Stacey Hudak"]
["Kristin L Rettig, PA-C",1164778767,"46-3131679","TX","PE - Midland Texas Orthopedic Group Inc","USA PPO","Participating","Enrollment Complete","2019-05-31","1164778767","463131679","2020-08-18","Confirmed provider is participating with PPO and H&W networks (list of networks attached). Kimberly Frazier"]
["Kristin L Rettig, PA-C",1164778767,"46-3131679","TX","PE - Midland Texas Orthopedic Group Inc","Scott&White (First Care)","Participating","Enrollment Complete","2020-09-28","","","2021-01-29","1/29/2021 - Rcvd roster from Scott&White (First Care) confirming participation of provider with TIN and location effective dates.  DCannon"]
["Kristin L Rettig, PA-C",1164778767,"46-3131679","TX","PE - Midland Texas Orthopedic Group Inc","Boon Chapman","Participating","Enrollment Complete","2020-05-01","","","2021-08-06","8/6/2021 Boon Chapman falls under the Multiplan umbrella, received roster from Multiplan provider is listed on roster under TIN/location as PAR effective 5/1/2020.  DCannon"]
["Kristin L Rettig, PA-C",1164778767,"46-3131679","TX","PE - Midland Texas Orthopedic Group Inc","TriCare Standard","Participating","Enrollment Complete","2019-06-06","1164778767","","2020-03-03","03/03/2020 - Rec'd confirmation of provider enrollment through payer portal. Provider is linked to group at this service location - Stacey Hudak"]
["Kristin L Rettig, PA-C",1164778767,"46-3131679","TX","PE - Midland Texas Orthopedic Group Inc","Liberty Mutual","Participating","Enrollment Complete","2019-11-01","1164778767","463131679","2021-01-27","1/27/2021 - Per follow-up notes provider is on file and participating at location and under TIN effective 11/1/2019.  DCannon"]
["Kristin L Rettig, PA-C",1164778767,"46-3131679","TX","PE - Midland Texas Orthopedic Group Inc","Sedgwick","Participating","Enrollment Complete","2019-05-31","","","2021-01-26","1/26/2021 - Per follow-up notes provider is par with TIN and location effective 5/31/2019.  DCannon"]
["Kristin L Rettig, PA-C",1164778767,"46-3131679","TX","PE - Midland Texas Orthopedic Group Inc","Multiplan","Participating","Enrollment Complete","2020-05-21","1164778767","","2020-09-23","Provider is delegated under Physician Optimal INC"]
["Kristin L Rettig, PA-C",1164778767,"46-3131679","TX","PE - Midland Texas Orthopedic Group Inc","Gallagher","Participating","Enrollment Complete","2014-01-01","","","2020-07-27","7/27/2020- S/W  Jack of  Gallagher (thru Coventry) @ 800-243-2336 and she transferred the call to cred dept. S/W  Lynn  and  she confirmed group is par with Worker's Comp Network under the TAX ID eff 1/1/2014.  Provider is  par as a delegated  with Worker's Comp Network under the TAX ID eff 5/1/2019. Physical location is on file. Group ID# 2559513 and Individual ID# 3039403. Call ref#181324888. - Elonah Grace B. Gelig"]
["Kristin L Rettig, PA-C",1164778767,"46-3131679","TX","PE - Midland Texas Orthopedic Group Inc","Rail Road Medicare","Participating","Enrollment Complete","2019-02-18","P02405660","","2020-03-25","3/25/2020- Per online check, provider is now PAR effective 02/18/2019 with provider number P02405660. Attached welcome letter to payor line\n-tisha rader"]
["Kristin L Rettig, PA-C",1164778767,"46-3131679","TX","PE - Midland Texas Orthopedic Group Inc","United Health Care","Participating","Enrollment Complete","2019-11-01","1164778767","","2020-08-31","08/31/2020 - moved to completed status after reviewing follow up complete status - Stacey Hudak"]
["Rachelle M Campos, APRN-FNP-BC",1447882915,"46-3131679","TX","PE - Midland Texas Orthopedic Group Inc","Liberty Mutual","Participating","Enrollment Complete","2020-10-01","","","2021-08-06","8/6/2021 Moved to enrollment complete per notes from First Health/Coventry. Provider is effective 10/1/2020. KFrazier"]
["Rachelle M Campos, APRN-FNP-BC",1447882915,"46-3131679","TX","PE - Midland Texas Orthopedic Group Inc","USA PPO","Participating","Enrollment Complete","2020-07-24","1302718","","2021-01-26","1/26/2021 - Per follow-up notes provider is par with TIN and location effective 7/24/2020.  DCannon"]
["Rachelle M Campos, APRN-FNP-BC",1447882915,"46-3131679","TX","PE - Midland Texas Orthopedic Group Inc","Gallagher","Participating","Enrollment Complete","2020-10-01","","","2021-08-06","8/6/2021 Moved to enrollment complete per notes from First Health/Coventry. Provider is effective 10/1/2020. KFrazier"]
["Rachelle M Campos, APRN-FNP-BC",1447882915,"46-3131679","TX","PE - Midland Texas Orthopedic Group Inc","Medicare","Participating","Enrollment Complete","2020-02-11","1B4358","320497","2020-04-23","04/23/2020 - Found porivder as EFF under gorup enrollment through PECOS - Stacey Hudak"]
["Rachelle M Campos, APRN-FNP-BC",1447882915,"46-3131679","TX","PE - Midland Texas Orthopedic Group Inc","Galaxy Health","Participating","Enrollment Complete","2019-09-01","1447882915","","2020-08-21","08/21/2020 - Rec'd email confirmation that this roster was processed and this provider was made effective with the requested eff date of 9-1-2019 - Stacey Hudak"]
["Rachelle M Campos, APRN-FNP-BC",1447882915,"46-3131679","TX","PE - Midland Texas Orthopedic Group Inc","Omni PPO","Participating","Enrollment Complete","2019-09-01","1447882915","","2020-07-27","IMS complete"]
["Rachelle M Campos, APRN-FNP-BC",1447882915,"46-3131679","TX","PE - Midland Texas Orthopedic Group Inc","Caprock (CapStar)","Participating","Enrollment Complete","2019-09-01","1447882915","","2020-09-23","09/23/2020 - rec'd confirmation from the payer that this August 2020 roster was completed. This provider/service location was added to PriMed Agreement - OK to move to completed status. - Stacey Hudak"]
["Rachelle M Campos, APRN-FNP-BC",1447882915,"46-3131679","TX","PE - Midland Texas Orthopedic Group Inc","Boon Chapman","Participating","Enrollment Complete","2020-05-06","","","2021-08-06","8/6/2021 Boon Chapman falls under the Multiplan umbrella, received roster from Multiplan provider is listed on roster under TIN/location as PAR effective 5/6/2020.  DCannon"]
["Rachelle M Campos, APRN-FNP-BC",1447882915,"46-3131679","TX","PE - Midland Texas Orthopedic Group Inc","Sedgwick","Participating","Enrollment Complete","2020-07-24","1302718","","2021-01-26","1/26/2021 - Per follow-up notes provider is par with TIN and location effective 7/24/2020.  DCannon"]
["Rachelle M Campos, APRN-FNP-BC",1447882915,"46-3131679","TX","PE - Midland Texas Orthopedic Group Inc","Wellcare","Participating","Enrollment Complete","2021-11-01","","","2022-11-15","11/15/2022 Per roster received from Wellcare provider is PAR and linked to group TIN/location effective 11/1/2021.  DCannon"]
["Rachelle M Campos, APRN-FNP-BC",1447882915,"46-3131679","TX","PE - Midland Texas Orthopedic Group Inc","United Health Care","Participating","Enrollment Complete","2020-04-01","7365931","","2020-09-08","09/08/2020 - Rec'd spreadsheet from the payer that confirms this provider is PAR with commercial 4-1-2020, community & state 4-1-2020 and Medicare 6-1-2020 products. This service location IS listed on file for this provider under this TIN. Moved to completed status using providers Unique UHC ID#  - Stacey Hudak"]
["Rachelle M Campos, APRN-FNP-BC",1447882915,"46-3131679","TX","PE - Midland Texas Orthopedic Group Inc","First Health Coventry","Participating","Enrollment Complete","2020-10-01","3372421","","2021-01-27","1/27/2021 - Per follow-up notes provider is on file and participating in network at location and under TIN effective 10/1/2020.  DCannon"]
["Rachelle M Campos, APRN-FNP-BC",1447882915,"46-3131679","TX","PE - Midland Texas Orthopedic Group Inc","Multiplan","Participating","Enrollment Complete","2020-05-06","1447882915"," West Texas Physician Alliance","2020-09-23","09/23/2020 - moved to completed status after reviewing follow up complete status - Stacey Hudak"]
["Rachelle M Campos, APRN-FNP-BC",1447882915,"46-3131679","TX","PE - Midland Texas Orthopedic Group Inc","Ambetter","Participating","Enrollment Complete","2022-04-01","","","2022-06-13","6/13/2022 Received April Monthly Validation roster from Superior and provider is PAR and linked effective 4/1/2022.  DCannon"]
["Rachelle M Campos, APRN-FNP-BC",1447882915,"46-3131679","TX","PE - Midland Texas Orthopedic Group Inc","HealthSmart PPO","Participating","Enrollment Complete","2020-05-06","1447882915","","2020-06-05","06/05/2020 - Rec'd email from the payer stating this provider is EFF - Stacey hudak"]
["Rachelle M Campos, APRN-FNP-BC",1447882915,"46-3131679","TX","PE - Midland Texas Orthopedic Group Inc","Cigna","Participating","Enrollment Complete","2020-05-06","1447882915","","2020-07-23","7/23/2020 - moved to a completed status after reviewing follow up complete note  Stacey Hudak"]
["Rachelle M Campos, APRN-FNP-BC",1447882915,"46-3131679","TX","PE - Midland Texas Orthopedic Group Inc","Rail Road Medicare","Participating","Enrollment Complete","2020-02-11","P02476693","DU5783","2020-07-20","07/20/2020 - downloaded and attached welcome letter - Stacey Hudak"]
["Rachelle M Campos, APRN-FNP-BC",1447882915,"46-3131679","TX","PE - Midland Texas Orthopedic Group Inc","Triwest VA","In House Enrollment","In House Enrollment","","","","2021-01-13","01/13/2021 - MQA Team is working with Representatives at BCBS-TX to ensure all providers are enrolled and loaded to participate with the VACCN network in a timely manner. However, we are currently awaiting a full roster of providers currently participating and will update all records accordingly upon receipt. Kfrazier"]
["Rachelle M Campos, APRN-FNP-BC",1447882915,"46-3131679","TX","PE - Midland Texas Orthopedic Group Inc","Zurich","Participating","Enrollment Complete","2021-10-01","","","2021-08-06","8/6/2021 Moved to enrollment complete per notes from First Health/Coventry. Provider is effective 10/1/2020. KFrazier"]
["Rachelle M Campos, APRN-FNP-BC",1447882915,"46-3131679","TX","PE - Midland Texas Orthopedic Group Inc","Amerigroup","Participating","Enrollment Complete","2021-02-12","10337649","","2023-09-20","9/20/2023 Per email received from Amerigroup provider is PAR and linked to group TIN effective 2/12/2021.  DCannon"]
["Rachelle M Campos, APRN-FNP-BC",1447882915,"46-3131679","TX","PE - Midland Texas Orthopedic Group Inc","Texas Mutual","Participating","Enrollment Complete","2020-06-01","","","2020-08-05","8/5/2020- Per email response received from  Texas Mutual on  8/4/2020, provider NPI# is on file for the provider and is participating effective  6/1/2020 under the group and TIN#. Physical location is on file. - Elonah Grace B. Gelig"]
["Rachelle M Campos, APRN-FNP-BC",1447882915,"46-3131679","TX","PE - Midland Texas Orthopedic Group Inc","Medicaid","Participating","Enrollment Complete","","410281601","3310906-01","2020-07-15","07/15/2020 - logged onto to TMHP and was able to find that this provider has been approved - TPI 410281601 - Stacey HUdak"]
["Rachelle M Campos, APRN-FNP-BC",1447882915,"46-3131679","TX","PE - Midland Texas Orthopedic Group Inc","Scott&White (First Care)","Participating","Enrollment Complete","2020-09-28","","","2021-01-29","1/29/2021 - Rcvd roster from Scott&White (First Care) confirming participation of provider with TIN and location effective dates.  DCannon"]
["Rachelle M Campos, APRN-FNP-BC",1447882915,"46-3131679","TX","PE - Midland Texas Orthopedic Group Inc","Superior","Participating","Enrollment Complete","2020-08-01","1447882915","","2020-08-06","8/6/2020 - Rec'd an email from the payer stating this provider was added to their database EFF: 8-1-2020 after receiving/processing the July roster - Stacey Hudak"]
["Rachelle M Campos, APRN-FNP-BC",1447882915,"46-3131679","TX","PE - Midland Texas Orthopedic Group Inc","Wellmed","Participating","Enrollment Complete","2022-01-01","","","2023-03-23","3/23/2023 Rcvd roster from UHC w/ all Wellmed participating providers.  Provider is PAR effective 1/1/2022.  DCannon"]
["Rachelle M Campos, APRN-FNP-BC",1447882915,"46-3131679","TX","PE - Midland Texas Orthopedic Group Inc","Humana","Participating","Enrollment Complete","2020-05-06","","","2021-11-18","11/18/2021 Rcvd full roster from Humana listing provider as PAR and linked to group TIN/location effective 5/6/2020.  DCannon"]
["Rachelle M Campos, APRN-FNP-BC",1447882915,"46-3131679","TX","PE - Midland Texas Orthopedic Group Inc","TriCare Standard","Participating","Enrollment Complete","2020-08-12","1447882915","","2020-09-24","09/24/2020 - moved to completed status after reivewing follow up complete - Stacey Hudak"]
["Rachelle M Campos, APRN-FNP-BC",1447882915,"46-3131679","TX","PE - Midland Texas Orthopedic Group Inc","IMS","Participating","Enrollment Complete","2019-09-01","1447882915","","2020-07-27","07/27/2020 - Rec'd roster response back from the payer regarding 7/15/2020 submission stating that all requested providers/service locations have been added to PriMed agreement - Stacey Hudak"]
["Rachelle M Campos, APRN-FNP-BC",1447882915,"46-3131679","TX","PE - Midland Texas Orthopedic Group Inc","CAQH","Participating","CAQH Reattested","2023-10-23","","","2023-09-28","9/28/2023 CAQH Reattested by ds team wthompson"]
["Jonathan C Burkes, MD",1538571609,"46-3131679","TX","PE - Midland Texas Orthopedic Group Inc","Ambetter","Participating","Enrollment Complete","2022-04-01","","","2022-06-13","6/13/2022 Received April Monthly Validation roster from Superior and provider is PAR and linked effective 4/1/2022.  DCannon"]
["Jonathan C Burkes, MD",1538571609,"46-3131679","TX","PE - Midland Texas Orthopedic Group Inc","IMS","Participating","Enrollment Complete","2020-08-01","","","2020-08-25","Confirmed provider is participating under delegation effective 8/1/2020. Kimberly Frazier"]
["Jonathan C Burkes, MD",1538571609,"46-3131679","TX","PE - Midland Texas Orthopedic Group Inc","Gallagher","Participating","Enrollment Complete","2020-11-01","","","2021-08-06","8/6/2021 Moved to enrollment complete per notes from First Health/Coventry. Provider is effective 11/1/2020. Kfrazier"]
["Jonathan C Burkes, MD",1538571609,"46-3131679","TX","PE - Midland Texas Orthopedic Group Inc","Humana","Participating","Enrollment Complete","2020-08-05","","","2021-11-18","11/18/2021 Rcvd full roster from Humana listing provider as PAR and linked to group TIN/location effective 8/5/2020.  DCannon"]
["Jonathan C Burkes, MD",1538571609,"46-3131679","TX","PE - Midland Texas Orthopedic Group Inc","Zurich","Participating","Enrollment Complete","2020-11-01","","","2021-08-06","8/6/2021 Moved to enrollment complete per notes from First Health/Coventry. Provider is effective 11/1/2020. Kfrazier"]
["Jonathan C Burkes, MD",1538571609,"46-3131679","TX","PE - Midland Texas Orthopedic Group Inc","USA PPO","Participating","Enrollment Complete","2020-10-13","","","2021-03-12","3/12/2021 Per verification on payor website USAMCO.com provider is loaded as participating.  Sent email to LeNetrice Myart for a roster for the PriMed delegation agreement.  DCannon"]
["Jonathan C Burkes, MD",1538571609,"46-3131679","TX","PE - Midland Texas Orthopedic Group Inc","TriCare Standard","Participating","Enrollment Complete","2020-10-24","","","2020-11-03","11/3/2020 Confirmed via self-service portal provider is certified non-network under Group Tax ID and location effective 10/24/2020. Kimberly Frazier"]
["Jonathan C Burkes, MD",1538571609,"46-3131679","TX","PE - Midland Texas Orthopedic Group Inc","Scott&White (First Care)","Participating","Enrollment Complete","2020-09-28","","","2021-01-29","1/29/2021 - Rcvd roster from Scott&White (First Care) confirming participation of provider with TIN and location effective dates.  DCannon"]
["Jonathan C Burkes, MD",1538571609,"46-3131679","TX","PE - Midland Texas Orthopedic Group Inc","Molina","Participating","Enrollment Complete","2021-03-12","","","2021-03-15","3/15/2021 Received forwarded email from Margaret.White@molinahealthcare.com confirming provider is now participating with network under group Tax ID with specialty of orthopedic surgery and orthopedic trauma effective 3/12/2021. KFrazier"]
["Jonathan C Burkes, MD",1538571609,"46-3131679","TX","PE - Midland Texas Orthopedic Group Inc","First Health Coventry","Participating","Enrollment Complete","2020-11-01","","","2021-01-26","1/26/2021 - Per follow-up notes provider is par with TIN and location effective 11/1/2020.  DCannon"]
["Jonathan C Burkes, MD",1538571609,"46-3131679","TX","PE - Midland Texas Orthopedic Group Inc","Omni PPO","Participating","Enrollment Complete","2020-08-01","","","2020-08-25","Confirmed provider is participating under delegation effective 8/1/2020. Kimberly Frazier"]
["Jonathan C Burkes, MD",1538571609,"46-3131679","TX","PE - Midland Texas Orthopedic Group Inc","United Health Care","Participating","Enrollment Complete","2020-09-13","7196467","","2020-11-20","11/20/2020 - Rcvd email from UHC confirming enrollment status.  Provider is participating effective 9/13/2020, provider # 7196467."]
["Jonathan C Burkes, MD",1538571609,"46-3131679","TX","PE - Midland Texas Orthopedic Group Inc","Triwest VA","In House Enrollment","In House Enrollment","","","","2021-01-13","1/6/2021 MQA Team is working with Representatives at BCBS-TX to ensure all providers are enrolled and loaded to participate with the VACCN network in a timely manner. However, we are currently awaiting a full roster of providers currently participating and will update all records accordingly upon receipt. Kfrazier"]
["Jonathan C Burkes, MD",1538571609,"46-3131679","TX","PE - Midland Texas Orthopedic Group Inc","Superior","Participating","Enrollment Complete","2020-10-01","1538571609","","2020-10-02","10/02/2020 - Rec'd email from the payer stating this provider has been added to the PriMed delegation - Stacey Hudak"]
["Jonathan C Burkes, MD",1538571609,"46-3131679","TX","PE - Midland Texas Orthopedic Group Inc","Tricare Prime","Participating","Enrollment Complete","2020-10-24","","","2020-11-03","11/3/2020 Confirmed via self-service portal provider is participating under Group Tax ID and location effective 10/24/2020. Kimberly Frazier"]
["Jonathan C Burkes, MD",1538571609,"46-3131679","TX","PE - Midland Texas Orthopedic Group Inc","HealthSmart PPO","Participating","Enrollment Complete","2020-09-02","","","2021-01-27","1/27/2021 - Rcvd email from payer showing provider as participating at location and linked to TIN effective 9/2/2020.  DCannon"]
["Jonathan C Burkes, MD",1538571609,"46-3131679","TX","PE - Midland Texas Orthopedic Group Inc","Amerigroup","Participating","Enrollment Complete","2021-02-12","10499208","","2023-09-20","9/20/2023 Per email received from Amerigroup provider is PAR and linked to group TIN effective 2/12/2021.  DCannon"]
["Jonathan C Burkes, MD",1538571609,"46-3131679","TX","PE - Midland Texas Orthopedic Group Inc","Medicaid","Participating","Enrollment Complete","2020-09-24","414415601","331090601","2021-10-06","10/6/2021 Confirmed license update complete via TMHP Portal.  DCannon"]
["Jonathan C Burkes, MD",1538571609,"46-3131679","TX","PE - Midland Texas Orthopedic Group Inc","Wellmed","Participating","Enrollment Complete","2022-01-01","","","2023-03-23","3/23/2023 Rcvd roster from UHC w/ all Wellmed participating providers.  Provider is PAR effective 1/1/2022.  DCannon"]
["Jonathan C Burkes, MD",1538571609,"46-3131679","TX","PE - Midland Texas Orthopedic Group Inc","CAQH","Participating","CAQH Reattested","2023-09-29","","","2023-09-29","9/29/2023 CAQH reviewed and re-attested.  DCannon"]
["Jonathan C Burkes, MD",1538571609,"46-3131679","TX","PE - Midland Texas Orthopedic Group Inc","Boon Chapman","Participating","Enrollment Complete","2021-01-01","","","2021-08-06","8/6/2021 Boon Chapman falls under the Multiplan umbrella, received roster from Multiplan provider is listed on roster under TIN/location as PAR effective 1/1/2021.  DCannon"]
["Jonathan C Burkes, MD",1538571609,"46-3131679","TX","PE - Midland Texas Orthopedic Group Inc","Sedgwick","Participating","Enrollment Complete","2020-11-27","1310347","","2021-01-26","1/26/2021 - Per follow-up notes provider is par with TIN and location effective 11/27/2020.  DCannon"]
["Jonathan C Burkes, MD",1538571609,"46-3131679","TX","PE - Midland Texas Orthopedic Group Inc","Caprock (CapStar)","Participating","Enrollment Complete","2020-08-05","1538571609","","2020-09-16","09/16/2020- Rec'd spreadsheet from the payer confirming this provider/service location have been made effective under the primed roster - Stacey Hudak"]
["Jonathan C Burkes, MD",1538571609,"46-3131679","TX","PE - Midland Texas Orthopedic Group Inc","Liberty Mutual","Participating","Enrollment Complete","2020-11-27","","","2021-08-06","8/6/2021 Moved to enrollment complete per notes from First Health/Coventry. Provider is effective 11/27/2020. Kfrazier"]
["Jonathan C Burkes, MD",1538571609,"46-3131679","TX","PE - Midland Texas Orthopedic Group Inc","Medicare","Participating","Enrollment Complete","2020-08-24","1F6412","320497","2020-08-13","8/13/2020 - Rec'd email from the payer stating this has been approved. Signed into PECOS to confirm - Stacey Hudak"]
["Jonathan C Burkes, MD",1538571609,"46-3131679","TX","PE - Midland Texas Orthopedic Group Inc","Multiplan","Participating","Enrollment Complete","2021-01-01","","","2021-02-20","2/20/2021 Rcvd approval letter from MultiPlan for WesTexas OrthoPedics providers effective 1/1/2021.  DCannon"]
["Jonathan C Burkes, MD",1538571609,"46-3131679","TX","PE - Midland Texas Orthopedic Group Inc","Galaxy Health","Participating","Enrollment Complete","2020-08-24","1538571609","","2020-08-24","08/21/2020 - Rec'd email confirmation that this roster was processed and this provider was made effective with the requested eff date of 9-1-2019 - Stacey Hudak"]
["Jonathan C Burkes, MD",1538571609,"46-3131679","TX","PE - Midland Texas Orthopedic Group Inc","Rail Road Medicare","Participating","Enrollment Complete","2020-08-24","Q00083402","DU5783","2021-06-09","6/9/2021 Submitted on-line application and immediately received assigned RR PTAN, which is Q00083402 under group RR PTAN DU5783, effective 8/24/2020. KFrazier"]
["Jonathan C Burkes, MD",1538571609,"46-3131679","TX","PE - Midland Texas Orthopedic Group Inc","Aetna","Participating","Enrollment Complete","2020-08-05","","","2020-08-05",""]
["Jonathan C Burkes, MD",1538571609,"46-3131679","TX","PE - Midland Texas Orthopedic Group Inc","Cigna","Participating","Enrollment Complete","2020-09-02","1899502","","2021-03-08","3/8/2021 Rcvd confirmation from Cigna that provider is now participating under TIN and linked to location effective 9/2/2020.  CPID # 1899502.  DCannon"]
["Jonathan C Burkes, MD",1538571609,"46-3131679","TX","PE - Midland Texas Orthopedic Group Inc","Wellcare","Participating","Enrollment Complete","2021-11-01","","","2022-11-15","11/15/2022 Per roster received from Wellcare provider is PAR and linked to group TIN/location effective 11/1/2021.  DCannon"]
["Jonathan C Burkes, MD",1538571609,"46-3131679","TX","PE - Midland Texas Orthopedic Group Inc","Texas Mutual","Participating","Enrollment Complete","2020-07-08","","","2021-01-23","11/25/2020 - Confirmed provider is participating under group Tax ID and practice location. KFrazier"]
["Valarie Ramirez Alcala, PA",1790251031,"46-3131679","TX","PE - Midland Texas Orthopedic Group Inc","IMS","Participating","Enrollment Complete","2022-05-09","","","2022-07-05","7/5/2022 Rcvd email from G.Aviles at IMS/OMNI that delegation roster provider load for June has been completed.  Provider is PAR and linked to group effective 5/9/2022.  DCannon"]
["Valarie Ramirez Alcala, PA",1790251031,"46-3131679","TX","PE - Midland Texas Orthopedic Group Inc","Alliance WC","Participating","Enrollment Complete","2022-09-16","","","2022-09-27","9/27/2022 Rcvd PSWCA - Alliance approval letter.  Provider is PAR and linked to group TIN effective 9/16/2022.  DCannon"]
["Valarie Ramirez Alcala, PA",1790251031,"46-3131679","TX","PE - Midland Texas Orthopedic Group Inc","Texas Municipal League","Participating","Enrollment Complete","2022-09-16","","","2022-09-27","9/27/2022 Rcvd PSWCA - Alliance approval letter.  Provider is PAR and linked to group TIN effective 9/16/2022.  DCannon"]
["Valarie Ramirez Alcala, PA",1790251031,"46-3131679","TX","PE - Midland Texas Orthopedic Group Inc","Ambetter","Participating","Enrollment Complete","2022-06-01","","","2022-06-13","6/13/2022 Per roster received from Superior provider is PAR w/ Ambetter and linked to group delegation roster effective 6/1/2022.  DCannon"]
["Valarie Ramirez Alcala, PA",1790251031,"46-3131679","TX","PE - Midland Texas Orthopedic Group Inc","Gallagher","Panel Closed","Panel Closed","","","","2023-02-03","2.3.23 Received confirmation from Alex Bennes Alex_Bennes@gbtpa.com that the Gallagher network is through the Aetna/First Health network and not Coventry. ABoles"]
["Valarie Ramirez Alcala, PA",1790251031,"46-3131679","TX","PE - Midland Texas Orthopedic Group Inc","United Health Care","Participating","Enrollment Complete","2022-05-09","007091179","","2022-06-29","6/29/2022 Per email received from  from UHC monthly delegated roster submission has been completed and provider is PAR and in linked to group TIN effective 5/9/2022.   MPIN# 007091179.   DCannon"]
["Valarie Ramirez Alcala, PA",1790251031,"46-3131679","TX","PE - Midland Texas Orthopedic Group Inc","Scott&White (First Care)","Participating","Enrollment Complete","2022-05-09","","","2022-08-11","8/11/2022 Rcvd email from Scott & White that monthly delegated roster for June has been completed and providers are loaded to group delegation roster effective 5/9/2022.  DCannon"]
["Valarie Ramirez Alcala, PA",1790251031,"46-3131679","TX","PE - Midland Texas Orthopedic Group Inc","Amerigroup","Participating","Enrollment Complete","2022-04-14","","","2023-09-20","9/20/2023 Per email received from Amerigroup provider is PAR and linked to group TIN effective 4/14/2022.  DCannon"]
["Valarie Ramirez Alcala, PA",1790251031,"46-3131679","TX","PE - Midland Texas Orthopedic Group Inc","CAQH","Participating","CAQH Reattested","2023-10-03","","","2023-10-03","10/3/2023 CAQH reviewed and re-attested.  DCannon"]
["Valarie Ramirez Alcala, PA",1790251031,"46-3131679","TX","PE - Midland Texas Orthopedic Group Inc","Wellcare","Participating","Enrollment Complete","2022-06-01","","","2022-07-01","7/1/2022 Received June Monthly Validation roster from Superior and provider is PAR and linked effective 6/1/2022.  DCannon"]
["Valarie Ramirez Alcala, PA",1790251031,"46-3131679","TX","PE - Midland Texas Orthopedic Group Inc","USA PPO","Participating","Enrollment Complete","2022-05-09","","","2022-10-13","10/13/2022 In following up with USAMCO (800-872-3860) I was told that you can confirm participating via the USA MCO website  https://providersearch.usamco.com/hwprovsearch.  Provider is PAR and linked to location/TIN effective 5/9/2022.  DCannon"]
["Valarie Ramirez Alcala, PA",1790251031,"46-3131679","TX","PE - Midland Texas Orthopedic Group Inc","Aetna","Participating","Enrollment Complete","2022-05-09","6757971","","2022-06-02","6/2/2022 Per Aetna provider directory provider is PAR and linked to group TIN/location effective 5/9/2022.   DCannon"]
["Valarie Ramirez Alcala, PA",1790251031,"46-3131679","TX","PE - Midland Texas Orthopedic Group Inc","Sedgwick","In Process","Pending Contracting","","","","2023-11-20","Emailed ProviderData@Careworks.com to see if group has a direct contract with Sedgwick. Jen Videan"]
["Valarie Ramirez Alcala, PA",1790251031,"46-3131679","TX","PE - Midland Texas Orthopedic Group Inc","Cigna","Participating","Enrollment Complete","2022-08-05","6284348","","2022-08-23","8.20.2022 -Per follow-up note provider is PAR and linked to group TIN# effective 8/5/2022, the physical location is on file and the Provider ID is  6284348.   DCannon"]
["Valarie Ramirez Alcala, PA",1790251031,"46-3131679","TX","PE - Midland Texas Orthopedic Group Inc","Texas Mutual","Participating","Enrollment Complete","2022-08-01","","","2022-08-04","8/4/2022 Received approval letter for TX Mutual/Workwell.  Provider is PAR effective 8/1/2022.  DCannon"]
["Valarie Ramirez Alcala, PA",1790251031,"46-3131679","TX","PE - Midland Texas Orthopedic Group Inc","Tricare Prime","Participating","Enrollment Complete","2022-04-29","","","2022-06-02","6/1/2022 Per Tricare portal provider is PAR and linked to group TIN/location effective 4/29/2022.  DCannon"]
["Valarie Ramirez Alcala, PA",1790251031,"46-3131679","TX","PE - Midland Texas Orthopedic Group Inc","Medicaid","Participating","Enrollment Complete","2022-03-14","1790251031","","2023-03-15","3/15/2023 Rcvd confirmation that license has been on TMHP portal.  Provider is PAR effective 3/14/2022.  DCannon"]
["Valarie Ramirez Alcala, PA",1790251031,"46-3131679","TX","PE - Midland Texas Orthopedic Group Inc","Boon Chapman","Participating","Enrollment Complete","2022-05-09","","","2022-07-24","7/24/2022 Per email from Marcie Eckhart-Havens Multiplan July delegated roster has been completed  and provider is PAR and linked to group TIN effective 5/09/2022.  DCannon"]
["Valarie Ramirez Alcala, PA",1790251031,"46-3131679","TX","PE - Midland Texas Orthopedic Group Inc","Travelers WC","Panel Closed","Panel Closed","","","","2023-01-25","1.25.23 Confirmed with Jennifer Hoffman <JMHOFFMA@travelers.com> that providers must first be enrolled in Coventry's network before they can be considered for Travelers WC. Provider placed in 'Pending other enrollment' status. ABoles"]
["Valarie Ramirez Alcala, PA",1790251031,"46-3131679","TX","PE - Midland Texas Orthopedic Group Inc","Humana","Participating","Enrollment Complete","2022-05-09","","","2022-08-20","8/20/2022 Per email received from Vernita Young July monthly delegated roster is complete and provider is PAR and linked to group TIN/location effective 5/9/2022.  DCannon"]
["Valarie Ramirez Alcala, PA",1790251031,"46-3131679","TX","PE - Midland Texas Orthopedic Group Inc","Superior","Participating","Enrollment Complete","2022-06-01","","","2022-06-01","6/1/2022 Per roster received from Superior May monthly delegated submission is complete and provider is PAR and linked to group TIN/locations effective  6/1/2022.  DCannon"]
["Valarie Ramirez Alcala, PA",1790251031,"46-3131679","TX","PE - Midland Texas Orthopedic Group Inc","TriCare Standard","Participating","Enrollment Complete","2022-04-29","","","2022-05-19","5/19/2022 Per Tricare portal provider is PAR and linked to group TIN/location effective 4/29/2022.  DCannon"]
["Valarie Ramirez Alcala, PA",1790251031,"46-3131679","TX","PE - Midland Texas Orthopedic Group Inc","Medicare","Participating","Enrollment Complete","2022-03-14","2E8661","320497","2022-06-21","6/21/2022 Rcvd Medicare approval letter.  PTAN # 2E8661 - effective 3/14/2022.  DCannon"]
["Valarie Ramirez Alcala, PA",1790251031,"46-3131679","TX","PE - Midland Texas Orthopedic Group Inc","Wellmed","Participating","Enrollment Complete","2022-05-21","","","2023-03-23","3/23/2023 Rcvd roster from UHC w/ all Wellmed participating providers.  Provider is PAR effective 5/21/2022.  DCannon"]
["Valarie Ramirez Alcala, PA",1790251031,"46-3131679","TX","PE - Midland Texas Orthopedic Group Inc","Coventry Workers Comp","Panel Closed","Panel Closed","","","","2023-05-22","Enrollment Panel is Closed. MS"]
["Valarie Ramirez Alcala, PA",1790251031,"46-3131679","TX","PE - Midland Texas Orthopedic Group Inc","Multiplan","Participating","Enrollment Complete","2022-05-09","","","2022-07-24","7/24/2022 Per email from Marcie Eckhart-Havens Multiplan July delegated roster has been completed  and provider is PAR and linked to group TIN effective 5/9/2022.  DCannon"]
["Valarie Ramirez Alcala, PA",1790251031,"46-3131679","TX","PE - Midland Texas Orthopedic Group Inc","Caprock (CapStar)","Participating","Enrollment Complete","2022-04-14","","","2022-07-15","7/15/2022 Per roster rcvd from Caprock provider is PAR and linked to group effective 4/14/2022.  DCannon"]
["Valarie Ramirez Alcala, PA",1790251031,"46-3131679","TX","PE - Midland Texas Orthopedic Group Inc","Rail Road Medicare","Participating","Enrollment Complete","2022-03-14","Q00321030","DU5783","2022-09-06","9/6/2022 Rcvd RR Medicare approval letter. RR Medicare PTAN #  Q00321030 - effective 3/14/2022.  DCannon"]
["Valarie Ramirez Alcala, PA",1790251031,"46-3131679","TX","PE - Midland Texas Orthopedic Group Inc","Triwest VA","In House Enrollment","In House Enrollment","","","","2022-04-18",""]
["Valarie Ramirez Alcala, PA",1790251031,"46-3131679","TX","PE - Midland Texas Orthopedic Group Inc","Liberty Mutual","Panel Closed","Panel Closed","","","","2023-02-01","2.1.23 Called Liberty Mutual HCN @ 972-550-7899 and left message with call back info & sent email to texasmutual@libertymutual.com requesting clarification about their networks partnership with Coventry/First Health. ABoles"]
["Valarie Ramirez Alcala, PA",1790251031,"46-3131679","TX","PE - Midland Texas Orthopedic Group Inc","First Health Coventry","Participating","Enrollment Complete","2022-05-09","","","2022-09-16","9/16/2022  Per First Health online provider directory provider is PAR and linked to group/locations  effective 5/9/2022.  PID # 3218134.  DCannon"]
["Valarie Ramirez Alcala, PA",1790251031,"46-3131679","TX","PE - Midland Texas Orthopedic Group Inc","Omni PPO","Participating","Enrollment Complete","2022-05-09","","","2022-07-05","7/5/2022 Rcvd email from G.Aviles at IMS/OMNI that delegation roster provider load for June has been completed.  Provider is PAR and linked to group effective 5/9/2022.  DCannon"]
["Valarie Ramirez Alcala, PA",1790251031,"46-3131679","TX","PE - Midland Texas Orthopedic Group Inc","Galaxy Health","Participating","Enrollment Complete","2022-05-09","","","2022-08-17","8/17/2022 Per email from Karen Avalos at Galaxy delegated roster for May is complete and provider is loaded effective 5/9/2022.  DCannon"]
["Valarie Ramirez Alcala, PA",1790251031,"46-3131679","TX","PE - Midland Texas Orthopedic Group Inc","Zurich","Panel Closed","Panel Closed","","","","2023-02-03","2.3.23 Plan pends enrollment with Coventry WC. ABoles"]
["Valarie Ramirez Alcala, PA",1790251031,"46-3131679","TX","PE - Midland Texas Orthopedic Group Inc","HealthSmart PPO","Participating","Enrollment Complete","2022-05-09","","","2022-06-02","6/1/2022 Per Healthsmart website provider is PAR and loaded under TIN/location effective 5/9/2022.  DCannon"]
["Caroline D Hammond, PA",1720698574,"46-3131679","TX","PE - Midland Texas Orthopedic Group Inc","Wellmed","Participating","Enrollment Complete","2022-05-11","","","2023-03-23","3/23/2023 Rcvd roster from UHC w/ all Wellmed participating providers.  Provider is PAR effective 5/11/2022.  DCannon"]
["Caroline D Hammond, PA",1720698574,"46-3131679","TX","PE - Midland Texas Orthopedic Group Inc","Rail Road Medicare","Participating","Enrollment Complete","2022-03-14","Q00267370","DU5783","2022-05-26","5/26/2022 Rcvd RR Medicare approval letter. RR Medicare PTAN #  Q00267370 - effective 3/14/2022.  DCannon"]
["Caroline D Hammond, PA",1720698574,"46-3131679","TX","PE - Midland Texas Orthopedic Group Inc","Triwest VA","In House Enrollment","Enrollment on Hold","","","","2022-10-17","10/17/2022 - Received roster from Scarlett of TriWest VA; provider status: \"No action provider will need to complete initial credentialing prior to adding CCN. Please resubmit your request to add CCN once provider has fully Initial Credentialing.\""]
["Caroline D Hammond, PA",1720698574,"46-3131679","TX","PE - Midland Texas Orthopedic Group Inc","First Health Coventry","Participating","Enrollment Complete","2022-05-01","3557984","","2022-10-11","10.11.2022: MA: S/W Lesly of First Health @800-226-5116. Provider NPI# is on file for the provider, in netwrok with First Health and link under the group and TIN effective 05/01/2022. Provider ID# 3557984. Physical location is on file. Ref# 438604. - Mary Rose Acebedo"]
["Caroline D Hammond, PA",1720698574,"46-3131679","TX","PE - Midland Texas Orthopedic Group Inc","Medicare","Participating","Enrollment Complete","2022-03-14","2D2395","320497","2022-05-06","5/6/2022 Rcvd Medicare approval letter.  PTAN # 2D2395 - effective 3/14/2022.  DCannon"]
["Caroline D Hammond, PA",1720698574,"46-3131679","TX","PE - Midland Texas Orthopedic Group Inc","Liberty Mutual","Panel Closed","Panel Closed","","","","2023-07-19","07/18/2023. We appreciate your interest in joining the Coventry Network.  At this time, our panels are closed, and we are not accepting new applications.  Please check back routinely to stay apprised of our panel status. We will update this site when we are open for new applicants. Gallagher, Hartford, Liberty Mutual, Travelers and Zurich fall under Coventry. Jen Videan"]
["Caroline D Hammond, PA",1720698574,"46-3131679","TX","PE - Midland Texas Orthopedic Group Inc","HealthSmart PPO","Participating","Enrollment Complete","2022-05-09","","","2022-06-02","6/1/2022 Per Healthsmart website provider is PAR and loaded under TIN/location effective 5/9/2022.  DCannon"]
["Caroline D Hammond, PA",1720698574,"46-3131679","TX","PE - Midland Texas Orthopedic Group Inc","Superior","Participating","Enrollment Complete","2022-06-01","","","2022-06-01","6/1/2022 Rcvd roster from Superior Health Plan confirming provider is PAR and linked to group TIN/location effective 6/1/2022.  DCannon"]
["Caroline D Hammond, PA",1720698574,"46-3131679","TX","PE - Midland Texas Orthopedic Group Inc","Gallagher","Panel Closed","Panel Closed","","","","2023-07-19","07/18/2023. We appreciate your interest in joining the Coventry Network.  At this time, our panels are closed, and we are not accepting new applications.  Please check back routinely to stay apprised of our panel status. We will update this site when we are open for new applicants. Gallagher, Hartford, Liberty Mutual, Travelers and Zurich fall under Coventry. Jen Videan"]
["Caroline D Hammond, PA",1720698574,"46-3131679","TX","PE - Midland Texas Orthopedic Group Inc","CAQH","Participating","CAQH Reattested","2023-10-05","15556542","","2023-10-05","10/5/2023 CAQH reviewed and re-attested.  DCannon"]
["Caroline D Hammond, PA",1720698574,"46-3131679","TX","PE - Midland Texas Orthopedic Group Inc","Scott&White (First Care)","Participating","Enrollment Complete","2022-05-09","","","2022-08-11","8/11/2022 Rcvd email from Scott & White that monthly delegated roster for June has been completed and providers are loaded to group delegation roster effective 5/9/2022.  DCannon"]
["Caroline D Hammond, PA",1720698574,"46-3131679","TX","PE - Midland Texas Orthopedic Group Inc","Travelers WC","Panel Closed","Panel Closed","","","","2023-07-19","07/18/2023. We appreciate your interest in joining the Coventry Network.  At this time, our panels are closed, and we are not accepting new applications.  Please check back routinely to stay apprised of our panel status. We will update this site when we are open for new applicants. Gallagher, Hartford, Liberty Mutual, Travelers and Zurich fall under Coventry. Jen Videan"]
["Caroline D Hammond, PA",1720698574,"46-3131679","TX","PE - Midland Texas Orthopedic Group Inc","Corvel Healthcare Corp.","Participating","Enrollment Complete","2022-08-09","","","2022-08-09","8/9/2022 Rcvd Corvel approval letter.  Provider is PAR and linked to group TIN/locations effective 8/9/2022.  DCannon"]
["Caroline D Hammond, PA",1720698574,"46-3131679","TX","PE - Midland Texas Orthopedic Group Inc","Zurich","Panel Closed","Panel Closed","","","","2023-07-19","07/18/2023. We appreciate your interest in joining the Coventry Network.  At this time, our panels are closed, and we are not accepting new applications.  Please check back routinely to stay apprised of our panel status. We will update this site when we are open for new applicants. Gallagher, Hartford, Liberty Mutual, Travelers and Zurich fall under Coventry. Jen Videan"]
["Caroline D Hammond, PA",1720698574,"46-3131679","TX","PE - Midland Texas Orthopedic Group Inc","IMS","Participating","Enrollment Complete","2022-05-09","","","2022-07-05","7/5/2022 Rcvd email from G.Aviles at IMS/OMNI that delegation roster provider load for June has been completed.  Provider is PAR and linked to group effective 5/9/2022.  DCannon"]
["Caroline D Hammond, PA",1720698574,"46-3131679","TX","PE - Midland Texas Orthopedic Group Inc","Omni PPO","Participating","Enrollment Complete","2022-05-09","","","2022-07-05","7/5/2022 Rcvd email from G.Aviles at IMS/OMNI that delegation roster provider load for June has been completed.  Provider is PAR and linked to group effective 5/9/2022.  DCannon"]
["Caroline D Hammond, PA",1720698574,"46-3131679","TX","PE - Midland Texas Orthopedic Group Inc","Broadspire Services Inc.","In Process","Pending Info/Document","","","","2023-11-21","Emailed Priscilla and Neerja for status of signed group agreements. Unable to move forward with individual provider until group agreement is in place.  Jen Videan"]
["Caroline D Hammond, PA",1720698574,"46-3131679","TX","PE - Midland Texas Orthopedic Group Inc","Medicaid","Participating","Enrollment Complete","2022-03-14","1720698574","","2023-07-27","7/27/2023 Per TX Medicaid portal provider license and board certificate has been updated. \n Provider is PAR and linked to group effective 3/14/2022.  DCannon"]
["Caroline D Hammond, PA",1720698574,"46-3131679","TX","PE - Midland Texas Orthopedic Group Inc","TriCare Standard","Participating","Enrollment Complete","2022-10-01","","","2022-10-28","10/28/2022 Per Tricare/Humana Military portal provider is PAR and linked to group TIN/location effective 10/1/2022.  DCannon"]
["Caroline D Hammond, PA",1720698574,"46-3131679","TX","PE - Midland Texas Orthopedic Group Inc","Ambetter","Participating","Enrollment Complete","2022-06-01","","","2022-06-13","6/13/2022 Per roster received from Superior provider is PAR and linked to group delegation roster effective 6/1/2022."]
["Caroline D Hammond, PA",1720698574,"46-3131679","TX","PE - Midland Texas Orthopedic Group Inc","Texas Municipal League","Participating","Enrollment Complete","2022-09-16","","","2022-09-27","9/27/2022 Rcvd PSWCA - Alliance approval letter.  Provider is PAR and linked to group TIN effective 9/16/2022.  DCannon"]
["Caroline D Hammond, PA",1720698574,"46-3131679","TX","PE - Midland Texas Orthopedic Group Inc","USA PPO","Participating","Enrollment Complete","2022-05-09","","","2022-09-06","9/6/2022 In following up with USAMCO (800-872-3860) I was told that you can confirm participating via the USA MCO website  https://providersearch.usamco.com/hwprovsearch.  Provider is PAR and linked to location/TIN effective 5/9/2022.  DCannon"]
["Caroline D Hammond, PA",1720698574,"46-3131679","TX","PE - Midland Texas Orthopedic Group Inc","Cigna","Participating","Enrollment Complete","2022-08-08","9392106","","2022-09-27","9/27/2022 Per follow-up note - S/W Sophie of Cigna @ 1-800-882-4462. NPI# is on file for the provider and is participating effective 08/08/2022 under the group and TIN. Provider ID# 9392106. Physical location is on file.  DCannon"]
["Caroline D Hammond, PA",1720698574,"46-3131679","TX","PE - Midland Texas Orthopedic Group Inc","Sedgwick","In Process","Pending Contracting","","","","2023-11-20","Emailed ProviderData@Careworks.com to see if group has a direct contract with Sedgwick. Jen Videan"]
["Caroline D Hammond, PA",1720698574,"46-3131679","TX","PE - Midland Texas Orthopedic Group Inc","Galaxy Health","Participating","Enrollment Complete","2022-05-09","","","2022-08-17","8/17/2022 Per email from Karen Avalos at Galaxy delegated roster for May is complete and provider is loaded effective 5/9/2022.  DCannon"]
["Caroline D Hammond, PA",1720698574,"46-3131679","TX","PE - Midland Texas Orthopedic Group Inc","Aetna","Participating","Enrollment Complete","2022-05-09","6227554","","2022-06-02","6/2/2022 Per Aetna provider directory provider is PAR and linked to group TIN/location effective 5/9/2022.   DCannon"]
["Caroline D Hammond, PA",1720698574,"46-3131679","TX","PE - Midland Texas Orthopedic Group Inc","Alliance WC","Participating","Enrollment Complete","2022-09-16","","","2022-09-27","9/27/2022 Rcvd PSWCA - Alliance approval letter.  Provider is PAR and linked to group TIN effective 9/16/2022.  DCannon"]
["Caroline D Hammond, PA",1720698574,"46-3131679","TX","PE - Midland Texas Orthopedic Group Inc","Tricare Prime","Panel Closed","Panel Closed","","","","2022-10-28","10/28/2022 Per Tricare/Humana Military is currently not accepting requests to join the medical surgical network. Will check back soon to see if we are accepting network providers.  DCannon"]
["Caroline D Hammond, PA",1720698574,"46-3131679","TX","PE - Midland Texas Orthopedic Group Inc","Coventry Workers Comp","Panel Closed","Panel Closed","","","","2023-05-22","Enrollment Panel is Closed. MS"]
["Caroline D Hammond, PA",1720698574,"46-3131679","TX","PE - Midland Texas Orthopedic Group Inc","Boon Chapman","Participating","Enrollment Complete","2022-05-09","","","2022-07-24","7/24/2022 Per email from Marcie Eckhart-Havens Multiplan July delegated roster has been completed  and provider is PAR and linked to group TIN effective 5/9/2022.  DCannon"]
["Caroline D Hammond, PA",1720698574,"46-3131679","TX","PE - Midland Texas Orthopedic Group Inc","Multiplan","Participating","Enrollment Complete","2022-05-09","","","2022-07-24","7/24/2022 Per email from Marcie Eckhart-Havens Multiplan July delegated roster has been completed  and provider is PAR and linked to group TIN effective 5/9/2022.  DCannon"]
["Caroline D Hammond, PA",1720698574,"46-3131679","TX","PE - Midland Texas Orthopedic Group Inc","Texas Mutual","Participating","Enrollment Complete","2022-08-01","","","2022-08-04","8/4/2022 Received approval letter for TX Mutual/Workwell.  Provider is PAR effective 8/1/2022.  DCannon"]
["Caroline D Hammond, PA",1720698574,"46-3131679","TX","PE - Midland Texas Orthopedic Group Inc","Caprock (CapStar)","Participating","Enrollment Complete","2022-05-09","","","2022-07-15","7/15/2022 Per roster rcvd from Caprock provider is PAR and linked to group effective 5/9/2022.  DCannon"]
["Caroline D Hammond, PA",1720698574,"46-3131679","TX","PE - Midland Texas Orthopedic Group Inc","Humana","Participating","Enrollment Complete","2022-05-09","","","2022-08-20","8/20/2022 Per email received from Vernita Young July monthly delegated roster is complete and provider is PAR and linked to group TIN/location effective 5/9/2022.  DCannon"]
["Caroline D Hammond, PA",1720698574,"46-3131679","TX","PE - Midland Texas Orthopedic Group Inc","Amerigroup","Participating","Enrollment Complete","2022-05-09","","","2022-09-23","9/23/2022 Per roster received from Joe Rodriguez at Amerigroup provider is PAR and linked to group TIN effective 5/9/2022.  DCannon"]
["Caroline D Hammond, PA",1720698574,"46-3131679","TX","PE - Midland Texas Orthopedic Group Inc","United Health Care","Participating","Enrollment Complete","2022-05-09","008029436","","2022-06-29","6/29/2022 Per email received from  from UHC monthly delegated roster submission has been completed and provider is PAR and in linked to group TIN effective 5/9/2022.   MPIN# 008029436.   DCannon"]
["John C Dean, MD",1013923291,"46-3131679","TX","PE - Midland Texas Orthopedic Group Inc","Medicare","Participating","Enrollment Complete","2013-08-01","321613YV2D","320497","2020-01-30","01/30/2020 - Found that this provider is EFF thorugh PECOS group application - Stacey Hudak"]
["John C Dean, MD",1013923291,"46-3131679","TX","PE - Midland Texas Orthopedic Group Inc","Caprock (CapStar)","Participating","Enrollment Complete","2013-08-01","1013923291","","",""]
["John C Dean, MD",1013923291,"46-3131679","TX","PE - Midland Texas Orthopedic Group Inc","Zurich","Participating","Enrollment Complete","2014-01-01","","","2021-08-06","8/6/2021 Moved to enrollment complete per notes from First Health/Coventry. Provider is effective 1/1/2014. KFrazier"]
["John C Dean, MD",1013923291,"46-3131679","TX","PE - Midland Texas Orthopedic Group Inc","Sedgwick","Participating","Enrollment Complete","2020-06-16","417566","","2021-01-26","1/26/2021 - Per follow-up notes provider is par with TIN and location effective 6/16/2020.  DCannon"]
["John C Dean, MD",1013923291,"46-3131679","TX","PE - Midland Texas Orthopedic Group Inc","Wellcare","Participating","Enrollment Complete","2021-11-01","","","2022-11-15","11/15/2022 Per roster received from Wellcare provider is PAR and linked to group TIN/location effective 11/1/2021.  DCannon"]
["John C Dean, MD",1013923291,"46-3131679","TX","PE - Midland Texas Orthopedic Group Inc","USA PPO","Participating","Enrollment Complete","2020-06-16","1013923291","463131679","2020-08-19","Confirmed provider is participating with PPO and H&W networks (list of networks is attached). Kimberly Frazier"]
["John C Dean, MD",1013923291,"46-3131679","TX","PE - Midland Texas Orthopedic Group Inc","Boon Chapman","Participating","Enrollment Complete","2013-08-01","","","2021-08-06","8/6/2021 Boon Chapman falls under the Multiplan umbrella, received roster from Multiplan provider is listed on roster under TIN/location as PAR effective 8/1/2013.  DCannon"]
["John C Dean, MD",1013923291,"46-3131679","TX","PE - Midland Texas Orthopedic Group Inc","IMS","Participating","Enrollment Complete","2013-08-31","1013923291","","2020-06-22","06/22/2020- Rec'd email from the payer confirming this provider is PAR with this group/service location - Stacey Hudak"]
["John C Dean, MD",1013923291,"46-3131679","TX","PE - Midland Texas Orthopedic Group Inc","United Health Care","Participating","Enrollment Complete","2020-01-01","1013923291","","2020-08-31","08/31/2020 - moved to completed status after reviewing follow up status - Stacey Hudak"]
["John C Dean, MD",1013923291,"46-3131679","TX","PE - Midland Texas Orthopedic Group Inc","Galaxy Health","Participating","Enrollment Complete","2016-10-18","1013923291","","2020-07-10","07/10/2020 - updated payer line to enrollment complete status instead of \"Delegated status\" for report running purposes - Stacey Hudak"]
["John C Dean, MD",1013923291,"46-3131679","TX","PE - Midland Texas Orthopedic Group Inc","Gallagher","Participating","Enrollment Complete","2014-01-01","2019864","2559513","2021-08-06","8/6/2021 Moved to enrollment complete per notes from First Health/Coventry. Provider is effective 1/1/2014. KFrazier"]
["John C Dean, MD",1013923291,"46-3131679","TX","PE - Midland Texas Orthopedic Group Inc","Cigna","Participating","Enrollment Complete","2013-08-01","1013923291","","2020-02-20","02/20/2020 - Had the follow up team call Cigna to verify provider enrollment with this TIN. They were advised that this provider is EFF as of 8-1-2013 under a DIRECT CONTRACT at this service location. - Stacey Hudak"]
["John C Dean, MD",1013923291,"46-3131679","TX","PE - Midland Texas Orthopedic Group Inc","CAQH","Participating","CAQH Reattested","2023-10-05","","","2023-10-05","10/05/2023 - CAQH  updated and uploaded dea, board and license, reviewed and re-attested - dkonar"]
["John C Dean, MD",1013923291,"46-3131679","TX","PE - Midland Texas Orthopedic Group Inc","Triwest VA","Participating","Enrollment Complete","2022-08-01","","","2022-11-14","11/14/22 Per Scarlett Abigail, provider effective from 8/1/22"]
["John C Dean, MD",1013923291,"46-3131679","TX","PE - Midland Texas Orthopedic Group Inc","Wellmed","Participating","Enrollment Complete","2022-01-01","","","2023-03-23","3/23/2023 Rcvd roster from UHC w/ all Wellmed participating providers.  Provider is PAR effective 1/1/2022.  DCannon"]
["John C Dean, MD",1013923291,"46-3131679","TX","PE - Midland Texas Orthopedic Group Inc","Ambetter","Participating","Enrollment Complete","2022-04-01","","","2022-06-13","6/13/2022 Per roster received from Superior provider is PAR and linked to group delegation roster effective 4/1/2022."]
["John C Dean, MD",1013923291,"46-3131679","TX","PE - Midland Texas Orthopedic Group Inc","HealthSmart PPO","Participating","Enrollment Complete","2019-05-15","1013923291","","2020-06-05","06/05/2020 - Rec'd email from the payer stating this provider is EFF - Stacey Hudak"]
["John C Dean, MD",1013923291,"46-3131679","TX","PE - Midland Texas Orthopedic Group Inc","Omni PPO","Participating","Enrollment Complete","2013-08-31","1013923291","","2020-06-25",""]
["John C Dean, MD",1013923291,"46-3131679","TX","PE - Midland Texas Orthopedic Group Inc","TriCare Standard","Participating","Enrollment Complete","2014-04-01","1013923291","","2020-03-03","03/03/2020 - Rec'd confirmation of provider enrollment through payer portal. Provider is linked to group at this service location - Stacey Hudak"]
["John C Dean, MD",1013923291,"46-3131679","TX","PE - Midland Texas Orthopedic Group Inc","First Health Coventry","Participating","Enrollment Complete","2014-01-01","2019864","","2020-03-20","3-20-2020 - Rec'd email from the payer verifying that this provider is EFF under PID# 2019864 - Stacey Hudak"]
["John C Dean, MD",1013923291,"46-3131679","TX","PE - Midland Texas Orthopedic Group Inc","Scott&White (First Care)","Participating","Enrollment Complete","2016-12-19","","","2021-01-29","1/29/2021 - Rcvd roster from Scott&White (First Care) confirming participation of provider with TIN and location effective dates.  DCannon"]
["John C Dean, MD",1013923291,"46-3131679","TX","PE - Midland Texas Orthopedic Group Inc","Humana","Participating","Enrollment Complete","2020-01-01","1013923291","","2020-07-19","7/19/2020 - Received email spreadsheet from the payor confirming that this provider is EFF at this service location and PAR with the PRIMED DELEGATED agreement - Pam Porter"]
["John C Dean, MD",1013923291,"46-3131679","TX","PE - Midland Texas Orthopedic Group Inc","Texas Mutual","Participating","Enrollment Complete","2020-01-07","","","2021-01-23","11/25/2020-Confirmed provider is participating under group Tax ID and practice location. Rafael Calixtro"]
["John C Dean, MD",1013923291,"46-3131679","TX","PE - Midland Texas Orthopedic Group Inc","Multiplan","Participating","Enrollment Complete","2013-08-01","1013923291","West Texas Physician Alliance","2020-09-28","09/28/2020 - moved to completed status after reviewing follow up complete note - Stacey Hudak"]
["John C Dean, MD",1013923291,"46-3131679","TX","PE - Midland Texas Orthopedic Group Inc","Rail Road Medicare","Participating","Enrollment Complete","2013-08-01","P01348965","DU5783","2020-03-10","03/10/2020 - Found EFF info through payer site - Stacey Hudak"]
["John C Dean, MD",1013923291,"46-3131679","TX","PE - Midland Texas Orthopedic Group Inc","Amerigroup","Participating","Enrollment Complete","2019-07-19","02709262","","2021-05-04","5/4/2021 Rcvd roster from Amerigroup listing provider as PAR and in network effective 7/19/2019.  DCannon"]
["John C Dean, MD",1013923291,"46-3131679","TX","PE - Midland Texas Orthopedic Group Inc","Liberty Mutual","Participating","Enrollment Complete","2018-06-01","","","2021-01-27","1/27/2021 - Per follow-up notes provider is on file and participating at location and under TIN effective 06/01/2018.  DCannon"]
["John C Dean, MD",1013923291,"46-3131679","TX","PE - Midland Texas Orthopedic Group Inc","Superior","Participating","Enrollment Complete","2016-10-01","1013923291","","2020-07-14","07/14/2020 - Rec'd spreadsheet from the delegated team stating this provider has been linked to the PriMed contract since 10-1-2016  **see the other enrollment complete line to see details about when this provider became effective with various specific products** - stacey Hudak"]
["John C Dean, MD",1013923291,"46-3131679","TX","PE - Midland Texas Orthopedic Group Inc","Medicaid","Participating","Enrollment Complete","","119245205","331090601","2021-10-06","10/6/2021 Confirmed license update complete via TMHP Portal.  DCannon"]
["John C Dean, MD",1013923291,"46-3131679","TX","PE - Midland Texas Orthopedic Group Inc","Aetna","Participating","Enrollment Complete","2019-07-15","1013923291","","2020-02-03","02/03/2020 - Rec'd confirmation from the payer stating this provider is EFF 7-15-2019 under a DIRECT CONTRACT. Service location is linked to the provider and next reval is due 7-15-2022 - Stacey Hudak"]
["Jessie J Dickens, MD",1215254156,"46-3131679","TX","PE - Midland Texas Orthopedic Group Inc","Medicare","Participating","Enrollment Complete","2016-08-15","536764YV2D"," 320497","2020-01-30","01/30/2020 - Found provider is PAR with Medicare through group enrollment in PECOS - Stacey Hudak"]
["Jessie J Dickens, MD",1215254156,"46-3131679","TX","PE - Midland Texas Orthopedic Group Inc","Medicaid","Participating","Enrollment Complete","2016-08-15","364970901","331090601","2020-02-18","02/18/2020 - Rec'd letter from the payer stating \"Per our records shows you already enrolled using the same Medicare ID and same location under suffix\n01 revalidation date is until 06/19/2024.\"  I still have to locate this providers TPI - Stacey Hudak"]
["Jessie J Dickens, MD",1215254156,"46-3131679","TX","PE - Midland Texas Orthopedic Group Inc","First Health Coventry","Participating","Enrollment Complete","2016-06-01","1215254156","","2020-04-29","04/29/2020  - Rec'd email back from MULTIPLAN stating \" We received the attached demographic update from Coventry.\n\n The provider, Jessie Dickens is alreadycontracted with tax id number 46-3131679 under the groups :\n\n5026  West Texas Physicians Alliance  forMultiPlan \n\n5031  Permian Basin Healthcare Network   forMultiPlan and PHCS\n\n\nThere is no Workers Compensation linked to eitherof these contracts.\n\n5615 Deauville Ste 220 Midland, TX 79706 locationis already on file effective 06/01/2016. \n\nBilling address: Po Box 14800 Belfast, ME 04915 is also on file effective 06/01/2016.\n \nPlease advise if there is anything else you needfrom MultiPlan.\n \nThankyou and please let me know if you have any further questions.  \n   \nTamera Burich  \n\nKeyAccount Representative  \n\ntamera.burich@multiplan.com  \n\n \nMultiPlan  \n\n301N Broadway Ste 301 \n\nDePere WI 54115 \n\nPh:920-347-3268  \n\nFax: (888)850-7604 \" - Stacey Hudak"]
["Jessie J Dickens, MD",1215254156,"46-3131679","TX","PE - Midland Texas Orthopedic Group Inc","CAQH","Participating","CAQH Reattested","2023-10-05","12803191","","2023-10-05","10/05/2023 - Updated DEA, License, credential contact and reattested - rkedar"]
["Jessie J Dickens, MD",1215254156,"46-3131679","TX","PE - Midland Texas Orthopedic Group Inc","Aetna","Participating","Enrollment Complete","2019-08-01","1215254156","","2020-02-03","02/03/2020 - Confirmed with payer that this provider is EFF 8-1-2019 through a DELEGATED GROUP: Permian Basin Health.  This service location is on file and linked to the provider - Stacey Hudak"]
["Jessie J Dickens, MD",1215254156,"46-3131679","TX","PE - Midland Texas Orthopedic Group Inc","Humana","Participating","Enrollment Complete","2020-01-01","1215254156","","2020-07-19","7/19/2020 - Received email spreadsheet from the payor confirming that this provider is EFF at this service location and PAR with the PRIMED DELEGATED agreement - Pam Porter"]
["Jessie J Dickens, MD",1215254156,"46-3131679","TX","PE - Midland Texas Orthopedic Group Inc","Zurich","Participating","Enrollment Complete","2016-06-01","","","2021-08-06","8/6/2021 Moved to enrollment complete per notes from First Health/Coventry. Provider is effective 6/1/2016. KFrazier"]
["Jessie J Dickens, MD",1215254156,"46-3131679","TX","PE - Midland Texas Orthopedic Group Inc","Galaxy Health","Participating","Enrollment Complete","2016-06-01","1215254156","","2020-07-10","07/10/2020 - updated payer line to enrollment complete status instead of \"Delegated status\" for report running purposes - Stacey Hudak"]
["Jessie J Dickens, MD",1215254156,"46-3131679","TX","PE - Midland Texas Orthopedic Group Inc","Triwest VA","Participating","Enrollment Complete","2022-08-01","","","2022-11-14","11/14/22 Per Scarlett Abigail, provider effective from 8/1/22"]
["Jessie J Dickens, MD",1215254156,"46-3131679","TX","PE - Midland Texas Orthopedic Group Inc","Cigna","Participating","Enrollment Complete","2016-12-14","1215254156","","2020-02-20","02/20/2020 - Had the follow up team call Cigna to verify provider enrollment with this TIN. They were advised that this provider is EFF as of 12-14-2016 under a DIRECT CONTRACT at this service location. - Stacey Hudak"]
["Jessie J Dickens, MD",1215254156,"46-3131679","TX","PE - Midland Texas Orthopedic Group Inc","Boon Chapman","Participating","Enrollment Complete","2016-06-01","1215254156","","2020-10-05","Enrollment thru PHCS"]
["Jessie J Dickens, MD",1215254156,"46-3131679","TX","PE - Midland Texas Orthopedic Group Inc","Liberty Mutual","Panel Closed","Panel Closed","","","","2023-07-19","07/18/2023. We appreciate your interest in joining the Coventry Network.  At this time, our panels are closed, and we are not accepting new applications.  Please check back routinely to stay apprised of our panel status. We will update this site when we are open for new applicants. Gallagher, Hartford, Liberty Mutual, Travelers and Zurich fall under Coventry. Jen Videan"]
["Jessie J Dickens, MD",1215254156,"46-3131679","TX","PE - Midland Texas Orthopedic Group Inc","Gallagher","Participating","Enrollment Complete","2016-06-01","","","2021-08-06","8/6/2021 Moved to enrollment complete per notes from First Health/Coventry. Provider is effective 6/1/2016. KFrazier"]
["Jessie J Dickens, MD",1215254156,"46-3131679","TX","PE - Midland Texas Orthopedic Group Inc","Multiplan","Participating","Enrollment Complete","2016-06-01","1215254156","","2020-04-29","The provider, Jessie Dickens is alreadycontracted with tax id number 46-3131679 under the groups :\n\n5026  West Texas Physicians Alliance  forMultiPlan \n\n5031  Permian Basin Healthcare Network   forMultiPlan and PHCS\n\n \n\n \n\nThere is no Workers Compensation linked to eitherof these contracts.\n\n \n\n5615 Deauville Ste 220 Midland, TX 79706 locationis already on file effective 06/01/2016. \n\nBilling address: Po Box 14800 Belfast, ME 04915 is also on file effective 06/01/2016.\n\n \n\nPlease advise if there is anything else you needfrom MultiPlan."]
["Jessie J Dickens, MD",1215254156,"46-3131679","TX","PE - Midland Texas Orthopedic Group Inc","TriCare Standard","Participating","Enrollment Complete","2017-03-14","1215254156","","2020-03-03","03/03/2020 - Rec'd confirmation of provider enrollment through payer portal. Provider is linked to group at this service location - Stacey Hudak"]
["Jessie J Dickens, MD",1215254156,"46-3131679","TX","PE - Midland Texas Orthopedic Group Inc","Omni PPO","Participating","Enrollment Complete","2016-07-28","1215254156","","2020-06-25",""]
["Jessie J Dickens, MD",1215254156,"46-3131679","TX","PE - Midland Texas Orthopedic Group Inc","Wellcare","Participating","Enrollment Complete","2021-11-01","","","2022-11-15","11/15/2022 Per roster received from Wellcare provider is PAR and linked to group TIN/location effective 11/1/2021.  DCannon"]
["Jessie J Dickens, MD",1215254156,"46-3131679","TX","PE - Midland Texas Orthopedic Group Inc","Amerigroup","Participating","Enrollment Complete","2021-02-12","1215254156","","2023-09-20","9/20/2023 Per email received from Amerigroup provider is PAR and linked to group TIN effective 2/12/2021.  DCannon"]
["Jessie J Dickens, MD",1215254156,"46-3131679","TX","PE - Midland Texas Orthopedic Group Inc","Texas Mutual","Participating","Enrollment Complete","2020-01-08","","","2021-01-23","11/25/2020-Confirmed provider is participating under group Tax ID and practice location. Rafael Calixtro"]
["Jessie J Dickens, MD",1215254156,"46-3131679","TX","PE - Midland Texas Orthopedic Group Inc","Superior","Participating","Enrollment Complete","2016-10-01","1598757080","","2020-07-14","07/14/2020 - Rec'd spreadsheet from the delegated team stating this provider has been linked to the PriMed contract since 10/1/2016  **see the other enrollment complete line to see details about when this provider became effective with various specific products** - stacey Hudak"]
["Jessie J Dickens, MD",1215254156,"46-3131679","TX","PE - Midland Texas Orthopedic Group Inc","Scott&White (First Care)","Participating","Enrollment Complete","2016-12-19","","","2021-01-29","1/29/2021 - Rcvd roster from Scott&White (First Care) confirming participation of provider with TIN and location effective dates.  DCannon"]
["Jessie J Dickens, MD",1215254156,"46-3131679","TX","PE - Midland Texas Orthopedic Group Inc","HealthSmart PPO","Participating","Enrollment Complete","2019-05-10","1215254156","","2020-06-05","06/05/2020 - Rec'd email from the payer stating this provider is EFF - Stacey Hudak"]
["Jessie J Dickens, MD",1215254156,"46-3131679","TX","PE - Midland Texas Orthopedic Group Inc","USA PPO","Participating","Enrollment Complete","2016-10-26","1215254156","463131679","2020-08-21","Confirmed provider is participating with PPO and H&W networks (list of networks attached). Kimberly Frazier"]
["Jessie J Dickens, MD",1215254156,"46-3131679","TX","PE - Midland Texas Orthopedic Group Inc","Caprock (CapStar)","Participating","Enrollment Complete","2019-05-10","1215254156","","",""]
["Jessie J Dickens, MD",1215254156,"46-3131679","TX","PE - Midland Texas Orthopedic Group Inc","United Health Care","Participating","Enrollment Complete","2020-01-01","1215254156","",44074,"08/31/2020 - moved to completed status after reviewing follow up completed note - Stacey Hudak"]
["Jessie J Dickens, MD",1215254156,"46-3131679","TX","PE - Midland Texas Orthopedic Group Inc","IMS","Participating","Enrollment Complete","2016-07-28","1215254156","","2020-06-22","06/22/2020- Rec'd email from the payer confirming this provider is PAR with this group/service location - Stacey Hudak"]
["Jessie J Dickens, MD",1215254156,"46-3131679","TX","PE - Midland Texas Orthopedic Group Inc","Sedgwick","Participating","Enrollment Complete","2016-10-26","1238662","","2021-01-26","1/26/2021 - Per follow-up notes provider is par with TIN and location effective 10/26/2016.  DCannon"]
["Jessie J Dickens, MD",1215254156,"46-3131679","TX","PE - Midland Texas Orthopedic Group Inc","Wellmed","Participating","Enrollment Complete","2022-01-01","","","2023-03-23","3/23/2023 Rcvd roster from UHC w/ all Wellmed participating providers.  Provider is PAR effective 1/1/2022.  DCannon"]
["Jessie J Dickens, MD",1215254156,"46-3131679","TX","PE - Midland Texas Orthopedic Group Inc","Ambetter","Participating","Enrollment Complete","2022-04-01","","","2022-06-13","6/13/2022 Received April Monthly Validation roster from Superior and provider is PAR and linked effective 4/1/2022.  DCannon"]
["Jessie J Dickens, MD",1215254156,"46-3131679","TX","PE - Midland Texas Orthopedic Group Inc","Rail Road Medicare","Participating","Enrollment Complete","2016-08-15","P02008203","DU5783","2020-03-10","03/10/2020 - Found EFF information through payer site - Stacey Hudak"]
["Rebecca A Sanchez, PA",1174846364,"46-3131679","TX","PE - Midland Texas Orthopedic Group Inc","Zurich","Participating","Enrollment Complete","2020-03-20","","","2022-12-15","12/15/2022 Per Coventry WC website provider is PAR in Zurich WC and linked to TIN/locations effective 3/20/2020.  DCannon"]
["Rebecca A Sanchez, PA",1174846364,"46-3131679","TX","PE - Midland Texas Orthopedic Group Inc","Boon Chapman","Participating","Enrollment Complete","2021-01-01","","","2021-08-06","8/6/2021 Boon Chapman falls under the Multiplan umbrella, received roster from Multiplan provider is listed on roster under TIN/location as PAR effective 1/1/2021.  DCannon"]
["Rebecca A Sanchez, PA",1174846364,"46-3131679","TX","PE - Midland Texas Orthopedic Group Inc","Texas Mutual","Participating","Enrollment Complete","2020-01-07","","","2021-01-23","11/25/2020 - Confirmed provider is participating under group Tax ID and practice location. - EL KING MORENO"]
["Rebecca A Sanchez, PA",1174846364,"46-3131679","TX","PE - Midland Texas Orthopedic Group Inc","USA PPO","Participating","Enrollment Complete","2021-01-26","1174241","","2021-03-12","3/12/2021 Per verification on payor website USAMCO.com provider is loaded as participating.  Rcvd Roster LeNetrice Myart with provider numbers and effective dates for providers.  DCannon"]
["Rebecca A Sanchez, PA",1174846364,"46-3131679","TX","PE - Midland Texas Orthopedic Group Inc","Multiplan","Participating","Enrollment Complete","2021-01-01","","","2021-02-20","2/20/2021 Rcvd approval letter from MultiPlan for WesTexas OrthoPedics providers effective 1/1/2021.  DCannon"]
["Rebecca A Sanchez, PA",1174846364,"46-3131679","TX","PE - Midland Texas Orthopedic Group Inc","Scott&White (First Care)","Participating","Enrollment Complete","2020-09-28","","","2021-01-29","1/29/2021 - Rcvd roster from Scott&White (First Care) confirming participation of provider with TIN and location effective dates.  DCannon"]
["Rebecca A Sanchez, PA",1174846364,"46-3131679","TX","PE - Midland Texas Orthopedic Group Inc","HealthSmart PPO","Participating","Enrollment Complete","2020-03-04","","","2020-07-21","07/21/2020 - rec'd email with a spreadsheet showing this provider/TIN/service location are PAR with this payer under WEST TEXAS PHYSICIANS ALLIANCE Delegated - Stacey Hudak"]
["Rebecca A Sanchez, PA",1174846364,"46-3131679","TX","PE - Midland Texas Orthopedic Group Inc","Aetna","Participating","Enrollment Complete","2019-11-01","1174846364","","2020-06-09","06/09/2020 - S/W Lorie of Aetna @ 8003531232, As per since the provider is PA credentialing is not required. provider NPI# is on file for the provider and is participating effective 11/01/2019 under the group and TIN#. Physical location is on file. Call ref# 5309803465. - Stacey Hudak"]
["Rebecca A Sanchez, PA",1174846364,"46-3131679","TX","PE - Midland Texas Orthopedic Group Inc","Liberty Mutual","Participating","Enrollment Complete","2020-03-20","","","2022-12-15","12/15/2022 Per Coventry WC website provider is PAR in Liberty Mutual WC and linked to TIN/locations effective 3/20/2020.  DCannon"]
["Rebecca A Sanchez, PA",1174846364,"46-3131679","TX","PE - Midland Texas Orthopedic Group Inc","Wellmed","Participating","Enrollment Complete","2022-01-01","","","2023-03-23","3/23/2023 Rcvd roster from UHC w/ all Wellmed participating providers.  Provider is PAR effective 1/1/2022.  DCannon"]
["Rebecca A Sanchez, PA",1174846364,"46-3131679","TX","PE - Midland Texas Orthopedic Group Inc","Caprock (CapStar)","Participating","Enrollment Complete","2020-03-04","1174846364","","2020-06-02","06/02/2020 - rec'd spreadsheet back from the payer Mary Rodriguez <MRodriguez@caprockhp.com> confirming this provider/service location is EFF with this payer - Stacey Hudak"]
["Rebecca A Sanchez, PA",1174846364,"46-3131679","TX","PE - Midland Texas Orthopedic Group Inc","Medicare","Participating","Enrollment Complete","2019-11-18","934064","320497","2020-03-10","03/10/2020 - Rec'd welcome letter from the payer - Stacey Hudak"]
["Rebecca A Sanchez, PA",1174846364,"46-3131679","TX","PE - Midland Texas Orthopedic Group Inc","Sedgwick","Participating","Enrollment Complete","2020-05-29","1174241","","2021-01-26","1/26/2021 - Per follow-up notes provider is par with TIN and location effective 5/29/2020.  DCannon"]
["Rebecca A Sanchez, PA",1174846364,"46-3131679","TX","PE - Midland Texas Orthopedic Group Inc","TriCare Standard","Participating","Enrollment Complete","2020-05-29","","","2020-11-17","11/17/2020 - Checked the Humana-Military website provider credentialing is completed effective 5/29/2020.  DCannon"]
["Rebecca A Sanchez, PA",1174846364,"46-3131679","TX","PE - Midland Texas Orthopedic Group Inc","Superior","Participating","Enrollment Complete","2020-08-01","1174846364","","2020-08-06","8/6/2020 - Rec'd an email from the payer stating this provider was added to their database EFF: 8-1-2020 after receiving/processing the July roster - Stacey Hudak"]
["Rebecca A Sanchez, PA",1174846364,"46-3131679","TX","PE - Midland Texas Orthopedic Group Inc","Amerigroup","Participating","Enrollment Complete","2020-03-20","","","2023-09-20","9/20/2023 Per email received from Amerigroup provider is PAR and linked to group TIN effective 3/20/2020.  DCannon"]
["Rebecca A Sanchez, PA",1174846364,"46-3131679","TX","PE - Midland Texas Orthopedic Group Inc","Medicaid","Participating","Enrollment Complete","","409592901","3310906-01","2023-02-25","2/25/2023 Per TMHP web portal license update has been approved.  DCannon"]
["Rebecca A Sanchez, PA",1174846364,"46-3131679","TX","PE - Midland Texas Orthopedic Group Inc","First Health Coventry","Participating","Enrollment Complete","2020-03-20","","","2022-04-26","4/26/2022 Per First Health provider directory provider is PAR and linked to group TIN/location.  DCannon"]
["Rebecca A Sanchez, PA",1174846364,"46-3131679","TX","PE - Midland Texas Orthopedic Group Inc","Cigna","Participating","Enrollment Complete","2019-10-01","0186460","","2020-02-27","02/27/2020 - rec'd email from the payer stating \"This is to confirm that your request has been completed\" Completion Notice - Cigna Internal Reference # W20200226902641\nHCP Name: Rebecca Sanchez\nPID: 0186460\nEffective date: 10/01/2019  - Stacey Hudak"]
["Rebecca A Sanchez, PA",1174846364,"46-3131679","TX","PE - Midland Texas Orthopedic Group Inc","Rail Road Medicare","Participating","Enrollment Complete","2019-11-18","P02450879","DU5783","2020-08-28","08/28/2020 - moved to completed status after confirming EFF date through payer portal - Stacey Hudak"]
["Rebecca A Sanchez, PA",1174846364,"46-3131679","TX","PE - Midland Texas Orthopedic Group Inc","Tricare Prime","Participating","Enrollment Complete","2020-05-29","","","2020-11-17","11/17/2020 - Checked the Humana-Military website provider credentialing is completed effective 5/29/2020.  DCannon"]
["Rebecca A Sanchez, PA",1174846364,"46-3131679","TX","PE - Midland Texas Orthopedic Group Inc","Triwest VA","In House Enrollment","In House Enrollment","","","","2021-01-13","1/6/2021 MQA Team is working with Representatives at BCBS-TX to ensure all providers are enrolled and loaded to participate with the VACCN network in a timely manner. However, we are currently awaiting a full roster of providers currently participating and will update all records accordingly upon receipt. Kfrazier"]
["Rebecca A Sanchez, PA",1174846364,"46-3131679","TX","PE - Midland Texas Orthopedic Group Inc","Wellcare","Participating","Enrollment Complete","2021-11-01","","","2022-12-01","12/1/2022 Per roster received from Wellcare provider is PAR and linked to group TIN/location effective 11/1/2021.  DCannon"]
["Rebecca A Sanchez, PA",1174846364,"46-3131679","TX","PE - Midland Texas Orthopedic Group Inc","Humana","Participating","Enrollment Complete","2020-01-01","1174846364","","2020-07-19","7/19/2020 - Received email spreadsheet from the payor confirming that this provider is EFF at this service location and PAR with the PRIMED DELEGATED agreement - Pam Porter"]
["Rebecca A Sanchez, PA",1174846364,"46-3131679","TX","PE - Midland Texas Orthopedic Group Inc","IMS","Participating","Enrollment Complete","2019-09-01","1174846364","","2020-07-27","07/27/2020 - Rec'd roster response back from the payer regarding 7/15/2020 submission stating that all requested providers/service locations have been added to PriMed agreement - Stacey Hudak"]
["Rebecca A Sanchez, PA",1174846364,"46-3131679","TX","PE - Midland Texas Orthopedic Group Inc","CAQH","Participating","CAQH Reattested","2023-10-05","","","2023-10-05","10/5/2023 CAQH reviewed and re-attested.  DCannon"]
["Rebecca A Sanchez, PA",1174846364,"46-3131679","TX","PE - Midland Texas Orthopedic Group Inc","United Health Care","Participating","Enrollment Complete","2020-03-02","1174846364","","2020-07-30","7/30/2020 - moved to completed status after reviewing follow up complete note - Stacey Hudak"]
["Rebecca A Sanchez, PA",1174846364,"46-3131679","TX","PE - Midland Texas Orthopedic Group Inc","Omni PPO","Participating","Enrollment Complete","2019-09-01","1174846364","","2020-07-27","IMS complete"]
["Rebecca A Sanchez, PA",1174846364,"46-3131679","TX","PE - Midland Texas Orthopedic Group Inc","Ambetter","Participating","Enrollment Complete","2022-04-01","","","2022-06-13","6/13/2022 Per roster received from Superior provider is PAR and linked to group delegation roster effective 4/1/2022."]
["Rebecca A Sanchez, PA",1174846364,"46-3131679","TX","PE - Midland Texas Orthopedic Group Inc","Galaxy Health","Participating","Enrollment Complete","2019-09-01","1174846364","","2020-08-21","08/21/2020 - Rec'd email confirmation that this roster was processed and this provider was made effective with the requested eff date of 9-1-2019 - Stacey Hudak"]
["Chelsea N Luebke (Sandridge), APRN-FNP-BC",1427452945,"46-3131679","TX","PE - Midland Texas Orthopedic Group Inc","CAQH","Participating","CAQH Reattested","2023-10-04","","","2023-10-04","10/04/2023 - Updated License board and re-attested - rkedare"]
["Chelsea N Luebke (Sandridge), APRN-FNP-BC",1427452945,"46-3131679","TX","PE - Midland Texas Orthopedic Group Inc","Boon Chapman","Participating","Enrollment Complete","2018-01-03","","","2021-08-06","8/6/2021 Boon Chapman falls under the Multiplan umbrella, received roster from Multiplan provider is listed on roster under TIN/location as PAR effective 1/3/2018.  DCannon"]
["Chelsea N Luebke (Sandridge), APRN-FNP-BC",1427452945,"46-3131679","TX","PE - Midland Texas Orthopedic Group Inc","United Health Care","Participating","Enrollment Complete","2018-01-01","5396301","","2020-07-30","7/30/2020 - moved to completed status after reviewing follow up complete note - Stacey Hudak"]
["Chelsea N Luebke (Sandridge), APRN-FNP-BC",1427452945,"46-3131679","TX","PE - Midland Texas Orthopedic Group Inc","Cigna","Participating","Enrollment Complete","2019-05-15","1427452945","","2020-07-20","07/20/2020- moved to completed status after reviewing follow up complete note - Stacey Hudak"]
["Chelsea N Luebke (Sandridge), APRN-FNP-BC",1427452945,"46-3131679","TX","PE - Midland Texas Orthopedic Group Inc","Medicare","Participating","Enrollment Complete","2017-11-27","381252YV2D","320497","2020-02-18","02/18/2020 - Rec'd email from the payer stating APPROVED. My contract corrects and address updates have been accepted. This enrollment is now current.  - Stacey Hudak"]
["Chelsea N Luebke (Sandridge), APRN-FNP-BC",1427452945,"46-3131679","TX","PE - Midland Texas Orthopedic Group Inc","Liberty Mutual","Panel Closed","Panel Closed","","","","2023-07-19","07/18/2023. We appreciate your interest in joining the Coventry Network.  At this time, our panels are closed, and we are not accepting new applications.  Please check back routinely to stay apprised of our panel status. We will update this site when we are open for new applicants. Gallagher, Hartford, Liberty Mutual, Travelers and Zurich fall under Coventry. Jen Videan"]
["Chelsea N Luebke (Sandridge), APRN-FNP-BC",1427452945,"46-3131679","TX","PE - Midland Texas Orthopedic Group Inc","Superior","Participating","Enrollment Complete","2018-09-01","1427452945","","2020-07-14","07/14/2020 - Rec'd email from the payer stating this provider is EFF under PRIMED DELEGATED agreement - Stacey Hudak"]
["Chelsea N Luebke (Sandridge), APRN-FNP-BC",1427452945,"46-3131679","TX","PE - Midland Texas Orthopedic Group Inc","Medicaid","Participating","Enrollment Complete","2017-11-27","343965503","","2020-06-25","06/25/2020 - Rec'd proof of enrollment from the clinic and updated payer line - Stacey Hudak"]
["Chelsea N Luebke (Sandridge), APRN-FNP-BC",1427452945,"46-3131679","TX","PE - Midland Texas Orthopedic Group Inc","Galaxy Health","Participating","Enrollment Complete","2018-01-03","1427452945","","2020-07-10","07/10/2020 - updated payer line to enrollment complete status instead of \"Delegated status\" for report running purposes - Stacey Hudak"]
["Chelsea N Luebke (Sandridge), APRN-FNP-BC",1427452945,"46-3131679","TX","PE - Midland Texas Orthopedic Group Inc","Humana","Participating","Enrollment Complete","2020-01-01","1427452945","","2020-07-19","7/19/2020 - received email spreadsheet from the payor confirming that this provider is Eff at this service location and PAR with the PRIMED DELEGATED agreement - Pam Porter"]
["Chelsea N Luebke (Sandridge), APRN-FNP-BC",1427452945,"46-3131679","TX","PE - Midland Texas Orthopedic Group Inc","Texas Mutual","Participating","Enrollment Complete","2018-03-01","","","2021-01-26","1/26/2021 - Per follow-up notes provider is par with TIN and location effective 3/1/2018.  DCannon"]
["Chelsea N Luebke (Sandridge), APRN-FNP-BC",1427452945,"46-3131679","TX","PE - Midland Texas Orthopedic Group Inc","Rail Road Medicare","Participating","Enrollment Complete","2017-11-27","P02027037","DU5783","2020-03-10","03/10/2020 - Found EFF info through payer portal - Stacey Hudak"]
["Chelsea N Luebke (Sandridge), APRN-FNP-BC",1427452945,"46-3131679","TX","PE - Midland Texas Orthopedic Group Inc","USA PPO","Participating","Enrollment Complete","2018-07-31","","","2020-09-09","Confirmed provider is participating with PPO and H&W networks (list of networks attached). Kimberly Frazier"]
["Chelsea N Luebke (Sandridge), APRN-FNP-BC",1427452945,"46-3131679","TX","PE - Midland Texas Orthopedic Group Inc","First Health Coventry","Participating","Enrollment Complete","2018-08-01","2878466","","2020-03-20","03/20/2020 - Rec'd from the payer stating this provider is EFF under PID# 2878466 - Stacey Hudak"]
["Chelsea N Luebke (Sandridge), APRN-FNP-BC",1427452945,"46-3131679","TX","PE - Midland Texas Orthopedic Group Inc","Sedgwick","Participating","Enrollment Complete","2018-07-31","","","2021-05-06","5/6/2021  In following up with USAMCO (800-872-3860) I was told that you can confirm participating via the USA MCO website  https://providersearch.usamco.com/hwprovsearch.  Provider is PAR and linked to location/TIN effective 7/31/2018.  DCannon"]
["Chelsea N Luebke (Sandridge), APRN-FNP-BC",1427452945,"46-3131679","TX","PE - Midland Texas Orthopedic Group Inc","Wellmed","Participating","Enrollment Complete","2022-01-01","","","2023-03-23","3/23/2023 Rcvd roster from UHC w/ all Wellmed participating providers.  Provider is PAR effective 1/1/2022.  DCannon"]
["Chelsea N Luebke (Sandridge), APRN-FNP-BC",1427452945,"46-3131679","TX","PE - Midland Texas Orthopedic Group Inc","Wellcare","Participating","Enrollment Complete","2021-11-01","","","2022-12-01","12/1/2022 Per roster received from Wellcare provider is PAR and linked to group TIN/location effective 11/1/2021.  DCannon"]
["Chelsea N Luebke (Sandridge), APRN-FNP-BC",1427452945,"46-3131679","TX","PE - Midland Texas Orthopedic Group Inc","TriCare Standard","Participating","Enrollment Complete","2018-05-29","1427452945","","2020-03-03","03/03/2020 - Rec'd confirmation of provider enrollment through payer portal. Provider is linked to group at this service location - Stacey Hudak"]
["Chelsea N Luebke (Sandridge), APRN-FNP-BC",1427452945,"46-3131679","TX","PE - Midland Texas Orthopedic Group Inc","Ambetter","Participating","Enrollment Complete","2022-04-01","","","2022-06-13","6/13/2022 Per roster received from Superior provider is PAR and linked to group delegation roster effective 4/1/2022."]
["Chelsea N Luebke (Sandridge), APRN-FNP-BC",1427452945,"46-3131679","TX","PE - Midland Texas Orthopedic Group Inc","IMS","Participating","Enrollment Complete","2018-07-24","1427452945","","2020-06-22","06/22/2020- Rec'd email from the payer confirming this provider is PAR with this group/service location - Stacey Hudak"]
["Chelsea N Luebke (Sandridge), APRN-FNP-BC",1427452945,"46-3131679","TX","PE - Midland Texas Orthopedic Group Inc","Aetna","Participating","Enrollment Complete","2019-08-01","1427452945","","2020-02-03","02/03/2020 - Rec'd confirmation from the payer stating this provider is EFF 8-1-2019 under a DIRECT CONTRACT. This service location is on file and linked to the provider - Stacey Hudak"]
["Chelsea N Luebke (Sandridge), APRN-FNP-BC",1427452945,"46-3131679","TX","PE - Midland Texas Orthopedic Group Inc","Scott&White (First Care)","Participating","Enrollment Complete","2018-07-31","","","2021-01-29","1/29/2021 - Rcvd roster from Scott&White (First Care) confirming participation of provider with TIN and location effective dates.  DCannon"]
["Chelsea N Luebke (Sandridge), APRN-FNP-BC",1427452945,"46-3131679","TX","PE - Midland Texas Orthopedic Group Inc","Caprock (CapStar)","Participating","Enrollment Complete","2018-07-24","1427452945","","2020-06-02","06/02/2020 - rec'd spreadsheet back from the payer Mary Rodriguez <MRodriguez@caprockhp.com> confirming this provider/service location is EFF with this payer - Stacey Hudak"]
["Chelsea N Luebke (Sandridge), APRN-FNP-BC",1427452945,"46-3131679","TX","PE - Midland Texas Orthopedic Group Inc","Triwest VA","Participating","Enrollment Complete","2022-08-01","","","2022-11-14","11/14/22 Per Scarlett Abigail, provider effective from 8/1/22"]
["Chelsea N Luebke (Sandridge), APRN-FNP-BC",1427452945,"46-3131679","TX","PE - Midland Texas Orthopedic Group Inc","Omni PPO","Participating","Enrollment Complete","2018-07-24","1427452945","","2020-06-25",""]
["Chelsea N Luebke (Sandridge), APRN-FNP-BC",1427452945,"46-3131679","TX","PE - Midland Texas Orthopedic Group Inc","Multiplan","Participating","Enrollment Complete","2018-01-03","1427452945","Midland Texas Orthopedic Group Inc.","2020-09-24","09/24/2020 -moved to completed status after reviewing follow up complete note - Stacey Hudak"]
["Chelsea N Luebke (Sandridge), APRN-FNP-BC",1427452945,"46-3131679","TX","PE - Midland Texas Orthopedic Group Inc","Gallagher","Panel Closed","Panel Closed","","","","2023-07-19","07/18/2023. We appreciate your interest in joining the Coventry Network.  At this time, our panels are closed, and we are not accepting new applications.  Please check back routinely to stay apprised of our panel status. We will update this site when we are open for new applicants. Gallagher, Hartford, Liberty Mutual, Travelers and Zurich fall under Coventry. Jen Videan"]
["Chelsea N Luebke (Sandridge), APRN-FNP-BC",1427452945,"46-3131679","TX","PE - Midland Texas Orthopedic Group Inc","HealthSmart PPO","Participating","Enrollment Complete","2019-07-18","1427452945","","2020-06-05","06/05/2020 - Rec'd email from the payer stating this provider is EFF - Stacey Hudak"]
["Chelsea N Luebke (Sandridge), APRN-FNP-BC",1427452945,"46-3131679","TX","PE - Midland Texas Orthopedic Group Inc","Amerigroup","Participating","Enrollment Complete","2018-07-24","06012077","","2023-09-20","9/20/2023 Per email received from Amerigroup provider is PAR and linked to group TIN effective 7/24/2018.  DCannon"]
["Chelsea N Luebke (Sandridge), APRN-FNP-BC",1427452945,"46-3131679","TX","PE - Midland Texas Orthopedic Group Inc","Zurich","Panel Closed","Panel Closed","","","","2023-07-19","07/18/2023. We appreciate your interest in joining the Coventry Network.  At this time, our panels are closed, and we are not accepting new applications.  Please check back routinely to stay apprised of our panel status. We will update this site when we are open for new applicants. Gallagher, Hartford, Liberty Mutual, Travelers and Zurich fall under Coventry. Jen Videan"]
["Vikram R Vadyala, MD",1497985188,"47-1394805","TX","PE - Vikram Vadyala, PLLC","Caprock (CapStar)","Participating","Enrollment Complete","2018-06-19","1497985188","","2020-06-02","06/02/2020 - rec'd spreadsheet back from the payer Mary Rodriguez <MRodriguez@caprockhp.com> confirming this provider/service location is EFF with this payer - Stacey Hudak"]
["Vikram R Vadyala, MD",1497985188,"47-1394805","TX","PE - Vikram Vadyala, PLLC","Scott&White (First Care)","Participating","Enrollment Complete","2018-10-25","1497985188","","2020-08-20","8/20/2020 - Rec'd spreadsheet from the payer stating this provider has been affiliated with PRIMED DELEGATED AGREEMENT under this TIN/Service Location. Provider is networked with:\nFirstCare MyChoice PPO\nFirstCare Select Benefit Network\nHMO Enhanced Benefit Network\nMedicaid (FC)\nMedicare (FC)\nPPO Limited Benefit Network\n- Stacey Hudak"]
["Vikram R Vadyala, MD",1497985188,"47-1394805","TX","PE - Vikram Vadyala, PLLC","Aetna","Participating","Enrollment Complete","2017-12-01","1497985188","","2020-04-23","04/23/2020--S/W JR of Aetna @ 800-353-1232. Per rep the Provider is on file, linked & participating under the GRP & TIN effective 12/1/2017. Physical Location is on file. Provider ID #5424885. Call ref # 5234180829\ncopied note from spreadsheet-tisha rader"]
["Chisom Nwoye, MD",1841780806,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Multiplan","Participating","Enrollment Complete","2022-06-13","","","2023-09-01","9/1/2023 Per email received from Multiplan provider is PAR and linked to group TIN/locations effective 6/13/2022.  DCannon"]
["Chisom Nwoye, MD",1841780806,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Multiplan","Participating","Enrollment Complete","2022-06-13","","","2023-09-01","9/1/2023 Per email received from Multiplan provider is PAR and linked to group TIN/locations effective 6/13/2022.  DCannon"]
["Chisom Nwoye, MD",1841780806,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Multiplan","Participating","Enrollment Complete","2022-06-13","","","2023-09-01","9/1/2023 Per email received from Multiplan provider is PAR and linked to group TIN/locations effective 6/13/2022.  DCannon"]
["Chisom Nwoye, MD",1841780806,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Multiplan","Participating","Enrollment Complete","2022-06-13","","","2023-09-01","9/1/2023 Per email received from Multiplan provider is PAR and linked to group TIN/locations effective 6/13/2022.  DCannon"]
["Chisom Nwoye, MD",1841780806,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Scott&White (First Care)","Participating","Enrollment Complete","2022-06-13","","","2022-08-11","8/11/2022 Rcvd email from Scott & White that monthly delegated roster for June has been completed and providers are loaded to group delegation roster effective 6/13/2022.  DCannon"]
["Chisom Nwoye, MD",1841780806,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Rail Road Medicare","Participating","Enrollment Complete","2022-05-01","Q00274901","","2022-06-11","Rcvd RR Medicare approval letter. RR Medicare PTAN #  Q00274901 - effective 5/1/2022.  DCannon"]
["Chisom Nwoye, MD",1841780806,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","TriCare Standard","Participating","Enrollment Complete","2023-07-28","","","2023-08-01","4705 Briarwood: 08.01.2023 : S/W Gwen F of TriCare Standard @ 8004445445 transferred call to WPS dept and S/W Becky - provider is participating and certified under the group and TIN effective 07/28/2023. Provider ID is 473465832-79707-C002. Recred date is 02/28/2025. Physical location is on file. Call ref#Becky08012023. - Charmaine Pimentel"]
["Chisom Nwoye, MD",1841780806,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","TriCare Standard","Participating","Enrollment Complete","2023-07-28","","","2023-08-01","4705 Briarwood: 08.01.2023 : S/W Gwen F of TriCare Standard @ 8004445445 transferred call to WPS dept and S/W Becky - provider is participating and certified under the group and TIN effective 07/28/2023. Provider ID is 473465832-79707-C002. Recred date is 02/28/2025. Physical location is on file. Call ref#Becky08012023. - Charmaine Pimentel"]
["Chisom Nwoye, MD",1841780806,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","TriCare Standard","Participating","Enrollment Complete","2023-07-28","","","2023-10-26","Eastridge location completed effective 10/9/2023. MS"]
["Chisom Nwoye, MD",1841780806,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","TriCare Standard","Participating","Enrollment Complete","2023-07-28","","","2023-10-26","Eastridge location completed effective 10/9/2023. MS"]
["Chisom Nwoye, MD",1841780806,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","TriCare Standard","Participating","Enrollment Complete","2023-07-28","","","2023-11-05","Provider has been linked to Andrews Hwy location eff 10/26/23. MS"]
["Chisom Nwoye, MD",1841780806,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","TriCare Standard","Participating","Enrollment Complete","2023-07-28","","","2023-11-05","Provider has been linked to Andrews Hwy location eff 10/26/23. MS"]
["Chisom Nwoye, MD",1841780806,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","TriCare Standard","Participating","Enrollment Complete","2023-07-28","","","2023-08-01","4705 Briarwood: 08.01.2023 : S/W Gwen F of TriCare Standard @ 8004445445 transferred call to WPS dept and S/W Becky - provider is participating and certified under the group and TIN effective 07/28/2023. Provider ID is 473465832-79707-C002. Recred date is 02/28/2025. Physical location is on file. Call ref#Becky08012023. - Charmaine Pimentel"]
["Chisom Nwoye, MD",1841780806,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","TriCare Standard","Participating","Enrollment Complete","2023-07-28","","","2023-08-01","4705 Briarwood: 08.01.2023 : S/W Gwen F of TriCare Standard @ 8004445445 transferred call to WPS dept and S/W Becky - provider is participating and certified under the group and TIN effective 07/28/2023. Provider ID is 473465832-79707-C002. Recred date is 02/28/2025. Physical location is on file. Call ref#Becky08012023. - Charmaine Pimentel"]
["Chisom Nwoye, MD",1841780806,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","TriCare Standard","Participating","Enrollment Complete","2023-07-28","","","2023-10-26","Eastridge location completed effective 10/9/2023. MS"]
["Chisom Nwoye, MD",1841780806,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","TriCare Standard","Participating","Enrollment Complete","2023-07-28","","","2023-10-26","Eastridge location completed effective 10/9/2023. MS"]
["Chisom Nwoye, MD",1841780806,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","TriCare Standard","Participating","Enrollment Complete","2023-07-28","","","2023-11-05","Provider has been linked to Andrews Hwy location eff 10/26/23. MS"]
["Chisom Nwoye, MD",1841780806,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","TriCare Standard","Participating","Enrollment Complete","2023-07-28","","","2023-11-05","Provider has been linked to Andrews Hwy location eff 10/26/23. MS"]
["Chisom Nwoye, MD",1841780806,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","TriCare Standard","Participating","Enrollment Complete","2023-07-28","","","2023-08-01","4705 Briarwood: 08.01.2023 : S/W Gwen F of TriCare Standard @ 8004445445 transferred call to WPS dept and S/W Becky - provider is participating and certified under the group and TIN effective 07/28/2023. Provider ID is 473465832-79707-C002. Recred date is 02/28/2025. Physical location is on file. Call ref#Becky08012023. - Charmaine Pimentel"]
["Chisom Nwoye, MD",1841780806,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","TriCare Standard","Participating","Enrollment Complete","2023-07-28","","","2023-08-01","4705 Briarwood: 08.01.2023 : S/W Gwen F of TriCare Standard @ 8004445445 transferred call to WPS dept and S/W Becky - provider is participating and certified under the group and TIN effective 07/28/2023. Provider ID is 473465832-79707-C002. Recred date is 02/28/2025. Physical location is on file. Call ref#Becky08012023. - Charmaine Pimentel"]
["Chisom Nwoye, MD",1841780806,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","TriCare Standard","Participating","Enrollment Complete","2023-07-28","","","2023-10-26","Eastridge location completed effective 10/9/2023. MS"]
["Chisom Nwoye, MD",1841780806,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","TriCare Standard","Participating","Enrollment Complete","2023-07-28","","","2023-10-26","Eastridge location completed effective 10/9/2023. MS"]
["Chisom Nwoye, MD",1841780806,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","TriCare Standard","Participating","Enrollment Complete","2023-07-28","","","2023-11-05","Provider has been linked to Andrews Hwy location eff 10/26/23. MS"]
["Chisom Nwoye, MD",1841780806,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","TriCare Standard","Participating","Enrollment Complete","2023-07-28","","","2023-11-05","Provider has been linked to Andrews Hwy location eff 10/26/23. MS"]
["Chisom Nwoye, MD",1841780806,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","United Health Care","Participating","Enrollment Complete","2022-06-13","","","2022-07-20","7/20/2022 Per email received from  from UHC monthly delegated roster submission has been completed and provider is PAR and in linked to group TIN effective 6/13/2022.   MPIN# 008092273.   DCannon"]
["Chisom Nwoye, MD",1841780806,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","Medicare","Participating","Enrollment Complete","2022-05-01","","","2023-09-06","Confirmed this provider was added. MS"]
["Chisom Nwoye, MD",1841780806,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Medicare","Participating","Enrollment Complete","2022-05-01","2E0739","423838","2023-07-27","7/27/2023 Per PECOS new locations have been added to group record.  Provider is PAR and linked to group/locations effective 5/1/2022.  PID # 2E0739.  DCannon"]
["Chisom Nwoye, MD",1841780806,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Medicare","Participating","Enrollment Complete","2022-05-01","2E0739","423838","2023-07-27","7/27/2023 Per PECOS new locations have been added to group record.  Provider is PAR and linked to group/locations effective 5/1/2022.  PID # 2E0739.  DCannon"]
["Chisom Nwoye, MD",1841780806,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Medicare","Participating","Enrollment Complete","2022-05-01","2E0739","423838","2023-07-27","7/27/2023 Per PECOS new locations have been added to group record.  Provider is PAR and linked to group/locations effective 5/1/2022.  PID # 2E0739.  DCannon"]
["Chisom Nwoye, MD",1841780806,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Medicare","Participating","Enrollment Complete","2022-05-01","2E0739","423838","2023-07-27","7/27/2023 Per PECOS new locations have been added to group record.  Provider is PAR and linked to group/locations effective 5/1/2022.  PID # 2E0739.  DCannon"]
["Chisom Nwoye, MD",1841780806,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","Scott&White (First Care)","Participating","Enrollment Complete","2023-09-14","","","2023-09-29","9/29/2023 Rcvd confirmation from Scott & White that provider has been loaded at all locations effective 9/14/2023.  DCannon"]
["Chisom Nwoye, MD",1841780806,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Caprock (CapStar)","Participating","Enrollment Complete","2020-01-01","","","2022-10-12","10/12/2022 Per email from Priscilla Albertine she rcvd confirmation from Mary Rodriguez at Caprock that provider is PAR and linked to group TIN/locations effective 1/1/2020.  DCannon"]
["Chisom Nwoye, MD",1841780806,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Gallagher","Panel Closed","Panel Closed","","","","2023-07-24"," We appreciate your interest in joining the Coventry Network.  At this time, our panels are closed, and we are not accepting new applications.  Please check back routinely to stay apprised of our panel status. We will update this site when we are open for new applicants. Gallagher, Hartford, Liberty Mutual, Travelers and Zurich fall under Coventry. Jen Videan"]
["Chisom Nwoye, MD",1841780806,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Gallagher","Panel Closed","Panel Closed","","","","2023-07-24"," We appreciate your interest in joining the Coventry Network.  At this time, our panels are closed, and we are not accepting new applications.  Please check back routinely to stay apprised of our panel status. We will update this site when we are open for new applicants. Gallagher, Hartford, Liberty Mutual, Travelers and Zurich fall under Coventry. Jen Videan"]
["Chisom Nwoye, MD",1841780806,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Gallagher","Panel Closed","Panel Closed","","","","2023-07-24"," We appreciate your interest in joining the Coventry Network.  At this time, our panels are closed, and we are not accepting new applications.  Please check back routinely to stay apprised of our panel status. We will update this site when we are open for new applicants. Gallagher, Hartford, Liberty Mutual, Travelers and Zurich fall under Coventry. Jen Videan"]
["Chisom Nwoye, MD",1841780806,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Gallagher","Panel Closed","Panel Closed","","","","2023-07-24"," We appreciate your interest in joining the Coventry Network.  At this time, our panels are closed, and we are not accepting new applications.  Please check back routinely to stay apprised of our panel status. We will update this site when we are open for new applicants. Gallagher, Hartford, Liberty Mutual, Travelers and Zurich fall under Coventry. Jen Videan"]
["Chisom Nwoye, MD",1841780806,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","Gallagher","Panel Closed","Panel Closed","","","","2023-07-24"," We appreciate your interest in joining the Coventry Network.  At this time, our panels are closed, and we are not accepting new applications.  Please check back routinely to stay apprised of our panel status. We will update this site when we are open for new applicants. Gallagher, Hartford, Liberty Mutual, Travelers and Zurich fall under Coventry. Jen Videan"]
["Chisom Nwoye, MD",1841780806,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","Gallagher","Panel Closed","Panel Closed","","","","2023-07-24"," We appreciate your interest in joining the Coventry Network.  At this time, our panels are closed, and we are not accepting new applications.  Please check back routinely to stay apprised of our panel status. We will update this site when we are open for new applicants. Gallagher, Hartford, Liberty Mutual, Travelers and Zurich fall under Coventry. Jen Videan"]
["Chisom Nwoye, MD",1841780806,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Travelers WC","Panel Closed","Panel Closed","","","","2023-07-24",""]
["Chisom Nwoye, MD",1841780806,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Travelers WC","Panel Closed","Panel Closed","","","","2023-07-24",""]
["Chisom Nwoye, MD",1841780806,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Travelers WC","Panel Closed","Panel Closed","","","","2023-07-24",""]
["Chisom Nwoye, MD",1841780806,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Travelers WC","Panel Closed","Panel Closed","","","","2023-07-24",""]
["Chisom Nwoye, MD",1841780806,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","Travelers WC","Panel Closed","Panel Closed","","","","2023-07-24",""]
["Chisom Nwoye, MD",1841780806,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","Travelers WC","Panel Closed","Panel Closed","","","","2023-07-24",""]
["Chisom Nwoye, MD",1841780806,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","USA PPO","Participating","Enrollment Complete","2022-06-13","","","2023-11-20","11/20/2023  In following up with USAMCO (800-872-3860) I was told that you can confirm participating via the USA MCO website  https://providersearch.usamco.com/hwprovsearch.  Provider is PAR and linked to location/TIN effective 6/13/2022.  DCannon"]
["Chisom Nwoye, MD",1841780806,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Caprock (CapStar)","Participating","Enrollment Complete","2023-05-01","","","2023-07-18","7/18/2023 Per email received from Caprock provider has been added to new location 4705 Briarwood Ave. and  6950 Eastridge Rd. effective 5/1/2023.  DCannon"]
["Chisom Nwoye, MD",1841780806,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Caprock (CapStar)","Participating","Enrollment Complete","2023-05-01","","","2023-07-18","7/18/2023 Per email received from Caprock provider has been added to new location 4705 Briarwood Ave. and  6950 Eastridge Rd. effective 5/1/2023.  DCannon"]
["Chisom Nwoye, MD",1841780806,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Caprock (CapStar)","Participating","Enrollment Complete","2023-05-01","","","2023-07-18","7/18/2023 Per email received from Caprock provider has been added to new location 4705 Briarwood Ave. and  6950 Eastridge Rd. effective 5/1/2023.  DCannon"]
["Chisom Nwoye, MD",1841780806,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Caprock (CapStar)","Participating","Enrollment Complete","2023-05-01","","","2023-07-18","7/18/2023 Per email received from Caprock provider has been added to new location 4705 Briarwood Ave. and  6950 Eastridge Rd. effective 5/1/2023.  DCannon"]
["Chisom Nwoye, MD",1841780806,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Alliance WC","Participating","Enrollment Complete","2022-12-30","","","2022-12-11","01/11/2023 - Received welcome letter confirming participation with PSWCA, eff. 12/30/2022.  DCannon"]
["Chisom Nwoye, MD",1841780806,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Cigna","Participating","Enrollment Complete","2023-05-01","","","2023-07-18","7/18/2023 Rcvd email from Cigna that provider is PAR and linked to new practice locations effective 5/1/2023.  PID # 6819516 DCannon"]
["Chisom Nwoye, MD",1841780806,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Cigna","Participating","Enrollment Complete","2023-05-01","","","2023-07-18","7/18/2023 Rcvd email from Cigna that provider is PAR and linked to new practice locations effective 5/1/2023.  PID # 6819516 DCannon"]
["Chisom Nwoye, MD",1841780806,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Cigna","Participating","Enrollment Complete","2023-05-01","","","2023-07-18","7/18/2023 Rcvd email from Cigna that provider is PAR and linked to new practice locations effective 5/1/2023.  PID # 6819516 DCannon"]
["Chisom Nwoye, MD",1841780806,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Cigna","Participating","Enrollment Complete","2023-05-01","","","2023-07-18","7/18/2023 Rcvd email from Cigna that provider is PAR and linked to new practice locations effective 5/1/2023.  PID # 6819516 DCannon"]
["Chisom Nwoye, MD",1841780806,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Zurich","Panel Closed","Panel Closed","","","","2023-07-19","07/18/2023. We appreciate your interest in joining the Coventry Network.  At this time, our panels are closed, and we are not accepting new applications.  Please check back routinely to stay apprised of our panel status. We will update this site when we are open for new applicants. Gallagher, Hartford, Liberty Mutual, Travelers and Zurich fall under Coventry. Jen Videan"]
["Chisom Nwoye, MD",1841780806,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","HealthSmart PPO","In Process","Payor Follow Up","","","","2023-11-14","11/14/2023 Per Healthsmart provider portal provider is still not loaded under group TIN.  Per phone conversation with Lee Kinard at Healthsmart provider portal should be updated  by 11/27/2023.  Will allow more time, check back in 2 weeks.   DCannon"]
["Chisom Nwoye, MD",1841780806,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","HealthSmart PPO","In Process","Payor Follow Up","","","","2023-11-14","11/14/2023 Per Healthsmart provider portal provider is still not loaded under group TIN.  Per phone conversation with Lee Kinard at Healthsmart provider portal should be updated  by 11/27/2023.  Will allow more time, check back in 2 weeks.   DCannon"]
["Chisom Nwoye, MD",1841780806,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","HealthSmart PPO","In Process","Payor Follow Up","","","","2023-11-14","11/14/2023 Per Healthsmart provider portal provider is still not loaded under group TIN.  Per phone conversation with Lee Kinard at Healthsmart provider portal should be updated  by 11/27/2023.  Will allow more time, check back in 2 weeks.   DCannon"]
["Chisom Nwoye, MD",1841780806,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","HealthSmart PPO","In Process","Payor Follow Up","","","","2023-11-14","11/14/2023 Per Healthsmart provider portal provider is still not loaded under group TIN.  Per phone conversation with Lee Kinard at Healthsmart provider portal should be updated  by 11/27/2023.  Will allow more time, check back in 2 weeks.   DCannon"]
["Chisom Nwoye, MD",1841780806,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","USA PPO","Participating","Enrollment Complete","2022-06-13","","","2022-09-27","9/27/2022 Per follow-up note -  Provider NPI# is on file and in network with USA MCO. Link to the group and TIN# effective 6/13/2022. Location is on file, Provider ID is 1334093. Next recredentialing date is 6/13/2025. DCannon"]
["Chisom Nwoye, MD",1841780806,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","Humana","In Process","Payor Follow Up","","","","2023-11-17","11/17/2023 Sent follow-up email to Marcus Wester at Humana to check status of August monthly delegated roster submission.  Provider Add - CO-16128465, Provider Changes - CO-16128615,  Provider Terms - CO-16128699.  DCannon"]
["Chisom Nwoye, MD",1841780806,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Coventry Workers Comp","Panel Closed","Panel Closed","","","","2023-05-22","Enrollment Panel is Closed. MS"]
["Chisom Nwoye, MD",1841780806,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Liberty Mutual","Panel Closed","Panel Closed","","","","2023-07-24"," We appreciate your interest in joining the Coventry Network.  At this time, our panels are closed, and we are not accepting new applications.  Please check back routinely to stay apprised of our panel status. We will update this site when we are open for new applicants. Gallagher, Hartford, Liberty Mutual, Travelers and Zurich fall under Coventry. Jen Videan"]
["Chisom Nwoye, MD",1841780806,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Liberty Mutual","Panel Closed","Panel Closed","","","","2023-07-24"," We appreciate your interest in joining the Coventry Network.  At this time, our panels are closed, and we are not accepting new applications.  Please check back routinely to stay apprised of our panel status. We will update this site when we are open for new applicants. Gallagher, Hartford, Liberty Mutual, Travelers and Zurich fall under Coventry. Jen Videan"]
["Chisom Nwoye, MD",1841780806,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Liberty Mutual","Panel Closed","Panel Closed","","","","2023-07-24"," We appreciate your interest in joining the Coventry Network.  At this time, our panels are closed, and we are not accepting new applications.  Please check back routinely to stay apprised of our panel status. We will update this site when we are open for new applicants. Gallagher, Hartford, Liberty Mutual, Travelers and Zurich fall under Coventry. Jen Videan"]
["Chisom Nwoye, MD",1841780806,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Liberty Mutual","Panel Closed","Panel Closed","","","","2023-07-24"," We appreciate your interest in joining the Coventry Network.  At this time, our panels are closed, and we are not accepting new applications.  Please check back routinely to stay apprised of our panel status. We will update this site when we are open for new applicants. Gallagher, Hartford, Liberty Mutual, Travelers and Zurich fall under Coventry. Jen Videan"]
["Chisom Nwoye, MD",1841780806,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","Liberty Mutual","Panel Closed","Panel Closed","","","","2023-07-24"," We appreciate your interest in joining the Coventry Network.  At this time, our panels are closed, and we are not accepting new applications.  Please check back routinely to stay apprised of our panel status. We will update this site when we are open for new applicants. Gallagher, Hartford, Liberty Mutual, Travelers and Zurich fall under Coventry. Jen Videan"]
["Chisom Nwoye, MD",1841780806,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","Liberty Mutual","Panel Closed","Panel Closed","","","","2023-07-24"," We appreciate your interest in joining the Coventry Network.  At this time, our panels are closed, and we are not accepting new applications.  Please check back routinely to stay apprised of our panel status. We will update this site when we are open for new applicants. Gallagher, Hartford, Liberty Mutual, Travelers and Zurich fall under Coventry. Jen Videan"]
["Chisom Nwoye, MD",1841780806,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","HealthSmart PPO","In Process","Payor Follow Up","","","","2023-11-14","11/14/2023 Per Healthsmart provider portal provider is still not loaded under group TIN.  Per phone conversation with Lee Kinard at Healthsmart provider portal should be updated  by 11/27/2023.  Will allow more time, check back in 2 weeks.   DCannon"]
["Chisom Nwoye, MD",1841780806,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Omni PPO","Participating","Enrollment Complete","2022-06-13","","","2022-07-05","7/5/2022 Rcvd email from G.Aviles at IMS/OMNI that delegation roster provider load for June has been completed.  Provider is PAR and linked to group effective 6/13/2022.  DCannon"]
["Chisom Nwoye, MD",1841780806,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","BCBSTX","Participating","Enrollment Complete","2021-12-03","","","2023-10-02","10/2/2023 Per BCBS TX roster received from Priscilla Albertine at MQA provider is PAR and linked to group effective 12/3/2021.  DCannon"]
["Chisom Nwoye, MD",1841780806,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","BCBSTX","Participating","Enrollment Complete","2021-12-03","","","2023-10-02","10/2/2023 Per BCBS TX roster received from Priscilla Albertine at MQA provider is PAR and linked to group effective 12/3/2021.  DCannon"]
["Chisom Nwoye, MD",1841780806,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","BCBSTX","Participating","Enrollment Complete","2021-12-03","","","2023-10-02","10/2/2023 Per BCBS TX roster received from Priscilla Albertine at MQA provider is PAR and linked to group effective 12/3/2021.  DCannon"]
["Chisom Nwoye, MD",1841780806,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","BCBSTX","Participating","Enrollment Complete","2021-12-03","","","2023-10-02","10/2/2023 Per BCBS TX roster received from Priscilla Albertine at MQA provider is PAR and linked to group effective 12/3/2021.  DCannon"]
["Chisom Nwoye, MD",1841780806,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","BCBSTX","Participating","Enrollment Complete","2021-12-03","","","2023-10-02","10/2/2023 Per BCBS TX roster received from Priscilla Albertine at MQA provider is PAR and linked to group effective 12/3/2021.  DCannon"]
["Chisom Nwoye, MD",1841780806,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","BCBSTX","Participating","Enrollment Complete","2021-12-03","","","2023-10-02","10/2/2023 Per BCBS TX roster received from Priscilla Albertine at MQA provider is PAR and linked to group effective 12/3/2021.  DCannon"]
["Chisom Nwoye, MD",1841780806,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","BCBSTX","Participating","Enrollment Complete","2021-12-03","","","2023-10-02","10/2/2023 Per BCBS TX roster received from Priscilla Albertine at MQA provider is PAR and linked to group effective 12/3/2021.  DCannon"]
["Chisom Nwoye, MD",1841780806,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","BCBSTX","Participating","Enrollment Complete","2021-12-03","","","2023-10-02","10/2/2023 Per BCBS TX roster received from Priscilla Albertine at MQA provider is PAR and linked to group effective 12/3/2021.  DCannon"]
["Chisom Nwoye, MD",1841780806,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Corvel Healthcare Corp.","Participating","Enrollment Complete","2022-06-13","1334093","","2022-08-23","08/23/2022 - Per follow-up note - Per email response received from Corvel Healthcare Corp on 08/17/2022. Provider NPI# is on file active and par under the TIN and Group effective 06/13/2022. Physical location is on file. Provider ID 1334093.  DCannon"]
["Chisom Nwoye, MD",1841780806,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","Boon Chapman","Participating","Enrollment Complete","2022-06-13","","","2023-09-01","9/1/2023 Per email received from Multiplan provider is PAR and linked to group TIN/locations effective 6/13/2022.  DCannon"]
["Chisom Nwoye, MD",1841780806,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Multiplan","Participating","Enrollment Complete","2022-06-13","","","2023-09-01","9/1/2023 Per email received from Multiplan provider is PAR and linked to group TIN/locations effective 6/13/2022.  DCannon"]
["Chisom Nwoye, MD",1841780806,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","Aetna","Participating","Enrollment Complete","2023-06-19","6910036","","2023-09-19","09.19.2023 S/W Joe of Aetna @ 1-800-353-1232. Per rep, provider is in network with Aetna for the state of TX and participating under the group and TIN# effective 06/19/2023. PIN: 6910036. Physical location is on file. No next recredentialing date available. Payer# 60054. Call ref# 6163696629. - Willie Ravas"]
["Chisom Nwoye, MD",1841780806,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Triwest VA","In House Enrollment","In House Enrollment","","","","2022-04-27",""]
["Chisom Nwoye, MD",1841780806,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","IMS","Participating","Enrollment Complete","2023-05-01","","","2023-07-20","7/20/2023 Per email received from IMS/OMNI May delegated roster has been processed and provider is PAR and linked to group effective 5/1/2023.  DCannon"]
["Chisom Nwoye, MD",1841780806,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","IMS","Participating","Enrollment Complete","2023-05-01","","","2023-07-20","7/20/2023 Per email received from IMS/OMNI May delegated roster has been processed and provider is PAR and linked to group effective 5/1/2023.  DCannon"]
["Chisom Nwoye, MD",1841780806,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","IMS","Participating","Enrollment Complete","2023-05-01","","","2023-07-20","7/20/2023 Per email received from IMS/OMNI May delegated roster has been processed and provider is PAR and linked to group effective 5/1/2023.  DCannon"]
["Chisom Nwoye, MD",1841780806,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","IMS","Participating","Enrollment Complete","2023-05-01","","","2023-07-20","7/20/2023 Per email received from IMS/OMNI May delegated roster has been processed and provider is PAR and linked to group effective 5/1/2023.  DCannon"]
["Chisom Nwoye, MD",1841780806,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Liberty Mutual","Panel Closed","Panel Closed","","","","2023-07-19","07/18/2023. We appreciate your interest in joining the Coventry Network.  At this time, our panels are closed, and we are not accepting new applications.  Please check back routinely to stay apprised of our panel status. We will update this site when we are open for new applicants. Gallagher, Hartford, Liberty Mutual, Travelers and Zurich fall under Coventry. Jen Videan"]
["Chisom Nwoye, MD",1841780806,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Boon Chapman","Participating","Enrollment Complete","2022-06-13","","","2023-09-01","9/1/2023 Per email received from Multiplan provider is PAR and linked to group TIN/locations effective 6/13/2022.  DCannon"]
["Chisom Nwoye, MD",1841780806,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Boon Chapman","Participating","Enrollment Complete","2022-06-13","","","2023-09-01","9/1/2023 Per email received from Multiplan provider is PAR and linked to group TIN/locations effective 6/13/2022.  DCannon"]
["Chisom Nwoye, MD",1841780806,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Boon Chapman","Participating","Enrollment Complete","2022-06-13","","","2023-09-01","9/1/2023 Per email received from Multiplan provider is PAR and linked to group TIN/locations effective 6/13/2022.  DCannon"]
["Chisom Nwoye, MD",1841780806,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Boon Chapman","Participating","Enrollment Complete","2022-06-13","","","2023-09-01","9/1/2023 Per email received from Multiplan provider is PAR and linked to group TIN/locations effective 6/13/2022.  DCannon"]
["Chisom Nwoye, MD",1841780806,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Texas Mutual","Participating","Enrollment Complete","2023-09-01","","","2023-09-06","Rcvd approval letter from Dee Dee Johnson at Texas Mutual. Jen Videan"]
["Chisom Nwoye, MD",1841780806,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Galaxy Health","Participating","Enrollment Complete","2022-06-13","","","2022-08-17","8/17/2022 Per email from Karen Avalos at Galaxy delegated roster for June is complete and provider is loaded effective 6/13/2022.  DCannon"]
["Chisom Nwoye, MD",1841780806,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Zurich","Panel Closed","Panel Closed","","","","2023-07-24"," We appreciate your interest in joining the Coventry Network.  At this time, our panels are closed, and we are not accepting new applications.  Please check back routinely to stay apprised of our panel status. We will update this site when we are open for new applicants. Gallagher, Hartford, Liberty Mutual, Travelers and Zurich fall under Coventry. Jen Videan"]
["Chisom Nwoye, MD",1841780806,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Zurich","Panel Closed","Panel Closed","","","","2023-07-24"," We appreciate your interest in joining the Coventry Network.  At this time, our panels are closed, and we are not accepting new applications.  Please check back routinely to stay apprised of our panel status. We will update this site when we are open for new applicants. Gallagher, Hartford, Liberty Mutual, Travelers and Zurich fall under Coventry. Jen Videan"]
["Chisom Nwoye, MD",1841780806,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Zurich","Panel Closed","Panel Closed","","","","2023-07-24"," We appreciate your interest in joining the Coventry Network.  At this time, our panels are closed, and we are not accepting new applications.  Please check back routinely to stay apprised of our panel status. We will update this site when we are open for new applicants. Gallagher, Hartford, Liberty Mutual, Travelers and Zurich fall under Coventry. Jen Videan"]
["Chisom Nwoye, MD",1841780806,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Zurich","Panel Closed","Panel Closed","","","","2023-07-24"," We appreciate your interest in joining the Coventry Network.  At this time, our panels are closed, and we are not accepting new applications.  Please check back routinely to stay apprised of our panel status. We will update this site when we are open for new applicants. Gallagher, Hartford, Liberty Mutual, Travelers and Zurich fall under Coventry. Jen Videan"]
["Chisom Nwoye, MD",1841780806,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","Zurich","Panel Closed","Panel Closed","","","","2023-07-24"," We appreciate your interest in joining the Coventry Network.  At this time, our panels are closed, and we are not accepting new applications.  Please check back routinely to stay apprised of our panel status. We will update this site when we are open for new applicants. Gallagher, Hartford, Liberty Mutual, Travelers and Zurich fall under Coventry. Jen Videan"]
["Chisom Nwoye, MD",1841780806,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","Zurich","Panel Closed","Panel Closed","","","","2023-07-24"," We appreciate your interest in joining the Coventry Network.  At this time, our panels are closed, and we are not accepting new applications.  Please check back routinely to stay apprised of our panel status. We will update this site when we are open for new applicants. Gallagher, Hartford, Liberty Mutual, Travelers and Zurich fall under Coventry. Jen Videan"]
["Chisom Nwoye, MD",1841780806,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Texas Municipal League","Participating","Enrollment Complete","","","","2023-11-20","Participating. Please see Alliance WC for notes. MS"]
["Chisom Nwoye, MD",1841780806,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Texas Municipal League","Participating","Enrollment Complete","","","","2023-11-20","Participating. Please see Alliance WC for notes. MS"]
["Chisom Nwoye, MD",1841780806,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Texas Municipal League","Participating","Enrollment Complete","","","","2023-11-20","Participating. Please see Alliance WC for notes. MS"]
["Chisom Nwoye, MD",1841780806,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Texas Municipal League","Participating","Enrollment Complete","","","","2023-11-20","Participating. Please see Alliance WC for notes. MS"]
["Chisom Nwoye, MD",1841780806,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","Texas Municipal League","Participating","Enrollment Complete","","","","2023-11-20","Participating. Please see Alliance WC for notes. MS"]
["Chisom Nwoye, MD",1841780806,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","Texas Municipal League","Participating","Enrollment Complete","","","","2023-11-20","Participating. Please see Alliance WC for notes. MS"]
["Chisom Nwoye, MD",1841780806,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Humana","Participating","Enrollment Complete","2022-06-13","","","2022-09-16","9/16/2022 Per email received from Vernita Young July monthly delegated roster is complete and provider is PAR and linked to group TIN/location effective 6/13/2022.  DCannon"]
["Chisom Nwoye, MD",1841780806,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","Caprock (CapStar)","Participating","Enrollment Complete","2023-10-02","","","2023-09-12","9/12/2023 Per email received from Caprock provider has been added to new location 6301 Andrews Hwy effective 10/2/2023.  DCannon"]
["Chisom Nwoye, MD",1841780806,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Aetna","Participating","Enrollment Complete","2022-07-01","6910036","","2022-07-28","7/28/2022 Per follow-up note:  07.14.22. S/W Rachel of Aetna @ 1-800-353-1232. Provider NPI# is on file for the provider and is participating effective 07/01/22 under the group and TIN#. PIN 6910036. Physical location is on file. Ref# 6100299498 - Ria Dee Bieren  DCannon"]
["Chisom Nwoye, MD",1841780806,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","USA PPO","In Process","Payor Follow Up","","","","2023-11-27","11/27/2023 Per USA PPO provider portal provider is still not loaded under new locations.  Will allow more time, check back in 2 weeks.  \nDCannon"]
["Chisom Nwoye, MD",1841780806,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","USA PPO","In Process","Payor Follow Up","","","","2023-11-27","11/27/2023 Per USA PPO provider portal provider is still not loaded under new locations.  Will allow more time, check back in 2 weeks.  \nDCannon"]
["Chisom Nwoye, MD",1841780806,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","USA PPO","In Process","Payor Follow Up","","","","2023-11-27","11/27/2023 Per USA PPO provider portal provider is still not loaded under new locations.  Will allow more time, check back in 2 weeks.  \nDCannon"]
["Chisom Nwoye, MD",1841780806,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","USA PPO","In Process","Payor Follow Up","","","","2023-11-27","11/27/2023 Per USA PPO provider portal provider is still not loaded under new locations.  Will allow more time, check back in 2 weeks.  \nDCannon"]
["Chisom Nwoye, MD",1841780806,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","First Health Coventry","Participating","Enrollment Complete","2022-06-13","","","2022-08-10","8/10/2022 Per First Health web portal provider is PAR and linked to group TIN/location effective 6/13/2022.  PID # 3567571.  DCannon"]
["Chisom Nwoye, MD",1841780806,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","Multiplan","Participating","Enrollment Complete","2022-06-13","","","2023-09-01","9/1/2023 Per email received from Multiplan provider is PAR and linked to group TIN/locations effective 6/13/2022.  DCannon"]
["Chisom Nwoye, MD",1841780806,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Tricare Prime","Participating","Enrollment Complete","2022-06-13","","","2022-06-21","6/21/2022  Per Tricare portal, provider has been added to group TIN and location effective 6/13/2022.  DCannon"]
["Chisom Nwoye, MD",1841780806,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","First Health Coventry","Participating","Enrollment Complete","2023-05-01","","","2023-07-24","Confirmed via online directory. MS"]
["Chisom Nwoye, MD",1841780806,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","First Health Coventry","Participating","Enrollment Complete","2023-05-01","","","2023-07-24","Confirmed via online directory. MS"]
["Chisom Nwoye, MD",1841780806,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","First Health Coventry","Participating","Enrollment Complete","2023-05-01","","","2023-07-24","Confirmed via online directory. MS"]
["Chisom Nwoye, MD",1841780806,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","First Health Coventry","Participating","Enrollment Complete","2023-05-01","","","2023-07-24","Confirmed via online directory. MS"]
["Chisom Nwoye, MD",1841780806,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Texas Mutual","Participating","Enrollment Complete","","","","2023-10-06","6950 Eastridge and 4705 Briarwood have been added to provider's profile. Effective dates are not given. 6301 Andrew Hwy cannot be added until a site visit is completed. Jen Videan"]
["Chisom Nwoye, MD",1841780806,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Texas Mutual","Participating","Enrollment Complete","","","","2023-10-06","6950 Eastridge and 4705 Briarwood have been added to provider's profile. Effective dates are not given. 6301 Andrew Hwy cannot be added until a site visit is completed. Jen Videan"]
["Chisom Nwoye, MD",1841780806,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Texas Mutual","Participating","Enrollment Complete","","","","2023-10-06","6950 Eastridge and 4705 Briarwood have been added to provider's profile. Effective dates are not given. 6301 Andrew Hwy cannot be added until a site visit is completed. Jen Videan"]
["Chisom Nwoye, MD",1841780806,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Texas Mutual","Participating","Enrollment Complete","","","","2023-10-06","6950 Eastridge and 4705 Briarwood have been added to provider's profile. Effective dates are not given. 6301 Andrew Hwy cannot be added until a site visit is completed. Jen Videan"]
["Chisom Nwoye, MD",1841780806,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","Texas Mutual","Participating","Enrollment Complete","","","","2023-10-06","6950 Eastridge and 4705 Briarwood have been added to provider's profile. Effective dates are not given. 6301 Andrew Hwy cannot be added until a site visit is completed. Jen Videan"]
["Chisom Nwoye, MD",1841780806,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","Texas Mutual","Participating","Enrollment Complete","","","","2023-10-06","6950 Eastridge and 4705 Briarwood have been added to provider's profile. Effective dates are not given. 6301 Andrew Hwy cannot be added until a site visit is completed. Jen Videan"]
["Chisom Nwoye, MD",1841780806,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","HealthSmart PPO","Participating","Enrollment Complete","2022-06-13","","","2022-08-10","8/10/2022 Per Healthsmart website provider is PAR and loaded under TIN/location effective 6/13/2022.  DCannon"]
["Chisom Nwoye, MD",1841780806,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","Galaxy Health","Participating","Enrollment Complete","2023-10-02","","","2023-09-19","9/19/2023 Per email received from Galaxy August delegated roster has been processed and provider is PAR and linked to group/location effective 10/2/2023.  DCannon"]
["Chisom Nwoye, MD",1841780806,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","United Health Care","Participating","Enrollment Complete","2022-06-13","000008092273","","2023-09-07","9/7/2023 Per email from UHC May delegated roster has been completed.  Provider is PAR and linked to group TIN/locations effective 6/13/2022.  DCannon"]
["Chisom Nwoye, MD",1841780806,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","United Health Care","Participating","Enrollment Complete","2022-06-13","000008092273","","2023-09-07","9/7/2023 Per email from UHC May delegated roster has been completed.  Provider is PAR and linked to group TIN/locations effective 6/13/2022.  DCannon"]
["Chisom Nwoye, MD",1841780806,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","United Health Care","Participating","Enrollment Complete","2022-06-13","000008092273","","2023-09-07","9/7/2023 Per email from UHC May delegated roster has been completed.  Provider is PAR and linked to group TIN/locations effective 6/13/2022.  DCannon"]
["Chisom Nwoye, MD",1841780806,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","United Health Care","Participating","Enrollment Complete","2022-06-13","000008092273","","2023-09-07","9/7/2023 Per email from UHC May delegated roster has been completed.  Provider is PAR and linked to group TIN/locations effective 6/13/2022.  DCannon"]
["Chisom Nwoye, MD",1841780806,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Amerigroup","Participating","Enrollment Complete","2022-06-13","","","2022-09-23","9/23/2022 Per roster received from Joe Rodriguez at Amerigroup provider is PAR and linked to group TIN effective 6/13/2022.  DCannon"]
["Chisom Nwoye, MD",1841780806,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","United Health Care","Participating","Enrollment Complete","2022-06-13","00008092273024","","2023-10-13","10/13/2023 Per email received from  from UHC monthly delegated roster submission has been completed and provider is PAR and in linked to group TIN effective 6/13/2022.   MPIN# 008092273.   DCannon"]
["Chisom Nwoye, MD",1841780806,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","TriCare Standard","Participating","Enrollment Complete","2022-06-13","","","2022-06-21","6/21/2022  Per Tricare portal, provider has been added to group TIN and location effective 6/13/2022.  DCannon"]
["Chisom Nwoye, MD",1841780806,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Aetna","Participating","Enrollment Complete","2022-07-01","","","2023-09-07","9/7/2023 Per email response from Mary Hanna at Aetna, May delegated roster is complete.  Provider is PAR and linked to group TIN/location effective 7/1/2022.  DCannon"]
["Chisom Nwoye, MD",1841780806,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Aetna","Participating","Enrollment Complete","2022-07-01","","","2023-09-07","9/7/2023 Per email response from Mary Hanna at Aetna, May delegated roster is complete.  Provider is PAR and linked to group TIN/location effective 7/1/2022.  DCannon"]
["Chisom Nwoye, MD",1841780806,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Aetna","Participating","Enrollment Complete","2022-07-01","","","2023-09-07","9/7/2023 Per email response from Mary Hanna at Aetna, May delegated roster is complete.  Provider is PAR and linked to group TIN/location effective 7/1/2022.  DCannon"]
["Chisom Nwoye, MD",1841780806,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Aetna","Participating","Enrollment Complete","2022-07-01","","","2023-09-07","9/7/2023 Per email response from Mary Hanna at Aetna, May delegated roster is complete.  Provider is PAR and linked to group TIN/location effective 7/1/2022.  DCannon"]
["Chisom Nwoye, MD",1841780806,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Coventry Workers Comp","Panel Closed","Panel Closed","","","","2023-07-24"," 7/24/2023 We appreciate your interest in joining the Coventry Network.  At this time, our panels are closed, and we are not accepting new applications.  Please check back routinely to stay apprised of our panel status. We will update this site when we are open for new applicants. Gallagher, Hartford, Liberty Mutual, Travelers and Zurich fall under Coventry. Jen Videan"]
["Chisom Nwoye, MD",1841780806,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Coventry Workers Comp","Panel Closed","Panel Closed","","","","2023-07-24"," 7/24/2023 We appreciate your interest in joining the Coventry Network.  At this time, our panels are closed, and we are not accepting new applications.  Please check back routinely to stay apprised of our panel status. We will update this site when we are open for new applicants. Gallagher, Hartford, Liberty Mutual, Travelers and Zurich fall under Coventry. Jen Videan"]
["Chisom Nwoye, MD",1841780806,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Coventry Workers Comp","Panel Closed","Panel Closed","","","","2023-07-24"," 7/24/2023 We appreciate your interest in joining the Coventry Network.  At this time, our panels are closed, and we are not accepting new applications.  Please check back routinely to stay apprised of our panel status. We will update this site when we are open for new applicants. Gallagher, Hartford, Liberty Mutual, Travelers and Zurich fall under Coventry. Jen Videan"]
["Chisom Nwoye, MD",1841780806,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Coventry Workers Comp","Panel Closed","Panel Closed","","","","2023-07-24"," 7/24/2023 We appreciate your interest in joining the Coventry Network.  At this time, our panels are closed, and we are not accepting new applications.  Please check back routinely to stay apprised of our panel status. We will update this site when we are open for new applicants. Gallagher, Hartford, Liberty Mutual, Travelers and Zurich fall under Coventry. Jen Videan"]
["Chisom Nwoye, MD",1841780806,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","Coventry Workers Comp","Panel Closed","Panel Closed","","","","2023-07-24"," 7/24/2023 We appreciate your interest in joining the Coventry Network.  At this time, our panels are closed, and we are not accepting new applications.  Please check back routinely to stay apprised of our panel status. We will update this site when we are open for new applicants. Gallagher, Hartford, Liberty Mutual, Travelers and Zurich fall under Coventry. Jen Videan"]
["Chisom Nwoye, MD",1841780806,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","Coventry Workers Comp","Panel Closed","Panel Closed","","","","2023-07-24"," 7/24/2023 We appreciate your interest in joining the Coventry Network.  At this time, our panels are closed, and we are not accepting new applications.  Please check back routinely to stay apprised of our panel status. We will update this site when we are open for new applicants. Gallagher, Hartford, Liberty Mutual, Travelers and Zurich fall under Coventry. Jen Videan"]
["Chisom Nwoye, MD",1841780806,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","IMS","Participating","Enrollment Complete","2022-06-13","","","2022-07-05","7/5/2022 Rcvd email from G.Aviles at IMS/OMNI that delegation roster provider load for June has been completed.  Provider is PAR and linked to group effective 6/13/2022.  DCannon"]
["Chisom Nwoye, MD",1841780806,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Gallagher","Panel Closed","Panel Closed","","","","2023-07-19","07/18/2023. We appreciate your interest in joining the Coventry Network.  At this time, our panels are closed, and we are not accepting new applications.  Please check back routinely to stay apprised of our panel status. We will update this site when we are open for new applicants. Gallagher, Hartford, Liberty Mutual, Travelers and Zurich fall under Coventry. Jen Videan"]
["Chisom Nwoye, MD",1841780806,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Sedgwick","Participating","Enrollment Complete","2022-11-08","","","2023-05-17","received approval letter from Careworks effective 5/17/2023. MS."]
["Chisom Nwoye, MD",1841780806,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Alliance WC","Participating","Enrollment Complete","2022-12-30","","","2022-09-21","Per Michelle Killough provider is effective 12/30/2022. Jen Videan"]
["Chisom Nwoye, MD",1841780806,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Alliance WC","Participating","Enrollment Complete","2022-12-30","","","2022-09-21","Per Michelle Killough provider is effective 12/30/2022. Jen Videan"]
["Chisom Nwoye, MD",1841780806,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","Alliance WC","Participating","Enrollment Complete","2022-12-30","","","2022-09-21","Per Michelle Killough provider is effective 12/30/2022. Jen Videan"]
["Chisom Nwoye, MD",1841780806,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","Alliance WC","Participating","Enrollment Complete","2022-12-30","","","2022-09-21","Per Michelle Killough provider is effective 12/30/2022. Jen Videan"]
["Chisom Nwoye, MD",1841780806,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Alliance WC","Participating","Enrollment Complete","2022-12-30","","","2022-09-21","Per Michelle Killough provider is effective 12/30/2022. Jen Videan"]
["Chisom Nwoye, MD",1841780806,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Alliance WC","Participating","Enrollment Complete","2022-12-30","","","2022-09-21","Per Michelle Killough provider is effective 12/30/2022. Jen Videan"]
["Chisom Nwoye, MD",1841780806,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Triwest VA","In House Enrollment","In House Enrollment","","","","2023-05-01",""]
["Chisom Nwoye, MD",1841780806,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Triwest VA","In House Enrollment","In House Enrollment","","","","2023-05-01",""]
["Chisom Nwoye, MD",1841780806,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Triwest VA","In House Enrollment","In House Enrollment","","","","2023-05-01",""]
["Chisom Nwoye, MD",1841780806,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Triwest VA","In House Enrollment","In House Enrollment","","","","2023-05-01",""]
["Chisom Nwoye, MD",1841780806,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Scott&White (First Care)","Participating","Enrollment Complete","2023-05-01","","","2023-08-17","8/17/2023 Received email from Scott & White HPDELEGATION@BSWHealth.org that provider load from May has been completed and provider is PAR effective 5/1/2023.  DCannon"]
["Chisom Nwoye, MD",1841780806,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Scott&White (First Care)","Participating","Enrollment Complete","2023-05-01","","","2023-08-17","8/17/2023 Received email from Scott & White HPDELEGATION@BSWHealth.org that provider load from May has been completed and provider is PAR effective 5/1/2023.  DCannon"]
["Chisom Nwoye, MD",1841780806,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Scott&White (First Care)","Participating","Enrollment Complete","2023-05-01","","","2023-08-17","8/17/2023 Received email from Scott & White HPDELEGATION@BSWHealth.org that provider load from May has been completed and provider is PAR effective 5/1/2023.  DCannon"]
["Chisom Nwoye, MD",1841780806,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Scott&White (First Care)","Participating","Enrollment Complete","2023-05-01","","","2023-08-17","8/17/2023 Received email from Scott & White HPDELEGATION@BSWHealth.org that provider load from May has been completed and provider is PAR effective 5/1/2023.  DCannon"]
["Chisom Nwoye, MD",1841780806,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","Cigna","Participating","Enrollment Complete","2023-06-19","6819516","","2023-09-19","09.19.2023 S/W Sofie of Cigna @ 1-800-882-4462. Per rep, provider is showing participating and link under the Group and TIN with an Effective date 06/19/2023. Provider ID 6819516. Service location is on file. Call ref#:SofieS09192023."]
["Chisom Nwoye, MD",1841780806,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","IMS","Participating","Enrollment Complete","2023-10-02","","","2023-09-05","9/5/2023 Per email received from IMS/OMNI May delegated roster has been processed and provider is PAR and linked to group effective 10/2/2023.  DCannon"]
["Chisom Nwoye, MD",1841780806,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Galaxy Health","Participating","Enrollment Complete","2023-05-01","","","2023-07-20","7/20/2023 Per email received from Galaxy May delegated roster has been processed and provider is PAR and linked to group effective 5/1/2023.  DCannon"]
["Chisom Nwoye, MD",1841780806,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Galaxy Health","Participating","Enrollment Complete","2023-05-01","","","2023-07-20","7/20/2023 Per email received from Galaxy May delegated roster has been processed and provider is PAR and linked to group effective 5/1/2023.  DCannon"]
["Chisom Nwoye, MD",1841780806,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Galaxy Health","Participating","Enrollment Complete","2023-05-01","","","2023-07-20","7/20/2023 Per email received from Galaxy May delegated roster has been processed and provider is PAR and linked to group effective 5/1/2023.  DCannon"]
["Chisom Nwoye, MD",1841780806,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Galaxy Health","Participating","Enrollment Complete","2023-05-01","","","2023-07-20","7/20/2023 Per email received from Galaxy May delegated roster has been processed and provider is PAR and linked to group effective 5/1/2023.  DCannon"]
["Chisom Nwoye, MD",1841780806,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","Amerigroup","Participating","Enrollment Complete","2022-06-13","","","2023-10-19","10/19/2023 Per email received from Jessica Bess at  Multiplan provider is PAR with Amerigroup and linked to group TIN/locations thru Multiplan enrollment effective 6/13/2022.  DCannon"]
["Chisom Nwoye, MD",1841780806,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Tricare Prime","Panel Closed","Panel Closed","","","","2023-08-17","8/17/2023 Unfortunately, at this time the network is closed. Humana Military thanks you for your interest in joining the TRICARE East Region network to provide care for our beneficiaries. At this time, we are not currently expanding our network based on your specialty and location within the East Region. Please understand that every market is different based on the beneficiary population and the types of services needed in a particular location. Thank you again for your inquiry.   You can monitor the link below for network opening status.    Join the TRICARE East network (humanamilitary.com)   Humana Military is currently not accepting requests to join the medical surgical network. We apologize for the inconvenience, but we hope you check back soon to see if we are accepting network providers."]
["Chisom Nwoye, MD",1841780806,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Tricare Prime","Panel Closed","Panel Closed","","","","2023-08-17","8/17/2023 Unfortunately, at this time the network is closed. Humana Military thanks you for your interest in joining the TRICARE East Region network to provide care for our beneficiaries. At this time, we are not currently expanding our network based on your specialty and location within the East Region. Please understand that every market is different based on the beneficiary population and the types of services needed in a particular location. Thank you again for your inquiry.   You can monitor the link below for network opening status.    Join the TRICARE East network (humanamilitary.com)   Humana Military is currently not accepting requests to join the medical surgical network. We apologize for the inconvenience, but we hope you check back soon to see if we are accepting network providers."]
["Chisom Nwoye, MD",1841780806,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Tricare Prime","Panel Closed","Panel Closed","","","","2023-08-17","8/17/2023 Unfortunately, at this time the network is closed. Humana Military thanks you for your interest in joining the TRICARE East Region network to provide care for our beneficiaries. At this time, we are not currently expanding our network based on your specialty and location within the East Region. Please understand that every market is different based on the beneficiary population and the types of services needed in a particular location. Thank you again for your inquiry.   You can monitor the link below for network opening status.    Join the TRICARE East network (humanamilitary.com)   Humana Military is currently not accepting requests to join the medical surgical network. We apologize for the inconvenience, but we hope you check back soon to see if we are accepting network providers."]
["Chisom Nwoye, MD",1841780806,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Tricare Prime","Panel Closed","Panel Closed","","","","2023-08-17","8/17/2023 Unfortunately, at this time the network is closed. Humana Military thanks you for your interest in joining the TRICARE East Region network to provide care for our beneficiaries. At this time, we are not currently expanding our network based on your specialty and location within the East Region. Please understand that every market is different based on the beneficiary population and the types of services needed in a particular location. Thank you again for your inquiry.   You can monitor the link below for network opening status.    Join the TRICARE East network (humanamilitary.com)   Humana Military is currently not accepting requests to join the medical surgical network. We apologize for the inconvenience, but we hope you check back soon to see if we are accepting network providers."]
["Chisom Nwoye, MD",1841780806,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","Tricare Prime","Panel Closed","Panel Closed","","","","2023-08-17","8/17/2023 Unfortunately, at this time the network is closed. Humana Military thanks you for your interest in joining the TRICARE East Region network to provide care for our beneficiaries. At this time, we are not currently expanding our network based on your specialty and location within the East Region. Please understand that every market is different based on the beneficiary population and the types of services needed in a particular location. Thank you again for your inquiry.   You can monitor the link below for network opening status.    Join the TRICARE East network (humanamilitary.com)   Humana Military is currently not accepting requests to join the medical surgical network. We apologize for the inconvenience, but we hope you check back soon to see if we are accepting network providers."]
["Chisom Nwoye, MD",1841780806,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","Tricare Prime","Panel Closed","Panel Closed","","","","2023-08-17","8/17/2023 Unfortunately, at this time the network is closed. Humana Military thanks you for your interest in joining the TRICARE East Region network to provide care for our beneficiaries. At this time, we are not currently expanding our network based on your specialty and location within the East Region. Please understand that every market is different based on the beneficiary population and the types of services needed in a particular location. Thank you again for your inquiry.   You can monitor the link below for network opening status.    Join the TRICARE East network (humanamilitary.com)   Humana Military is currently not accepting requests to join the medical surgical network. We apologize for the inconvenience, but we hope you check back soon to see if we are accepting network providers."]
["Chisom Nwoye, MD",1841780806,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Humana","Participating","Enrollment Complete","2022-06-13","","","2023-09-01","9/1/2023 Per email received from Humana provider is PAR and linked to group TIN/locations effective 6/13/2022.  DCannon"]
["Chisom Nwoye, MD",1841780806,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Humana","Participating","Enrollment Complete","2022-06-13","","","2023-09-01","9/1/2023 Per email received from Humana provider is PAR and linked to group TIN/locations effective 6/13/2022.  DCannon"]
["Chisom Nwoye, MD",1841780806,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Humana","Participating","Enrollment Complete","2022-06-13","","","2023-09-01","9/1/2023 Per email received from Humana provider is PAR and linked to group TIN/locations effective 6/13/2022.  DCannon"]
["Chisom Nwoye, MD",1841780806,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Humana","Participating","Enrollment Complete","2022-06-13","","","2023-09-01","9/1/2023 Per email received from Humana provider is PAR and linked to group TIN/locations effective 6/13/2022.  DCannon"]
["Chisom Nwoye, MD",1841780806,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Omni PPO","Participating","Enrollment Complete","2023-05-01","","","2023-07-20","7/20/2023 Per email received from IMS/OMNI April delegated roster has been processed and provider is PAR and linked to group effective 5/1/2023.  DCannon"]
["Chisom Nwoye, MD",1841780806,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Omni PPO","Participating","Enrollment Complete","2023-05-01","","","2023-07-20","7/20/2023 Per email received from IMS/OMNI April delegated roster has been processed and provider is PAR and linked to group effective 5/1/2023.  DCannon"]
["Chisom Nwoye, MD",1841780806,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Omni PPO","Participating","Enrollment Complete","2023-05-01","","","2023-07-20","7/20/2023 Per email received from IMS/OMNI April delegated roster has been processed and provider is PAR and linked to group effective 5/1/2023.  DCannon"]
["Chisom Nwoye, MD",1841780806,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Omni PPO","Participating","Enrollment Complete","2023-05-01","","","2023-07-20","7/20/2023 Per email received from IMS/OMNI April delegated roster has been processed and provider is PAR and linked to group effective 5/1/2023.  DCannon"]
["Chisom Nwoye, MD",1841780806,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Travelers WC","Panel Closed","Panel Closed","","","","2023-07-19","07/18/2023. We appreciate your interest in joining the Coventry Network.  At this time, our panels are closed, and we are not accepting new applications.  Please check back routinely to stay apprised of our panel status. We will update this site when we are open for new applicants. Gallagher, Hartford, Liberty Mutual, Travelers and Zurich fall under Coventry. Jen Videan"]
["Chisom Nwoye, MD",1841780806,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","First Health Coventry","Participating","Enrollment Complete","2022-06-01","3567571","","2023-09-20","09.20.2023 S/W Ashnti of First Health @ 800-226-5116 and transferred me over to Courtney. Per rep, provider is in network with First Health for the state of TX and linked to the group and TIN# effective 06/01/2022. Next recredentialing date is on 06/01/2025. PIN: 3567571. Servicing location is on file. Payer# 73159. Call ref# 760029. - Willie Ravas"]
["Chisom Nwoye, MD",1841780806,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","CAQH","Participating","CAQH Reattested","2023-11-16","","","2023-11-16","11/16/2023 CAQH Reattested updated mailing addresses"]
["Chisom Nwoye, MD",1841780806,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Corvel Healthcare Corp.","Participating","Enrollment Complete","2022-11-08","","","2023-08-29","Rcvd welcome letter from Karina Garcia at Corvel. Jen Videan"]
["Chisom Nwoye, MD",1841780806,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Corvel Healthcare Corp.","Participating","Enrollment Complete","2022-11-08","","","2023-08-29","Rcvd welcome letter from Karina Garcia at Corvel. Jen Videan"]
["Chisom Nwoye, MD",1841780806,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Corvel Healthcare Corp.","Participating","Enrollment Complete","2022-11-08","","","2023-08-29","Rcvd welcome letter from Karina Garcia at Corvel. Jen Videan"]
["Chisom Nwoye, MD",1841780806,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Corvel Healthcare Corp.","Participating","Enrollment Complete","2022-11-08","","","2023-08-29","Rcvd welcome letter from Karina Garcia at Corvel. Jen Videan"]
["Chisom Nwoye, MD",1841780806,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","Corvel Healthcare Corp.","Participating","Enrollment Complete","2022-11-08","","","2023-08-29","Rcvd welcome letter from Karina Garcia at Corvel. Jen Videan"]
["Chisom Nwoye, MD",1841780806,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","Corvel Healthcare Corp.","Participating","Enrollment Complete","2022-11-08","","","2023-08-29","Rcvd welcome letter from Karina Garcia at Corvel. Jen Videan"]
["Chisom Nwoye, MD",1841780806,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","Omni PPO","Participating","Enrollment Complete","2023-10-02","","","2023-09-05","9/5/2023 Per email received from IMS/OMNI May delegated roster has been processed and provider is PAR and linked to group effective 10/2/2023.  DCannon"]
["Chisom Nwoye, MD",1841780806,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","Triwest VA","In House Enrollment","In House Enrollment","","","","2023-07-22",""]
["Chisom Nwoye, MD",1841780806,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Medicare","Participating","Enrollment Complete","2022-05-01","2E0739","423838","2022-05-27","5/27/2022 Rcvd Medicare approval letter.  PTAN # 2E0739 - effective 5/1/2022.  DCannon"]
["Chisom Nwoye, MD",1841780806,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Amerigroup","Participating","Enrollment Complete","2022-06-13","","","2023-10-19","10/19/2023 Per email received from Jessica Bess at  Multiplan provider is PAR with Amerigroup and linked to group TIN/locations thru Multiplan enrollment effective 6/13/2022.  DCannon"]
["Chisom Nwoye, MD",1841780806,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Amerigroup","Participating","Enrollment Complete","2022-06-13","","","2023-10-19","10/19/2023 Per email received from Jessica Bess at  Multiplan provider is PAR with Amerigroup and linked to group TIN/locations thru Multiplan enrollment effective 6/13/2022.  DCannon"]
["Chisom Nwoye, MD",1841780806,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Amerigroup","Participating","Enrollment Complete","2022-06-13","","","2023-10-19","10/19/2023 Per email received from Jessica Bess at  Multiplan provider is PAR with Amerigroup and linked to group TIN/locations thru Multiplan enrollment effective 6/13/2022.  DCannon"]
["Chisom Nwoye, MD",1841780806,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Amerigroup","Participating","Enrollment Complete","2022-06-13","","","2023-10-19","10/19/2023 Per email received from Jessica Bess at  Multiplan provider is PAR with Amerigroup and linked to group TIN/locations thru Multiplan enrollment effective 6/13/2022.  DCannon"]
["Chisom Nwoye, MD",1841780806,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Sedgwick","Participating","Enrollment Complete","2023-07-31","","","2023-08-01","Rcvd email from providerdata@careworks.com  request to add 3 new location is complete. Effective 7/31/2023. Jen Videan"]
["Chisom Nwoye, MD",1841780806,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Sedgwick","Participating","Enrollment Complete","2023-07-31","","","2023-08-01","Rcvd email from providerdata@careworks.com  request to add 3 new location is complete. Effective 7/31/2023. Jen Videan"]
["Chisom Nwoye, MD",1841780806,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Sedgwick","Participating","Enrollment Complete","2023-07-31","","","2023-08-01","Rcvd email from providerdata@careworks.com  request to add 3 new location is complete. Effective 7/31/2023. Jen Videan"]
["Chisom Nwoye, MD",1841780806,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Sedgwick","Participating","Enrollment Complete","2023-07-31","","","2023-08-01","Rcvd email from providerdata@careworks.com  request to add 3 new location is complete. Effective 7/31/2023. Jen Videan"]
["Chisom Nwoye, MD",1841780806,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","Sedgwick","Participating","Enrollment Complete","2023-07-31","","","2023-08-01","Rcvd email from providerdata@careworks.com  request to add 3 new location is complete. Effective 7/31/2023. Jen Videan"]
["Chisom Nwoye, MD",1841780806,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","Sedgwick","Participating","Enrollment Complete","2023-07-31","","","2023-08-01","Rcvd email from providerdata@careworks.com  request to add 3 new location is complete. Effective 7/31/2023. Jen Videan"]
["Chisom Nwoye, MD",1841780806,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Texas Municipal League","Participating","Enrollment Complete","2022-12-30","","","2023-01-11","01/11/2023 - Received welcome letter confirming participation with PSWCA, eff. 12/30/2022.  DCannon"]
["Chisom Nwoye, MD",1841780806,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Boon Chapman","Participating","Enrollment Complete","2022-06-13","","","2023-09-01","9/1/2023 Per email received from Multiplan provider is PAR and linked to group TIN/locations effective 6/13/2022.  DCannon"]
["Morgan Sims, PA-C",1952865057,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","United Health Care","Participating","Enrollment Complete","2021-10-01","007021658","","2023-11-17","11/17/2023 Per email rcvd from UHC provider is PAR and linked to group TIN and locations effective 10/1/2021.  MPIN # 007021658.  DCannon"]
["Morgan Sims, PA-C",1952865057,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Wellmed","Participating","Enrollment Complete","2022-01-01","","","2023-09-29","9/29/2023 Per email from UHC May delegated roster has been completed.  Provider is PAR and linked to group TIN/locations effective 1/1/2022.  DCannon"]
["Morgan Sims, PA-C",1952865057,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Wellmed","Participating","Enrollment Complete","2022-01-01","","","2023-09-29","9/29/2023 Per email from UHC May delegated roster has been completed.  Provider is PAR and linked to group TIN/locations effective 1/1/2022.  DCannon"]
["Morgan Sims, PA-C",1952865057,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Wellmed","Participating","Enrollment Complete","2022-01-01","","","2023-09-29","9/29/2023 Per email from UHC May delegated roster has been completed.  Provider is PAR and linked to group TIN/locations effective 1/1/2022.  DCannon"]
["Morgan Sims, PA-C",1952865057,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Wellmed","Participating","Enrollment Complete","2022-01-01","","","2023-09-29","9/29/2023 Per email from UHC May delegated roster has been completed.  Provider is PAR and linked to group TIN/locations effective 1/1/2022.  DCannon"]
["Morgan Sims, PA-C",1952865057,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","USA PPO","Participating","Enrollment Complete","2022-01-12","","","2023-11-20","11/20/2023  In following up with USAMCO (800-872-3860) I was told that you can confirm participating via the USA MCO website  https://providersearch.usamco.com/hwprovsearch.  Provider is PAR and linked to location/TIN effective 1/12/2022.  DCannon"]
["Morgan Sims, PA-C",1952865057,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Medicare","Participating","Enrollment Complete","2021-09-01","1U8148","423838","2023-09-29","9/29/2023 Per PECOS new locations have been added to group record.  Provider is PAR and linked to group/locations effective 9/1/221.  PID # 1U8148.  DCannon"]
["Morgan Sims, PA-C",1952865057,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Medicare","Participating","Enrollment Complete","2021-09-01","1U8148","423838","2023-09-29","9/29/2023 Per PECOS new locations have been added to group record.  Provider is PAR and linked to group/locations effective 9/1/221.  PID # 1U8148.  DCannon"]
["Morgan Sims, PA-C",1952865057,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Medicare","Participating","Enrollment Complete","2021-09-01","1U8148","423838","2023-09-29","9/29/2023 Per PECOS new locations have been added to group record.  Provider is PAR and linked to group/locations effective 9/1/221.  PID # 1U8148.  DCannon"]
["Morgan Sims, PA-C",1952865057,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Medicare","Participating","Enrollment Complete","2021-09-01","1U8148","423838","2023-09-29","9/29/2023 Per PECOS new locations have been added to group record.  Provider is PAR and linked to group/locations effective 9/1/221.  PID # 1U8148.  DCannon"]
["Morgan Sims, PA-C",1952865057,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","Medicare","Participating","Enrollment Complete","2021-09-01","1U8148","423838","2023-09-29","9/29/2023 Per PECOS new locations have been added to group record.  Provider is PAR and linked to group/locations effective 9/1/221.  PID # 1U8148.  DCannon"]
["Morgan Sims, PA-C",1952865057,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","Medicare","Participating","Enrollment Complete","2021-09-01","1U8148","423838","2023-09-29","9/29/2023 Per PECOS new locations have been added to group record.  Provider is PAR and linked to group/locations effective 9/1/221.  PID # 1U8148.  DCannon"]
["Morgan Sims, PA-C",1952865057,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","United Health Care","Participating","Enrollment Complete","2021-10-01","007021658","","2023-11-17","11/17/2023 Per email rcvd from UHC provider is PAR and linked to group TIN and locations effective 10/1/2021.  MPIN # 007021658.  DCannon"]
["Morgan Sims, PA-C",1952865057,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","United Health Care","Participating","Enrollment Complete","2021-10-01","007021658","","2023-11-17","11/17/2023 Per email rcvd from UHC provider is PAR and linked to group TIN and locations effective 10/1/2021.  MPIN # 007021658.  DCannon"]
["Morgan Sims, PA-C",1952865057,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","United Health Care","Participating","Enrollment Complete","2021-10-01","007021658","","2023-11-17","11/17/2023 Per email rcvd from UHC provider is PAR and linked to group TIN and locations effective 10/1/2021.  MPIN # 007021658.  DCannon"]
["Morgan Sims, PA-C",1952865057,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","United Health Care","Participating","Enrollment Complete","2021-10-01","007021658","","2023-11-17","11/17/2023 Per email rcvd from UHC provider is PAR and linked to group TIN and locations effective 10/1/2021.  MPIN # 007021658.  DCannon"]
["Morgan Sims, PA-C",1952865057,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Aetna","Participating","Enrollment Complete","2021-09-01","","","2021-12-08","12/8/2021 Per email from Mary Hanna @ Aetna provider is PAR and linked to group/locations effective 9/1/2021.  DCannon"]
["Morgan Sims, PA-C",1952865057,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Aetna","Participating","Enrollment Complete","2021-09-01","","","2023-09-29","9/29/2023 Per email from Aetna provider is PAR and linked to group TIN/location effective 9/1/2021.  DCannon"]
["Morgan Sims, PA-C",1952865057,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Aetna","Participating","Enrollment Complete","2021-09-01","","","2023-09-29","9/29/2023 Per email from Aetna provider is PAR and linked to group TIN/location effective 9/1/2021.  DCannon"]
["Morgan Sims, PA-C",1952865057,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Aetna","Participating","Enrollment Complete","2021-09-01","","","2023-09-29","9/29/2023 Per email from Aetna provider is PAR and linked to group TIN/location effective 9/1/2021.  DCannon"]
["Morgan Sims, PA-C",1952865057,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Aetna","Participating","Enrollment Complete","2021-09-01","","","2023-09-29","9/29/2023 Per email from Aetna provider is PAR and linked to group TIN/location effective 9/1/2021.  DCannon"]
["Morgan Sims, PA-C",1952865057,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","TriCare Standard","Participating","Enrollment Complete","2023-10-26","","","2023-10-26","Provider is linked to Briarwood and Eastridge locations eff 10/9/23. MS"]
["Morgan Sims, PA-C",1952865057,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","TriCare Standard","Participating","Enrollment Complete","2023-10-26","","","2023-10-26","Provider is linked to Briarwood and Eastridge locations eff 10/9/23. MS"]
["Morgan Sims, PA-C",1952865057,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","TriCare Standard","Participating","Enrollment Complete","2023-10-26","","","2023-11-05","Provider is linked to Andrews Hwy location eff 10/26/23. MS"]
["Morgan Sims, PA-C",1952865057,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","TriCare Standard","Participating","Enrollment Complete","2023-10-26","","","2023-11-05","Provider is linked to Andrews Hwy location eff 10/26/23. MS"]
["Morgan Sims, PA-C",1952865057,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","TriCare Standard","Participating","Enrollment Complete","2023-10-26","","","2023-10-26","Provider is linked to Briarwood and Eastridge locations eff 10/9/23. MS"]
["Morgan Sims, PA-C",1952865057,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","TriCare Standard","Participating","Enrollment Complete","2023-10-26","","","2023-10-26","Provider is linked to Briarwood and Eastridge locations eff 10/9/23. MS"]
["Morgan Sims, PA-C",1952865057,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","TriCare Standard","Participating","Enrollment Complete","2023-10-26","","","2023-11-05","Provider is linked to Andrews Hwy location eff 10/26/23. MS"]
["Morgan Sims, PA-C",1952865057,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","TriCare Standard","Participating","Enrollment Complete","2023-10-26","","","2023-11-05","Provider is linked to Andrews Hwy location eff 10/26/23. MS"]
["Morgan Sims, PA-C",1952865057,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","TriCare Standard","Participating","Enrollment Complete","2023-10-26","","","2023-10-26","Provider is linked to Briarwood and Eastridge locations eff 10/9/23. MS"]
["Morgan Sims, PA-C",1952865057,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","TriCare Standard","Participating","Enrollment Complete","2023-10-26","","","2023-10-26","Provider is linked to Briarwood and Eastridge locations eff 10/9/23. MS"]
["Morgan Sims, PA-C",1952865057,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","TriCare Standard","Participating","Enrollment Complete","2023-10-26","","","2023-11-05","Provider is linked to Andrews Hwy location eff 10/26/23. MS"]
["Morgan Sims, PA-C",1952865057,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","TriCare Standard","Participating","Enrollment Complete","2023-10-26","","","2023-11-05","Provider is linked to Andrews Hwy location eff 10/26/23. MS"]
["Morgan Sims, PA-C",1952865057,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Triwest VA","In House Enrollment","In House Enrollment","","","","2023-09-29",""]
["Morgan Sims, PA-C",1952865057,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Triwest VA","In House Enrollment","In House Enrollment","","","","2023-09-29",""]
["Morgan Sims, PA-C",1952865057,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Triwest VA","In House Enrollment","In House Enrollment","","","","2023-09-29",""]
["Morgan Sims, PA-C",1952865057,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Triwest VA","In House Enrollment","In House Enrollment","","","","2023-09-29",""]
["Morgan Sims, PA-C",1952865057,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","Triwest VA","In House Enrollment","In House Enrollment","","","","2023-09-29",""]
["Morgan Sims, PA-C",1952865057,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","Triwest VA","In House Enrollment","In House Enrollment","","","","2023-09-29",""]
["Morgan Sims, PA-C",1952865057,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Alliance WC","Participating","Enrollment Complete","2022-01-14","","","2023-11-28","Texas Municipal League is through Alliance WC. TML added so adding Alliance WC now. Per TML payor line provider is par 01/14/2022. Jen Videan"]
["Morgan Sims, PA-C",1952865057,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Alliance WC","Participating","Enrollment Complete","2022-01-14","","","2023-11-28","Texas Municipal League is through Alliance WC. TML added so adding Alliance WC now. Per TML payor line provider is par 01/14/2022. Jen Videan"]
["Morgan Sims, PA-C",1952865057,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","Alliance WC","Participating","Enrollment Complete","2022-01-14","","","2023-11-28","Texas Municipal League is through Alliance WC. TML added so adding Alliance WC now. Per TML payor line provider is par 01/14/2022. Jen Videan"]
["Morgan Sims, PA-C",1952865057,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","Alliance WC","Participating","Enrollment Complete","2022-01-14","","","2023-11-28","Texas Municipal League is through Alliance WC. TML added so adding Alliance WC now. Per TML payor line provider is par 01/14/2022. Jen Videan"]
["Morgan Sims, PA-C",1952865057,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Alliance WC","Participating","Enrollment Complete","2022-01-14","","","2023-11-28","Texas Municipal League is through Alliance WC. TML added so adding Alliance WC now. Per TML payor line provider is par 01/14/2022. Jen Videan"]
["Morgan Sims, PA-C",1952865057,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Alliance WC","Participating","Enrollment Complete","2022-01-14","","","2023-11-28","Texas Municipal League is through Alliance WC. TML added so adding Alliance WC now. Per TML payor line provider is par 01/14/2022. Jen Videan"]
["Morgan Sims, PA-C",1952865057,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Alliance WC","Participating","Enrollment Complete","2022-01-14","","","2023-11-28","Texas Municipal League is through Alliance WC. TML added so adding Alliance WC now. Per TML payor line provider is par 01/14/2022. Jen Videan"]
["Morgan Sims, PA-C",1952865057,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Alliance WC","Participating","Enrollment Complete","2022-01-14","","","2023-11-28","Texas Municipal League is through Alliance WC. TML added so adding Alliance WC now. Per TML payor line provider is par 01/14/2022. Jen Videan"]
["Morgan Sims, PA-C",1952865057,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Omni PPO","Participating","Enrollment Complete","2021-09-01","","","2021-12-31","12/31/2021 Rcvd email from German Aviles <german.aciles@imsm.net> at IMS/OMNI stating that the monthly delegated roster provider loads for October and November have been completed.  Provider is PAR and linked to location/TIN effective 9/1/2021. DCannon"]
["Morgan Sims, PA-C",1952865057,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Texas Mutual","Participating","Enrollment Complete","2022-04-01","","","2022-04-07","4/7/2022 Received welcome letter from wwtxcontracts@texasmutual.com, provider is par and eff 4/1/2022. Cbankston"]
["Morgan Sims, PA-C",1952865057,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","First Health Coventry","Participating","Enrollment Complete","2022-11-01","3208919","","2023-01-09","1.19.2023 S/W Britney of First Health @ 800-226-5116. Transferred the call and spoke with Courtney. Provider is on file and participating. Link under the group and TIN effective 11/1/2022. Location is on file. Provider ID is 3208919. Next recredentialing date is every 3 years (11/1/2025). No information for the payer#. -Kim Monique Fabian. -Kim Monique Fabian"]
["Morgan Sims, PA-C",1952865057,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","USA PPO","Participating","Enrollment Complete","2022-01-12","1277846","","2022-02-24","02/24/2022 Per follow-up note on 2/18/2022 - Provider NPI# is on file for the provider and is participating under the group and TIN effective 01/12/2022. PIN# 1277846. Next recredentialing date is on 01/12/2025. Physical location is on file. No Payer#. Call ref#  DCannon"]
["Morgan Sims, PA-C",1952865057,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","Humana","In Process","Payor Follow Up","","","","2023-11-17","11/17/2023 Sent follow-up email to Marcus Wester at Humana to check status of August monthly delegated roster submission.  Provider Add - CO-16128465, Provider Changes - CO-16128615,  Provider Terms - CO-16128699.  DCannon"]
["Morgan Sims, PA-C",1952865057,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Sedgwick","Participating","Enrollment Complete","2023-10-18","","","2023-10-23","Rcvd acceptance ltr from cynthia.clancy@sedgwick.com. Provider is effective 10/18/2023 at 210 W Longview Ave. Jen Videan"]
["Morgan Sims, PA-C",1952865057,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","United Health Care","Participating","Enrollment Complete","2021-10-01","007021658","","2023-11-17","11/17/2023 Per email rcvd from UHC provider is PAR and linked to group TIN and location effective 10/1/2021.  MPIN # 007021658.  DCannon"]
["Morgan Sims, PA-C",1952865057,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Zurich","Panel Closed","Panel Closed","","","","2023-09-19","09/19/2023. We appreciate your interest in joining the Coventry Network.  At this time, our panels are closed, and we are not accepting new applications.  Please check back routinely to stay apprised of our panel status. We will update this site when we are open for new applicants. Gallagher, Hartford, Liberty Mutual, Travelers and Zurich fall under Coventry. Jen Videan"]
["Morgan Sims, PA-C",1952865057,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","Omni PPO","Participating","Enrollment Complete","2023-10-02","","","2023-09-05","9/5/2023 Per email received from IMS/OMNI August delegated roster has been processed and provider is PAR and linked to group effective 10/2/2023.  DCannon"]
["Morgan Sims, PA-C",1952865057,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","CAQH","Participating","CAQH Reattested","2023-11-27","14399669","","2023-11-27","11/27/2023 Updated mailing address for every WesTex location"]
["Morgan Sims, PA-C",1952865057,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","CAQH","Participating","CAQH Reattested","2023-11-27","14399669","","2023-11-27","11/27/2023 Updated mailing address for every WesTex location"]
["Morgan Sims, PA-C",1952865057,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","CAQH","Participating","CAQH Reattested","2023-11-27","14399669","","2023-11-27","11/27/2023 Updated mailing address for every WesTex location"]
["Morgan Sims, PA-C",1952865057,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","CAQH","Participating","CAQH Reattested","2023-11-27","14399669","","2023-11-27","11/27/2023 Updated mailing address for every WesTex location"]
["Morgan Sims, PA-C",1952865057,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","CAQH","Participating","CAQH Reattested","2023-11-27","14399669","","2023-11-27","11/27/2023 Updated mailing address for every WesTex location"]
["Morgan Sims, PA-C",1952865057,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","CAQH","Participating","CAQH Reattested","2023-11-27","14399669","","2023-11-27","11/27/2023 Updated mailing address for every WesTex location"]
["Morgan Sims, PA-C",1952865057,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","CAQH","Participating","CAQH Reattested","2023-11-27","14399669","","2023-11-27","11/27/2023 Updated mailing address for every WesTex location"]
["Morgan Sims, PA-C",1952865057,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","CAQH","Participating","CAQH Reattested","2023-11-27","14399669","","2023-11-27","11/27/2023 Updated mailing address for every WesTex location"]
["Morgan Sims, PA-C",1952865057,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","CAQH","Participating","CAQH Reattested","2023-11-27","14399669","","2023-11-27","11/27/2023 Updated mailing address for every WesTex location"]
["Morgan Sims, PA-C",1952865057,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","CAQH","Participating","CAQH Reattested","2023-11-27","14399669","","2023-11-27","11/27/2023 Updated mailing address for every WesTex location"]
["Morgan Sims, PA-C",1952865057,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Wellmed","Participating","Enrollment Complete","2022-01-01","","","2023-03-23","3/23/2023 Rcvd roster from UHC w/ all Wellmed participating providers.  Provider is PAR effective 1/1/2022.  DCannon"]
["Morgan Sims, PA-C",1952865057,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","HealthSmart PPO","In Process","Payor Follow Up","","","","2023-11-14","11/14/2023 Per Healthsmart provider portal provider is still not loaded under group TIN.  Per phone conversation with Lee Kinard at Healthsmart provider portal should be updated  by 11/27/2023.  Will allow more time, check back in 2 weeks.   DCannon"]
["Morgan Sims, PA-C",1952865057,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","HealthSmart PPO","In Process","Payor Follow Up","","","","2023-11-14","11/14/2023 Per Healthsmart provider portal provider is still not loaded under group TIN.  Per phone conversation with Lee Kinard at Healthsmart provider portal should be updated  by 11/27/2023.  Will allow more time, check back in 2 weeks.   DCannon"]
["Morgan Sims, PA-C",1952865057,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","HealthSmart PPO","In Process","Payor Follow Up","","","","2023-11-14","11/14/2023 Per Healthsmart provider portal provider is still not loaded under group TIN.  Per phone conversation with Lee Kinard at Healthsmart provider portal should be updated  by 11/27/2023.  Will allow more time, check back in 2 weeks.   DCannon"]
["Morgan Sims, PA-C",1952865057,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","HealthSmart PPO","In Process","Payor Follow Up","","","","2023-11-14","11/14/2023 Per Healthsmart provider portal provider is still not loaded under group TIN.  Per phone conversation with Lee Kinard at Healthsmart provider portal should be updated  by 11/27/2023.  Will allow more time, check back in 2 weeks.   DCannon"]
["Morgan Sims, PA-C",1952865057,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Triwest VA","In House Enrollment","In House Enrollment","","","","2021-09-26","9/26/2021 Processed in-house through BCBSTX. KFrazier"]
["Morgan Sims, PA-C",1952865057,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Scott&White (First Care)","Participating","Enrollment Complete","2023-05-01","","","2023-09-29","9/29/2023 Received email from Scott & White HPDELEGATION@BSWHealth.org that provider load from May has been completed and provider is PAR effective 5/1/2023.  DCannon"]
["Morgan Sims, PA-C",1952865057,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Scott&White (First Care)","Participating","Enrollment Complete","2023-05-01","","","2023-09-29","9/29/2023 Received email from Scott & White HPDELEGATION@BSWHealth.org that provider load from May has been completed and provider is PAR effective 5/1/2023.  DCannon"]
["Morgan Sims, PA-C",1952865057,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Scott&White (First Care)","Participating","Enrollment Complete","2023-05-01","","","2023-09-29","9/29/2023 Received email from Scott & White HPDELEGATION@BSWHealth.org that provider load from May has been completed and provider is PAR effective 5/1/2023.  DCannon"]
["Morgan Sims, PA-C",1952865057,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Scott&White (First Care)","Participating","Enrollment Complete","2023-05-01","","","2023-09-29","9/29/2023 Received email from Scott & White HPDELEGATION@BSWHealth.org that provider load from May has been completed and provider is PAR effective 5/1/2023.  DCannon"]
["Morgan Sims, PA-C",1952865057,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","Aetna","Participating","Enrollment Complete","2021-09-01","","","2023-10-06","10.6.2023 S/W Mark of Aetna @ 1-800-353-1232. Per rep, provider is in network with Aetna for the state of TX and participating under the group and TIN# effective 09/1/2021. Physical location is on file. No next recredentialing date available.   DCannon"]
["Morgan Sims, PA-C",1952865057,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","IMS","Participating","Enrollment Complete","2021-09-01","","","2021-12-31","12/31/2021 Rcvd email from German Aviles <german.aciles@imsm.net> at IMS/OMNI stating that the monthly delegated roster provider loads for October and November have been completed.  Provider is PAR and linked to location/TIN effective 9/1/2021. DCannon"]
["Morgan Sims, PA-C",1952865057,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","First Health Coventry","Participating","Enrollment Complete","2022-11-01","3208919","","2023-09-29","9/29/2023 Per First Health web portal provider is PAR and linked to group TIN/location effective 11/1/2022.  PID # 3208919.  DCannon"]
["Morgan Sims, PA-C",1952865057,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","First Health Coventry","Participating","Enrollment Complete","2022-11-01","3208919","","2023-09-29","9/29/2023 Per First Health web portal provider is PAR and linked to group TIN/location effective 11/1/2022.  PID # 3208919.  DCannon"]
["Morgan Sims, PA-C",1952865057,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","First Health Coventry","Participating","Enrollment Complete","2022-11-01","3208919","","2023-09-29","9/29/2023 Per First Health web portal provider is PAR and linked to group TIN/location effective 11/1/2022.  PID # 3208919.  DCannon"]
["Morgan Sims, PA-C",1952865057,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","First Health Coventry","Participating","Enrollment Complete","2022-11-01","3208919","","2023-09-29","9/29/2023 Per First Health web portal provider is PAR and linked to group TIN/location effective 11/1/2022.  PID # 3208919.  DCannon"]
["Morgan Sims, PA-C",1952865057,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Omni PPO","Participating","Enrollment Complete","2023-05-01","","","2023-09-29","9/29/2023 Per email received from IMS/OMNI May delegated roster has been processed and provider is PAR and linked to group effective 5/1/2023.  DCannon"]
["Morgan Sims, PA-C",1952865057,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Omni PPO","Participating","Enrollment Complete","2023-05-01","","","2023-09-29","9/29/2023 Per email received from IMS/OMNI May delegated roster has been processed and provider is PAR and linked to group effective 5/1/2023.  DCannon"]
["Morgan Sims, PA-C",1952865057,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Omni PPO","Participating","Enrollment Complete","2023-05-01","","","2023-09-29","9/29/2023 Per email received from IMS/OMNI May delegated roster has been processed and provider is PAR and linked to group effective 5/1/2023.  DCannon"]
["Morgan Sims, PA-C",1952865057,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Omni PPO","Participating","Enrollment Complete","2023-05-01","","","2023-09-29","9/29/2023 Per email received from IMS/OMNI May delegated roster has been processed and provider is PAR and linked to group effective 5/1/2023.  DCannon"]
["Morgan Sims, PA-C",1952865057,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Humana","Participating","Enrollment Complete","2021-09-01","","","2021-11-18","11/18/2021 Rcvd full roster from Humana listing provider as PAR and linked to group TIN/location effective 9/1/2021.  DCannon"]
["Morgan Sims, PA-C",1952865057,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Liberty Mutual","Panel Closed","Panel Closed","","","","2023-09-19","09/19/2023. We appreciate your interest in joining the Coventry Network.  At this time, our panels are closed, and we are not accepting new applications.  Please check back routinely to stay apprised of our panel status. We will update this site when we are open for new applicants. Gallagher, Hartford, Liberty Mutual, Travelers and Zurich fall under Coventry. Jen Videan"]
["Morgan Sims, PA-C",1952865057,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","Cigna","Participating","Enrollment Complete","2023-09-01","","","2023-10-20","Received confirmation of completion. Provider ID 0607671 Effective 9/1/2023. MS"]
["Morgan Sims, PA-C",1952865057,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","BCBSTX","Participating","Enrollment Complete","2020-09-10","","","2023-10-02","10/2/2023 Per BCBS TX roster received from Priscilla Albertine at MQA provider is PAR and linked to group effective 9/10/2020.  DCannon"]
["Morgan Sims, PA-C",1952865057,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","BCBSTX","Participating","Enrollment Complete","2020-09-10","","","2023-10-02","10/2/2023 Per BCBS TX roster received from Priscilla Albertine at MQA provider is PAR and linked to group effective 9/10/2020.  DCannon"]
["Morgan Sims, PA-C",1952865057,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","BCBSTX","Participating","Enrollment Complete","2020-09-10","","","2023-10-02","10/2/2023 Per BCBS TX roster received from Priscilla Albertine at MQA provider is PAR and linked to group effective 9/10/2020.  DCannon"]
["Morgan Sims, PA-C",1952865057,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","BCBSTX","Participating","Enrollment Complete","2020-09-10","","","2023-10-02","10/2/2023 Per BCBS TX roster received from Priscilla Albertine at MQA provider is PAR and linked to group effective 9/10/2020.  DCannon"]
["Morgan Sims, PA-C",1952865057,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","BCBSTX","Participating","Enrollment Complete","2020-09-10","","","2023-10-02","10/2/2023 Per BCBS TX roster received from Priscilla Albertine at MQA provider is PAR and linked to group effective 9/10/2020.  DCannon"]
["Morgan Sims, PA-C",1952865057,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","BCBSTX","Participating","Enrollment Complete","2020-09-10","","","2023-10-02","10/2/2023 Per BCBS TX roster received from Priscilla Albertine at MQA provider is PAR and linked to group effective 9/10/2020.  DCannon"]
["Morgan Sims, PA-C",1952865057,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","BCBSTX","Participating","Enrollment Complete","2020-09-10","","","2023-10-02","10/2/2023 Per BCBS TX roster received from Priscilla Albertine at MQA provider is PAR and linked to group effective 9/10/2020.  DCannon"]
["Morgan Sims, PA-C",1952865057,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","BCBSTX","Participating","Enrollment Complete","2020-09-10","","","2023-10-02","10/2/2023 Per BCBS TX roster received from Priscilla Albertine at MQA provider is PAR and linked to group effective 9/10/2020.  DCannon"]
["Morgan Sims, PA-C",1952865057,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","BCBSTX","Participating","Enrollment Complete","2020-09-10","","","2023-10-02","10/2/2023 Per BCBS TX roster received from Priscilla Albertine at MQA provider is PAR and linked to group effective 9/10/2020.  DCannon"]
["Morgan Sims, PA-C",1952865057,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","BCBSTX","Participating","Enrollment Complete","2020-09-10","","","2023-10-02","10/2/2023 Per BCBS TX roster received from Priscilla Albertine at MQA provider is PAR and linked to group effective 9/10/2020.  DCannon"]
["Morgan Sims, PA-C",1952865057,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","HealthSmart PPO","In Process","Payor Follow Up","","","","2023-11-14","11/14/2023 Per Healthsmart provider portal provider is still not loaded under group TIN.  Per phone conversation with Lee Kinard at Healthsmart provider portal should be updated  by 11/27/2023.  Will allow more time, check back in 2 weeks.   DCannon"]
["Morgan Sims, PA-C",1952865057,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","Scott&White (First Care)","Participating","Enrollment Complete","2023-09-14","","","2023-09-29","9/29/2023 Rcvd confirmation from Scott & White that provider has been loaded at all locations effective 9/14/2023.  DCannon"]
["Morgan Sims, PA-C",1952865057,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","Multiplan","Participating","Enrollment Complete","2021-09-01","","","2023-09-20","9/20/2023 Per email received from Jessica Bess at Multiplan August roster has been completed.  Provider is PAR and linked to group TIN/location effective 9/1/2021.  DCannon"]
["Morgan Sims, PA-C",1952865057,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","First Health Coventry","Participating","Enrollment Complete","2022-11-01","","","2023-10-12","10/12/2023 Per First Health web portal provider is PAR and linked to group TIN/location effective 11/1/2022.  PID # 3208919.  DCannon"]
["Morgan Sims, PA-C",1952865057,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Texas Mutual","In Process","Payor Follow Up","","","","2023-11-27","Per Dee Dee Johnson at Texas Mutual, The site visit for this location 96301 Andrews Hwy)is in the que. I will let you know when there are any updates. Jen Videan"]
["Morgan Sims, PA-C",1952865057,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Texas Mutual","In Process","Payor Follow Up","","","","2023-11-27","Per Dee Dee Johnson at Texas Mutual, The site visit for this location 96301 Andrews Hwy)is in the que. I will let you know when there are any updates. Jen Videan"]
["Morgan Sims, PA-C",1952865057,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Texas Mutual","In Process","Payor Follow Up","","","","2023-11-27","Per Dee Dee Johnson at Texas Mutual, The site visit for this location 96301 Andrews Hwy)is in the que. I will let you know when there are any updates. Jen Videan"]
["Morgan Sims, PA-C",1952865057,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Texas Mutual","In Process","Payor Follow Up","","","","2023-11-27","Per Dee Dee Johnson at Texas Mutual, The site visit for this location 96301 Andrews Hwy)is in the que. I will let you know when there are any updates. Jen Videan"]
["Morgan Sims, PA-C",1952865057,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","Texas Mutual","In Process","Payor Follow Up","","","","2023-11-27","Per Dee Dee Johnson at Texas Mutual, The site visit for this location 96301 Andrews Hwy)is in the que. I will let you know when there are any updates. Jen Videan"]
["Morgan Sims, PA-C",1952865057,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","Texas Mutual","In Process","Payor Follow Up","","","","2023-11-27","Per Dee Dee Johnson at Texas Mutual, The site visit for this location 96301 Andrews Hwy)is in the que. I will let you know when there are any updates. Jen Videan"]
["Morgan Sims, PA-C",1952865057,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Cigna","Participating","Enrollment Complete","2023-05-01","","","2023-09-29","9/29/2023 Rcvd email from Cigna that provider is PAR and linked to new practice locations effective 5/1/2023.  DCannon"]
["Morgan Sims, PA-C",1952865057,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Cigna","Participating","Enrollment Complete","2023-05-01","","","2023-09-29","9/29/2023 Rcvd email from Cigna that provider is PAR and linked to new practice locations effective 5/1/2023.  DCannon"]
["Morgan Sims, PA-C",1952865057,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Cigna","Participating","Enrollment Complete","2023-05-01","","","2023-09-29","9/29/2023 Rcvd email from Cigna that provider is PAR and linked to new practice locations effective 5/1/2023.  DCannon"]
["Morgan Sims, PA-C",1952865057,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Cigna","Participating","Enrollment Complete","2023-05-01","","","2023-09-29","9/29/2023 Rcvd email from Cigna that provider is PAR and linked to new practice locations effective 5/1/2023.  DCannon"]
["Morgan Sims, PA-C",1952865057,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","IMS","Participating","Enrollment Complete","2023-05-01","","","2023-09-29","9/29/2023 Per email received from IMS/OMNI May delegated roster has been processed and provider is PAR and linked to group effective 5/1/2023.  DCannon"]
["Morgan Sims, PA-C",1952865057,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","IMS","Participating","Enrollment Complete","2023-05-01","","","2023-09-29","9/29/2023 Per email received from IMS/OMNI May delegated roster has been processed and provider is PAR and linked to group effective 5/1/2023.  DCannon"]
["Morgan Sims, PA-C",1952865057,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","IMS","Participating","Enrollment Complete","2023-05-01","","","2023-09-29","9/29/2023 Per email received from IMS/OMNI May delegated roster has been processed and provider is PAR and linked to group effective 5/1/2023.  DCannon"]
["Morgan Sims, PA-C",1952865057,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","IMS","Participating","Enrollment Complete","2023-05-01","","","2023-09-29","9/29/2023 Per email received from IMS/OMNI May delegated roster has been processed and provider is PAR and linked to group effective 5/1/2023.  DCannon"]
["Morgan Sims, PA-C",1952865057,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Rail Road Medicare","Participating","Enrollment Complete","2021-09-01","Q00157212","","2021-11-02","11/2/21 Effective 9/1/21, PTAN Q00157212. Please allow three business days for the activation of this new PTAN. Cbankston"]
["Morgan Sims, PA-C",1952865057,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Scott&White (First Care)","Participating","Enrollment Complete","2021-09-01","","","2022-02-23","2/23/2022 Received email from Scott & White HPDELEGATION@BSWHealth.org that provider load from October has been completed and provider is PAR effective 9/1/2021.  DCannon"]
["Morgan Sims, PA-C",1952865057,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Texas Municipal League","Participating","Enrollment Complete","","","","2023-11-28","Added Alliance WC payor line. Texas Municipal League is through Alliance WC. TML added so adding Alliance WC now. Per TML payor line provider is par 01/14/2022. Jen Videan"]
["Morgan Sims, PA-C",1952865057,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Texas Municipal League","Participating","Enrollment Complete","","","","2023-11-28","Added Alliance WC payor line. Texas Municipal League is through Alliance WC. TML added so adding Alliance WC now. Per TML payor line provider is par 01/14/2022. Jen Videan"]
["Morgan Sims, PA-C",1952865057,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Texas Municipal League","Participating","Enrollment Complete","","","","2023-11-28","Added Alliance WC payor line. Texas Municipal League is through Alliance WC. TML added so adding Alliance WC now. Per TML payor line provider is par 01/14/2022. Jen Videan"]
["Morgan Sims, PA-C",1952865057,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Texas Municipal League","Participating","Enrollment Complete","","","","2023-11-28","Added Alliance WC payor line. Texas Municipal League is through Alliance WC. TML added so adding Alliance WC now. Per TML payor line provider is par 01/14/2022. Jen Videan"]
["Morgan Sims, PA-C",1952865057,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","Texas Municipal League","Participating","Enrollment Complete","","","","2023-11-28","Added Alliance WC payor line. Texas Municipal League is through Alliance WC. TML added so adding Alliance WC now. Per TML payor line provider is par 01/14/2022. Jen Videan"]
["Morgan Sims, PA-C",1952865057,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","Texas Municipal League","Participating","Enrollment Complete","","","","2023-11-28","Added Alliance WC payor line. Texas Municipal League is through Alliance WC. TML added so adding Alliance WC now. Per TML payor line provider is par 01/14/2022. Jen Videan"]
["Morgan Sims, PA-C",1952865057,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","IMS","Participating","Enrollment Complete","2023-10-02","","","2023-09-05","9/5/2023 Per email received from IMS/OMNI August delegated roster has been processed and provider is PAR and linked to group effective 10/2/2023.  DCannon"]
["Morgan Sims, PA-C",1952865057,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Cigna","Participating","Enrollment Complete","2021-09-01","","","2021-09-26","9/26/2021 Group is contracted as an ancillary facility, so no enrollment is required. KFrazier"]
["Morgan Sims, PA-C",1952865057,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","HealthSmart PPO","Participating","Enrollment Complete","2021-09-01","","","2021-12-03","12/3/2021 Per Healthsmart website provider is PAR and loaded under TIN/location effective 9/1/2021.  DCannon"]
["Morgan Sims, PA-C",1952865057,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","Wellmed","Participating","Enrollment Complete","2022-01-01","007021658","","2023-11-17","11/17/2023 Per email rcvd from UHC provider is PAR and linked to group TIN and locations effective 1/1/2022.  MPIN # 007021658.  DCannon"]
["Morgan Sims, PA-C",1952865057,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Sedgwick","In Process","Application Submitted","","","","2023-11-21","Emailed roster to cynthia.clancy@sedgwick.com to add 6301 Andrews Hwy to provider's profile. Jen Videan"]
["Morgan Sims, PA-C",1952865057,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Sedgwick","In Process","Application Submitted","","","","2023-11-21","Emailed roster to cynthia.clancy@sedgwick.com to add 6301 Andrews Hwy to provider's profile. Jen Videan"]
["Morgan Sims, PA-C",1952865057,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Sedgwick","In Process","Application Submitted","","","","2023-11-21","Emailed roster to cynthia.clancy@sedgwick.com to add 6301 Andrews Hwy to provider's profile. Jen Videan"]
["Morgan Sims, PA-C",1952865057,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Sedgwick","In Process","Application Submitted","","","",45251,"Emailed roster to cynthia.clancy@sedgwick.com to add 6301 Andrews Hwy to provider's profile. Jen Videan"]
["Morgan Sims, PA-C",1952865057,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","Sedgwick","In Process","Application Submitted","","","","2023-11-21","Emailed roster to cynthia.clancy@sedgwick.com to add 6301 Andrews Hwy to provider's profile. Jen Videan"]
["Morgan Sims, PA-C",1952865057,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","Sedgwick","In Process","Application Submitted","","","","2023-11-21","Emailed roster to cynthia.clancy@sedgwick.com to add 6301 Andrews Hwy to provider's profile. Jen Videan"]
["Morgan Sims, PA-C",1952865057,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","USA PPO","In Process","Payor Follow Up","","","","2023-11-27","11/27/2023 Per USA PPO provider portal provider is still not loaded under new locations.  Will allow more time, check back in 2 weeks.  \nDCannon"]
["Morgan Sims, PA-C",1952865057,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","USA PPO","In Process","Payor Follow Up","","","","2023-11-27","11/27/2023 Per USA PPO provider portal provider is still not loaded under new locations.  Will allow more time, check back in 2 weeks.  \nDCannon"]
["Morgan Sims, PA-C",1952865057,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","USA PPO","In Process","Payor Follow Up","","","","2023-11-27","11/27/2023 Per USA PPO provider portal provider is still not loaded under new locations.  Will allow more time, check back in 2 weeks.  \nDCannon"]
["Morgan Sims, PA-C",1952865057,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","USA PPO","In Process","Payor Follow Up","","","","2023-11-27","11/27/2023 Per USA PPO provider portal provider is still not loaded under new locations.  Will allow more time, check back in 2 weeks.  \nDCannon"]
["Morgan Sims, PA-C",1952865057,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Zurich","Panel Closed","Panel Closed","","","","2023-10-09","10/09/2023. We appreciate your interest in joining the Coventry Network.  At this time, our panels are closed, and we are not accepting new applications.  Please check back routinely to stay apprised of our panel status. We will update this site when we are open for new applicants. Gallagher, Hartford, Liberty Mutual, Travelers and Zurich fall under Coventry. Jen Videan"]
["Morgan Sims, PA-C",1952865057,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Zurich","Panel Closed","Panel Closed","","","","2023-10-09","10/09/2023. We appreciate your interest in joining the Coventry Network.  At this time, our panels are closed, and we are not accepting new applications.  Please check back routinely to stay apprised of our panel status. We will update this site when we are open for new applicants. Gallagher, Hartford, Liberty Mutual, Travelers and Zurich fall under Coventry. Jen Videan"]
["Morgan Sims, PA-C",1952865057,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Zurich","Panel Closed","Panel Closed","","","","2023-10-09","10/09/2023. We appreciate your interest in joining the Coventry Network.  At this time, our panels are closed, and we are not accepting new applications.  Please check back routinely to stay apprised of our panel status. We will update this site when we are open for new applicants. Gallagher, Hartford, Liberty Mutual, Travelers and Zurich fall under Coventry. Jen Videan"]
["Morgan Sims, PA-C",1952865057,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Zurich","Panel Closed","Panel Closed","","","","2023-10-09","10/09/2023. We appreciate your interest in joining the Coventry Network.  At this time, our panels are closed, and we are not accepting new applications.  Please check back routinely to stay apprised of our panel status. We will update this site when we are open for new applicants. Gallagher, Hartford, Liberty Mutual, Travelers and Zurich fall under Coventry. Jen Videan"]
["Morgan Sims, PA-C",1952865057,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","Zurich","Panel Closed","Panel Closed","","","","2023-10-09","10/09/2023. We appreciate your interest in joining the Coventry Network.  At this time, our panels are closed, and we are not accepting new applications.  Please check back routinely to stay apprised of our panel status. We will update this site when we are open for new applicants. Gallagher, Hartford, Liberty Mutual, Travelers and Zurich fall under Coventry. Jen Videan"]
["Morgan Sims, PA-C",1952865057,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","Zurich","Panel Closed","Panel Closed","","","","2023-10-09","10/09/2023. We appreciate your interest in joining the Coventry Network.  At this time, our panels are closed, and we are not accepting new applications.  Please check back routinely to stay apprised of our panel status. We will update this site when we are open for new applicants. Gallagher, Hartford, Liberty Mutual, Travelers and Zurich fall under Coventry. Jen Videan"]
["Morgan Sims, PA-C",1952865057,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Medicare","Participating","Enrollment Complete","2021-09-01","1U8148","423838","2021-10-01","10/1/2021 Per PECOS provider is PAR and linked to group/locations.  PTAN # 1U8148 - effective 9/1/2021.  DCannon"]
["Morgan Sims, PA-C",1952865057,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","Liberty Mutual","Panel Closed","Panel Closed","","","","2023-10-09","10/09/2023. We appreciate your interest in joining the Coventry Network.  At this time, our panels are closed, and we are not accepting new applications.  Please check back routinely to stay apprised of our panel status. We will update this site when we are open for new applicants. Gallagher, Hartford, Liberty Mutual, Travelers and Zurich fall under Coventry. Jen Videan"]
["Morgan Sims, PA-C",1952865057,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","Liberty Mutual","Panel Closed","Panel Closed","","","","2023-10-09","10/09/2023. We appreciate your interest in joining the Coventry Network.  At this time, our panels are closed, and we are not accepting new applications.  Please check back routinely to stay apprised of our panel status. We will update this site when we are open for new applicants. Gallagher, Hartford, Liberty Mutual, Travelers and Zurich fall under Coventry. Jen Videan"]
["Morgan Sims, PA-C",1952865057,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Liberty Mutual","Panel Closed","Panel Closed","","","","2023-10-09","10/09/2023. We appreciate your interest in joining the Coventry Network.  At this time, our panels are closed, and we are not accepting new applications.  Please check back routinely to stay apprised of our panel status. We will update this site when we are open for new applicants. Gallagher, Hartford, Liberty Mutual, Travelers and Zurich fall under Coventry. Jen Videan"]
["Morgan Sims, PA-C",1952865057,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Liberty Mutual","Panel Closed","Panel Closed","","","","2023-10-09","10/09/2023. We appreciate your interest in joining the Coventry Network.  At this time, our panels are closed, and we are not accepting new applications.  Please check back routinely to stay apprised of our panel status. We will update this site when we are open for new applicants. Gallagher, Hartford, Liberty Mutual, Travelers and Zurich fall under Coventry. Jen Videan"]
["Morgan Sims, PA-C",1952865057,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Liberty Mutual","Panel Closed","Panel Closed","","","","2023-10-09","10/09/2023. We appreciate your interest in joining the Coventry Network.  At this time, our panels are closed, and we are not accepting new applications.  Please check back routinely to stay apprised of our panel status. We will update this site when we are open for new applicants. Gallagher, Hartford, Liberty Mutual, Travelers and Zurich fall under Coventry. Jen Videan"]
["Morgan Sims, PA-C",1952865057,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Liberty Mutual","Panel Closed","Panel Closed","","","","2023-10-09","10/09/2023. We appreciate your interest in joining the Coventry Network.  At this time, our panels are closed, and we are not accepting new applications.  Please check back routinely to stay apprised of our panel status. We will update this site when we are open for new applicants. Gallagher, Hartford, Liberty Mutual, Travelers and Zurich fall under Coventry. Jen Videan"]
["Morgan Sims, PA-C",1952865057,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Humana","Participating","Enrollment Complete","2021-09-01","","","2023-09-29","9/15/2023 Per email received from Humana provider is PAR and linked to group TIN/locations effective 9/1/2021.  DCannon"]
["Morgan Sims, PA-C",1952865057,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Humana","Participating","Enrollment Complete","2021-09-01","","","2023-09-29","9/15/2023 Per email received from Humana provider is PAR and linked to group TIN/locations effective 9/1/2021.  DCannon"]
["Morgan Sims, PA-C",1952865057,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Humana","Participating","Enrollment Complete","2021-09-01","","","2023-09-29","9/15/2023 Per email received from Humana provider is PAR and linked to group TIN/locations effective 9/1/2021.  DCannon"]
["Morgan Sims, PA-C",1952865057,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Humana","Participating","Enrollment Complete","2021-09-01","","","2023-09-29","9/15/2023 Per email received from Humana provider is PAR and linked to group TIN/locations effective 9/1/2021.  DCannon"]
["Morgan Sims, PA-C",1952865057,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Gallagher","Panel Closed","Panel Closed","","","","2023-09-19","09/19/2023. We appreciate your interest in joining the Coventry Network.  At this time, our panels are closed, and we are not accepting new applications.  Please check back routinely to stay apprised of our panel status. We will update this site when we are open for new applicants. Gallagher, Hartford, Liberty Mutual, Travelers and Zurich fall under Coventry. Jen Videan"]
["Morgan Sims, PA-C",1952865057,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","TriCare Standard","Participating","Enrollment Complete","2021-12-17","","","2022-01-04","1/4/2022 Per Tricare portal, provider is linked to locations as of 12/17/2021. Cbankston"]
["Morgan Sims, PA-C",1952865057,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Multiplan","Participating","Enrollment Complete","2021-09-01","","","2023-09-29","9/29/2023 Per email received from Multiplan provider is PAR and linked to group TIN/locations effective 9/1/2021.  DCannon"]
["Morgan Sims, PA-C",1952865057,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Multiplan","Participating","Enrollment Complete","2021-09-01","","","2023-09-29","9/29/2023 Per email received from Multiplan provider is PAR and linked to group TIN/locations effective 9/1/2021.  DCannon"]
["Morgan Sims, PA-C",1952865057,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Multiplan","Participating","Enrollment Complete","2021-09-01","","","2023-09-29","9/29/2023 Per email received from Multiplan provider is PAR and linked to group TIN/locations effective 9/1/2021.  DCannon"]
["Morgan Sims, PA-C",1952865057,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Multiplan","Participating","Enrollment Complete","2021-09-01","","","2023-09-29","9/29/2023 Per email received from Multiplan provider is PAR and linked to group TIN/locations effective 9/1/2021.  DCannon"]
["Morgan Sims, PA-C",1952865057,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Texas Municipal League","Participating","Enrollment Complete","2022-01-14","","","2022-02-28","2/28/2022 Received email from michelle.killough@pswca.org, provider is par with location eff 1/14/2022. Cbankston"]
["Morgan Sims, PA-C",1952865057,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Gallagher","Panel Closed","Panel Closed","","","","2023-10-09","10/09/2023. We appreciate your interest in joining the Coventry Network.  At this time, our panels are closed, and we are not accepting new applications.  Please check back routinely to stay apprised of our panel status. We will update this site when we are open for new applicants. Gallagher, Hartford, Liberty Mutual, Travelers and Zurich fall under Coventry. Jen Videan"]
["Morgan Sims, PA-C",1952865057,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Gallagher","Panel Closed","Panel Closed","","","","2023-10-09","10/09/2023. We appreciate your interest in joining the Coventry Network.  At this time, our panels are closed, and we are not accepting new applications.  Please check back routinely to stay apprised of our panel status. We will update this site when we are open for new applicants. Gallagher, Hartford, Liberty Mutual, Travelers and Zurich fall under Coventry. Jen Videan"]
["Morgan Sims, PA-C",1952865057,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Gallagher","Panel Closed","Panel Closed","","","","2023-10-09","10/09/2023. We appreciate your interest in joining the Coventry Network.  At this time, our panels are closed, and we are not accepting new applications.  Please check back routinely to stay apprised of our panel status. We will update this site when we are open for new applicants. Gallagher, Hartford, Liberty Mutual, Travelers and Zurich fall under Coventry. Jen Videan"]
["Morgan Sims, PA-C",1952865057,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Gallagher","Panel Closed","Panel Closed","","","","2023-10-09","10/09/2023. We appreciate your interest in joining the Coventry Network.  At this time, our panels are closed, and we are not accepting new applications.  Please check back routinely to stay apprised of our panel status. We will update this site when we are open for new applicants. Gallagher, Hartford, Liberty Mutual, Travelers and Zurich fall under Coventry. Jen Videan"]
["Morgan Sims, PA-C",1952865057,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","Gallagher","Panel Closed","Panel Closed","","","","2023-10-09","10/09/2023. We appreciate your interest in joining the Coventry Network.  At this time, our panels are closed, and we are not accepting new applications.  Please check back routinely to stay apprised of our panel status. We will update this site when we are open for new applicants. Gallagher, Hartford, Liberty Mutual, Travelers and Zurich fall under Coventry. Jen Videan"]
["Morgan Sims, PA-C",1952865057,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","Gallagher","Panel Closed","Panel Closed","","","","2023-10-09","10/09/2023. We appreciate your interest in joining the Coventry Network.  At this time, our panels are closed, and we are not accepting new applications.  Please check back routinely to stay apprised of our panel status. We will update this site when we are open for new applicants. Gallagher, Hartford, Liberty Mutual, Travelers and Zurich fall under Coventry. Jen Videan"]
["Morgan Sims, PA-C",1952865057,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Multiplan","Participating","Enrollment Complete","2021-09-01","","","2022-03-10","3/10/2022 Rcvd roster from Multiplan listing provider as PAR and listed under group TIN/location effective 9/1/2021.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","First Health Coventry","Participating","Enrollment Complete","2023-09-01","3637790","","2023-11-20","11/20/2023 S/W Sam of First Health @ 800-226-5116, per rep provider is showing participating and link under the Group and TIN with an Effective date 9/1/2023. Provider ID 3637790. Physical locations are on file. Call ref#:773026. - DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","First Health Coventry","Participating","Enrollment Complete","2023-09-01","3637790","","2023-11-20","11/20/2023 S/W Sam of First Health @ 800-226-5116, per rep provider is showing participating and link under the Group and TIN with an Effective date 9/1/2023. Provider ID 3637790. Physical locations are on file. Call ref#:773026. - DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","First Health Coventry","Participating","Enrollment Complete","2023-09-01","3637790","","2023-11-20","11/20/2023 S/W Sam of First Health @ 800-226-5116, per rep provider is showing participating and link under the Group and TIN with an Effective date 9/1/2023. Provider ID 3637790. Physical locations are on file. Call ref#:773026. - DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","First Health Coventry","Participating","Enrollment Complete","2023-09-01","3637790","","2023-11-20","11/20/2023 S/W Sam of First Health @ 800-226-5116, per rep provider is showing participating and link under the Group and TIN with an Effective date 9/1/2023. Provider ID 3637790. Physical locations are on file. Call ref#:773026. - DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","First Health Coventry","Participating","Enrollment Complete","2023-09-01","3637790","",45250,"11/20/2023 S/W Sam of First Health @ 800-226-5116, per rep provider is showing participating and link under the Group and TIN with an Effective date 9/1/2023. Provider ID 3637790. Physical locations are on file. Call ref#:773026. - DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","First Health Coventry","Participating","Enrollment Complete","2023-09-01","3637790","",45250,"11/20/2023 S/W Sam of First Health @ 800-226-5116, per rep provider is showing participating and link under the Group and TIN with an Effective date 9/1/2023. Provider ID 3637790. Physical locations are on file. Call ref#:773026. - DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","First Health Coventry","Participating","Enrollment Complete","2023-09-01","3637790","","2023-11-20","11/20/2023 S/W Sam of First Health @ 800-226-5116, per rep provider is showing participating and link under the Group and TIN with an Effective date 9/1/2023. Provider ID 3637790. Physical locations are on file. Call ref#:773026. - DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","First Health Coventry","Participating","Enrollment Complete","2023-09-01","3637790","","2023-11-20","11/20/2023 S/W Sam of First Health @ 800-226-5116, per rep provider is showing participating and link under the Group and TIN with an Effective date 9/1/2023. Provider ID 3637790. Physical locations are on file. Call ref#:773026. - DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","BCBSTX","Participating","Enrollment Complete","2023-10-11","","","2023-10-10","10/10/2023 Rcvd email from Priscilla at MQA confirming provider is PAR and linked to group effective 10/11/2023.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","BCBSTX","Participating","Enrollment Complete","2023-10-11","","","2023-10-10","10/10/2023 Rcvd email from Priscilla at MQA confirming provider is PAR and linked to group effective 10/11/2023.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","BCBSTX","Participating","Enrollment Complete","2023-10-11","","","2023-10-10","10/10/2023 Rcvd email from Priscilla at MQA confirming provider is PAR and linked to group effective 10/11/2023.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","BCBSTX","Participating","Enrollment Complete","2023-10-11","","","2023-10-10","10/10/2023 Rcvd email from Priscilla at MQA confirming provider is PAR and linked to group effective 10/11/2023.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","BCBSTX","Participating","Enrollment Complete","2023-10-11","","","2023-10-10","10/10/2023 Rcvd email from Priscilla at MQA confirming provider is PAR and linked to group effective 10/11/2023.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","BCBSTX","Participating","Enrollment Complete","2023-10-11","","","2023-10-10","10/10/2023 Rcvd email from Priscilla at MQA confirming provider is PAR and linked to group effective 10/11/2023.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","BCBSTX","Participating","Enrollment Complete","2023-10-11","","","2023-10-10","10/10/2023 Rcvd email from Priscilla at MQA confirming provider is PAR and linked to group effective 10/11/2023.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","BCBSTX","Participating","Enrollment Complete","2023-10-11","","","2023-10-10","10/10/2023 Rcvd email from Priscilla at MQA confirming provider is PAR and linked to group effective 10/11/2023.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","TriCare Standard","Participating","Enrollment Complete","2023-09-04","","","2023-09-26","Confirmed provider is linked to Briarwood and Longview locations. MS"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","TriCare Standard","Participating","Enrollment Complete","2023-09-04","","","2023-09-26","Confirmed provider is linked to Briarwood and Longview locations. MS"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","TriCare Standard","Participating","Enrollment Complete","2023-09-04","","","2023-10-26","Confirmed Eastridge location effective 10/9/23. MS"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","TriCare Standard","Participating","Enrollment Complete","2023-09-04","","","2023-10-26","Confirmed Eastridge location effective 10/9/23. MS"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","TriCare Standard","Participating","Enrollment Complete","2023-09-04","","","2023-11-05","Provider linked to Andrews Hwy location eff 10/26/23. MS"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","TriCare Standard","Participating","Enrollment Complete","2023-09-04","","","2023-11-05","Provider linked to Andrews Hwy location eff 10/26/23. MS"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","TriCare Standard","Participating","Enrollment Complete","2023-09-04","","","2023-09-26","Confirmed provider is linked to Briarwood and Longview locations. MS"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","TriCare Standard","Participating","Enrollment Complete","2023-09-04","","","2023-09-26","Confirmed provider is linked to Briarwood and Longview locations. MS"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","TriCare Standard","Participating","Enrollment Complete","2023-09-04","","","2023-10-26","Confirmed Eastridge location effective 10/9/23. MS"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","TriCare Standard","Participating","Enrollment Complete","2023-09-04","","","2023-10-26","Confirmed Eastridge location effective 10/9/23. MS"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","TriCare Standard","Participating","Enrollment Complete","2023-09-04","","","2023-11-05","Provider linked to Andrews Hwy location eff 10/26/23. MS"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","TriCare Standard","Participating","Enrollment Complete","2023-09-04","","","2023-11-05","Provider linked to Andrews Hwy location eff 10/26/23. MS"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","TriCare Standard","Participating","Enrollment Complete","2023-09-04","","","2023-09-26","Confirmed provider is linked to Briarwood and Longview locations. MS"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","TriCare Standard","Participating","Enrollment Complete","2023-09-04","","","2023-09-26","Confirmed provider is linked to Briarwood and Longview locations. MS"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","TriCare Standard","Participating","Enrollment Complete","2023-09-04","","","2023-10-26","Confirmed Eastridge location effective 10/9/23. MS"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","TriCare Standard","Participating","Enrollment Complete","2023-09-04","","","2023-10-26","Confirmed Eastridge location effective 10/9/23. MS"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","TriCare Standard","Participating","Enrollment Complete","2023-09-04","","","2023-11-05","Provider linked to Andrews Hwy location eff 10/26/23. MS"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","TriCare Standard","Participating","Enrollment Complete","2023-09-04","","","2023-11-05","Provider linked to Andrews Hwy location eff 10/26/23. MS"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","TriCare Standard","Participating","Enrollment Complete","2023-09-04","","","2023-09-26","Confirmed provider is linked to Briarwood and Longview locations. MS"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","TriCare Standard","Participating","Enrollment Complete","2023-09-04","","","2023-09-26","Confirmed provider is linked to Briarwood and Longview locations. MS"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","TriCare Standard","Participating","Enrollment Complete","2023-09-04","","","2023-10-26","Confirmed Eastridge location effective 10/9/23. MS"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","TriCare Standard","Participating","Enrollment Complete","2023-09-04","","","2023-10-26","Confirmed Eastridge location effective 10/9/23. MS"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","TriCare Standard","Participating","Enrollment Complete","2023-09-04","","","2023-11-05","Provider linked to Andrews Hwy location eff 10/26/23. MS"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","TriCare Standard","Participating","Enrollment Complete","2023-09-04","","","2023-11-05","Provider linked to Andrews Hwy location eff 10/26/23. MS"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Omni PPO","Participating","Enrollment Complete","2023-09-01","","","2023-10-09","10/9/2023 Per email received from G. Aviles at IMS/OMNI September delegation roster has been completed.  Provider is PAR and linked to group/location effective 9/1/2023.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Omni PPO","Participating","Enrollment Complete","2023-09-01","","","2023-10-09","10/9/2023 Per email received from G. Aviles at IMS/OMNI September delegation roster has been completed.  Provider is PAR and linked to group/location effective 9/1/2023.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Omni PPO","Participating","Enrollment Complete","2023-09-01","","","2023-10-09","10/9/2023 Per email received from G. Aviles at IMS/OMNI September delegation roster has been completed.  Provider is PAR and linked to group/location effective 9/1/2023.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Omni PPO","Participating","Enrollment Complete","2023-09-01","","","2023-10-09","10/9/2023 Per email received from G. Aviles at IMS/OMNI September delegation roster has been completed.  Provider is PAR and linked to group/location effective 9/1/2023.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","Omni PPO","Participating","Enrollment Complete","2023-09-01","","","2023-10-09","10/9/2023 Per email received from G. Aviles at IMS/OMNI September delegation roster has been completed.  Provider is PAR and linked to group/location effective 9/1/2023.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","Omni PPO","Participating","Enrollment Complete","2023-09-01","","","2023-10-09","10/9/2023 Per email received from G. Aviles at IMS/OMNI September delegation roster has been completed.  Provider is PAR and linked to group/location effective 9/1/2023.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Omni PPO","Participating","Enrollment Complete","2023-09-01","","","2023-10-09","10/9/2023 Per email received from G. Aviles at IMS/OMNI September delegation roster has been completed.  Provider is PAR and linked to group/location effective 9/1/2023.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Omni PPO","Participating","Enrollment Complete","2023-09-01","","","2023-10-09","10/9/2023 Per email received from G. Aviles at IMS/OMNI September delegation roster has been completed.  Provider is PAR and linked to group/location effective 9/1/2023.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Liberty Mutual","Panel Closed","Panel Closed","","","","2023-09-05","09/05/2023.  We appreciate your interest in joining the Coventry Network.  At this time, our panels are closed, and we are not accepting new applications.  Please check back routinely to stay apprised of our panel status. We will update this site when we are open for new applicants. Gallagher, Hartford, Liberty Mutual, Travelers and Zurich fall under Coventry. Jen Videan"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Liberty Mutual","Panel Closed","Panel Closed","","","",45174,"09/05/2023.  We appreciate your interest in joining the Coventry Network.  At this time, our panels are closed, and we are not accepting new applications.  Please check back routinely to stay apprised of our panel status. We will update this site when we are open for new applicants. Gallagher, Hartford, Liberty Mutual, Travelers and Zurich fall under Coventry. Jen Videan"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Liberty Mutual","Panel Closed","Panel Closed","","","",45174,"09/05/2023.  We appreciate your interest in joining the Coventry Network.  At this time, our panels are closed, and we are not accepting new applications.  Please check back routinely to stay apprised of our panel status. We will update this site when we are open for new applicants. Gallagher, Hartford, Liberty Mutual, Travelers and Zurich fall under Coventry. Jen Videan"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Liberty Mutual","Panel Closed","Panel Closed","","","","2023-09-05","09/05/2023.  We appreciate your interest in joining the Coventry Network.  At this time, our panels are closed, and we are not accepting new applications.  Please check back routinely to stay apprised of our panel status. We will update this site when we are open for new applicants. Gallagher, Hartford, Liberty Mutual, Travelers and Zurich fall under Coventry. Jen Videan"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","Liberty Mutual","Panel Closed","Panel Closed","","","","2023-09-05","09/05/2023.  We appreciate your interest in joining the Coventry Network.  At this time, our panels are closed, and we are not accepting new applications.  Please check back routinely to stay apprised of our panel status. We will update this site when we are open for new applicants. Gallagher, Hartford, Liberty Mutual, Travelers and Zurich fall under Coventry. Jen Videan"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","Liberty Mutual","Panel Closed","Panel Closed","","","","2023-09-05","09/05/2023.  We appreciate your interest in joining the Coventry Network.  At this time, our panels are closed, and we are not accepting new applications.  Please check back routinely to stay apprised of our panel status. We will update this site when we are open for new applicants. Gallagher, Hartford, Liberty Mutual, Travelers and Zurich fall under Coventry. Jen Videan"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Liberty Mutual","Panel Closed","Panel Closed","","","","2023-09-05","09/05/2023.  We appreciate your interest in joining the Coventry Network.  At this time, our panels are closed, and we are not accepting new applications.  Please check back routinely to stay apprised of our panel status. We will update this site when we are open for new applicants. Gallagher, Hartford, Liberty Mutual, Travelers and Zurich fall under Coventry. Jen Videan"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Liberty Mutual","Panel Closed","Panel Closed","","","","2023-09-05","09/05/2023.  We appreciate your interest in joining the Coventry Network.  At this time, our panels are closed, and we are not accepting new applications.  Please check back routinely to stay apprised of our panel status. We will update this site when we are open for new applicants. Gallagher, Hartford, Liberty Mutual, Travelers and Zurich fall under Coventry. Jen Videan"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Cigna","Participating","Enrollment Complete","2023-03-10","8909854","","2023-10-03","10.03.2023 S/W Andrea of Cigna @ 1-800-882-4462. Per rep, provider is showing participating and link under the Group and TIN with an Effective date 03/10/2023. Provider ID#:8909854. Service location is on file. Call ref#:Andrea10032023. - Danico Gabriel Melendres"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Cigna","Participating","Enrollment Complete","2023-03-10","8909854","","2023-10-03","10.03.2023 S/W Andrea of Cigna @ 1-800-882-4462. Per rep, provider is showing participating and link under the Group and TIN with an Effective date 03/10/2023. Provider ID#:8909854. Service location is on file. Call ref#:Andrea10032023. - Danico Gabriel Melendres"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Cigna","Participating","Enrollment Complete","2023-03-10","8909854","","2023-10-03","10.03.2023 S/W Andrea of Cigna @ 1-800-882-4462. Per rep, provider is showing participating and link under the Group and TIN with an Effective date 03/10/2023. Provider ID#:8909854. Service location is on file. Call ref#:Andrea10032023. - Danico Gabriel Melendres"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Cigna","Participating","Enrollment Complete","2023-03-10","8909854","","2023-10-03","10.03.2023 S/W Andrea of Cigna @ 1-800-882-4462. Per rep, provider is showing participating and link under the Group and TIN with an Effective date 03/10/2023. Provider ID#:8909854. Service location is on file. Call ref#:Andrea10032023. - Danico Gabriel Melendres"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","Cigna","Participating","Enrollment Complete","2023-03-10","8909854","","2023-10-03","10.03.2023 S/W Andrea of Cigna @ 1-800-882-4462. Per rep, provider is showing participating and link under the Group and TIN with an Effective date 03/10/2023. Provider ID#:8909854. Service location is on file. Call ref#:Andrea10032023. - Danico Gabriel Melendres"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","Cigna","Participating","Enrollment Complete","2023-03-10","8909854","","2023-10-03","10.03.2023 S/W Andrea of Cigna @ 1-800-882-4462. Per rep, provider is showing participating and link under the Group and TIN with an Effective date 03/10/2023. Provider ID#:8909854. Service location is on file. Call ref#:Andrea10032023. - Danico Gabriel Melendres"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Cigna","Participating","Enrollment Complete","2023-03-10","8909854","","2023-10-03","10.03.2023 S/W Andrea of Cigna @ 1-800-882-4462. Per rep, provider is showing participating and link under the Group and TIN with an Effective date 03/10/2023. Provider ID#:8909854. Service location is on file. Call ref#:Andrea10032023. - Danico Gabriel Melendres"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Cigna","Participating","Enrollment Complete","2023-03-10","8909854","","2023-10-03","10.03.2023 S/W Andrea of Cigna @ 1-800-882-4462. Per rep, provider is showing participating and link under the Group and TIN with an Effective date 03/10/2023. Provider ID#:8909854. Service location is on file. Call ref#:Andrea10032023. - Danico Gabriel Melendres"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Multiplan","Participating","Enrollment Complete","2022-08-12","","","2023-10-12","10/12/2023 Per email received from Jessica Bess at  Multiplan provider is PAR and linked to group TIN/locations effective 8/12/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Multiplan","Participating","Enrollment Complete","2022-08-12","","","2023-10-12","10/12/2023 Per email received from Jessica Bess at  Multiplan provider is PAR and linked to group TIN/locations effective 8/12/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Multiplan","Participating","Enrollment Complete","2022-08-12","","","2023-10-12","10/12/2023 Per email received from Jessica Bess at  Multiplan provider is PAR and linked to group TIN/locations effective 8/12/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Multiplan","Participating","Enrollment Complete","2022-08-12","","","2023-10-12","10/12/2023 Per email received from Jessica Bess at  Multiplan provider is PAR and linked to group TIN/locations effective 8/12/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","Multiplan","Participating","Enrollment Complete","2022-08-12","","","2023-10-12","10/12/2023 Per email received from Jessica Bess at  Multiplan provider is PAR and linked to group TIN/locations effective 8/12/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","Multiplan","Participating","Enrollment Complete","2022-08-12","","","2023-10-12","10/12/2023 Per email received from Jessica Bess at  Multiplan provider is PAR and linked to group TIN/locations effective 8/12/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Multiplan","Participating","Enrollment Complete","2022-08-12","","","2023-10-12","10/12/2023 Per email received from Jessica Bess at  Multiplan provider is PAR and linked to group TIN/locations effective 8/12/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Multiplan","Participating","Enrollment Complete","2022-08-12","","","2023-10-12","10/12/2023 Per email received from Jessica Bess at  Multiplan provider is PAR and linked to group TIN/locations effective 8/12/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Rail Road Medicare","Participating","Enrollment Complete","2023-08-01","Q00596491","DX4335","2023-11-08","Enrollment completed via online portal. MS"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Rail Road Medicare","Participating","Enrollment Complete","2023-08-01","Q00596491","DX4335","2023-11-08","Enrollment completed via online portal. MS"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Rail Road Medicare","Participating","Enrollment Complete","2023-08-01","Q00596491","DX4335","2023-11-08","Enrollment completed via online portal. MS"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Rail Road Medicare","Participating","Enrollment Complete","2023-08-01","Q00596491","DX4335","2023-11-08","Enrollment completed via online portal. MS"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","Rail Road Medicare","Participating","Enrollment Complete","2023-08-01","Q00596491","DX4335","2023-11-08","Enrollment completed via online portal. MS"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","Rail Road Medicare","Participating","Enrollment Complete","2023-08-01","Q00596491","DX4335","2023-11-08","Enrollment completed via online portal. MS"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Rail Road Medicare","Participating","Enrollment Complete","2023-08-01","Q00596491","DX4335","2023-11-08","Enrollment completed via online portal. MS"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Rail Road Medicare","Participating","Enrollment Complete","2023-08-01","Q00596491","DX4335","2023-11-08","Enrollment completed via online portal. MS"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Aetna","Participating","Enrollment Complete","2023-09-01","6669419","","2023-10-24","10.24.2023 S/W Julie of Aetna @ 1-800-353-1232. Per rep, Provider is in network with Aetna and linked to the group and TIN# effective 09/01/2023. No next recredentialing date available. PIN: 6669419. Servicing location is on file. Payer# 60054. Call ref# 6167809743. - Willie Ravas"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Aetna","Participating","Enrollment Complete","2023-09-01","6669419","","2023-10-24","10.24.2023 S/W Julie of Aetna @ 1-800-353-1232. Per rep, Provider is in network with Aetna and linked to the group and TIN# effective 09/01/2023. No next recredentialing date available. PIN: 6669419. Servicing location is on file. Payer# 60054. Call ref# 6167809743. - Willie Ravas"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Aetna","Participating","Enrollment Complete","2023-09-01","6669419","","2023-10-24","10.24.2023 S/W Julie of Aetna @ 1-800-353-1232. Per rep, Provider is in network with Aetna and linked to the group and TIN# effective 09/01/2023. No next recredentialing date available. PIN: 6669419. Servicing location is on file. Payer# 60054. Call ref# 6167809743. - Willie Ravas"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Aetna","Participating","Enrollment Complete","2023-09-01","6669419","","2023-10-24","10.24.2023 S/W Julie of Aetna @ 1-800-353-1232. Per rep, Provider is in network with Aetna and linked to the group and TIN# effective 09/01/2023. No next recredentialing date available. PIN: 6669419. Servicing location is on file. Payer# 60054. Call ref# 6167809743. - Willie Ravas"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","Aetna","Participating","Enrollment Complete","2023-09-01","6669419","","2023-10-24","10.24.2023 S/W Julie of Aetna @ 1-800-353-1232. Per rep, Provider is in network with Aetna and linked to the group and TIN# effective 09/01/2023. No next recredentialing date available. PIN: 6669419. Servicing location is on file. Payer# 60054. Call ref# 6167809743. - Willie Ravas"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","Aetna","Participating","Enrollment Complete","2023-09-01","6669419","","2023-10-24","10.24.2023 S/W Julie of Aetna @ 1-800-353-1232. Per rep, Provider is in network with Aetna and linked to the group and TIN# effective 09/01/2023. No next recredentialing date available. PIN: 6669419. Servicing location is on file. Payer# 60054. Call ref# 6167809743. - Willie Ravas"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Aetna","Participating","Enrollment Complete","2023-09-01","6669419","","2023-10-24","10.24.2023 S/W Julie of Aetna @ 1-800-353-1232. Per rep, Provider is in network with Aetna and linked to the group and TIN# effective 09/01/2023. No next recredentialing date available. PIN: 6669419. Servicing location is on file. Payer# 60054. Call ref# 6167809743. - Willie Ravas"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Aetna","Participating","Enrollment Complete","2023-09-01","6669419","","2023-10-24","10.24.2023 S/W Julie of Aetna @ 1-800-353-1232. Per rep, Provider is in network with Aetna and linked to the group and TIN# effective 09/01/2023. No next recredentialing date available. PIN: 6669419. Servicing location is on file. Payer# 60054. Call ref# 6167809743. - Willie Ravas"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Medicare","Participating","Enrollment Complete","2023-08-01","6B4211","","2023-10-20","Received welcome letter. MS"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Medicare","Participating","Enrollment Complete","2023-08-01","6B4211","","2023-10-20","Received welcome letter. MS"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Medicare","Participating","Enrollment Complete","2023-08-01","6B4211","","2023-10-20","Received welcome letter. MS"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Medicare","Participating","Enrollment Complete","2023-08-01","6B4211","","2023-10-20","Received welcome letter. MS"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","Medicare","Participating","Enrollment Complete","2023-08-01","6B4211","","2023-10-20","Received welcome letter. MS"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","Medicare","Participating","Enrollment Complete","2023-08-01","6B4211","","2023-10-20","Received welcome letter. MS"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Medicare","Participating","Enrollment Complete","2023-08-01","6B4211","","2023-10-20","Received welcome letter. MS"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Medicare","Participating","Enrollment Complete","2023-08-01","6B4211","","2023-10-20","Received welcome letter. MS"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","Tricare Prime","Panel Closed","Panel Closed","","","","2023-09-02","Confirmed with rep the Tricare medical/surgical provider panel is closed at this time. MS"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","Tricare Prime","Panel Closed","Panel Closed","","","","2023-09-02","Confirmed with rep the Tricare medical/surgical provider panel is closed at this time. MS"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Tricare Prime","Panel Closed","Panel Closed","","","","2023-09-02","Confirmed with rep the Tricare medical/surgical provider panel is closed at this time. MS"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Tricare Prime","Panel Closed","Panel Closed","","","","2023-09-02","Confirmed with rep the Tricare medical/surgical provider panel is closed at this time. MS"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Tricare Prime","Panel Closed","Panel Closed","","","","2023-09-02","Confirmed with rep the Tricare medical/surgical provider panel is closed at this time. MS"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Tricare Prime","Panel Closed","Panel Closed","","","","2023-09-02","Confirmed with rep the Tricare medical/surgical provider panel is closed at this time. MS"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Tricare Prime","Panel Closed","Panel Closed","","","","2023-09-02","Confirmed with rep the Tricare medical/surgical provider panel is closed at this time. MS"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Tricare Prime","Panel Closed","Panel Closed","","","","2023-09-02","Confirmed with rep the Tricare medical/surgical provider panel is closed at this time. MS"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Broadspire Services Inc.","Participating","Enrollment Complete","2023-05-23","","","2023-09-15","Rcvd confirmation from providerrelations@primehealthservices.com provider has been loaded to roster, with effective date 05/23/2023. Jen Videan"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Broadspire Services Inc.","Participating","Enrollment Complete","2023-05-23","","","2023-09-15","Rcvd confirmation from providerrelations@primehealthservices.com provider has been loaded to roster, with effective date 05/23/2023. Jen Videan"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Broadspire Services Inc.","Participating","Enrollment Complete","2023-05-23","","","2023-09-15","Rcvd confirmation from providerrelations@primehealthservices.com provider has been loaded to roster, with effective date 05/23/2023. Jen Videan"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Broadspire Services Inc.","Participating","Enrollment Complete","2023-05-23","","","2023-09-15","Rcvd confirmation from providerrelations@primehealthservices.com provider has been loaded to roster, with effective date 05/23/2023. Jen Videan"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","Broadspire Services Inc.","Participating","Enrollment Complete","2023-05-23","","","2023-09-15","Rcvd confirmation from providerrelations@primehealthservices.com provider has been loaded to roster, with effective date 05/23/2023. Jen Videan"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","Broadspire Services Inc.","Participating","Enrollment Complete","2023-05-23","","","2023-09-15","Rcvd confirmation from providerrelations@primehealthservices.com provider has been loaded to roster, with effective date 05/23/2023. Jen Videan"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Broadspire Services Inc.","Participating","Enrollment Complete","2023-05-23","","","2023-09-15","Rcvd confirmation from providerrelations@primehealthservices.com provider has been loaded to roster, with effective date 05/23/2023. Jen Videan"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Broadspire Services Inc.","Participating","Enrollment Complete","2023-05-23","","","2023-09-15","Rcvd confirmation from providerrelations@primehealthservices.com provider has been loaded to roster, with effective date 05/23/2023. Jen Videan"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Humana","In Process","Payor Follow Up","","","","2023-11-17","11/17/2023 Sent follow-up email to Marcus Wester at Humana to check status of September monthly delegated roster submission.  Provider Add - CO16127988, Provider Changes - CO-16128096,  Provider Terms - CO-16128221.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Humana","In Process","Payor Follow Up","","","","2023-11-17","11/17/2023 Sent follow-up email to Marcus Wester at Humana to check status of September monthly delegated roster submission.  Provider Add - CO16127988, Provider Changes - CO-16128096,  Provider Terms - CO-16128221.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Humana","In Process","Payor Follow Up","","","","2023-11-17","11/17/2023 Sent follow-up email to Marcus Wester at Humana to check status of September monthly delegated roster submission.  Provider Add - CO16127988, Provider Changes - CO-16128096,  Provider Terms - CO-16128221.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Humana","In Process","Payor Follow Up","","","","2023-11-17","11/17/2023 Sent follow-up email to Marcus Wester at Humana to check status of September monthly delegated roster submission.  Provider Add - CO16127988, Provider Changes - CO-16128096,  Provider Terms - CO-16128221.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","Humana","In Process","Payor Follow Up","","","","2023-11-17","11/17/2023 Sent follow-up email to Marcus Wester at Humana to check status of September monthly delegated roster submission.  Provider Add - CO16127988, Provider Changes - CO-16128096,  Provider Terms - CO-16128221.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","Humana","In Process","Payor Follow Up","","","","2023-11-17","11/17/2023 Sent follow-up email to Marcus Wester at Humana to check status of September monthly delegated roster submission.  Provider Add - CO16127988, Provider Changes - CO-16128096,  Provider Terms - CO-16128221.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Humana","In Process","Payor Follow Up","","","","2023-11-17","11/17/2023 Sent follow-up email to Marcus Wester at Humana to check status of September monthly delegated roster submission.  Provider Add - CO16127988, Provider Changes - CO-16128096,  Provider Terms - CO-16128221.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Humana","In Process","Payor Follow Up","","","","2023-11-17","11/17/2023 Sent follow-up email to Marcus Wester at Humana to check status of September monthly delegated roster submission.  Provider Add - CO16127988, Provider Changes - CO-16128096,  Provider Terms - CO-16128221.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","United Health Care","Participating","Enrollment Complete","2023-09-01","008193055","","2023-09-28","9/28/2023 Rcvd email confirmation from UHC that September delegated roster has been completed.  Provider is PAR and linked to group/location effective 9/1/2023.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","United Health Care","Participating","Enrollment Complete","2023-09-01","008193055","","2023-09-28","9/28/2023 Rcvd email confirmation from UHC that September delegated roster has been completed.  Provider is PAR and linked to group/location effective 9/1/2023.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","United Health Care","Participating","Enrollment Complete","2023-09-01","008193055","","2023-09-28","9/28/2023 Rcvd email confirmation from UHC that September delegated roster has been completed.  Provider is PAR and linked to group/location effective 9/1/2023.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","United Health Care","Participating","Enrollment Complete","2023-09-01","008193055","","2023-09-28","9/28/2023 Rcvd email confirmation from UHC that September delegated roster has been completed.  Provider is PAR and linked to group/location effective 9/1/2023.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","United Health Care","Participating","Enrollment Complete","2023-09-01","008193055","","2023-09-28","9/28/2023 Rcvd email confirmation from UHC that September delegated roster has been completed.  Provider is PAR and linked to group/location effective 9/1/2023.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","United Health Care","Participating","Enrollment Complete","2023-09-01","008193055","","2023-09-28","9/28/2023 Rcvd email confirmation from UHC that September delegated roster has been completed.  Provider is PAR and linked to group/location effective 9/1/2023.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","United Health Care","Participating","Enrollment Complete","2023-09-01","008193055","","2023-09-28","9/28/2023 Rcvd email confirmation from UHC that September delegated roster has been completed.  Provider is PAR and linked to group/location effective 9/1/2023.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","United Health Care","Participating","Enrollment Complete","2023-09-01","008193055","","2023-09-28","9/28/2023 Rcvd email confirmation from UHC that September delegated roster has been completed.  Provider is PAR and linked to group/location effective 9/1/2023.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Sedgwick","In Process","Payor Follow Up","","","","2023-11-27","Per Sedgwick, your providers’ credentialing has been received & is currently under review at this time. 11/27/2023 Jen Videan \n\nEmailed spneast@sedgwickcms.com for status. Jen Videan"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Sedgwick","In Process","Payor Follow Up","","","","2023-11-27","Per Sedgwick, your providers’ credentialing has been received & is currently under review at this time. 11/27/2023 Jen Videan \n\nEmailed spneast@sedgwickcms.com for status. Jen Videan"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","Sedgwick","In Process","Payor Follow Up","","","","2023-11-27","Per Sedgwick, your providers’ credentialing has been received & is currently under review at this time. 11/27/2023 Jen Videan \n\nEmailed spneast@sedgwickcms.com for status. Jen Videan"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","Sedgwick","In Process","Payor Follow Up","","","","2023-11-27","Per Sedgwick, your providers’ credentialing has been received & is currently under review at this time. 11/27/2023 Jen Videan \n\nEmailed spneast@sedgwickcms.com for status. Jen Videan"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Sedgwick","In Process","Payor Follow Up","","","","2023-11-27","Per Sedgwick, your providers’ credentialing has been received & is currently under review at this time. 11/27/2023 Jen Videan \n\nEmailed spneast@sedgwickcms.com for status. Jen Videan"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Sedgwick","In Process","Payor Follow Up","","","","2023-11-27","Per Sedgwick, your providers’ credentialing has been received & is currently under review at this time. 11/27/2023 Jen Videan \n\nEmailed spneast@sedgwickcms.com for status. Jen Videan"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Sedgwick","In Process","Payor Follow Up","","","","2023-11-27","Per Sedgwick, your providers’ credentialing has been received & is currently under review at this time. 11/27/2023 Jen Videan \n\nEmailed spneast@sedgwickcms.com for status. Jen Videan"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Sedgwick","In Process","Payor Follow Up","","","","2023-11-27","Per Sedgwick, your providers’ credentialing has been received & is currently under review at this time. 11/27/2023 Jen Videan \n\nEmailed spneast@sedgwickcms.com for status. Jen Videan"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Medicaid","Enrollment Stopped","Enrollment Stopped","","","","2023-11-16","11/16/2023 No Medicaid enrollment is needed for the provider as this group does not enroll in Medicaid.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Medicaid","Enrollment Stopped","Enrollment Stopped","","","","2023-11-16","11/16/2023 No Medicaid enrollment is needed for the provider as this group does not enroll in Medicaid.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Medicaid","Enrollment Stopped","Enrollment Stopped","","","","2023-11-16","11/16/2023 No Medicaid enrollment is needed for the provider as this group does not enroll in Medicaid.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Medicaid","Enrollment Stopped","Enrollment Stopped","","","","2023-11-16","11/16/2023 No Medicaid enrollment is needed for the provider as this group does not enroll in Medicaid.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","Medicaid","Enrollment Stopped","Enrollment Stopped","","","","2023-11-16","11/16/2023 No Medicaid enrollment is needed for the provider as this group does not enroll in Medicaid.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","Medicaid","Enrollment Stopped","Enrollment Stopped","","","","2023-11-16","11/16/2023 No Medicaid enrollment is needed for the provider as this group does not enroll in Medicaid.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Medicaid","Enrollment Stopped","Enrollment Stopped","","","","2023-11-16","11/16/2023 No Medicaid enrollment is needed for the provider as this group does not enroll in Medicaid.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Medicaid","Enrollment Stopped","Enrollment Stopped","","","","2023-11-16","11/16/2023 No Medicaid enrollment is needed for the provider as this group does not enroll in Medicaid.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","Medicaid","Enrollment Stopped","Enrollment Stopped","","","","2023-11-16","11/16/2023 No Medicaid enrollment is needed for the provider as this group does not enroll in Medicaid.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","Medicaid","Enrollment Stopped","Enrollment Stopped","","","","2023-11-16","11/16/2023 No Medicaid enrollment is needed for the provider as this group does not enroll in Medicaid.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Triwest VA","In House Enrollment","In House Enrollment","","","","2023-08-29",""]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Triwest VA","In House Enrollment","In House Enrollment","","","","2023-08-29",""]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Triwest VA","In House Enrollment","In House Enrollment","","","","2023-08-29",""]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Triwest VA","In House Enrollment","In House Enrollment","","","","2023-08-29",""]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","Triwest VA","In House Enrollment","In House Enrollment","","","","2023-08-29",""]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","Triwest VA","In House Enrollment","In House Enrollment","","","","2023-08-29",""]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Triwest VA","In House Enrollment","In House Enrollment","","","","2023-08-29",""]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Triwest VA","In House Enrollment","In House Enrollment","","","","2023-08-29",""]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Corvel Healthcare Corp.","In Process","Payor Follow Up","","","","2023-11-27","Emailed Karina Garcia at Corvel for status. Jen Videan"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Corvel Healthcare Corp.","In Process","Payor Follow Up","","","","2023-11-27","Emailed Karina Garcia at Corvel for status. Jen Videan"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","Corvel Healthcare Corp.","In Process","Payor Follow Up","","","","2023-11-27","Emailed Karina Garcia at Corvel for status. Jen Videan"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","Corvel Healthcare Corp.","In Process","Payor Follow Up","","","","2023-11-27","Emailed Karina Garcia at Corvel for status. Jen Videan"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Corvel Healthcare Corp.","In Process","Payor Follow Up","","","","2023-11-27","Emailed Karina Garcia at Corvel for status. Jen Videan"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Corvel Healthcare Corp.","In Process","Payor Follow Up","","","","2023-11-27","Emailed Karina Garcia at Corvel for status. Jen Videan"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Corvel Healthcare Corp.","In Process","Payor Follow Up","","","","2023-11-27","Emailed Karina Garcia at Corvel for status. Jen Videan"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Corvel Healthcare Corp.","In Process","Payor Follow Up","","","","2023-11-27","Emailed Karina Garcia at Corvel for status. Jen Videan"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","IMS","Participating","Enrollment Complete","2023-09-01","","","2023-10-09","10/9/2023 Per email received from G. Aviles at IMS/OMNI September delegation roster has been completed.  Provider is PAR and linked to group/location effective 9/1/2023.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","IMS","Participating","Enrollment Complete","2023-09-01","","","2023-10-09","10/9/2023 Per email received from G. Aviles at IMS/OMNI September delegation roster has been completed.  Provider is PAR and linked to group/location effective 9/1/2023.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","IMS","Participating","Enrollment Complete","2023-09-01","","","2023-10-09","10/9/2023 Per email received from G. Aviles at IMS/OMNI September delegation roster has been completed.  Provider is PAR and linked to group/location effective 9/1/2023.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","IMS","Participating","Enrollment Complete","2023-09-01","","","2023-10-09","10/9/2023 Per email received from G. Aviles at IMS/OMNI September delegation roster has been completed.  Provider is PAR and linked to group/location effective 9/1/2023.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","IMS","Participating","Enrollment Complete","2023-09-01","","","2023-10-09","10/9/2023 Per email received from G. Aviles at IMS/OMNI September delegation roster has been completed.  Provider is PAR and linked to group/location effective 9/1/2023.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","IMS","Participating","Enrollment Complete","2023-09-01","","","2023-10-09","10/9/2023 Per email received from G. Aviles at IMS/OMNI September delegation roster has been completed.  Provider is PAR and linked to group/location effective 9/1/2023.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","IMS","Participating","Enrollment Complete","2023-09-01","","","2023-10-09","10/9/2023 Per email received from G. Aviles at IMS/OMNI September delegation roster has been completed.  Provider is PAR and linked to group/location effective 9/1/2023.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","IMS","Participating","Enrollment Complete","2023-09-01","","","2023-10-09","10/9/2023 Per email received from G. Aviles at IMS/OMNI September delegation roster has been completed.  Provider is PAR and linked to group/location effective 9/1/2023.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","USA PPO","In Process","Payor Follow Up","","","","2023-11-27","11/27/2023 Per USA PPO provider portal provider is still not loaded under new locations.  Will allow more time, check back in 2 weeks.  \nDCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","USA PPO","In Process","Payor Follow Up","","","","2023-11-27","11/27/2023 Per USA PPO provider portal provider is still not loaded under new locations.  Will allow more time, check back in 2 weeks.  \nDCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","USA PPO","In Process","Payor Follow Up","","","","2023-11-27","11/27/2023 Per USA PPO provider portal provider is still not loaded under new locations.  Will allow more time, check back in 2 weeks.  \nDCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","USA PPO","In Process","Payor Follow Up","","","","2023-11-27","11/27/2023 Per USA PPO provider portal provider is still not loaded under new locations.  Will allow more time, check back in 2 weeks.  \nDCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","USA PPO","In Process","Payor Follow Up","","","","2023-11-27","11/27/2023 Per USA PPO provider portal provider is still not loaded under new locations.  Will allow more time, check back in 2 weeks.  \nDCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","USA PPO","In Process","Payor Follow Up","","","","2023-11-27","11/27/2023 Per USA PPO provider portal provider is still not loaded under new locations.  Will allow more time, check back in 2 weeks.  \nDCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","USA PPO","In Process","Payor Follow Up","","","","2023-11-27","11/27/2023 Per USA PPO provider portal provider is still not loaded under new locations.  Will allow more time, check back in 2 weeks.  \nDCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","USA PPO","In Process","Payor Follow Up","","","","2023-11-27","11/27/2023 Per USA PPO provider portal provider is still not loaded under new locations.  Will allow more time, check back in 2 weeks.  \nDCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","Scott&White (First Care)","Participating","Enrollment Complete","2023-10-15","","","2023-10-12","10/12/2023 Per email received from Scott & White provider is PAR and linked to group TIN/locations effective 10/15/2023.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","Scott&White (First Care)","Participating","Enrollment Complete","2023-10-15","","","2023-10-12","10/12/2023 Per email received from Scott & White provider is PAR and linked to group TIN/locations effective 10/15/2023.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Scott&White (First Care)","Participating","Enrollment Complete","2023-10-15","","","2023-10-12","10/12/2023 Per email received from Scott & White provider is PAR and linked to group TIN/locations effective 10/15/2023.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Scott&White (First Care)","Participating","Enrollment Complete","2023-10-15","","","2023-10-12","10/12/2023 Per email received from Scott & White provider is PAR and linked to group TIN/locations effective 10/15/2023.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Scott&White (First Care)","Participating","Enrollment Complete","2023-10-15","","","2023-10-12","10/12/2023 Per email received from Scott & White provider is PAR and linked to group TIN/locations effective 10/15/2023.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Scott&White (First Care)","Participating","Enrollment Complete","2023-10-15","","","2023-10-12","10/12/2023 Per email received from Scott & White provider is PAR and linked to group TIN/locations effective 10/15/2023.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Scott&White (First Care)","Participating","Enrollment Complete","2023-10-15","","","2023-10-12","10/12/2023 Per email received from Scott & White provider is PAR and linked to group TIN/locations effective 10/15/2023.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Scott&White (First Care)","Participating","Enrollment Complete","2023-10-15","","","2023-10-12","10/12/2023 Per email received from Scott & White provider is PAR and linked to group TIN/locations effective 10/15/2023.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Amerigroup","Participating","Enrollment Complete","2022-08-12","","","2023-10-19","10/19/2023 Per email received from Jessica Bess at  Multiplan provider is PAR with Amerigroup and linked to group TIN/locations thru Multiplan enrollment effective 8/12/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","Amerigroup","Participating","Enrollment Complete","2022-08-12","","","2023-10-19","10/19/2023 Per email received from Jessica Bess at  Multiplan provider is PAR with Amerigroup and linked to group TIN/locations thru Multiplan enrollment effective 8/12/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","Hartford","Panel Closed","Panel Closed","","","","2023-09-01","09/01/2023.  We appreciate your interest in joining the Coventry Network.  At this time, our panels are closed, and we are not accepting new applications.  Please check back routinely to stay apprised of our panel status. We will update this site when we are open for new applicants. Gallagher, Hartford, Liberty Mutual, Travelers and Zurich fall under Coventry. Jen Videan"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Texas Mutual","In Process","Payor Follow Up","","","","2023-11-22","Emailed Dee Dee Johnson at Texas Mutual to check status of 6301 Andrews Hwy.  Jen Videan"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Texas Mutual","In Process","Payor Follow Up","","","","2023-11-22","Emailed Dee Dee Johnson at Texas Mutual to check status of 6301 Andrews Hwy.  Jen Videan"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Caprock (CapStar)","Participating","Enrollment Complete","2023-09-01","","","2023-09-27","9/27/2023 Rcvd email confirmation from Caprock that the September roster has been completed.  Provider is PAR and linked to group/location effective 9/1/2023.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","Caprock (CapStar)","Participating","Enrollment Complete","2023-09-01","","","2023-09-27","9/27/2023 Rcvd email confirmation from Caprock that the September roster has been completed.  Provider is PAR and linked to group/location effective 9/1/2023.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Texas Municipal League","Thru Other Payor","Thru Other Payor","","","","2023-11-20","See status updates under Alliance WC payor line."]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Alliance WC","Participating","Enrollment Complete","","","","2023-11-27","Rcvd Welcome letter. Provider effective 11/17/2023. Jen Videan"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Gallagher","Panel Closed","Panel Closed","","","","2023-09-01","09/01/2023.  We appreciate your interest in joining the Coventry Network.  At this time, our panels are closed, and we are not accepting new applications.  Please check back routinely to stay apprised of our panel status. We will update this site when we are open for new applicants. Gallagher, Hartford, Liberty Mutual, Travelers and Zurich fall under Coventry. Jen Videan"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Gallagher","Panel Closed","Panel Closed","","","","2023-09-01","09/01/2023.  We appreciate your interest in joining the Coventry Network.  At this time, our panels are closed, and we are not accepting new applications.  Please check back routinely to stay apprised of our panel status. We will update this site when we are open for new applicants. Gallagher, Hartford, Liberty Mutual, Travelers and Zurich fall under Coventry. Jen Videan"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Zurich","Panel Closed","Panel Closed","","","","2023-09-01","09/01/2023.  We appreciate your interest in joining the Coventry Network.  At this time, our panels are closed, and we are not accepting new applications.  Please check back routinely to stay apprised of our panel status. We will update this site when we are open for new applicants. Gallagher, Hartford, Liberty Mutual, Travelers and Zurich fall under Coventry. Jen Videan"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Travelers WC","Panel Closed","Panel Closed","","","","2023-09-01","09/01/2023.  We appreciate your interest in joining the Coventry Network.  At this time, our panels are closed, and we are not accepting new applications.  Please check back routinely to stay apprised of our panel status. We will update this site when we are open for new applicants. Gallagher, Hartford, Liberty Mutual, Travelers and Zurich fall under Coventry. Jen Videan"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","HealthSmart PPO","In Process","Payor Follow Up","","","","2023-11-14","11/14/2023 Per Healthsmart provider portal provider is still not loaded under group TIN.  Per phone conversation with Lee Kinard at Healthsmart provider portal should be updated  by 11/27/2023.  Will allow more time, check back in 2 weeks.   DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Wellmed","Participating","Enrollment Complete","2023-09-01","","","2023-09-28","9/28/2023 Rcvd email confirmation from UHC that September delegated roster has been completed.  Provider is PAR and linked to group/location effective 9/1/2023.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","Wellmed","Participating","Enrollment Complete","2023-09-01","","","2023-09-28","9/28/2023 Rcvd email confirmation from UHC that September delegated roster has been completed.  Provider is PAR and linked to group/location effective 9/1/2023.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Galaxy Health","Participating","Enrollment Complete","2023-09-01","","","2023-10-11","10/11/2023 Per email received from Galaxy September delegated roster has been processed and provider is PAR and linked to group/location effective 9/1/2023.  DCannon"]
["Haley D Brennan, PA-C",1528430865,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","United Health Care","Participating","Enrollment Complete","2020-04-22","","","2023-09-07","9/7/2023 Per email from UHC May delegated roster has been completed.  Provider is PAR and linked to group TIN/locations effective 4/22/2020.  DCannon"]
["Haley D Brennan, PA-C",1528430865,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Triwest VA","In House Enrollment","In House Enrollment","","","","2023-07-24","5/1/2023 Add new locations - 4705 Briarwood Ave, 6950 Eastridge Rd.  and 6301 Andrews Hwy.  DCannon"]
["Haley D Brennan, PA-C",1528430865,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","Triwest VA","In House Enrollment","In House Enrollment","","","","2023-07-24","5/1/2023 Add new locations - 4705 Briarwood Ave, 6950 Eastridge Rd.  and 6301 Andrews Hwy.  DCannon"]
["Haley D Brennan, PA-C",1528430865,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Gallagher","Panel Closed","Panel Closed","","","","2023-08-15","We appreciate your interest in joining the Coventry Network.  At this time, our panels are closed, and we are not accepting new applications.  Please check back routinely to stay apprised of our panel status. We will update this site when we are open for new applicants. Gallagher, Hartford, Liberty Mutual, Travelers and Zurich fall under Coventry. Jen Videan"]
["Haley D Brennan, PA-C",1528430865,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","USA PPO","In Process","Payor Follow Up","","","","2023-11-27","11/27/2023 Per USA PPO provider portal provider is still not loaded under new locations.  Will allow more time, check back in 2 weeks.  \nDCannon"]
["Haley D Brennan, PA-C",1528430865,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","BCBSTX","Participating","Enrollment Complete","2017-10-19","","","2023-10-02","10/2/2023 Per BCBS TX roster received from Priscilla Albertine at MQA provider is PAR and linked to group effective 10/19/2017.  DCannon"]
["Haley D Brennan, PA-C",1528430865,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","Scott&White (First Care)","Participating","Enrollment Complete","2023-09-14","","","2023-09-29","9/29/2023 Rcvd confirmation from Scott & White that provider has been loaded at all locations effective 9/14/2023.  DCannon"]
["Haley D Brennan, PA-C",1528430865,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Triwest VA","In House Enrollment","In House Enrollment","","","","2021-01-13","1/6/2021 MQA Team is working with Representatives at BCBS-TX to ensure all providers are enrolled and loaded to participate with the VACCN network in a timely manner. However, we are currently awaiting a full roster of providers currently participating and will update all records accordingly upon receipt. Kfrazier"]
["Haley D Brennan, PA-C",1528430865,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Sedgwick","In Process","Payor Follow Up","","","","2023-11-27","Per Sedgwick,  Ms. Brennan’s credentialing has been completed & is on the December 2023 credentialing meeting.  It is tentatively scheduled for 12/20/2023. Jen Videan"]
["Haley D Brennan, PA-C",1528430865,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","IMS","Participating","Enrollment Complete","2023-10-02","","","2023-09-05","9/5/2023 Per email received from IMS/OMNI May delegated roster has been processed and provider is PAR and linked to group effective 10/2/2023.  DCannon"]
["Haley D Brennan, PA-C",1528430865,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Wellmed","Participating","Enrollment Complete","2020-06-01","","","2023-09-19","9/19/2023  Provider is PAR and linked to group/locations effective 6/1/2020.  DCannon"]
["Haley D Brennan, PA-C",1528430865,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","IMS","Participating","Enrollment Complete","2023-05-01","","","2023-07-20","7/20/2023 Per email received from IMS/OMNI May delegated roster has been processed and provider is PAR and linked to group effective 5/1/2023.  DCannon"]
["Haley D Brennan, PA-C",1528430865,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Scott&White (First Care)","Participating","Enrollment Complete","2023-05-01","","","2023-08-24","8/24/2023 Per email rcvd from Scott & White provider is PAR and linked to group TIN/location effective 5/1/2023.  DCannon"]
["Haley D Brennan, PA-C",1528430865,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Zurich","Panel Closed","Panel Closed","","","","2023-08-22","08/22/2023  We appreciate your interest in joining the Coventry Network.  At this time, our panels are closed, and we are not accepting new applications.  Please check back routinely to stay apprised of our panel status. We will update this site when we are open for new applicants. Gallagher, Hartford, Liberty Mutual, Travelers and Zurich fall under Coventry. Jen Videan"]
["Haley D Brennan, PA-C",1528430865,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Multiplan","Participating","Enrollment Complete","2023-05-01","","","2023-07-25","7/25/2023 Rcvd email from Jessica Bess at Multiplan with a full roster and provider is PAR w/ group and location effective 5/1/2023.  DCannon"]
["Haley D Brennan, PA-C",1528430865,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Multiplan","Participating","Enrollment Complete","2023-05-01","","","2023-07-25","7/25/2023 Rcvd email from Jessica Bess at Multiplan with a full roster and provider is PAR w/ group and location effective 5/1/2023.  DCannon"]
["Haley D Brennan, PA-C",1528430865,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","Texas Mutual","In Process","Payor Follow Up","","","","2023-11-22","Emailed Dee Dee Johnson at Texas Mutual to check status of 6301 Andrews Hwy.  Jen Videan"]
["Haley D Brennan, PA-C",1528430865,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Omni PPO","Participating","Enrollment Complete","2023-05-01","","","2023-07-20","7/20/2023 Per email received from IMS/OMNI May delegated roster has been processed and provider is PAR and linked to group effective 5/1/2023.  DCannon"]
["Haley D Brennan, PA-C",1528430865,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Liberty Mutual","Panel Closed","Panel Closed","","","","2023-08-22","08/22/2023  We appreciate your interest in joining the Coventry Network.  At this time, our panels are closed, and we are not accepting new applications.  Please check back routinely to stay apprised of our panel status. We will update this site when we are open for new applicants. Gallagher, Hartford, Liberty Mutual, Travelers and Zurich fall under Coventry. Jen Videan"]
["Haley D Brennan, PA-C",1528430865,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","Liberty Mutual","Panel Closed","Panel Closed","","","","2023-08-22","08/22/2023  We appreciate your interest in joining the Coventry Network.  At this time, our panels are closed, and we are not accepting new applications.  Please check back routinely to stay apprised of our panel status. We will update this site when we are open for new applicants. Gallagher, Hartford, Liberty Mutual, Travelers and Zurich fall under Coventry. Jen Videan"]
["Haley D Brennan, PA-C",1528430865,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Medicare","Participating","Enrollment Complete","2018-10-01","715814","423838","2023-07-27","7/27/2023 Per PECOS new locations have been added to group record.  Provider is PAR and linked to group/locations effective 10/1/2018.  PID # 715814.  DCannon"]
["Haley D Brennan, PA-C",1528430865,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Amerigroup","Participating","Enrollment Complete","2023-05-01","","","2023-10-20","10/18/2023 Per email received from Jessica Bess at  Multiplan provider is PAR with Amerigroup and linked to group TIN/locations thru Multiplan enrollment effective 5/1/2023.  DCannon"]
["Haley D Brennan, PA-C",1528430865,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","TriCare Standard","Participating","Enrollment Complete","2023-07-28","","","2023-11-05","Andrews Hwy linked eff 10.26.2023"]
["Haley D Brennan, PA-C",1528430865,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","TriCare Standard","Participating","Enrollment Complete","2023-07-28","","","2023-08-23","Provider is linked to the Briarwood location effective 7/28. MS"]
["Haley D Brennan, PA-C",1528430865,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","TriCare Standard","Participating","Enrollment Complete","2023-07-28","","","2023-10-26","Eastridge location is completed effective 10/9/2023. MS"]
["Paula Kaye Brookings, APRN-FNP-BC",1295136034,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Multiplan","Participating","Enrollment Complete","2023-05-01","","","2023-09-07","9/7/2023 Per email received from Jessica Bess at Multiplan provider is PAR and linked to group TIN/location effective 5/1/2023.  DCannon"]
["Paula Kaye Brookings, APRN-FNP-BC",1295136034,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Humana","Participating","Enrollment Complete","2021-09-01","","","2021-11-18","11/18/2021 Rcvd full roster from Humana listing provider as PAR and linked to group TIN/location effective 9/1/2021.  DCannon"]
["Paula Kaye Brookings, APRN-FNP-BC",1295136034,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","United Health Care","Participating","Enrollment Complete","2021-01-07","","","2023-09-07","9/7/2023 Per email from UHC May delegated roster has been completed.  Provider is PAR and linked to group TIN/locations effective 1/7/2021.  DCannon"]
["Paula Kaye Brookings, APRN-FNP-BC",1295136034,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","BCBSTX","Participating","Enrollment Complete","2020-05-10","","","2023-10-02","10/2/2023 Per BCBS TX roster received from Priscilla Albertine at MQA provider is PAR and linked to group effective 5/10/2020.  DCannon"]
["Paula Kaye Brookings, APRN-FNP-BC",1295136034,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","HealthSmart PPO","Participating","Enrollment Complete","2021-03-26","","","2021-06-03","6/1/2021 Per Healthsmart website provider is PAR and loaded under TIN/location effective 3/26/2021.  DCannon"]
["Paula Kaye Brookings, APRN-FNP-BC",1295136034,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Humana","Enrollment Stopped","Enrollment Stopped","","","","2023-10-09","10/9/2023 Provider no longer with group effective 9/1/2023.  DCannon"]
["Paula Kaye Brookings, APRN-FNP-BC",1295136034,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Gallagher","Panel Closed","Panel Closed","","","","2023-09-03","9/3/20023 Coventry panel closed at this time.  DCannon"]
["Paula Kaye Brookings, APRN-FNP-BC",1295136034,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","Boon Chapman","Participating","Enrollment Complete","2023-10-02","","","2023-09-20","9/20/2023 Per email received from Jessica Bess at Multiplan August roster has been completed.  Provider is PAR and linked to group TIN/location effective 10/2/2023.  DCannon"]
["Paula Kaye Brookings, APRN-FNP-BC",1295136034,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","HealthSmart PPO","Enrollment Stopped","Enrollment Stopped","","","","2023-10-09","10/9/2023 Provider no longer with group effective 9/1/2023.  DCannon"]
["Paula Kaye Brookings, APRN-FNP-BC",1295136034,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","First Health Coventry","Participating","Enrollment Complete","2021-03-26","3512025","","2022-04-05","4/5/2022  Per First Health online provider directory provider is PAR and linked to group/locations  effective 3/26/2021.  DCannon"]
["Paula Kaye Brookings, APRN-FNP-BC",1295136034,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","Travelers WC","Panel Closed","Panel Closed","","","","2023-09-03","9/3/2023 Coventry panel closed at this time.  DCannon"]
["Paula Kaye Brookings, APRN-FNP-BC",1295136034,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Zurich","Panel Closed","Panel Closed","","","","2023-09-03","9/3/2023 Coventry panel closed at this time.  DCannon"]
["Paula Kaye Brookings, APRN-FNP-BC",1295136034,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Omni PPO","Participating","Enrollment Complete","2023-05-01","","","2023-07-20","7/20/2023 Per email received from IMS/OMNI May delegated roster has been processed and provider is PAR and linked to group effective 5/1/2023.  DCannon"]
["Paula Kaye Brookings, APRN-FNP-BC",1295136034,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Wellmed","Participating","Enrollment Complete","2021-01-07","","","2023-09-07","9/7/2023 Per email from UHC May delegated roster has been completed.  Provider is PAR and linked to group TIN/locations effective 1/7/2021.  DCannon"]
["Paula Kaye Brookings, APRN-FNP-BC",1295136034,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Corvel Healthcare Corp.","Enrollment Stopped","Enrollment Stopped","","","","2023-10-09","10/9/2023 Provider no longer with group effective 9/1/2023.  DCannon"]
["Paula Kaye Brookings, APRN-FNP-BC",1295136034,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Texas Municipal League","Enrollment Stopped","Enrollment Stopped","","","","2023-11-22","Provider no longer with TIN. MS"]
["Paula Kaye Brookings, APRN-FNP-BC",1295136034,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Medicare","Participating","Enrollment Complete","","","","2023-09-08","Provider is enrolled with all locations under WesTex. MS"]
["Paula Kaye Brookings, APRN-FNP-BC",1295136034,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","HealthSmart PPO","Enrollment Stopped","Enrollment Stopped","","","","2023-10-09","10/9/2023 Provider no longer with group effective 9/1/2023.  DCannon"]
["Paula Kaye Brookings, APRN-FNP-BC",1295136034,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","United Health Care","Enrollment Stopped","Enrollment Stopped","","","","2023-10-09","10/9/2023 Provider no longer with group effective 9/1/2023.  DCannon"]
["Paula Kaye Brookings, APRN-FNP-BC",1295136034,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","First Health Coventry","Participating","Enrollment Complete","2021-03-26","3512025","","2023-09-05","9/5/2023 Per First Health web portal provider is PAR and linked to group TIN/location effective 3/26/2021.  PID # 3512025.  DCannon"]
["Paula Kaye Brookings, APRN-FNP-BC",1295136034,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Aetna","Participating","Enrollment Complete","2021-03-26","","","2023-09-07","9/7/2023 Per email response from Mary Hanna at Aetna, May delegated roster is complete.  Provider is PAR and linked to group TIN/location effective 3/26/2021.  DCannon"]
["Paula Kaye Brookings, APRN-FNP-BC",1295136034,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Cigna","Participating","Enrollment Complete","2023-05-01","","","2023-07-18","7/18/2023 Rcvd email from Cigna that provider is PAR and linked to new practice locations effective 5/1/2023.  PID # 2032079 DCannon"]
["Paula Kaye Brookings, APRN-FNP-BC",1295136034,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Alliance WC","Enrollment Stopped","Enrollment Stopped","","","","2023-10-09","10/9/2023 Provider no longer with group effective 9/1/2023.  DCannon"]
["Paula Kaye Brookings, APRN-FNP-BC",1295136034,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Alliance WC","Enrollment Stopped","Enrollment Stopped","","","","2023-10-09","10/9/2023 Provider no longer with group effective 9/1/2023.  DCannon"]
["Paula Kaye Brookings, APRN-FNP-BC",1295136034,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Galaxy Health","Participating","Enrollment Complete","2021-03-26","","","2021-06-04","6/4/2021 Per Karen Avalos at Galaxy Health monthly delegated submission is complete and provider is PAR and linked to group TIN/locations effective 3/26/2021.  DCannon"]
["Paula Kaye Brookings, APRN-FNP-BC",1295136034,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","USA PPO","Enrollment Stopped","Enrollment Stopped","","","","2023-10-09","10/9/2023 Provider no longer with group effective 9/1/2023.  DCannon"]
["Paula Kaye Brookings, APRN-FNP-BC",1295136034,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Texas Mutual","Participating","Enrollment Complete","","","","2023-10-06","Paula Brookings NP (NPI 1295136034)- eff: 06/01/2021\n4705 Briarwood Ave. Midland, TX 79707 and 6950 Eastridge Rd. Odessa, TX 79765. Jen Videan \nPaula Brookings, NP is no longer with WesTex Urgent Care, PLLC, effective 09/01/2023."]
["Paula Kaye Brookings, APRN-FNP-BC",1295136034,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Caprock (CapStar)","Participating","Enrollment Complete","2023-05-01","","",45125,"7/18/2023 Per email received from Caprock provider has been added to new location 4705 Briarwood Ave and 6950 Eastridge Rd. effective 5/1/2023.  DCannon"]
["Nathan L Vaughn, APRN-FNP-BC",1821674151,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Medicare","Participating","Enrollment Complete","2023-10-03","6C9448","423838","2023-11-08","Received approval letter eff 10/3/23. MS"]
["Nathan L Vaughn, APRN-FNP-BC",1821674151,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Medicare","Participating","Enrollment Complete","2023-10-03","6C9448","423838","2023-11-08","Received approval letter eff 10/3/23. MS"]
["Nathan L Vaughn, APRN-FNP-BC",1821674151,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","Sedgwick","In Process","Payor Follow Up","","","","2023-11-27","Per Sedgwick, your providers’ credentialing has been received & is currently under review at this time. Jen Videan"]
["Nathan L Vaughn, APRN-FNP-BC",1821674151,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Aetna","In Process","Pending PSV","","","","2023-10-02",""]
["Nathan L Vaughn, APRN-FNP-BC",1821674151,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","Aetna","In Process","Pending PSV","","","","2023-10-02",""]
["Nathan L Vaughn, APRN-FNP-BC",1821674151,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Boon Chapman","Thru Other Payor","Pending Other Enrollment","","","","2023-11-17","11/17/2023 Pending Multiplan enrollment.  DCannon"]
["Nathan L Vaughn, APRN-FNP-BC",1821674151,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","United Health Care","In Process","Pending PSV","","","","2023-10-02",""]
["Nathan L Vaughn, APRN-FNP-BC",1821674151,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","United Health Care","In Process","Pending PSV","","","","2023-10-02",""]
["Nathan L Vaughn, APRN-FNP-BC",1821674151,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","Corvel Healthcare Corp.","In Process","Application Submitted","","","","2023-11-17","Roster emailed to Karina Garcia at Corvel. Jen Videan"]
["Nathan L Vaughn, APRN-FNP-BC",1821674151,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","Broadspire Services Inc.","Participating","Enrollment Complete","2023-05-23","","","2023-11-06","Per providerrelations@primehealthservices.com, provider has been added. effective date 05/23/2023. Jen Videan"]
["Nathan L Vaughn, APRN-FNP-BC",1821674151,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Caprock (CapStar)","In Process","Pending PSV","","","","2023-10-02",""]
["Nathan L Vaughn, APRN-FNP-BC",1821674151,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","Caprock (CapStar)","In Process","Pending PSV","","","","2023-10-02",""]
["Nathan L Vaughn, APRN-FNP-BC",1821674151,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","TriCare Standard","Participating","Enrollment Complete","2023-10-26","","","2023-10-26","Briarwood, Eastridge and Longview locations are eff 10/9/23. MS"]
["Nathan L Vaughn, APRN-FNP-BC",1821674151,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","TriCare Standard","Participating","Enrollment Complete","2023-10-26","","","2023-10-26","Briarwood, Eastridge and Longview locations are eff 10/9/23. MS"]
["Nathan L Vaughn, APRN-FNP-BC",1821674151,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","TriCare Standard","Participating","Enrollment Complete","2023-10-26","","","2023-10-26","Briarwood, Eastridge and Longview locations are eff 10/9/23. MS"]
["Nathan L Vaughn, APRN-FNP-BC",1821674151,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","HealthSmart PPO","In Process","Pending PSV","","","","2023-10-02",""]
["Nathan L Vaughn, APRN-FNP-BC",1821674151,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","HealthSmart PPO","In Process","Pending PSV","","","","2023-10-02",""]
["Nathan L Vaughn, APRN-FNP-BC",1821674151,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Cigna","Participating","Enrollment Complete","","","","2023-10-27","Group has an ancillary contract in place, therefore, all services for midlevels will be billed under the group. no credentialing is required. MS"]
["Nathan L Vaughn, APRN-FNP-BC",1821674151,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Cigna","Participating","Enrollment Complete","","","","2023-10-27","Group has an ancillary contract in place, therefore, all services for midlevels will be billed under the group. no credentialing is required. MS"]
["Nathan L Vaughn, APRN-FNP-BC",1821674151,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Coventry Workers Comp","Panel Closed","Panel Closed","","","","2023-10-09"," Per Coventry website, at this time, our panels are closed, and we are not accepting new applications. Jen Videan"]
["Nathan L Vaughn, APRN-FNP-BC",1821674151,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","Zurich","Panel Closed","Panel Closed","","","","2023-10-09","10/09/2023. We appreciate your interest in joining the Coventry Network.  At this time, our panels are closed, and we are not accepting new applications.  Please check back routinely to stay apprised of our panel status. We will update this site when we are open for new applicants. Gallagher, Hartford, Liberty Mutual, Travelers and Zurich fall under Coventry. Jen Videan"]
["Nathan L Vaughn, APRN-FNP-BC",1821674151,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","USA PPO","In Process","Pending PSV","","","","2023-10-02",""]
["Nathan L Vaughn, APRN-FNP-BC",1821674151,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","IMS","In Process","Pending PSV","","","","2023-10-02",""]
["Nathan L Vaughn, APRN-FNP-BC",1821674151,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","IMS","In Process","Pending PSV","","","","2023-10-02",""]
["Nathan L Vaughn, APRN-FNP-BC",1821674151,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Alliance WC","In Process","Payor Follow Up","","","","2023-11-27","Per Michelle Killough, The application for this provider was received at the end of October after we had already closed October applications so it was put with November applications.\nWe process new applications once a month, at the end of the month.  Once a provider is approved or denied, you will hear from us the first or second week of the following month.  Depending on when the application is submitted, our review/approval process can take 4-6 weeks. Jen Videan"]
["Nathan L Vaughn, APRN-FNP-BC",1821674151,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Scott&White (First Care)","In Process","Pending PSV","","","","2023-10-02",""]
["Nathan L Vaughn, APRN-FNP-BC",1821674151,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Galaxy Health","In Process","Pending PSV","","","","2023-10-02",""]
["Nathan L Vaughn, APRN-FNP-BC",1821674151,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Liberty Mutual","Panel Closed","Panel Closed","","","","2023-10-09","10/09/2023. We appreciate your interest in joining the Coventry Network.  At this time, our panels are closed, and we are not accepting new applications.  Please check back routinely to stay apprised of our panel status. We will update this site when we are open for new applicants. Gallagher, Hartford, Liberty Mutual, Travelers and Zurich fall under Coventry. Jen Videan"]
["Nathan L Vaughn, APRN-FNP-BC",1821674151,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Ambetter","Thru Other Payor","Pending Other Enrollment","","","","2023-11-17","11/17/2023 Pending Superior enrollment.  DCannon"]
["Nathan L Vaughn, APRN-FNP-BC",1821674151,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Omni PPO","In Process","Pending PSV","","","","2023-10-02",""]
["Nathan L Vaughn, APRN-FNP-BC",1821674151,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Omni PPO","In Process","Pending PSV","","","","2023-10-02",""]
["Nathan L Vaughn, APRN-FNP-BC",1821674151,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","Multiplan","In Process","Pending PSV","","","","2023-10-02",""]
["Nathan L Vaughn, APRN-FNP-BC",1821674151,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","Tricare Prime","Panel Closed","Panel Closed","","","","2023-10-09","Payor has confirmed the panel is closed. MS"]
["Nathan L Vaughn, APRN-FNP-BC",1821674151,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","BCBSTX","Participating","Enrollment Complete","2023-10-24","","","2023-11-06","11/06/2023: Received confirmation provider is enrolled and participating with the following networks, eff. 10/24/2023:\nBAV - Blue Advantage HMO\t,\nHME - Health Select,\nBCA - BlueChoice PPO,\nHMO - Blue Essentials, and\nPMC - Medicare Advantage PPO\n- PA"]
["Nathan L Vaughn, APRN-FNP-BC",1821674151,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","Humana","In Process","Pending PSV","","","","2023-10-02",""]
["Nathan L Vaughn, APRN-FNP-BC",1821674151,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Amerigroup","In Process","Pending PSV","","","","2023-10-02",""]
["Nathan L Vaughn, APRN-FNP-BC",1821674151,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Amerigroup","In Process","Pending PSV","","","","2023-10-02",""]
["Nathan L Vaughn, APRN-FNP-BC",1821674151,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","First Health Coventry","In Process","Pending PSV","","","","2023-10-02",""]
["Nathan L Vaughn, APRN-FNP-BC",1821674151,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","Wellmed","Thru Other Payor","Pending Other Enrollment","","","","2023-11-17","11/17/2023 Pending UHC enrollment.  DCannon"]
["Jeffery Dickson, NP",1851865067,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Alliance WC","Participating","Enrollment Complete","2021-10-08","","","2021-12-02","12/2/21 Received email from michelle.killough@pswca.org, provider eff 10/08/2021 with Tax ID 75-2656723. Cbankston"]
["Jeffery Dickson, NP",1851865067,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","TriCare Standard","Participating","Enrollment Complete","2023-10-26","","","2023-11-05","Provider is linked to Andrews Hwy location eff 10/26/23. MS"]
["Jeffery Dickson, NP",1851865067,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","TriCare Standard","Participating","Enrollment Complete","2023-10-26","","","2023-11-05","Provider is linked to Andrews Hwy location eff 10/26/23. MS"]
["Jeffery Dickson, NP",1851865067,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","TriCare Standard","Participating","Enrollment Complete","2023-10-26","","","2023-11-05","Provider is linked to Andrews Hwy location eff 10/26/23. MS"]
["Jeffery Dickson, NP",1851865067,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Wellmed","Participating","Enrollment Complete","2023-05-01","","","2023-09-07","9/7/2023 Per email from UHC May delegated roster has been completed.  Provider is PAR and linked to group TIN/locations effective 5/1/2023.  DCannon"]
["Jeffery Dickson, NP",1851865067,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Aetna","Participating","Enrollment Complete","2021-09-01","","","2023-09-05","9/5/2023 Per email from Priscilla Albertine at MQA she received a roster confirming that provider is PAR and linked to group TIN/location effective 9/1/2021.  DCannon"]
["Jeffery Dickson, NP",1851865067,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Aetna","Participating","Enrollment Complete","2021-09-01","","","2023-09-05","9/5/2023 Per email from Priscilla Albertine at MQA she received a roster confirming that provider is PAR and linked to group TIN/location effective 9/1/2021.  DCannon"]
["Jeffery Dickson, NP",1851865067,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Alliance WC","Participating","Enrollment Complete","2021-10-08","","","2023-11-13","Per Michelle Killough @ Alliance WC provider is effective 10/08/2021.  Providers are paid via tax ID number, so they are paid no matter what location they provide services from.  The Alliance will only list two locations per provider on our website.  Jen Videan"]
["Jeffery Dickson, NP",1851865067,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","Texas Mutual","In Process","Payor Follow Up","","","","2023-11-22","Emailed wwtxcontracts@texasmutual.com to check status of 6301 Andrews Hwy and request of effective date for 4705 Briarwood Ave. Midland, TX 79707 and 6950 Eastridge Rd. Odessa, TX 79765 already listed on his profile. Jen Videan"]
["Jeffery Dickson, NP",1851865067,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","USA PPO","Participating","Enrollment Complete","2021-08-13","","","2023-11-20","11/20/2023  In following up with USAMCO (800-872-3860) I was told that you can confirm participating via the USA MCO website  https://providersearch.usamco.com/hwprovsearch.  Provider is PAR and linked to location/TIN effective 8/13/2021.  DCannon"]
["Jeffery Dickson, NP",1851865067,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Caprock (CapStar)","Participating","Enrollment Complete","2023-05-01","","","2023-09-01","9/1/2023 Per email received from Caprock provider has been added to new location 4705 Briarwood Ave. and  6950 Eastridge Rd. effective 5/1/2023.  DCannon"]
["Jeffery Dickson, NP",1851865067,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Wellmed","Participating","Enrollment Complete","2022-01-01","","","2023-03-23","3/23/2023 Rcvd roster from UHC w/ all Wellmed participating providers.  Provider is PAR effective 1/1/2022.  DCannon"]
["Jeffery Dickson, NP",1851865067,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Multiplan","Participating","Enrollment Complete","2023-05-01","","","2023-07-25","7/25/2023 Rcvd email from Jessica Bess at Multiplan with a full roster and provider is PAR w/ group effective 5/1/2023.  DCannon"]
["Jeffery Dickson, NP",1851865067,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Humana","Participating","Enrollment Complete","2021-09-01","","","2023-09-15","9/15/2023 Per email received from Humana provider is PAR and linked to group TIN/locations effective 9/1/2021.  DCannon"]
["Jeffery Dickson, NP",1851865067,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","Multiplan","Participating","Enrollment Complete","2023-10-01","","","2023-09-20","9/20/2023 Per email received from Jessica Bess at Multiplan August roster has been completed.  Provider is PAR and linked to group TIN/location effective 10/2/2023.  DCannon"]
["Jeffery Dickson, NP",1851865067,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Coventry Workers Comp","Panel Closed","Panel Closed","","","","2023-09-05","09/05/2023. We appreciate your interest in joining the Coventry Network.  At this time, our panels are closed, and we are not accepting new applications.  Please check back routinely to stay apprised of our panel status. We will update this site when we are open for new applicants. Gallagher, Hartford, Liberty Mutual, Travelers and Zurich fall under Coventry. Jen Videan"]
["Jeffery Dickson, NP",1851865067,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","BCBSTX","Participating","Enrollment Complete","2020-07-16","","","2023-10-02","10/2/2023 Per BCBS TX roster received from Priscilla Albertine at MQA provider is PAR and linked to group effective 7/16/2020.  DCannon"]
["Jeffery Dickson, NP",1851865067,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","USA PPO","Participating","Enrollment Complete","2021-08-13","","","2021-12-03","12/3/2021  In following up with USAMCO (800-872-3860) I was told that you can confirm participating via the USA MCO website  https://providersearch.usamco.com/hwprovsearch.  Provider is PAR and linked to location/TIN effective 8/13/2021.  DCannon"]
["Jeffery Dickson, NP",1851865067,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","United Health Care","Participating","Enrollment Complete","2021-08-13","","","2023-09-07","9/7/2023 Per email from UHC May delegated roster has been completed.  Provider is PAR and linked to group TIN/locations effective 8/13/2021.  DCannon"]
["Jeffery Dickson, NP",1851865067,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Boon Chapman","Participating","Enrollment Complete","2021-08-13","","","2021-09-16","9/15/2021 Received welcome letter from Multiplan listing provider has PAR under group TIN/location effective 8/13/2021.  DCannon"]
["Jeffery Dickson, NP",1851865067,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","Wellmed","Participating","Enrollment Complete","2023-10-02","007017728","","2023-11-15","11/15/2023 Per email received from UHC provider is PAR and linked to group TIN effective 10/2/2023.  MPIN# 007017728.  DCannon"]
["Jeffery Dickson, NP",1851865067,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","IMS","Participating","Enrollment Complete","2023-10-02","","","2023-09-05","9/5/2023 Per email received from IMS/OMNI May delegated roster has been processed and provider is PAR and linked to group effective 10/2/2023.  DCannon"]
["Shawn Collins Harris, NP",1679236053,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Texas Municipal League","Participating","Enrollment Complete","","","","2023-11-20","participating. please see the Alliance WC payor line for updates. MS"]
["Shawn Collins Harris, NP",1679236053,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Broadspire Services Inc.","Participating","Enrollment Complete","2023-05-23","","","2023-08-29","Per Benjamin Richbourg at Corvel provider has been loaded into their system.  Per Benjamin they do not have effective dates for individual providers. Only effective date is the one on the contract which is 05/23/2023. Jen Videan"]
["Shawn Collins Harris, NP",1679236053,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","TriCare Standard","Participating","Enrollment Complete","2023-09-20","","","2023-09-25","Confirmed enrollment at the Briarwood location effective 9/20/2023. MS"]
["Shawn Collins Harris, NP",1679236053,"47-3465832","TX","","TriCare Standard","Participating","Enrollment Complete","2023-09-20","","","2023-11-05","Revalidation completed. MS"]
["Shawn Collins Harris, NP",1679236053,"47-3465832","TX","","TriCare Standard","Participating","Enrollment Complete","2023-09-20","","","2023-11-05","Provider linked to Andrews Hwy location eff 10/26/23. MS"]
["Shawn Collins Harris, NP",1679236053,"47-3465832","TX","","TriCare Standard","Participating","Enrollment Complete","2023-09-20","","","2023-11-05","Revalidation completed. MS"]
["Shawn Collins Harris, NP",1679236053,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","TriCare Standard","Participating","Enrollment Complete","2023-09-20","","","2023-10-26","Eastridge location confirmed eff 10/9/23. MS"]
["Shawn Collins Harris, NP",1679236053,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","TriCare Standard","Participating","Enrollment Complete","2023-09-20","","","2023-11-05","Provider linked to Andrews Hwy location eff 10/26/23. MS"]
["Shawn Collins Harris, NP",1679236053,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","Omni PPO","Participating","Enrollment Complete","2023-10-02","","","2023-09-05","9/5/2023 Per email received from IMS/OMNI May delegated roster has been processed and provider is PAR and linked to group effective 10/2/2023.  DCannon"]
["Shawn Collins Harris, NP",1679236053,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","IMS","Participating","Enrollment Complete","2023-05-01","","","2023-07-20","7/20/2023 Per email received from IMS/OMNI May delegated roster has been processed and provider is PAR and linked to group effective 5/1/2023.  DCannon"]
["Shawn Collins Harris, NP",1679236053,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Wellmed","Participating","Enrollment Complete","2022-04-16","","","2023-09-07","9/7/2023 Per email from UHC May delegated roster has been completed.  Provider is PAR and linked to group TIN/locations effective 4/16/2022.  DCannon"]
["Shawn Collins Harris, NP",1679236053,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","USA PPO","In Process","Payor Follow Up","","","","2023-11-27","11/27/2023 Per USA PPO provider portal provider is still not loaded under new locations.  Will allow more time, check back in 2 weeks.  \nDCannon"]
["Shawn Collins Harris, NP",1679236053,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Scott&White (First Care)","Participating","Enrollment Complete","2023-05-01","","","2023-09-04","9/4/2023 Received email from Scott & White HPDELEGATION@BSWHealth.org that provider load from May has been completed and provider is PAR effective 5/1/2023.  DCannon"]
["Shawn Collins Harris, NP",1679236053,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Cigna","Participating","Enrollment Complete","","","","2023-10-27","Group has an ancillary contract in place, therefore, all services for midlevels will be billed under the group. no credentialing is required. MS"]
["Shawn Collins Harris, NP",1679236053,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","TriCare Standard","Participating","Enrollment Complete","2022-08-10","","","2022-09-08","9/8/2022 Per Tricare portal provider is PAR and linked to group TIN/location effective 8/10/2022.  DCannon"]
["Shawn Collins Harris, NP",1679236053,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","First Health Coventry","Participating","Enrollment Complete","2022-10-01","3627806","","2023-01-19","01.19.2023 S/W Kurtney of First Health @ 800-226-5116. Per rep, provider is showing participating with an Effective date 10/01/2022 and link under the Group and TIN. Provider ID 3627806, Payer ID 73159 and Recredentialing date 10/01/2025. Service location is on file. Call ref#:517681. -Danico Gabriel Melendres"]
["Shawn Collins Harris, NP",1679236053,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Humana","Participating","Enrollment Complete","2023-05-01","","","2023-09-27","9/27/2023 Per email response from Marcus Wester at Humana May delegated roster has bee completed.  Provider is PAR and linked to group/location effective 5/1/2023.  DCannon"]
["Shawn Collins Harris, NP",1679236053,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","United Health Care","Participating","Enrollment Complete","2022-04-16","007967451","","2023-11-17","11/17/2023 Per email rcvd from UHC provider is PAR and linked to group TIN and location effective 4/16/2022.  MPIN # 007967451.  DCannon"]
["Shawn Collins Harris, NP",1679236053,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Liberty Mutual","Panel Closed","Panel Closed","","","","2023-09-04","9/4/2023 Coventry panel closed at this time.  DCannon"]
["Shawn Collins Harris, NP",1679236053,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Gallagher","Panel Closed","Panel Closed","","","","2023-09-04","9/4/2023 Coventry panel closed at this time."]
["Shawn Collins Harris, NP",1679236053,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","HealthSmart PPO","Participating","Enrollment Complete","2022-02-04","","","2022-03-25","3/25/2022 Per Healthsmart website provider is PAR and loaded under TIN/location effective 2/4/2022.  DCannon"]
["Shawn Collins Harris, NP",1679236053,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","IMS","Participating","Enrollment Complete","2022-02-04","","","2022-03-09","3/9/2022 Rcvd email from German Aviles confirming that February delegated roster has been completed and providers are loaded in IMS/Omni effective 2/4/2022.  DCannon"]
["Shawn Collins Harris, NP",1679236053,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Corvel Healthcare Corp.","Participating","Enrollment Complete","2022-02-04","1334000","","2022-08-23","08/23/2022 - Per follow-up note - Per email response received from Corvel Healthcare Corp on 08/17/2022. Provider NPI# is on file active and par under the TIN and Group effective 02/04/2022. Physical location is on file. Provider ID 1334000.  DCannon"]
["Shawn Collins Harris, NP",1679236053,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Medicare","Participating","Enrollment Complete","2022-03-12","2E9362","423838","2022-06-22","6/22/2022 Rcvd Medicare approval letter.  PTAN# 2E9362 - effective 3/12/2022.  DCannon"]
["Shawn Collins Harris, NP",1679236053,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Alliance WC","Participating","Enrollment Complete","2022-04-15","","","2022-04-22","4/22/2022 Rcvd approval letter from payor effective 4/15/2022.  DCannon"]
["Shawn Collins Harris, NP",1679236053,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Corvel Healthcare Corp.","Participating","Enrollment Complete","","","","2023-11-27","Per Karina Garcia at Corvel, Shawn Harris, NP NPI: 1679236053- credentialing approved since 08/01/2022, renewal 08/01/2025. For billing purposes we always reflect back to the contract date which for this group is 7/20/2020. Jen Videan"]
["Shawn Collins Harris, NP",1679236053,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Galaxy Health","Participating","Enrollment Complete","2022-02-04","","","2022-03-10","3/10/2022 Rcvd email from K. Avalos @ Galaxy that provider is PAR and linked to group TIN/location effective 2/4/2022.  DCannon"]
["Shawn Collins Harris, NP",1679236053,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Caprock (CapStar)","Participating","Enrollment Complete","2023-05-01","","","2023-09-05","9/5/2023 Rcvd email  confirmation from Caprock that provider is PAR and linked to group TIN/locations effective 5/1/2023.  DCannon"]
["Shawn Collins Harris, NP",1679236053,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Texas Mutual","In Process","Payor Follow Up","","","","2023-11-22","Emailed wwtxcontracts@texasmutual.com to check status of 6301 Andrews Hwy. Jen Videan"]
["Shawn Collins Harris, NP",1679236053,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Galaxy Health","Participating","Enrollment Complete","2023-05-01","","","2023-07-20","7/20/2023 Per email received from Galaxy May delegated roster has been processed and provider is PAR and linked to group effective 5/1/2023.  DCannon"]
["Shawn Collins Harris, NP",1679236053,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","HealthSmart PPO","In Process","Payor Follow Up","","","","2023-11-14","11/14/2023 Per Healthsmart provider portal provider is still not loaded under group TIN.  Per phone conversation with Lee Kinard at Healthsmart provider portal should be updated  by 11/27/2023.  Will allow more time, check back in 2 weeks.   DCannon"]
["Shawn Collins Harris, NP",1679236053,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Sedgwick","Participating","Enrollment Complete","2023-05-17","","","2023-11-27","Per Sedgwick, the credentialing for Harris was completed, & the effective date is 5/17/2023.\nJen Videan"]
["Shawn Collins Harris, NP",1679236053,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Amerigroup","Participating","Enrollment Complete","2023-05-01","","","2023-10-18","10/18/2023 Per email received from Jessica Bess at  Multiplan provider is PAR with Amerigroup and linked to group TIN/locations thru Multiplan enrollment effective 5/1/2023.  DCannon"]
["Ramon Lujan, NP",1205572716,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Cigna","Participating","Enrollment Complete","2023-05-01","","","2023-07-18","7/18/2023 Rcvd email from Cigna that provider is PAR and linked to new practice locations effective 5/1/2023.  PID # 6410739 DCannon"]
["Ramon Lujan, NP",1205572716,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Cigna","Participating","Enrollment Complete","2023-05-01","","","2023-07-18","7/18/2023 Rcvd email from Cigna that provider is PAR and linked to new practice locations effective 5/1/2023.  PID # 6410739 DCannon"]
["Ramon Lujan, NP",1205572716,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Wellmed","Participating","Enrollment Complete","2022-09-12","","","2023-09-07","9/7/2023 Per email from UHC May delegated roster has been completed.  Provider is PAR and linked to group TIN/locations effective 9/12/2022.  DCannon"]
["Ramon Lujan, NP",1205572716,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","First Health Coventry","Participating","Enrollment Complete","2022-11-01","3637702","","2023-09-05","9/5/2023 Per First Health web portal provider is PAR and linked to group TIN/location effective 11/1/2022.  PID #3637702.  DCannon"]
["Ramon Lujan, NP",1205572716,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Humana","Participating","Enrollment Complete","2022-09-12","","","2022-11-15","11/15/2022 Per email rcvd from Vernita Young at Humana delegated roster provider load for September is complete.  Provider is PAR and linked to group TIN/locations effective 9/12/2022.  DCannon"]
["Ramon Lujan, NP",1205572716,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Zurich","Panel Closed","Panel Closed","","","","2023-09-04","9/4/2023 Coventry panel is closed at this time.  DCannon"]
["Ramon Lujan, NP",1205572716,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Corvel Healthcare Corp.","Participating","Enrollment Complete","","","","2023-11-27","Per Karina Garcia at Corvel, Ramon Lujan, NP NPI: 1205572716- credentialing approved since 01/18/2023, renewal 01/18/2026. For billing purposes we always reflect back to the contract date which for this group is 7/20/2020. Jen Videan"]
["Ramon Lujan, NP",1205572716,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Scott&White (First Care)","Participating","Enrollment Complete","2023-05-01","","","2023-09-04","9/4/2023 Received email from Scott & White HPDELEGATION@BSWHealth.org that provider load from May has been completed and provider is PAR effective 5/1/2023.  DCannon"]
["Ramon Lujan, NP",1205572716,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","Sedgwick","In Process","Application Resubmitted","","","","2023-11-21","Emailed roster to cynthia.clancy@sedgwick.com to add 6301 Andrews Hwy to provider's profile. Jen Videan"]
["Ramon Lujan, NP",1205572716,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","Caprock (CapStar)","Participating","Enrollment Complete","2023-10-02","","","2023-09-12","9/12/2023 Per email received from Caprock provider has been added to new location 6301 Andrews Hwy effective 10/2/2023.  DCannon"]
["Ramon Lujan, NP",1205572716,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Scott&White (First Care)","Participating","Enrollment Complete","2022-10-15","","","2022-10-10","10/10/2022 Per roster received from Scott & White provider is PAR and linked to TIN effective 10/15/2022.  DCannon"]
["Ramon Lujan, NP",1205572716,"47-3465832","TX","","TriCare Standard","Participating","Enrollment Complete","2023-09-20","","","2023-10-26","Eastridge location confirmed eff 10/9/2023 MS"]
["Ramon Lujan, NP",1205572716,"47-3465832","TX","","TriCare Standard","Participating","Enrollment Complete","2023-09-20","","","2023-11-05","Provider linked to Andrews Hwy location eff 10/26/23. MS"]
["Ramon Lujan, NP",1205572716,"47-3465832","TX","","TriCare Standard","Participating","Enrollment Complete","2023-09-20","","","2023-10-26","Eastridge location confirmed eff 10/9/2023 MS"]
["Ramon Lujan, NP",1205572716,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","TriCare Standard","Participating","Enrollment Complete","2023-09-20","","","2023-09-25","Confirmed the provider is loaded at the Briarwood location effective 9/20/2023. MS"]
["Ramon Lujan, NP",1205572716,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","TriCare Standard","Participating","Enrollment Complete","2023-09-20","","","2023-11-05","Provider linked to Andrews Hwy location eff 10/26/23. MS"]
["Ramon Lujan, NP",1205572716,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","TriCare Standard","Participating","Enrollment Complete","2023-09-20","","","2023-11-05","Provider linked to Andrews Hwy location eff 10/26/23. MS"]
["Ramon Lujan, NP",1205572716,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","Medicare","Participating","Enrollment Complete","","","","2023-09-08","Provider is enrolled with all locations under WesTex. MS"]
["Ramon Lujan, NP",1205572716,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Texas Municipal League","Participating","Enrollment Complete","2023-01-06","","","2023-01-17","1/17/2023 Rcvd PSWCA/Alliance approval letter.  Provider is PAR and linked to group TIN effective 1/6/2023.  DCannon"]
["Ramon Lujan, NP",1205572716,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","Texas Mutual","In Process","Payor Follow Up","","","","2023-11-27","Per Dee Dee Johnson at Texas Mutual, The site visit for this location 96301 Andrews Hwy)is in the que. I will let you know when there are any updates. Jen Videan"]
["Ramon Lujan, NP",1205572716,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Texas Mutual","In Process","Payor Follow Up","","","","2023-11-27","Per Dee Dee Johnson at Texas Mutual, The site visit for this location 96301 Andrews Hwy)is in the que. I will let you know when there are any updates. Jen Videan"]
["Ramon Lujan, NP",1205572716,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Gallagher","Panel Closed","Panel Closed","","","","2023-09-04","9/4/2023 Coventry panel closed at this time.  DCannon"]
["Ramon Lujan, NP",1205572716,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","Gallagher","Panel Closed","Panel Closed","","","","2023-09-04","9/4/2023 Coventry panel closed at this time.  DCannon"]
["Ramon Lujan, NP",1205572716,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Alliance WC","Participating","Enrollment Complete","2023-01-06","","","2023-11-13","Per Michelle Killough @ Alliance WC provider is effective 01/06/2023.  Providers are paid via tax ID number, so they are paid no matter what location they provide services from.  The Alliance will only list two locations per provider on our website.  Jen Videan"]
["Ramon Lujan, NP",1205572716,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Texas Municipal League","Participating","Enrollment Complete","","","","2023-11-20","participating. please see Alliance WC for notes. MS"]
["Ramon Lujan, NP",1205572716,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Triwest VA","In House Enrollment","In House Enrollment","","","","2023-09-04",""]
["Ramon Lujan, NP",1205572716,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Multiplan","Participating","Enrollment Complete","2022-09-12","","","2023-07-25","7/25/2023 Rcvd email from Jessica Bess at Multiplan with a full roster and provider is PAR w/ group and location effective 9/12/2022.  DCannon"]
["Ramon Lujan, NP",1205572716,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Aetna","Participating","Enrollment Complete","2022-09-12","6785892","","2022-10-18","10/18/2022 Per email from Priscilla Albertine at MQA provider is PAR and linked to group TIN effective 9/12/2022.  PID # 6785892.  DCannon"]
["Ramon Lujan, NP",1205572716,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Broadspire Services Inc.","Participating","Enrollment Complete","2023-05-23","","","2023-09-15","Rcvd confirmation from providerrelations@primehealthservices.com provider has been loaded to roster, with effective date 05/23/2023. Jen Videan"]
["Ramon Lujan, NP",1205572716,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","HealthSmart PPO","In Process","Payor Follow Up","","","","2023-11-14","11/14/2023 Per Healthsmart provider portal provider is still not loaded under group TIN.  Per phone conversation with Lee Kinard at Healthsmart provider portal should be updated  by 11/27/2023.  Will allow more time, check back in 2 weeks.   DCannon"]
["Ramon Lujan, NP",1205572716,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Rail Road Medicare","Participating","Enrollment Complete","2022-10-01","","","2022-10-26","10/26/2022 Rcvd Rail Road Medicare approval letter.  PTAN # Q00353706 - effective 10/1/2022.  DCannon"]
["Ramon Lujan, NP",1205572716,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","Rail Road Medicare","Participating","Enrollment Complete","2022-10-01","","","2022-10-26","10/26/2022 Rcvd Rail Road Medicare approval letter.  PTAN # Q00353706 - effective 10/1/2022.  DCannon"]
["Ramon Lujan, NP",1205572716,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Liberty Mutual","Panel Closed","Panel Closed","","","","2023-09-04","9/4/2023 Coventry panel closed at this time.  DCannon"]
["Sacha A Stanley, APRN-FNP-BC",1780399857,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","Corvel Healthcare Corp.","In Process","Payor Follow Up","","","","2023-11-27","Emailed Karina Garcia at Corvel for status. Jen Videan"]
["Sacha A Stanley, APRN-FNP-BC",1780399857,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","IMS","Participating","Enrollment Complete","2023-09-07","","","2023-10-09","10/9/2023 Per email received from G. Aviles at IMS/OMNI September delegation roster has been completed.  Provider is PAR and linked to group/location effective 9/7/2023.  DCannon"]
["Sacha A Stanley, APRN-FNP-BC",1780399857,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","Medicare","In Process","Payor Follow Up","","","","2023-11-16","Application is still in process. T102020230003765. Signatures were submitted on 10/23/23. MS"]
["Sacha A Stanley, APRN-FNP-BC",1780399857,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Medicare","In Process","Payor Follow Up","","","","2023-11-16","Application is still in process. T102020230003765. Signatures were submitted on 10/23/23. MS"]
["Sacha A Stanley, APRN-FNP-BC",1780399857,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Gallagher","Panel Closed","Panel Closed","","","","2023-09-22","09/22/2023. We appreciate your interest in joining the Coventry Network.  At this time, our panels are closed, and we are not accepting new applications.  Please check back routinely to stay apprised of our panel status. We will update this site when we are open for new applicants. Gallagher, Hartford, Liberty Mutual, Travelers and Zurich fall under Coventry. Jen Videan"]
["Sacha A Stanley, APRN-FNP-BC",1780399857,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","HealthSmart PPO","In Process","Payor Follow Up","","","","2023-11-14","11/14/2023 Per Healthsmart provider portal provider is still not loaded under group TIN.  Per phone conversation with Lee Kinard at Healthsmart provider portal should be updated  by 11/27/2023.  Will allow more time, check back in 2 weeks.   DCannon"]
["Sacha A Stanley, APRN-FNP-BC",1780399857,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Texas Mutual","In Process","Payor Follow Up","","","","2023-11-22","Emailed wwtxcontracts@texasmutual.com to check status of 6301 Andrews Hwy. Jen Videan"]
["Sacha A Stanley, APRN-FNP-BC",1780399857,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Sedgwick","In Process","Payor Follow Up","","","","2023-11-27","Per Sedgwick, your providers’ credentialing has been received & is currently under review at this time. 11/27/2023 Jen Videan \n\nEmailed spneast@sedgwickcms.com for status. Jen Videan"]
["Sacha A Stanley, APRN-FNP-BC",1780399857,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Scott&White (First Care)","Participating","Enrollment Complete","2023-10-15","","","2023-10-12","10/12/2023 Per email received from Scott & White provider is PAR and linked to group TIN/locations effective 10/15/2023.  DCannon"]
["Sacha A Stanley, APRN-FNP-BC",1780399857,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Scott&White (First Care)","Participating","Enrollment Complete","2023-10-15","","","2023-10-12","10/12/2023 Per email received from Scott & White provider is PAR and linked to group TIN/locations effective 10/15/2023.  DCannon"]
["Sacha A Stanley, APRN-FNP-BC",1780399857,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Omni PPO","Participating","Enrollment Complete","2023-09-07","","","2023-10-09","10/9/2023 Per email received from G. Aviles at IMS/OMNI September delegation roster has been completed.  Provider is PAR and linked to group/location effective 9/7/2023.  DCannon"]
["Sacha A Stanley, APRN-FNP-BC",1780399857,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Tricare Prime","Panel Closed","Panel Closed","","","","2023-09-07","9/7/2023 Panel is closed for enrollment.  DCannon"]
["Sacha A Stanley, APRN-FNP-BC",1780399857,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Tricare Prime","Panel Closed","Panel Closed","","","","2023-09-07","9/7/2023 Panel is closed for enrollment.  DCannon"]
["Sacha A Stanley, APRN-FNP-BC",1780399857,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Caprock (CapStar)","Participating","Enrollment Complete","2023-09-07","","","2023-09-27","9/27/2023 Rcvd email confirmation from Caprock that the September roster has been completed.  Provider is PAR and linked to group/location effective 9/7/2023.  DCannon"]
["Sacha A Stanley, APRN-FNP-BC",1780399857,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Liberty Mutual","Panel Closed","Panel Closed","","","",45191,"09/22/2023. We appreciate your interest in joining the Coventry Network.  At this time, our panels are closed, and we are not accepting new applications.  Please check back routinely to stay apprised of our panel status. We will update this site when we are open for new applicants. Gallagher, Hartford, Liberty Mutual, Travelers and Zurich fall under Coventry. Jen Videan"]
["Sacha A Stanley, APRN-FNP-BC",1780399857,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Broadspire Services Inc.","Participating","Enrollment Complete","2023-05-23","","","2023-11-15","Sacha Stanley, NP added to contract with WesTex with an effective date of 5/23/23. \nJen Videan"]
["Sacha A Stanley, APRN-FNP-BC",1780399857,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Broadspire Services Inc.","Participating","Enrollment Complete","2023-05-23","","","2023-11-15","Sacha Stanley, NP added to contract with WesTex with an effective date of 5/23/23. \nJen Videan"]
["Sacha A Stanley, APRN-FNP-BC",1780399857,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","USA PPO","In Process","Payor Follow Up","","","","2023-11-27","11/27/2023 Per USA PPO provider portal provider is still not loaded under new locations.  Will allow more time, check back in 2 weeks.  \nDCannon"]
["Sacha A Stanley, APRN-FNP-BC",1780399857,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","USA PPO","In Process","Payor Follow Up","","","","2023-11-27","11/27/2023 Per USA PPO provider portal provider is still not loaded under new locations.  Will allow more time, check back in 2 weeks.  \nDCannon"]
["Sacha A Stanley, APRN-FNP-BC",1780399857,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Multiplan","Participating","Enrollment Complete","2023-06-01","","","2023-10-12","10/12/2023 Per email received from Jessica Bess at  Multiplan provider is PAR and linked to group TIN/locations effective 6/1/2023.  DCannon"]
["Sacha A Stanley, APRN-FNP-BC",1780399857,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Cigna","Participating","Enrollment Complete","","","","2023-10-27","Group has an ancillary contract in place, therefore, all services for midlevels will be billed under the group. no credentialing is required. MS"]
["Sacha A Stanley, APRN-FNP-BC",1780399857,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Amerigroup","In Process","Payor Follow Up","","","","2023-10-27","10/27/2023 Sent follow-up email to Amerigroup to check status of September delegated roster submission.  DCannon"]
["Sacha A Stanley, APRN-FNP-BC",1780399857,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Travelers WC","Panel Closed","Panel Closed","","","","2023-09-22","09/22/2023. We appreciate your interest in joining the Coventry Network.  At this time, our panels are closed, and we are not accepting new applications.  Please check back routinely to stay apprised of our panel status. We will update this site when we are open for new applicants. Gallagher, Hartford, Liberty Mutual, Travelers and Zurich fall under Coventry. Jen Videan"]
["Sacha A Stanley, APRN-FNP-BC",1780399857,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","Hartford","Panel Closed","Panel Closed","","","","2023-09-22","09/22/2023. We appreciate your interest in joining the Coventry Network.  At this time, our panels are closed, and we are not accepting new applications.  Please check back routinely to stay apprised of our panel status. We will update this site when we are open for new applicants. Gallagher, Hartford, Liberty Mutual, Travelers and Zurich fall under Coventry. Jen Videan"]
["Sacha A Stanley, APRN-FNP-BC",1780399857,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Hartford","Panel Closed","Panel Closed","","","","2023-09-22","09/22/2023. We appreciate your interest in joining the Coventry Network.  At this time, our panels are closed, and we are not accepting new applications.  Please check back routinely to stay apprised of our panel status. We will update this site when we are open for new applicants. Gallagher, Hartford, Liberty Mutual, Travelers and Zurich fall under Coventry. Jen Videan"]
["Sacha A Stanley, APRN-FNP-BC",1780399857,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Boon Chapman","Participating","Enrollment Complete","2023-06-01","","","2023-10-12","10/12/2023 Per email received from Jessica Bess at  Multiplan provider is PAR and linked to group TIN/locations effective 6/1/2023.  DCannon"]
["Sacha A Stanley, APRN-FNP-BC",1780399857,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","First Health Coventry","Participating","Enrollment Complete","2023-09-07","3694275","","2023-11-20","11/20/2023 S/W Sam of First Health @ 800-226-5116, per rep provider is showing participating and link under the Group and TIN with an Effective date 9/7/2023. Provider ID 3694275. Physical locations are on file. Call ref#:773026. - DCannon"]
["Sacha A Stanley, APRN-FNP-BC",1780399857,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","First Health Coventry","Participating","Enrollment Complete","2023-09-07","3694275","","2023-11-20","11/20/2023 S/W Sam of First Health @ 800-226-5116, per rep provider is showing participating and link under the Group and TIN with an Effective date 9/7/2023. Provider ID 3694275. Physical locations are on file. Call ref#:773026. - DCannon"]
["Sacha A Stanley, APRN-FNP-BC",1780399857,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Triwest VA","In House Enrollment","In House Enrollment","","","","2023-09-07",""]
["Sacha A Stanley, APRN-FNP-BC",1780399857,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","TriCare Standard","Participating","Enrollment Complete","2023-09-20","","","2023-10-26","Eastridge location has been confirmed eff 10/9/23. MS"]
["Sacha A Stanley, APRN-FNP-BC",1780399857,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","TriCare Standard","Participating","Enrollment Complete","2023-09-20","","","2023-09-25","Confirmed provider is linked to Briarwood location effective 9/20/2023. MS"]
["Sacha A Stanley, APRN-FNP-BC",1780399857,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","TriCare Standard","Participating","Enrollment Complete","2023-09-20","","","2023-09-25","Confirmed provider is linked to Briarwood location effective 9/20/2023. MS"]
["Sacha A Stanley, APRN-FNP-BC",1780399857,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","TriCare Standard","Participating","Enrollment Complete","2023-09-20","","","2023-11-05","Provider linked to Andrews Hwy location eff 10/26/23. MS"]
["Sacha A Stanley, APRN-FNP-BC",1780399857,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","TriCare Standard","Participating","Enrollment Complete","2023-09-20","","","2023-11-05","Provider linked to Andrews Hwy location eff 10/26/23. MS"]
["Sacha A Stanley, APRN-FNP-BC",1780399857,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Aetna","Participating","Enrollment Complete","2023-09-07","8439204","","2023-10-24","10.24.2023 S/W Julie of Aetna @ 1-800-353-1232. Per rep, Provider is in network with Aetna and linked to the group and TIN# effective 09/07/2023. No next recredentialing date available. PIN: 8439204. Servicing location is on file. Payer# 60054. Call ref# 6167809743. - Willie Ravas"]
["Sacha A Stanley, APRN-FNP-BC",1780399857,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","Alliance WC","In Process","Application Submitted","","","","2023-11-14","Submitted Provider Data Form and required documents to Michelle Killough. Jen Videan"]
["Sacha A Stanley, APRN-FNP-BC",1780399857,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Humana","In Process","Payor Follow Up","","","","2023-11-17","11/17/2023 Sent follow-up email to Marcus Wester at Humana to check status of September monthly delegated roster submission.  Provider Add - CO16127988, Provider Changes - CO-16128096,  Provider Terms - CO-16128221.  DCannon"]
["Sacha A Stanley, APRN-FNP-BC",1780399857,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Humana","In Process","Payor Follow Up","","","","2023-11-17","11/17/2023 Sent follow-up email to Marcus Wester at Humana to check status of September monthly delegated roster submission.  Provider Add - CO16127988, Provider Changes - CO-16128096,  Provider Terms - CO-16128221.  DCannon"]
["Sacha A Stanley, APRN-FNP-BC",1780399857,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","United Health Care","Participating","Enrollment Complete","2023-06-01","008733826","","2023-09-28","9/28/2023 Rcvd email confirmation from UHC that September delegated roster has been completed.  Provider is PAR and linked to group/location effective 6/1/2023.  DCannon"]
["Sacha A Stanley, APRN-FNP-BC",1780399857,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Coventry Workers Comp","Panel Closed","Panel Closed","","","","2023-09-22","09/22/2023. We appreciate your interest in joining the Coventry Network.  At this time, our panels are closed, and we are not accepting new applications.  Please check back routinely to stay apprised of our panel status. We will update this site when we are open for new applicants. Gallagher, Hartford, Liberty Mutual, Travelers and Zurich fall under Coventry. Jen Videan"]
["Sacha A Stanley, APRN-FNP-BC",1780399857,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Galaxy Health","Participating","Enrollment Complete","2023-09-07","","","2023-10-11","10/11/2023 Per email received from Galaxy September delegated roster has been processed and provider is PAR and linked to group/location effective 9/7/2023.  DCannon"]
["Sacha A Stanley, APRN-FNP-BC",1780399857,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","BCBSTX","Participating","Enrollment Complete","2023-10-19","","","","Received confirmation provider is enrolled and participating with the following networks, eff. 10/19/2023:\nBAV - Blue Advantage HMO\t,\nHME - Health Select,\nBCA - BlueChoice PPO,\nHMO - Blue Essentials, and\nPMC - Medicare Advantage PPO\t\n- PA"]
["Stephanie R Powell, PA-C",1538714076,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","First Health Coventry","Participating","Enrollment Complete","2023-03-31","3671302","","2023-11-20","11/20/2023 S/W James of First Health @ 800-226-5116, per rep provider is showing participating and link under the Group and TIN with an Effective date 3/31/2023. Provider ID 3671302. Physical locations are on file. Call ref#:773110. - DCannon"]
["Stephanie R Powell, PA-C",1538714076,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Texas Municipal League","Participating","Enrollment Complete","","","","2023-11-20","participating, please see Alliance WC for updated notes. MS"]
["Stephanie R Powell, PA-C",1538714076,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","CAQH","Participating","CAQH Reattested","2023-11-28","","","2023-11-28","11/28/2023 Updated mailing address for all locations and uploaded liability"]
["Stephanie R Powell, PA-C",1538714076,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","CAQH","Participating","CAQH Reattested","2023-11-28","","","2023-11-28","11/28/2023 Updated mailing address for all locations and uploaded liability"]
["Stephanie R Powell, PA-C",1538714076,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Liberty Mutual","Panel Closed","Panel Closed","","","","2023-08-24","08/24/2023. We appreciate your interest in joining the Coventry Network.  At this time, our panels are closed, and we are not accepting new applications.  Please check back routinely to stay apprised of our panel status. We will update this site when we are open for new applicants. Gallagher, Hartford, Liberty Mutual, Travelers and Zurich fall under Coventry. Jen Videan"]
["Stephanie R Powell, PA-C",1538714076,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","USA PPO","In Process","Payor Follow Up","","","","2023-11-27","11/27/2023 Per USA PPO provider portal provider is still not loaded under new locations.  Will allow more time, check back in 2 weeks.  \nDCannon"]
["Stephanie R Powell, PA-C",1538714076,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Caprock (CapStar)","Participating","Enrollment Complete","2023-04-01","","","2023-09-27","9/27/2023 Rcvd email confirmation from Caprock that the September roster has been completed.  Provider is PAR and linked to group/location effective 4/1/2023.  DCannon"]
["Stephanie R Powell, PA-C",1538714076,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Alliance WC","Participating","Enrollment Complete","2023-06-09","","","2023-11-13","Per Michelle Killough @ Alliance WC provider is effective 06/09/2023.  Providers are paid via tax ID number, so they are paid no matter what location they provide services from.  The Alliance will only list two locations per provider on our website.  Jen Videan"]
["Stephanie R Powell, PA-C",1538714076,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Amerigroup","Participating","Enrollment Complete","2023-03-31","","","2023-10-18","10/18/2023 Per email received from Jessica Bess at  Multiplan provider is PAR with Amerigroup and linked to group TIN/locations thru Multiplan enrollment effective 3/31/2023.  DCannon"]
["Stephanie R Powell, PA-C",1538714076,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Tricare Prime","Panel Closed","Panel Closed","","","","2023-05-15","5/15/2023 Per Humana Military web portal Humana Military is currently not accepting requests to join the medical surgical network. We apologize for the inconvenience, but we hope you check back soon to see if we are accepting network providers.  DCannon"]
["Stephanie R Powell, PA-C",1538714076,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","Zurich","Panel Closed","Panel Closed","","","","2023-08-24","08/24/2023. We appreciate your interest in joining the Coventry Network.  At this time, our panels are closed, and we are not accepting new applications.  Please check back routinely to stay apprised of our panel status. We will update this site when we are open for new applicants. Gallagher, Hartford, Liberty Mutual, Travelers and Zurich fall under Coventry. Jen Videan"]
["Stephanie R Powell, PA-C",1538714076,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","USA PPO","In Process","Payor Follow Up","","","","2023-11-27","11/27/2023 Per USA PPO provider portal provider is still not loaded under new locations.  Will allow more time, check back in 2 weeks.  \nDCannon"]
["Stephanie R Powell, PA-C",1538714076,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Cigna","Participating","Enrollment Complete","","","","2023-10-27","Group has an active ancillary contract, so credentialing for midlevels isn't required. MS"]
["Stephanie R Powell, PA-C",1538714076,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","Coventry Workers Comp","Panel Closed","Panel Closed","","","","2023-08-24","08/24/2023. We appreciate your interest in joining the Coventry Network.  At this time, our panels are closed, and we are not accepting new applications.  Please check back routinely to stay apprised of our panel status. We will update this site when we are open for new applicants. Gallagher, Hartford, Liberty Mutual, Travelers and Zurich fall under Coventry. Jen Videan"]
["Stephanie R Powell, PA-C",1538714076,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Wellmed","Participating","Enrollment Complete","2023-06-26","007726107","","2023-11-17","11/17/2023 Per email rcvd from UHC provider is PAR and linked to group TIN and locations effective 6/26/2023.  MPIN # 007726107.  DCannon"]
["Stephanie R Powell, PA-C",1538714076,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","HealthSmart PPO","In Process","Payor Follow Up","","","","2023-11-14","11/14/2023 Per Healthsmart provider portal provider is still not loaded under group TIN.  Per phone conversation with Lee Kinard at Healthsmart provider portal should be updated  by 11/27/2023.  Will allow more time, check back in 2 weeks.   DCannon"]
["Stephanie R Powell, PA-C",1538714076,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Sedgwick","In Process","Application Submitted","","","","2023-11-21","Emailed roster to cynthia.clancy@sedgwick.com to add 6301 Andrews Hwy to provider's profile. Jen Videan"]
["Stephanie R Powell, PA-C",1538714076,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Sedgwick","In Process","Application Submitted","","","","2023-11-21","Emailed roster to cynthia.clancy@sedgwick.com to add 6301 Andrews Hwy to provider's profile. Jen Videan"]
["Stephanie R Powell, PA-C",1538714076,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","TriCare Standard","Participating","Enrollment Complete","2023-09-01","","","2023-09-26","Confirmed provider is loaded at the Briarwood location effective 9/1/23. MS"]
["Stephanie R Powell, PA-C",1538714076,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","TriCare Standard","Participating","Enrollment Complete","2023-09-01","","","2023-11-05","Provider linked to Andrews Hwy location eff 10/26/23. MS"]
["Stephanie R Powell, PA-C",1538714076,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","TriCare Standard","Participating","Enrollment Complete","2023-09-01","","","2023-09-26","Confirmation of Longview location effective 9/1/2023. MS"]
["Stephanie R Powell, PA-C",1538714076,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","HealthSmart PPO","In Process","Payor Follow Up","","","","2023-11-14","11/14/2023 Per Healthsmart provider portal provider is still not loaded under group TIN.  Per phone conversation with Lee Kinard at Healthsmart provider portal should be updated  by 11/27/2023.  Will allow more time, check back in 2 weeks.   DCannon"]
["Stephanie R Powell, PA-C",1538714076,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Scott&White (First Care)","Participating","Enrollment Complete","2023-05-14","","","2023-09-29","9/29/2023 Rcvd confirmation from Scott & White that provider has been loaded at all locations effective 5/14/2023.  DCannon"]
["Stephanie R Powell, PA-C",1538714076,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Rail Road Medicare","Participating","Enrollment Complete","2023-03-17","","","2023-07-27","7/27/2023 Rcvd RR Medicare approval letter.  Provider is PAR and linked to group effective 3/17/2023. PID # Q00521373.  DCannon"]
["Stephanie R Powell, PA-C",1538714076,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","Travelers WC","Panel Closed","Panel Closed","","","","2023-08-24","08/24/2023. We appreciate your interest in joining the Coventry Network.  At this time, our panels are closed, and we are not accepting new applications.  Please check back routinely to stay apprised of our panel status. We will update this site when we are open for new applicants. Gallagher, Hartford, Liberty Mutual, Travelers and Zurich fall under Coventry. Jen Videan"]
["Stephanie R Powell, PA-C",1538714076,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Texas Mutual","In Process","Payor Follow Up","","","","2023-11-22","Emailed wwtxcontracts@texasmutual.com to check status of 6301 Andrews Hwy. Jen Videan"]
["Stephanie R Powell, PA-C",1538714076,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Texas Mutual","In Process","Payor Follow Up","","","","2023-11-22","Emailed wwtxcontracts@texasmutual.com to check status of 6301 Andrews Hwy. Jen Videan"]
["Stephanie R Powell, PA-C",1538714076,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","United Health Care","Participating","Enrollment Complete","2023-06-26","00726107","","2023-11-17","11/17/2023 Per email rcvd from UHC provider is PAR and linked to group TIN and locations effective 6/26/2023.  MPIN # 007726107.  DCannon"]
["Stephanie R Powell, PA-C",1538714076,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Scott&White (First Care)","Participating","Enrollment Complete","2023-05-14","","","2023-09-04","9/4/2023 Received email from Scott & White HPDELEGATION@BSWHealth.org that provider load from May has been completed and provider is PAR effective 5/14/2023.  DCannon"]
["Stephanie R Powell, PA-C",1538714076,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","IMS","Participating","Enrollment Complete","2023-10-02","","","2023-09-05","9/5/2023 Per email received from IMS/OMNI May delegated roster has been processed and provider is PAR and linked to group effective 10/2/2023.  DCannon"]
["Stephanie R Powell, PA-C",1538714076,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Multiplan","Participating","Enrollment Complete","2023-03-31","","","2023-09-07","9/7/2023 Per email received from Jessica Bess at Multiplan provider is PAR and linked to group TIN/location effective 3/31/2023.  DCannon"]
["Stephanie R Powell, PA-C",1538714076,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Corvel Healthcare Corp.","In Process","Enrollment Complete","","","","2023-09-06","Rcvd approval letter from Karina Garcia. Effective 08/21/2023 for 210 W Longview, 4705 Briarwood and 6950 Eastridge. Jen Videan"]
["Stephanie R Powell, PA-C",1538714076,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Corvel Healthcare Corp.","In Process","Enrollment Complete","","","","2023-09-06","Rcvd approval letter from Karina Garcia. Effective 08/21/2023 for 210 W Longview, 4705 Briarwood and 6950 Eastridge. Jen Videan"]
["Stephanie R Powell, PA-C",1538714076,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Medicare","Participating","Enrollment Complete","2023-03-17","2V9975","","2023-08-25","Per PECOS provider is PAR and linked to group/locations effective 3/17/2023.  PID # 2V9975.  DCannon"]
["Stephanie R Powell, PA-C",1538714076,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","BCBSTX","Participating","Enrollment Complete","2023-07-28","","","2023-07-31","07/31/2023, PA: Received email from BCBSTX confirming provider is participating with Blue Essentials, Blue Advantage HMO, Blue Choice PPO, Medicare Advantage PPO and Health Select, effective 07/28/2023."]
["Stephanie R Powell, PA-C",1538714076,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","BCBSTX","Participating","Enrollment Complete","2023-07-28","","","2023-07-31","07/31/2023, PA: Received email from BCBSTX confirming provider is participating with Blue Essentials, Blue Advantage HMO, Blue Choice PPO, Medicare Advantage PPO and Health Select, effective 07/28/2023."]
["Stephanie R Powell, PA-C",1538714076,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","Gallagher","Panel Closed","Panel Closed","","","","2023-08-24","08/24/2023. We appreciate your interest in joining the Coventry Network.  At this time, our panels are closed, and we are not accepting new applications.  Please check back routinely to stay apprised of our panel status. We will update this site when we are open for new applicants. Gallagher, Hartford, Liberty Mutual, Travelers and Zurich fall under Coventry. Jen Videan"]
["Stephanie R Powell, PA-C",1538714076,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Broadspire Services Inc.","Participating","Enrollment Complete","2023-05-23","","","2023-08-24","Per Benjamin Richbourg, roster has been successfully loaded. They do not have effective dates for individual providers. The only effective date is the one on the contract. For this contract effective date is 05/23/2023. Jen Videan"]
["Stacey Jo Guse, NP",1184108664,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Liberty Mutual","Panel Closed","Panel Closed","","","","2023-05-18","Pending Coventry enrollment. MS"]
["Stacey Jo Guse, NP",1184108664,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Rail Road Medicare","Participating","Enrollment Complete","2023-03-03","Q00521328","DX4335","2023-07-27","7/27/2023 Rcvd RR Medicare approval letter.  Provider is PAR and linked to group effective 3/3/2023. PID # Q00521328.  DCannon"]
["Stacey Jo Guse, NP",1184108664,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Alliance WC","Participating","Enrollment Complete","","","","2023-11-27","Rcvd Welcome letter. Provider effective 11/17/2023. Jen Videan"]
["Stacey Jo Guse, NP",1184108664,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","Zurich","Panel Closed","Panel Closed","","","","2023-09-01","9/1/2023 Pending Coventry enrollment.  Coventry panel closed.  DCannon"]
["Stacey Jo Guse, NP",1184108664,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","HealthSmart PPO","In Process","Payor Follow Up","","","","2023-11-14","11/14/2023 Per Healthsmart provider portal provider is still not loaded under group TIN.  Per phone conversation with Lee Kinard at Healthsmart provider portal should be updated  by 11/27/2023.  Will allow more time, check back in 2 weeks.   DCannon"]
["Stacey Jo Guse, NP",1184108664,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Wellmed","Thru Other Payor","Pending Other Enrollment","","","","2023-11-17","11/17/2023 Pending UHC enrollment.  DCannon"]
["Stacey Jo Guse, NP",1184108664,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","First Health Coventry","Participating","Enrollment Complete","2023-05-01","","","2023-08-23","08.23.2023 S/W Bridgette of First Health @ 800-226-5116, per rep provider is showing participating and link under the Group and TIN with an Effective date 05/01/2023. Provider ID 3674804. Physical location is on file. Call ref#:734006. - Danico Gabriel Melendres"]
["Stacey Jo Guse, NP",1184108664,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Coventry Workers Comp","Panel Closed","Panel Closed","","","","2023-05-10","Per the representative at Travelers, the Coventry panel is closed, which also closes the panel for Travelers WC. Ref #12308451"]
["Stacey Jo Guse, NP",1184108664,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Humana","Participating","Enrollment Complete","2023-05-01","","","2023-09-15","9/15/2023 Per email received from Humana provider is PAR and linked to group TIN/locations effective 5/1/2023.  DCannon"]
["Stacey Jo Guse, NP",1184108664,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Triwest VA","In House Enrollment","In House Enrollment","","","","2023-04-19",""]
["Stacey Jo Guse, NP",1184108664,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Multiplan","Participating","Enrollment Complete","2023-05-01","","","2023-07-25","7/25/2023 Rcvd email from Jessica Bess at Multiplan with a full roster and provider is PAR w/ group effective 5/1/2023.  DCannon"]
["Stacey Jo Guse, NP",1184108664,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Caprock (CapStar)","Participating","Enrollment Complete","2023-05-01","","","2023-05-22","5/22/2023 Rcvd email from Caprock that May roster has been processed and provider is PAR w/ group effective 5/1/2023.  DCannon"]
["Stacey Jo Guse, NP",1184108664,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","TriCare Standard","Participating","Enrollment Complete","2023-10-26","","","2023-11-05","Provider is linked to Andrews Hwy location eff 10/26/23. MS"]
["Stacey Jo Guse, NP",1184108664,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Broadspire Services Inc.","Participating","Enrollment Complete","2023-05-23","","","2023-08-29","Per Benjamin Richbourg at Corvel provider has been loaded into their system.  Per Benjamin they do not have effective dates for individual providers. Only effective date is the one on the contract which is 05/23/2023. Jen Videan"]
["Stacey Jo Guse, NP",1184108664,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","Triwest VA","In House Enrollment","In House Enrollment","","","","2023-09-01",""]
["Stacey Jo Guse, NP",1184108664,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Amerigroup","Participating","Enrollment Complete","2023-05-01","","","2023-10-18","10/18/2023 Per email received from Jessica Bess at  Multiplan provider is PAR with Amerigroup and linked to group TIN/locations thru Multiplan enrollment effective 5/1/2023.  DCannon"]
["Stacey Jo Guse, NP",1184108664,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","IMS","Participating","Enrollment Complete","2023-05-01","","","2023-07-20","7/20/2023 Per email received from IMS/OMNI May delegated roster has been processed and provider is PAR and linked to group effective 5/1/2023.  DCannon"]
["Stacey Jo Guse, NP",1184108664,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Scott&White (First Care)","Participating","Enrollment Complete","2023-05-01","","","2023-08-17","8/17/2023 Received email from Scott & White HPDELEGATION@BSWHealth.org that provider load from May has been completed and provider is PAR effective 5/1/2023.  DCannon"]
["Stacey Jo Guse, NP",1184108664,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Cigna","Facility Enrollment","Enrollment Complete","","","","2023-05-18","Cigna does not require individual enrollment for facility based contracts. Provider will be billing claims under the facility, not individually. MS"]
["Stacey Jo Guse, NP",1184108664,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","BCBSTX","Participating","Enrollment Complete","2023-08-01","","","2023-07-31","07/31/2023, PA: Received email from BCBSTX confirming provider is participating with Blue Essentials, Blue Advantage HMO, Blue Choice PPO,  Medicare Advantage PPO and Health Select, effective 08/01/2023"]
["Stacey Jo Guse, NP",1184108664,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","HealthSmart PPO","In Process","Payor Follow Up","","","","2023-11-14","11/14/2023 Per Healthsmart provider portal provider is still not loaded under group TIN.  Per phone conversation with Lee Kinard at Healthsmart provider portal should be updated  by 11/27/2023.  Will allow more time, check back in 2 weeks.   DCannon"]
["Stacey Jo Guse, NP",1184108664,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","CAQH","Participating","CAQH Reattested","2023-11-28","","","2023-11-28","11/28/2023 Updated mailing address. Reattested WT"]
["Stacey Jo Guse, NP",1184108664,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Sedgwick","Participating","Enrollment Complete","2023-10-18","","","2023-10-23","Rcvd acceptance letter from cynthia.clancy@sedgwick.com, provider effective 10/18/2023 at 4705 Briarwood, 210 W. Longview Ave and 6950 Eastridge. Jen Videan"]
["Stacey Jo Guse, NP",1184108664,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Boon Chapman","Participating","Enrollment Complete","2023-05-01","","","2023-07-25","7/25/2023 Rcvd email from Jessica Bess at Multiplan with a full roster and provider is PAR w/ group effective 5/1/2023.  DCannon"]
["Stacey Jo Guse, NP",1184108664,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","United Health Care","In Process","Payor Receipt Validated","","","","2023-11-15","11/15/2023 Rcvd confirmation email that November delegated roster was received.  Reference Number: PR-7842834.  DCannon"]
["Stacey Jo Guse, NP",1184108664,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Tricare Prime","Panel Closed","Panel Closed","","","","2023-05-12","Panel is currently closed."]
["Stacey Jo Guse, NP",1184108664,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","IMS","Participating","Enrollment Complete","2023-10-02","","","2023-09-05","9/5/2023 Per email received from IMS/OMNI May delegated roster has been processed and provider is PAR and linked to group effective 10/2/2023.  DCannon"]
["Stacey Jo Guse, NP",1184108664,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Zurich","Panel Closed","Panel Closed","","","","2023-05-18","Pending Coventry enrollment. MS"]
["Stacey Jo Guse, NP",1184108664,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Galaxy Health","Participating","Enrollment Complete","2023-05-01","","","2023-07-20","7/20/2023 Per email received from Galaxy May delegated roster has been processed and provider is PAR and linked to group effective 5/1/2023.  DCannon"]
["Stacey Jo Guse, NP",1184108664,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Galaxy Health","Participating","Enrollment Complete","2023-05-01","","","2023-07-20","7/20/2023 Per email received from Galaxy May delegated roster has been processed and provider is PAR and linked to group effective 5/1/2023.  DCannon"]
["Andrea Sanders Sanchez, NP",1174237986,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","Cigna","Participating","Enrollment Complete","2023-05-01","","","2023-08-16","Received email confirmation of approval for updated location. MS"]
["Andrea Sanders Sanchez, NP",1174237986,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","HealthSmart PPO","In Process","Payor Follow Up","","","","2023-11-14","11/14/2023 Per Healthsmart provider portal provider is still not loaded under group TIN.  Per phone conversation with Lee Kinard at Healthsmart provider portal should be updated  by 11/27/2023.  Will allow more time, check back in 2 weeks.   DCannon"]
["Andrea Sanders Sanchez, NP",1174237986,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","HealthSmart PPO","In Process","Payor Follow Up","","","","2023-11-14","11/14/2023 Per Healthsmart provider portal provider is still not loaded under group TIN.  Per phone conversation with Lee Kinard at Healthsmart provider portal should be updated  by 11/27/2023.  Will allow more time, check back in 2 weeks.   DCannon"]
["Andrea Sanders Sanchez, NP",1174237986,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","TriCare Standard","Participating","Enrollment Complete","2023-08-08","","","2023-11-09","Received confirmation of Andrews Hwy location eff 11/6/2023. MS"]
["Andrea Sanders Sanchez, NP",1174237986,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","TriCare Standard","Participating","Enrollment Complete","2023-08-08","","","2023-11-09","Received confirmation of Andrews Hwy location eff 11/6/2023. MS"]
["Andrea Sanders Sanchez, NP",1174237986,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","TriCare Standard","Participating","Enrollment Complete","2023-08-08","","","2023-08-23","Confirmation the provider has been linked to the Briarwood and Longview locations. MS"]
["Andrea Sanders Sanchez, NP",1174237986,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Rail Road Medicare","Participating","Enrollment Complete","2023-04-29","","","2023-08-21","Confirmed enrollment. MS"]
["Andrea Sanders Sanchez, NP",1174237986,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Sedgwick","Participating","Enrollment Complete","2023-11-15","","","2023-11-27","Rcvd approval letter. Provider effective 11/15/2023. Jen Videan"]
["Andrea Sanders Sanchez, NP",1174237986,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Sedgwick","Participating","Enrollment Complete","2023-11-15","","","2023-11-27","Rcvd approval letter. Provider effective 11/15/2023. Jen Videan"]
["Andrea Sanders Sanchez, NP",1174237986,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Aetna","Participating","Enrollment Complete","2023-08-01","8219691","","2023-09-19","09.19.2023 S/W Kris of Aetna @ 1-800-353-1232. Per rep, provider is in network with Aetna for the state of TX and participating under the group and TIN# effective 08/01/2023. PIN: 8219691. Physical locations are on file. Next recredentialing date is on 08/01/2026. Payer# 60054. Call ref# 6163714512. - Willie Ravas"]
["Andrea Sanders Sanchez, NP",1174237986,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Amerigroup","In Process","Payor Follow Up","","","","2023-10-13","10/13/2023 Sent follow-up email to Cassandra Dunagon-Smith and Vanessa Christensen at Amerigroup to check status of follow-up request sent on 9/9/2023.  DCannon"]
["Andrea Sanders Sanchez, NP",1174237986,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Wellmed","Participating","Enrollment Complete","2023-08-01","","","2023-10-13","10/13/2023 Provider is PAR and linked to group TIN effective 8/1/2023.  DCannon"]
["Andrea Sanders Sanchez, NP",1174237986,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Omni PPO","Participating","Enrollment Complete","2023-08-01","","","2023-09-05","9/5/2023 Per email received from IMS/OMNI May delegated roster has been processed and provider is PAR and linked to group effective 8/1/2023.  DCannon"]
["Andrea Sanders Sanchez, NP",1174237986,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Omni PPO","Participating","Enrollment Complete","2023-08-01","","","2023-09-05","9/5/2023 Per email received from IMS/OMNI May delegated roster has been processed and provider is PAR and linked to group effective 8/1/2023.  DCannon"]
["Andrea Sanders Sanchez, NP",1174237986,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Caprock (CapStar)","Participating","Enrollment Complete","2023-08-01","","","2023-09-12","9/12/2023 Per email received from Caprock provider is PAR and linked to group TIN/locations effective 8/1/2023.  DCannon"]
["Andrea Sanders Sanchez, NP",1174237986,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Humana","In Process","Payor Follow Up","","","",45247,"11/17/2023 Sent follow-up email to Marcus Wester at Humana to check status of August monthly delegated roster submission.  Provider Add - CO-16128465, Provider Changes - CO-16128615,  Provider Terms - CO-16128699.  DCannon"]
["Andrea Sanders Sanchez, NP",1174237986,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Travelers WC","Panel Closed","Panel Closed","","","","2023-08-22","08/22/2023  We appreciate your interest in joining the Coventry Network.  At this time, our panels are closed, and we are not accepting new applications.  Please check back routinely to stay apprised of our panel status. We will update this site when we are open for new applicants. Gallagher, Hartford, Liberty Mutual, Travelers and Zurich fall under Coventry. Jen Videan"]
["Andrea Sanders Sanchez, NP",1174237986,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Coventry Workers Comp","Panel Closed","Panel Closed","","","","2023-08-22","08/22/2023  We appreciate your interest in joining the Coventry Network.  At this time, our panels are closed, and we are not accepting new applications.  Please check back routinely to stay apprised of our panel status. We will update this site when we are open for new applicants. Gallagher, Hartford, Liberty Mutual, Travelers and Zurich fall under Coventry. Jen Videan"]
["Andrea Sanders Sanchez, NP",1174237986,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Alliance WC","Participating","Enrollment Complete","2023-08-18","","","2023-09-21","Per Michelle Killough provider is effective 08/18/2023. Jen Videan"]
["Andrea Sanders Sanchez, NP",1174237986,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","Alliance WC","Participating","Enrollment Complete","2023-08-18","","","2023-09-21","Per Michelle Killough provider is effective 08/18/2023. Jen Videan"]
["Andrea Sanders Sanchez, NP",1174237986,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","IMS","Participating","Enrollment Complete","2023-08-01","","","2023-09-05","9/5/2023 Per email received from IMS/OMNI May delegated roster has been processed and provider is PAR and linked to group effective 8/1/2023.  DCannon"]
["Andrea Sanders Sanchez, NP",1174237986,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","CAQH","Participating","CAQH Reattested","2023-10-26","","","2023-10-26","10/26/2023 CAQH Reattested"]
["Andrea Sanders Sanchez, NP",1174237986,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","Zurich","Panel Closed","Panel Closed","","","","2023-08-22","08/22/2023  We appreciate your interest in joining the Coventry Network.  At this time, our panels are closed, and we are not accepting new applications.  Please check back routinely to stay apprised of our panel status. We will update this site when we are open for new applicants. Gallagher, Hartford, Liberty Mutual, Travelers and Zurich fall under Coventry. Jen Videan"]
["Andrea Sanders Sanchez, NP",1174237986,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Galaxy Health","Participating","Enrollment Complete","2023-08-01","","","2023-09-19","9/19/2023 Per email received from Galaxy August delegated roster has been processed and provider is PAR and linked to group/location effective 8/1/2023.  DCannon"]
["Andrea Sanders Sanchez, NP",1174237986,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Galaxy Health","Participating","Enrollment Complete","2023-08-01","","","2023-09-19","9/19/2023 Per email received from Galaxy August delegated roster has been processed and provider is PAR and linked to group/location effective 8/1/2023.  DCannon"]
["Andrea Sanders Sanchez, NP",1174237986,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","United Health Care","Participating","Enrollment Complete","2023-08-01","00008830908","","2023-10-13","10/13/2023 Per email received from  from UHC monthly delegated roster submission has been completed and provider is PAR and in linked to group TIN effective 8/1/2023.   MPIN# 00008830908.   DCannon"]
["Andrea Sanders Sanchez, NP",1174237986,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","USA PPO","Participating","Enrollment Complete","2023-08-01","","","2023-11-20","11/20/2023  In following up with USAMCO (800-872-3860) I was told that you can confirm participating via the USA MCO website  https://providersearch.usamco.com/hwprovsearch.  Provider is PAR and linked to location/TIN effective 8/1/2023.  DCannon"]
["Andrea Sanders Sanchez, NP",1174237986,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Texas Municipal League","Participating","Enrollment Complete","","","","2023-11-20","participating, please see Alliance WC for updated notes. MS"]
["Andrea Sanders Sanchez, NP",1174237986,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Corvel Healthcare Corp.","Participating","Enrollment Complete","","","","2023-10-26","Rcvd welcome letter from Karina Garcia at Corvel. Provider is effective 10/26/2023. Jen Videan"]
["Andrea Sanders Sanchez, NP",1174237986,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Medicare","Participating","Enrollment Complete","2023-04-29","","","2023-08-22","Confirmed provider is linked to all group locations. MS"]
["Andrea Sanders Sanchez, NP",1174237986,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","Medicare","Participating","Enrollment Complete","2023-04-29","","","2023-08-22","Confirmed provider is linked to all group locations. MS"]
["Andrea Sanders Sanchez, NP",1174237986,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","BCBSTX","Participating","Enrollment Complete","","","","2023-10-19","10/19/23 Enrollment complete and participating with all products.  Effective date 10/20/23"]
["Andrea Sanders Sanchez, NP",1174237986,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","First Health Coventry","Participating","Enrollment Complete","2023-06-19","3674906","","2023-11-07","11.07.2023 S/W Teresa of First Health @ 800-226-5116. Per rep, provider is showing participating and link under the Group and TIN with an Effective date 06/19/2023. Provider ID 3674906. Service location is on file. Call ref#:810269. - Danico Gabriel Melendres"]
["Andrea Sanders Sanchez, NP",1174237986,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Boon Chapman","Participating","Enrollment Complete","2023-08-01","","",45189,"9/20/2023 Per email received from Jessica Bess at Multiplan August roster has been completed.  Provider is PAR and linked to group TIN/location effective 8/1/2023.  DCannon"]
["Andrea Sanders Sanchez, NP",1174237986,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Gallagher","Panel Closed","Panel Closed","","","","2023-08-22","08/22/2023  We appreciate your interest in joining the Coventry Network.  At this time, our panels are closed, and we are not accepting new applications.  Please check back routinely to stay apprised of our panel status. We will update this site when we are open for new applicants. Gallagher, Hartford, Liberty Mutual, Travelers and Zurich fall under Coventry. Jen Videan"]
["Andrea Sanders Sanchez, NP",1174237986,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Broadspire Services Inc.","Participating","Enrollment Complete","2023-05-23","","","2023-11-09","Per Benjamin Richbourg roster has been loaded and provider is effective 05/23/2023. Jen Videan"]
["Andrea Sanders Sanchez, NP",1174237986,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","Broadspire Services Inc.","Participating","Enrollment Complete","2023-05-23","","","2023-11-09","Per Benjamin Richbourg roster has been loaded and provider is effective 05/23/2023. Jen Videan"]
["Andrea Sanders Sanchez, NP",1174237986,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","Triwest VA","In House Enrollment","In House Enrollment","","","","2023-08-04",""]
["Andrea Sanders Sanchez, NP",1174237986,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Liberty Mutual","Panel Closed","Panel Closed","","","","2023-08-22","08/22/2023  We appreciate your interest in joining the Coventry Network.  At this time, our panels are closed, and we are not accepting new applications.  Please check back routinely to stay apprised of our panel status. We will update this site when we are open for new applicants. Gallagher, Hartford, Liberty Mutual, Travelers and Zurich fall under Coventry. Jen Videan"]
["Andrea Sanders Sanchez, NP",1174237986,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Tricare Prime","Panel Closed","Panel Closed","","","","2023-08-17","Unfortunately, at this time the network is closed. Humana Military thanks you for your interest in joining the TRICARE East Region network to provide care for our beneficiaries. At this time, we are not currently expanding our network based on your specialty and location within the East Region. Please understand that every market is different based on the beneficiary population and the types of services needed in a particular location. Thank you again for your inquiry.   You can monitor the link below for network opening status.    Join the TRICARE East network (humanamilitary.com)   Humana Military is currently not accepting requests to join the medical surgical network. We apologize for the inconvenience, but we hope you check back soon to see if we are accepting network providers."]
["Andrea Sanders Sanchez, NP",1174237986,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Texas Mutual","In Process","Payor Follow Up","","","","2023-11-22","Emailed wwtxcontracts@texasmutual.com to check status of 6301 Andrews Hwy. Jen Videan"]
["Andrea Sanders Sanchez, NP",1174237986,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","Texas Mutual","In Process","Payor Follow Up","","","","2023-11-22","Emailed wwtxcontracts@texasmutual.com to check status of 6301 Andrews Hwy. Jen Videan"]
["Andrea Sanders Sanchez, NP",1174237986,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","Multiplan","Participating","Enrollment Complete","2023-08-01","","","2023-09-20","9/20/2023 Per email received from Jessica Bess at Multiplan August roster has been completed.  Provider is PAR and linked to group TIN/location effective 8/1/2023.  DCannon"]
["Kelly Burrows, FNP",1518292077,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Caprock (CapStar)","Participating","Enrollment Complete","2023-06-12","","","2023-09-27","9/27/2023 Rcvd email confirmation from Caprock that the September roster has been completed.  Provider is PAR and linked to group/location effective 6/12/2023.  DCannon"]
["Kelly Burrows, FNP",1518292077,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","TriCare Standard","In Process","Payor Follow Up","","","","2023-11-20","all locations are still pending as the provider is still listed with her previous last name. we are needing this to be updated. mS"]
["Kelly Burrows, FNP",1518292077,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","Coventry Workers Comp","Panel Closed","Panel Closed","","","","2023-08-24","08/24/2023. We appreciate your interest in joining the Coventry Network.  At this time, our panels are closed, and we are not accepting new applications.  Please check back routinely to stay apprised of our panel status. We will update this site when we are open for new applicants. Gallagher, Hartford, Liberty Mutual, Travelers and Zurich fall under Coventry. Jen Videan"]
["Kelly Burrows, FNP",1518292077,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","Coventry Workers Comp","Panel Closed","Panel Closed","","","","2023-08-24","08/24/2023. We appreciate your interest in joining the Coventry Network.  At this time, our panels are closed, and we are not accepting new applications.  Please check back routinely to stay apprised of our panel status. We will update this site when we are open for new applicants. Gallagher, Hartford, Liberty Mutual, Travelers and Zurich fall under Coventry. Jen Videan"]
["Kelly Burrows, FNP",1518292077,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Aetna","Participating","Enrollment Complete","2023-06-12","9695700","","2023-10-24","10.24.2023 S/W PhilC of Aetna @ 1-800-353-1232. Per rep, Provider is in network with Aetna and linked to the group and TIN# effective 06/12/2023. Next recredentialing date is 06/12/2026. PIN: 9695700. Servicing location is on file. Payer# 60054. Call ref# 6167813673. - Willie Ravas"]
["Kelly Burrows, FNP",1518292077,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","Rail Road Medicare","Participating","Enrollment Complete","2023-06-10","Q00596481","DX4335","2023-11-08","Received enrollment confirmation. MS"]
["Kelly Burrows, FNP",1518292077,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Rail Road Medicare","Participating","Enrollment Complete","2023-06-10","Q00596481","DX4335","2023-11-08","Received enrollment confirmation. MS"]
["Kelly Burrows, FNP",1518292077,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","IMS","Participating","Enrollment Complete","2023-10-01","","","2023-09-05","9/5/2023 Per email received from IMS/OMNI May delegated roster has been processed and provider is PAR and linked to group effective 10/2/2023.  DCannon"]
["Kelly Burrows, FNP",1518292077,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Scott&White (First Care)","Participating","Enrollment Complete","2023-07-20","","","2023-10-12","10/12/2023 Per email received from Scott & White provider is PAR and linked to group TIN/locations effective 7/20/2023.  DCannon"]
["Kelly Burrows, FNP",1518292077,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Scott&White (First Care)","Participating","Enrollment Complete","2023-07-20","","","2023-10-12","10/12/2023 Per email received from Scott & White provider is PAR and linked to group TIN/locations effective 7/20/2023.  DCannon"]
["Kelly Burrows, FNP",1518292077,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","CAQH","Participating","DO NOT ENROLL","2023-10-27","","","2023-06-01","6/1/2023- Per Notification form - Provider Maintains CAQH"]
["Kelly Burrows, FNP",1518292077,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","CAQH","Participating","DO NOT ENROLL","2023-10-27","","","2023-06-01","6/1/2023- Per Notification form - Provider Maintains CAQH"]
["Kelly Burrows, FNP",1518292077,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","CAQH","Participating","DO NOT ENROLL","2023-10-27","","","2023-06-01","6/1/2023- Per Notification form - Provider Maintains CAQH"]
["Kelly Burrows, FNP",1518292077,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Liberty Mutual","Panel Closed","Panel Closed","","","","2023-08-24","08/24/2023. We appreciate your interest in joining the Coventry Network.  At this time, our panels are closed, and we are not accepting new applications.  Please check back routinely to stay apprised of our panel status. We will update this site when we are open for new applicants. Gallagher, Hartford, Liberty Mutual, Travelers and Zurich fall under Coventry. Jen Videan"]
["Kelly Burrows, FNP",1518292077,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Travelers WC","Panel Closed","Panel Closed","","","","2023-08-24","08/24/2023. We appreciate your interest in joining the Coventry Network.  At this time, our panels are closed, and we are not accepting new applications.  Please check back routinely to stay apprised of our panel status. We will update this site when we are open for new applicants. Gallagher, Hartford, Liberty Mutual, Travelers and Zurich fall under Coventry. Jen Videan"]
["Kelly Burrows, FNP",1518292077,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","Tricare Prime","Panel Closed","Panel Closed","","","","2023-08-23",""]
["Kelly Burrows, FNP",1518292077,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","Gallagher","Panel Closed","Panel Closed","","","","2023-08-24","08/24/2023. We appreciate your interest in joining the Coventry Network.  At this time, our panels are closed, and we are not accepting new applications.  Please check back routinely to stay apprised of our panel status. We will update this site when we are open for new applicants. Gallagher, Hartford, Liberty Mutual, Travelers and Zurich fall under Coventry. Jen Videan"]
["Kelly Burrows, FNP",1518292077,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","Alliance WC","Participating","Enrollment Complete","2023-08-25","","","2023-11-13","Per Michelle Killough @ Alliance WC provider is effective 08/25/2023.  Providers are paid via tax ID number, so they are paid no matter what location they provide services from.  The Alliance will only list two locations per provider on our website.  Jen Videan"]
["Kelly Burrows, FNP",1518292077,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Alliance WC","Participating","Enrollment Complete","2023-08-25","","","2023-11-13","Per Michelle Killough @ Alliance WC provider is effective 08/25/2023.  Providers are paid via tax ID number, so they are paid no matter what location they provide services from.  The Alliance will only list two locations per provider on our website.  Jen Videan"]
["Kelly Burrows, FNP",1518292077,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","United Health Care","Participating","Enrollment Complete","2023-08-19","003289309","","2023-11-17","11/17/2023 Per email rcvd from UHC provider is PAR and linked to group TIN and location effective 8/19/2023.  MPIN # 003289309.  DCannon"]
["Kelly Burrows, FNP",1518292077,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Amerigroup","In Process","Payor Follow Up","","","","2023-10-27","10/27/2023 Sent follow-up email to Amerigroup to check status of September delegated roster submission.  DCannon"]
["Kelly Burrows, FNP",1518292077,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Amerigroup","In Process","Payor Follow Up","","","","2023-10-27","10/27/2023 Sent follow-up email to Amerigroup to check status of September delegated roster submission.  DCannon"]
["Kelly Burrows, FNP",1518292077,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Medicare","Participating","Enrollment Complete","2023-06-10","","","2023-09-21",""]
["Kelly Burrows, FNP",1518292077,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","BCBSTX","Participating","Enrollment Complete","2023-10-10","","","2023-10-10","10/10/2023 Rcvd email from Priscilla at MQA confirming provider is PAR and linked to group effective 10/10/2023.  DCannon"]
["Kelly Burrows, FNP",1518292077,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Zurich","Panel Closed","Panel Closed","","","",45162,"08/24/2023. We appreciate your interest in joining the Coventry Network.  At this time, our panels are closed, and we are not accepting new applications.  Please check back routinely to stay apprised of our panel status. We will update this site when we are open for new applicants. Gallagher, Hartford, Liberty Mutual, Travelers and Zurich fall under Coventry. Jen Videan"]
["Kelly Burrows, FNP",1518292077,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","HealthSmart PPO","In Process","Payor Follow Up","","","","2023-11-14","11/14/2023 Per Healthsmart provider portal provider is still not loaded under group TIN.  Per phone conversation with Lee Kinard at Healthsmart provider portal should be updated  by 11/27/2023.  Will allow more time, check back in 2 weeks.   DCannon"]
["Kelly Burrows, FNP",1518292077,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","IMS","Participating","Enrollment Complete","2023-06-12","","","2023-10-09","10/9/2023 Per email received from G. Aviles at IMS/OMNI September delegation roster has been completed.  Provider is PAR and linked to group/location effective 6/12/2023.  DCannon"]
["Kelly Burrows, FNP",1518292077,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Texas Mutual","In Process","Payor Follow Up","","","","2023-11-22","Emailed wwtxcontracts@texasmutual.com to check status of 6301 Andrews Hwy. Jen Videan"]
["Kelly Burrows, FNP",1518292077,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Cigna","Participating","Facility Enrollment","","","","2023-09-13","Rep confirmed there is an ancillary contract in place. Ancillary provider are not required to be enrolled individually. Claims are bill through the group. MS"]
["Kelly Burrows, FNP",1518292077,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Cigna","Participating","Facility Enrollment","","","","2023-09-13","Rep confirmed there is an ancillary contract in place. Ancillary provider are not required to be enrolled individually. Claims are bill through the group. MS"]
["Kelly Burrows, FNP",1518292077,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","USA PPO","In Process","Payor Follow Up","","","","2023-11-27","11/27/2023 Per USA PPO provider portal provider is still not loaded under new locations.  Will allow more time, check back in 2 weeks.  \nDCannon"]
["Kelly Burrows, FNP",1518292077,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","USA PPO","In Process","Payor Follow Up","","","","2023-11-27","11/27/2023 Per USA PPO provider portal provider is still not loaded under new locations.  Will allow more time, check back in 2 weeks.  \nDCannon"]
["Kelly Burrows, FNP",1518292077,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Sedgwick","Enrollment Stopped","Payor Follow Up","","","","2023-11-27","Sent email to Sedgwick for a specific reason for denial or if application can be resubmitted. Jen Videan"]
["Kelly Burrows, FNP",1518292077,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","Broadspire Services Inc.","Participating","Enrollment Complete","2023-05-23","","","2023-08-24","Per Benjamin Richbourg, roster has been successfully loaded. They do not have effective dates for individual providers. The only effective date is the one on the contract. For this contract effective date is 05/23/2023. Jen Videan"]
["Kelly Burrows, FNP",1518292077,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Broadspire Services Inc.","Participating","Enrollment Complete","2023-05-23","","","2023-08-24","Per Benjamin Richbourg, roster has been successfully loaded. They do not have effective dates for individual providers. The only effective date is the one on the contract. For this contract effective date is 05/23/2023. Jen Videan"]
["Kelly Burrows, FNP",1518292077,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","First Health Coventry","Participating","Enrollment Complete","2023-06-01","2243378","","2023-11-20","11/20/2023 S/W Sam of First Health @ 800-226-5116, per rep provider is showing participating and link under the Group and TIN with an Effective date 06/01/2023. Provider ID 2243378. Physical locations are on file. Call ref#:773026. - DCannon"]
["Kelly Burrows, FNP",1518292077,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Wellmed","Participating","Enrollment Complete","2023-08-19","003289309","","2023-11-17","11/17/2023 Per email rcvd from UHC provider is PAR and linked to group TIN and location effective 8/19/2023.  MPIN # 003289309.  DCannon"]
["Kelly Burrows, FNP",1518292077,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Galaxy Health","Participating","Enrollment Complete","2023-06-12","","","2023-10-11","10/11/2023 Per email received from Galaxy September delegated roster has been processed and provider is PAR and linked to group/location effective 6/12/2023.  DCannon"]
["Taylor Brown, APRN-FNP-BC",1104519057,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Wellmed","Participating","Enrollment Complete","2023-07-10","008760942","","2023-11-17","11/17/2023 Per email rcvd from UHC provider is PAR and linked to group TIN and location effective 7/10/2023.  MPIN # 008760942.  DCannon"]
["Taylor Brown, APRN-FNP-BC",1104519057,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Galaxy Health","Participating","Enrollment Complete","2023-07-10","","",45188,"9/19/2023 Per email received from Galaxy August delegated roster has been processed and provider is PAR and linked to group/location effective 7/10/2023.  DCannon"]
["Taylor Brown, APRN-FNP-BC",1104519057,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","Liberty Mutual","Panel Closed","Panel Closed","","","","2023-08-16","08/16/2023. We appreciate your interest in joining the Coventry Network.  At this time, our panels are closed, and we are not accepting new applications.  Please check back routinely to stay apprised of our panel status. We will update this site when we are open for new applicants. Gallagher, Hartford, Liberty Mutual, Travelers and Zurich fall under Coventry. Jen Videan"]
["Taylor Brown, APRN-FNP-BC",1104519057,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","Rail Road Medicare","Participating","Enrollment Complete","2023-07-20","Q00602406","DX4335","2023-11-16","notes are on other payor lines. MS"]
["Taylor Brown, APRN-FNP-BC",1104519057,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Rail Road Medicare","Participating","Enrollment Complete","2023-07-20","Q00602406","DX4335","2023-11-16","notes are on other payor lines. MS"]
["Taylor Brown, APRN-FNP-BC",1104519057,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","USA PPO","Participating","Enrollment Complete","2023-07-10","","","2023-11-20","11/20/2023  In following up with USAMCO (800-872-3860) I was told that you can confirm participating via the USA MCO website  https://providersearch.usamco.com/hwprovsearch.  Provider is PAR and linked to locations/TIN effective 7/10/2023.  DCannon"]
["Taylor Brown, APRN-FNP-BC",1104519057,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Corvel Healthcare Corp.","In Process","Payor Follow Up","","","","2023-11-27","Emailed Karina Garcia at Corvel for status. Jen Videan"]
["Taylor Brown, APRN-FNP-BC",1104519057,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","Multiplan","Participating","Enrollment Complete","2023-07-10","","","2023-09-20","9/20/2023 Per email received from Jessica Bess at Multiplan August roster has been completed.  Provider is PAR and linked to group TIN/location effective 7/10/2023.  DCannon"]
["Taylor Brown, APRN-FNP-BC",1104519057,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Texas Mutual","In Process","Payor Follow Up","","","","2023-11-22","Emailed wwtxcontracts@texasmutual.com to check status of 6301 Andrews Hwy. Jen Videan"]
["Taylor Brown, APRN-FNP-BC",1104519057,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Texas Mutual","In Process","Payor Follow Up","","","","2023-11-22","Emailed wwtxcontracts@texasmutual.com to check status of 6301 Andrews Hwy. Jen Videan"]
["Taylor Brown, APRN-FNP-BC",1104519057,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Gallagher","Panel Closed","Panel Closed","","","","2023-08-16","08/16/2023. We appreciate your interest in joining the Coventry Network.  At this time, our panels are closed, and we are not accepting new applications.  Please check back routinely to stay apprised of our panel status. We will update this site when we are open for new applicants. Gallagher, Hartford, Liberty Mutual, Travelers and Zurich fall under Coventry. Jen Videan"]
["Taylor Brown, APRN-FNP-BC",1104519057,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","Coventry Workers Comp","Panel Closed","Panel Closed","","","","2023-08-16","08/16/2023. We appreciate your interest in joining the Coventry Network.  At this time, our panels are closed, and we are not accepting new applications.  Please check back routinely to stay apprised of our panel status. We will update this site when we are open for new applicants. Jen Videan"]
["Taylor Brown, APRN-FNP-BC",1104519057,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","Coventry Workers Comp","Panel Closed","Panel Closed","","","","2023-08-16","08/16/2023. We appreciate your interest in joining the Coventry Network.  At this time, our panels are closed, and we are not accepting new applications.  Please check back routinely to stay apprised of our panel status. We will update this site when we are open for new applicants. Jen Videan"]
["Taylor Brown, APRN-FNP-BC",1104519057,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Scott&White (First Care)","Participating","Enrollment Complete","2023-09-14","","","2023-08-31","8/31/2023 Rcvd confirmation from Scott & White that provider has been loaded at all locations effective 9/14/2023.  DCannon"]
["Taylor Brown, APRN-FNP-BC",1104519057,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Ambetter","Participating","Enrollment Complete","2023-09-01","","","2023-09-13","9/13/2023 Rcvd email from Superior confirming that the August delegated roster provider load has been completed providers are PAR and loaded under TIN/locations effective 9/1/2023.  DCannon"]
["Taylor Brown, APRN-FNP-BC",1104519057,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Ambetter","Participating","Enrollment Complete","2023-09-01","","","2023-09-13","9/13/2023 Rcvd email from Superior confirming that the August delegated roster provider load has been completed providers are PAR and loaded under TIN/locations effective 9/1/2023.  DCannon"]
["Taylor Brown, APRN-FNP-BC",1104519057,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Boon Chapman","Participating","Enrollment Complete","2023-07-10","","","2023-09-20","9/20/2023 Per email received from Jessica Bess at Multiplan August roster has been completed.  Provider is PAR and linked to group TIN/location effective 7/10/2023.  DCannon"]
["Taylor Brown, APRN-FNP-BC",1104519057,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Caprock (CapStar)","Participating","Enrollment Complete","2023-07-10","","","2023-09-12","9/12/2023 Per email received from Caprock provider is PAR and linked to group TIN/location effective 7/10/2023.  DCannon"]
["Taylor Brown, APRN-FNP-BC",1104519057,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Caprock (CapStar)","Participating","Enrollment Complete","2023-07-10","","","2023-09-12","9/12/2023 Per email received from Caprock provider is PAR and linked to group TIN/location effective 7/10/2023.  DCannon"]
["Taylor Brown, APRN-FNP-BC",1104519057,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","Travelers WC","Panel Closed","Panel Closed","","","","2023-08-16","08/16/2023. We appreciate your interest in joining the Coventry Network.  At this time, our panels are closed, and we are not accepting new applications.  Please check back routinely to stay apprised of our panel status. We will update this site when we are open for new applicants. Gallagher, Hartford, Liberty Mutual, Travelers and Zurich fall under Coventry. Jen Videan"]
["Taylor Brown, APRN-FNP-BC",1104519057,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Alliance WC","Participating","Enrollment Complete","2023-08-25","","","2023-09-28","Per Michelle Killough provider is effective 08/25/2023. Jen Videan"]
["Taylor Brown, APRN-FNP-BC",1104519057,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Broadspire Services Inc.","Participating","Enrollment Complete","2023-05-23","","","2023-08-29","Per Benjamin Richbourg at Corvel provider has been loaded into their system.  Per Benjamin they do not have effective dates for individual providers. Only effective date is the one on the contract which is 05/23/2023. Jen Videan"]
["Taylor Brown, APRN-FNP-BC",1104519057,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","United Health Care","Participating","Enrollment Complete","2023-09-29","008760942","","2023-11-17","11/17/2023 Per email rcvd from UHC provider is PAR and linked to group TIN and location effective 9/29/2023.  MPIN # 008760942.  DCannon"]
["Taylor Brown, APRN-FNP-BC",1104519057,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","First Health Coventry","Participating","Enrollment Complete","2023-07-10","3701694","","2023-09-20","9/20/2023 Per First Health web portal provider is PAR and linked to group TIN/location effective 7/10/2023.  PID #3701694.  DCannon"]
["Taylor Brown, APRN-FNP-BC",1104519057,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","First Health Coventry","Participating","Enrollment Complete","2023-07-10","3701694","","2023-09-20","9/20/2023 Per First Health web portal provider is PAR and linked to group TIN/location effective 7/10/2023.  PID #3701694.  DCannon"]
["Taylor Brown, APRN-FNP-BC",1104519057,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","Omni PPO","Participating","Enrollment Complete","2023-07-10","","","2023-09-05","9/5/2023 Per email received from IMS/OMNI May delegated roster has been processed and provider is PAR and linked to group effective 7/10/2023.  DCannon"]
["Taylor Brown, APRN-FNP-BC",1104519057,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Omni PPO","Participating","Enrollment Complete","2023-07-10","","","2023-09-05","9/5/2023 Per email received from IMS/OMNI May delegated roster has been processed and provider is PAR and linked to group effective 7/10/2023.  DCannon"]
["Taylor Brown, APRN-FNP-BC",1104519057,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Tricare Prime","Panel Closed","Panel Closed","","","","2023-08-16",""]
["Taylor Brown, APRN-FNP-BC",1104519057,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Medicare","Participating","Enrollment Complete","2023-07-20","6C3759","","2023-11-01","Please see other payor line for enrollments notes. MS"]
["Taylor Brown, APRN-FNP-BC",1104519057,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Sedgwick","In Process","Application Resubmitted","","","","2023-11-21","Emailed roster to cynthia.clancy@sedgwick.com to add 6301 Andrews Hwy to provider's profile. Jen Videan"]
["Taylor Brown, APRN-FNP-BC",1104519057,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","Texas Municipal League","Participating","Enrollment Complete","","","","2023-11-20","participating, please see Alliance WC for updated notes. MS"]
["Taylor Brown, APRN-FNP-BC",1104519057,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","Triwest VA","In House Enrollment","In House Enrollment","","","","2023-08-16",""]
["Taylor Brown, APRN-FNP-BC",1104519057,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Triwest VA","In House Enrollment","In House Enrollment","","","","2023-08-16",""]
["Taylor Brown, APRN-FNP-BC",1104519057,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Amerigroup","In Process","Payor Follow Up","","","","2023-10-13","10/13/2023 Sent follow-up email to Cassandra Dunagon-Smith and Vanessa Christensen at Amerigroup to check status of follow-up request sent on 9/9/2023.  DCannon"]
["Taylor Brown, APRN-FNP-BC",1104519057,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Cigna","Participating","Facility Enrollment","","","","2023-09-13","Rep confirmed there is an ancillary contract in place. Ancillary provider are not required to be enrolled individually. Claims are bill through the group. MS"]
["Taylor Brown, APRN-FNP-BC",1104519057,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","IMS","Participating","Enrollment Complete","2023-07-10","","","2023-09-05","9/5/2023 Per email received from IMS/OMNI May delegated roster has been processed and provider is PAR and linked to group effective 7/10/2023.  DCannon"]
["Taylor Brown, APRN-FNP-BC",1104519057,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","TriCare Standard","Participating","Enrollment Complete","2023-08-16","","","2023-08-23","Provider is linked with Briarwood and Longview locations effective 8/16. MS"]
["Taylor Brown, APRN-FNP-BC",1104519057,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","TriCare Standard","Participating","Enrollment Complete","2023-08-16","","","2023-08-23","Provider is linked with Briarwood and Longview locations effective 8/16. MS"]
["Taylor Brown, APRN-FNP-BC",1104519057,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","TriCare Standard","Participating","Enrollment Complete","2023-08-16","","","2023-11-05","Revalidation completed. MS"]
["Taylor Brown, APRN-FNP-BC",1104519057,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","TriCare Standard","Participating","Enrollment Complete","2023-08-16","","","2023-10-26","Eastridge location confirmed effective 10/9/2023. MS"]
["Taylor Brown, APRN-FNP-BC",1104519057,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","TriCare Standard","Participating","Enrollment Complete","2023-08-16","","","2023-10-26","Eastridge location confirmed effective 10/9/2023. MS"]
["Taylor Brown, APRN-FNP-BC",1104519057,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","BCBSTX","Participating","Enrollment Complete","2023-05-25","","","2023-10-19","10/19/2023 Enrollment had to be resubmitted, new effective date for all products is 10/19/23. NGaneshraj"]
["Taylor Brown, APRN-FNP-BC",1104519057,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Aetna","Participating","Enrollment Complete","2023-07-10","8683782","","2023-09-19","09.19.2023 S/W IceB of Aetna @ 1-800-353-1232. Per rep, provider is in network with Aetna for the state of TX and participating under the group and TIN# effective 07/10/2023. PIN: 8683782. Physical locations are on file. No next recredentialing date available. Payer# 60054. Call ref# 6163752278. - Willie Ravas"]
["Taylor Brown, APRN-FNP-BC",1104519057,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Aetna","Participating","Enrollment Complete","2023-07-10","8683782","","2023-09-19","09.19.2023 S/W IceB of Aetna @ 1-800-353-1232. Per rep, provider is in network with Aetna for the state of TX and participating under the group and TIN# effective 07/10/2023. PIN: 8683782. Physical locations are on file. No next recredentialing date available. Payer# 60054. Call ref# 6163752278. - Willie Ravas"]
["Tiffany Nicol Bynum, APRN-FNP-BC",1376006403,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","Caprock (CapStar)","Participating","Enrollment Complete","2023-09-08","","","2023-09-27","9/27/2023 Rcvd email confirmation from Caprock that the September roster has been completed.  Provider is PAR and linked to group/location effective 9/8/2023.  DCannon"]
["Tiffany Nicol Bynum, APRN-FNP-BC",1376006403,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Galaxy Health","Participating","Enrollment Complete","2023-09-08","","","2023-10-11","10/11/2023 Per email received from Galaxy September delegated roster has been processed and provider is PAR and linked to group/location effective 9/8/2023.  DCannon"]
["Tiffany Nicol Bynum, APRN-FNP-BC",1376006403,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Rail Road Medicare","Participating","Enrollment Complete","2023-08-01","","","2023-10-11","Received confirmation of enrollment attached. MS"]
["Tiffany Nicol Bynum, APRN-FNP-BC",1376006403,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Scott&White (First Care)","Participating","Enrollment Complete","2023-10-15","","","2023-10-12","10/12/2023 Per email received from Scott & White provider is PAR and linked to group TIN/locations effective 10/15/2023.  DCannon"]
["Tiffany Nicol Bynum, APRN-FNP-BC",1376006403,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Amerigroup","In Process","Payor Follow Up","","","","2023-10-27","10/27/2023 Sent follow-up email to Amerigroup to check status of September delegated roster submission.  DCannon"]
["Tiffany Nicol Bynum, APRN-FNP-BC",1376006403,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Amerigroup","In Process","Payor Follow Up","","","","2023-10-27","10/27/2023 Sent follow-up email to Amerigroup to check status of September delegated roster submission.  DCannon"]
["Tiffany Nicol Bynum, APRN-FNP-BC",1376006403,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Liberty Mutual","Panel Closed","Panel Closed","","","","2023-08-15","We appreciate your interest in joining the Coventry Network.  At this time, our panels are closed, and we are not accepting new applications.  Please check back routinely to stay apprised of our panel status. We will update this site when we are open for new applicants. Gallagher, Hartford, Liberty Mutual, Travelers and Zurich fall under Coventry. Jen Videan"]
["Tiffany Nicol Bynum, APRN-FNP-BC",1376006403,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","United Health Care","Participating","Enrollment Complete","2023-09-08","008870743","","2023-09-28","9/28/2023 Rcvd email confirmation from UHC that September delegated roster has been completed.  Provider is PAR and linked to group/location effective 9/8/2023.  DCannon"]
["Tiffany Nicol Bynum, APRN-FNP-BC",1376006403,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","Wellcare","Participating","Enrollment Complete","2023-10-01","","","2023-11-03","11/3/2023 Rcvd email from Superior that provider is PAR and linked to group TIN/location effective 10/1/2023.  DCannon"]
["Tiffany Nicol Bynum, APRN-FNP-BC",1376006403,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Aetna","Participating","Enrollment Complete","2023-09-08","6474406","","2023-10-24","10.24.2023 S/W JoeO of Aetna @ 1-800-353-1232. Per rep, Provider is in network with Aetna and linked to the group and TIN# effective 09/08/2023. No next recredentialing date available. PIN: 6474406. Servicing location is on file. Payer# 60054. Call ref# 6167817975. - Willie Ravas"]
["Tiffany Nicol Bynum, APRN-FNP-BC",1376006403,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","TriCare Standard","Participating","Enrollment Complete","2023-08-23","","","2023-09-26","Confirmed Briarwood and Longview locations effective 8/23/23. MS"]
["Tiffany Nicol Bynum, APRN-FNP-BC",1376006403,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","TriCare Standard","Participating","Enrollment Complete","2023-08-23","","","2023-09-26","Confirmed Briarwood and Longview locations effective 8/23/23. MS"]
["Tiffany Nicol Bynum, APRN-FNP-BC",1376006403,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","TriCare Standard","Participating","Enrollment Complete","2023-08-23","","","2023-11-05","Revalidation completed. MS"]
["Tiffany Nicol Bynum, APRN-FNP-BC",1376006403,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","TriCare Standard","Participating","Enrollment Complete","2023-08-23","","","2023-09-26","Confirmed Briarwood and Longview locations effective 8/23/23. MS"]
["Tiffany Nicol Bynum, APRN-FNP-BC",1376006403,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","TriCare Standard","Participating","Enrollment Complete","2023-08-23","","","2023-11-05","Revalidation completed. MS"]
["Tiffany Nicol Bynum, APRN-FNP-BC",1376006403,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Medicare","Participating","Enrollment Complete","2023-08-01","2Y3057","","2023-08-29","Received completed enrollment. MS"]
["Tiffany Nicol Bynum, APRN-FNP-BC",1376006403,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Corvel Healthcare Corp.","In Process","Payor Follow Up","","","","2023-11-27","Emailed Karina Garcia at Corvel for status. Jen Videan"]
["Tiffany Nicol Bynum, APRN-FNP-BC",1376006403,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","HealthSmart PPO","In Process","Payor Follow Up","","","","2023-11-14","11/14/2023 Per Healthsmart provider portal provider is still not loaded under group TIN.  Per phone conversation with Lee Kinard at Healthsmart provider portal should be updated  by 11/27/2023.  Will allow more time, check back in 2 weeks.   DCannon"]
["Tiffany Nicol Bynum, APRN-FNP-BC",1376006403,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Sedgwick","In Process","Payor Follow Up","","","","2023-11-27","Per Sedgwick, Ms. Bynum’s credentialing has been completed & is on the December 2023 credentialing meeting.  It is tentatively scheduled for 12/20/2023. 11/27/2023 Jen Videan\n\n\nEmailed spneast@sedgwickcms.com for status. Jen Videan"]
["Tiffany Nicol Bynum, APRN-FNP-BC",1376006403,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","Sedgwick","In Process","Payor Follow Up","","","","2023-11-27","Per Sedgwick, Ms. Bynum’s credentialing has been completed & is on the December 2023 credentialing meeting.  It is tentatively scheduled for 12/20/2023. 11/27/2023 Jen Videan\n\n\nEmailed spneast@sedgwickcms.com for status. Jen Videan"]
["Tiffany Nicol Bynum, APRN-FNP-BC",1376006403,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Multiplan","Participating","Enrollment Complete","2023-09-08","","","2023-10-12","10/12/2023 Per email received from Jessica Bess at  Multiplan provider is PAR and linked to group TIN/locations effective 9/8/2023.  DCannon"]
["Tiffany Nicol Bynum, APRN-FNP-BC",1376006403,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Multiplan","Participating","Enrollment Complete","2023-09-08","","","2023-10-12","10/12/2023 Per email received from Jessica Bess at  Multiplan provider is PAR and linked to group TIN/locations effective 9/8/2023.  DCannon"]
["Tiffany Nicol Bynum, APRN-FNP-BC",1376006403,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Texas Municipal League","Participating","Enrollment Complete","","","","2023-11-20","participating, please see Alliance WC for updated notes. MS"]
["Tiffany Nicol Bynum, APRN-FNP-BC",1376006403,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Zurich","Panel Closed","Panel Closed","","","","2023-08-15","We appreciate your interest in joining the Coventry Network.  At this time, our panels are closed, and we are not accepting new applications.  Please check back routinely to stay apprised of our panel status. We will update this site when we are open for new applicants. Gallagher, Hartford, Liberty Mutual, Travelers and Zurich fall under Coventry. Jen Videan"]
["Tiffany Nicol Bynum, APRN-FNP-BC",1376006403,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Zurich","Panel Closed","Panel Closed","","","","2023-08-15","We appreciate your interest in joining the Coventry Network.  At this time, our panels are closed, and we are not accepting new applications.  Please check back routinely to stay apprised of our panel status. We will update this site when we are open for new applicants. Gallagher, Hartford, Liberty Mutual, Travelers and Zurich fall under Coventry. Jen Videan"]
["Tiffany Nicol Bynum, APRN-FNP-BC",1376006403,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Tricare Prime","Panel Closed","Panel Closed","","","","2023-08-17","Unfortunately, at this time the network is closed. Humana Military thanks you for your interest in joining the TRICARE East Region network to provide care for our beneficiaries. At this time, we are not currently expanding our network based on your specialty and location within the East Region. Please understand that every market is different based on the beneficiary population and the types of services needed in a particular location. Thank you again for your inquiry.   You can monitor the link below for network opening status.    Join the TRICARE East network (humanamilitary.com)   Humana Military is currently not accepting requests to join the medical surgical network. We apologize for the inconvenience, but we hope you check back soon to see if we are accepting network providers."]
["Tiffany Nicol Bynum, APRN-FNP-BC",1376006403,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Ambetter","Participating","Enrollment Complete","2023-10-01","","","2023-10-16","10/16/2023 Rcvd email from Superior that provider is PAR and linked to group TIN/location effective 10/1/2023.  DCannon"]
["Tiffany Nicol Bynum, APRN-FNP-BC",1376006403,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Ambetter","Participating","Enrollment Complete","2023-10-01","","","2023-10-16","10/16/2023 Rcvd email from Superior that provider is PAR and linked to group TIN/location effective 10/1/2023.  DCannon"]
["Tiffany Nicol Bynum, APRN-FNP-BC",1376006403,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","Broadspire Services Inc.","Participating","Enrollment Complete","2023-05-23","","","2023-08-29","Per Benjamin Richbourg at Corvel provider has been loaded into their system.  Per Benjamin they do not have effective dates for individual providers. Only effective date is the one on the contract which is 05/23/2023. Jen Videan"]
["Tiffany Nicol Bynum, APRN-FNP-BC",1376006403,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","First Health Coventry","Participating","Enrollment Complete","2023-09-08","3746844","","2023-11-20","11/20/2023 S/W James of First Health @ 800-226-5116, per rep provider is showing participating and link under the Group and TIN with an Effective date 9/8/2023. Provider ID 3746844. Physical locations are on file. Call ref#:773110. - DCannon"]
["Tiffany Nicol Bynum, APRN-FNP-BC",1376006403,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Texas Mutual","In Process","Payor Follow Up","","","","2023-11-22","Emailed wwtxcontracts@texasmutual.com to check status of 6301 Andrews Hwy. Jen Videan"]
["Tiffany Nicol Bynum, APRN-FNP-BC",1376006403,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","Wellmed","Participating","Enrollment Complete","2023-09-08","","","2023-09-28","9/28/2023 Rcvd email confirmation from UHC that September delegated roster has been completed.  Provider is PAR and linked to group/location effective 9/8/2023.  DCannon"]
["Tiffany Nicol Bynum, APRN-FNP-BC",1376006403,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Gallagher","Panel Closed","Panel Closed","","","","2023-08-15","We appreciate your interest in joining the Coventry Network.  At this time, our panels are closed, and we are not accepting new applications.  Please check back routinely to stay apprised of our panel status. We will update this site when we are open for new applicants. Gallagher, Hartford, Liberty Mutual, Travelers and Zurich fall under Coventry. Jen Videan"]
["Tiffany Nicol Bynum, APRN-FNP-BC",1376006403,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Gallagher","Panel Closed","Panel Closed","","","","2023-08-15","We appreciate your interest in joining the Coventry Network.  At this time, our panels are closed, and we are not accepting new applications.  Please check back routinely to stay apprised of our panel status. We will update this site when we are open for new applicants. Gallagher, Hartford, Liberty Mutual, Travelers and Zurich fall under Coventry. Jen Videan"]
["Tiffany Nicol Bynum, APRN-FNP-BC",1376006403,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Boon Chapman","Participating","Enrollment Complete","2023-09-08","","","2023-10-12","10/12/2023 Per email received from Jessica Bess at  Multiplan provider is PAR and linked to group TIN/locations effective 9/8/2023.  DCannon"]
["Tiffany Nicol Bynum, APRN-FNP-BC",1376006403,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Travelers WC","Panel Closed","Panel Closed","","","","2023-08-15","We appreciate your interest in joining the Coventry Network.  At this time, our panels are closed, and we are not accepting new applications.  Please check back routinely to stay apprised of our panel status. We will update this site when we are open for new applicants. Gallagher, Hartford, Liberty Mutual, Travelers and Zurich fall under Coventry. Jen Videan"]
["Tiffany Nicol Bynum, APRN-FNP-BC",1376006403,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","Omni PPO","Participating","Enrollment Complete","2023-09-08","","","2023-10-09","10/9/2023 Per email received from G. Aviles at IMS/OMNI September delegation roster has been completed.  Provider is PAR and linked to group/location effective 9/8/2023.  DCannon"]
["Tiffany Nicol Bynum, APRN-FNP-BC",1376006403,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Humana","In Process","Payor Follow Up","","","","2023-11-17","11/17/2023 Sent follow-up email to Marcus Wester at Humana to check status of September monthly delegated roster submission.  Provider Add - CO16127988, Provider Changes - CO-16128096,  Provider Terms - CO-16128221.  DCannon"]
["Tiffany Nicol Bynum, APRN-FNP-BC",1376006403,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Triwest VA","In House Enrollment","In House Enrollment","","","","2023-08-11",""]
["Tiffany Nicol Bynum, APRN-FNP-BC",1376006403,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","USA PPO","In Process","Payor Follow Up","","","","2023-11-27","11/27/2023 Per USA PPO provider portal provider is still not loaded under new locations.  Will allow more time, check back in 2 weeks.  \nDCannon"]
["Tiffany Nicol Bynum, APRN-FNP-BC",1376006403,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","USA PPO","In Process","Payor Follow Up","","","","2023-11-27","11/27/2023 Per USA PPO provider portal provider is still not loaded under new locations.  Will allow more time, check back in 2 weeks.  \nDCannon"]
["Tiffany Nicol Bynum, APRN-FNP-BC",1376006403,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Alliance WC","Participating","Enrollment Complete","2023-09-22","","","2023-09-27","Rcvd welcome letter from Barry Harris at barry.harris@pswca.org. Provider effective 09/22/2023. Jen Videan"]
["Tiffany Nicol Bynum, APRN-FNP-BC",1376006403,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","CAQH","Participating","CAQH Reattested","2023-10-05","","","2023-10-05","10/05/2023 - Updated Board, DEA, License, Insurance, Primary  Mail, Cred contact , no any record available for Affiliation and Re-attested - Mkhan"]
["Tiffany Nicol Bynum, APRN-FNP-BC",1376006403,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","IMS","Participating","Enrollment Complete","2023-09-08","","","2023-10-09","10/9/2023 Per email received from G. Aviles at IMS/OMNI September delegation roster has been completed.  Provider is PAR and linked to group/location effective 9/8/2023.  DCannon"]
["Tiffany Nicol Bynum, APRN-FNP-BC",1376006403,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Cigna","Facility Enrollment","Enrollment Complete","","","","2023-10-20","WTUC has an active Ancillary Contract in effect, which means any midlevel will not require credentialing and all services will be billed under the group contract. MS"]
["Kristen Grace Schlemeyer, PA",1790315737,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Alliance WC","In Process","Payor Follow Up","","","","2023-11-28","Application submitted on 11/06/2023. Applications are processed once a month, at the end of the month. Once a provider is approved or denied, you will hear from us the first or second week of the following month.  Depending on when the application is submitted, our review/approval process can take 4-6 weeks. Still within time frame. Allow more time. Jen Videan"]
["Kristen Grace Schlemeyer, PA",1790315737,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Alliance WC","In Process","Payor Follow Up","","","","2023-11-28","Application submitted on 11/06/2023. Applications are processed once a month, at the end of the month. Once a provider is approved or denied, you will hear from us the first or second week of the following month.  Depending on when the application is submitted, our review/approval process can take 4-6 weeks. Still within time frame. Allow more time. Jen Videan"]
["Kristen Grace Schlemeyer, PA",1790315737,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","TriCare Standard","Participating","Enrollment Complete","2023-09-20","","","2023-10-16","Confirmed provider is linked to all 3 locations effective 10/9/23. MS"]
["Kristen Grace Schlemeyer, PA",1790315737,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Zurich","Panel Closed","Panel Closed","","","","2023-10-12","10/12/2023. We appreciate your interest in joining the Coventry Network.  At this time, our panels are closed, and we are not accepting new applications.  Please check back routinely to stay apprised of our panel status. We will update this site when we are open for new applicants. Gallagher, Hartford, Liberty Mutual, Travelers and Zurich fall under Coventry. Jen Videan"]
["Kristen Grace Schlemeyer, PA",1790315737,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Amerigroup","In Process","Application Submitted","","","","2023-11-15","11/15/2023 Delegated roster submitted.  DCannon"]
["Kristen Grace Schlemeyer, PA",1790315737,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Humana","In Process","Application Submitted","","","",45245,"11/15/2023 Delegated roster submitted.  DCannon"]
["Kristen Grace Schlemeyer, PA",1790315737,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Broadspire Services Inc.","Participating","Enrollment Complete","2023-05-23","","","2023-11-06","Per providerrelations@primehealthservices.com, provider has been added. effective date 05/23/2023. Jen Videan"]
["Kristen Grace Schlemeyer, PA",1790315737,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Cigna","Participating","Enrollment Complete","","","","2023-10-27","Group has an ancillary contract in place, therefore, all services for midlevels will be billed under the group. no credentialing is required. MS"]
["Kristen Grace Schlemeyer, PA",1790315737,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Scott&White (First Care)","In Process","Application Submitted","","","","2023-11-15","11/15/2023 Delegated roster submitted.  DCannon"]
["Kristen Grace Schlemeyer, PA",1790315737,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Scott&White (First Care)","In Process","Application Submitted","","","","2023-11-15","11/15/2023 Delegated roster submitted.  DCannon"]
["Kristen Grace Schlemeyer, PA",1790315737,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Boon Chapman","Thru Other Payor","Pending Other Enrollment","","","","2023-11-09","11/9/2023 Pending Multiplan enrollment.  DCannon"]
["Kristen Grace Schlemeyer, PA",1790315737,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Boon Chapman","Thru Other Payor","Pending Other Enrollment","","","","2023-11-09","11/9/2023 Pending Multiplan enrollment.  DCannon"]
["Kristen Grace Schlemeyer, PA",1790315737,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Caprock (CapStar)","In Process","Application Submitted","","","","2023-11-15","11/15/2023 Delegated roster submitted.  DCannon"]
["Kristen Grace Schlemeyer, PA",1790315737,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Coventry Workers Comp","Panel Closed","Panel Closed","","","","2023-10-12","10/12/2023. We appreciate your interest in joining the Coventry Network.  At this time, our panels are closed, and we are not accepting new applications.  Please check back routinely to stay apprised of our panel status. We will update this site when we are open for new applicants. Gallagher, Hartford, Liberty Mutual, Travelers and Zurich fall under Coventry. Jen Videan"]
["Kristen Grace Schlemeyer, PA",1790315737,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Ambetter","Thru Other Payor","Pending Other Enrollment","","","","2023-11-09","11/9/2023 Pending Superior enrollment.  DCannon"]
["Kristen Grace Schlemeyer, PA",1790315737,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","BCBSTX","In Process","Payor Follow Up","","","","","11/28/2023; PSV/application still in process per BCBSTX portal. - PA"]
["Kristen Grace Schlemeyer, PA",1790315737,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Tricare Prime","Panel Closed","Panel Closed","","","","2023-10-09","Payor has closed the panel for new providers. MS"]
["Kristen Grace Schlemeyer, PA",1790315737,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Omni PPO","In Process","Application Submitted","","","","2023-11-15","11/15/2023 Delegated roster submitted.  DCannon"]
["Kristen Grace Schlemeyer, PA",1790315737,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Aetna","In Process","Application Submitted","","","","2023-11-15","11/15/2023 Delegated roster submitted.  DCannon"]
["Kristen Grace Schlemeyer, PA",1790315737,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","HealthSmart PPO","In Process","Application Submitted","","","","2023-11-15","11/15/2023 Delegated roster submitted.  DCannon"]
["Kristen Grace Schlemeyer, PA",1790315737,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Superior","In Process","Application Submitted","","","","2023-11-15","11/15/2023 Delegated roster submitted.  DCannon"]
["Kristen Grace Schlemeyer, PA",1790315737,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Wellmed","Thru Other Payor","Pending Other Enrollment","","","","2023-11-09","11/9/2023 Pending UHC enrollment.  DCannon"]
["Kristen Grace Schlemeyer, PA",1790315737,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","IMS","In Process","Application Submitted","","","","2023-11-15","11/15/2023 Delegated roster submitted.  DCannon"]
["Kristen Grace Schlemeyer, PA",1790315737,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","IMS","In Process","Application Submitted","","","","2023-11-15","11/15/2023 Delegated roster submitted.  DCannon"]
["Kristen Grace Schlemeyer, PA",1790315737,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Texas Mutual","In Process","Payor Follow Up","","","","2023-11-22","Emailed wwtxcontracts@texasmutual.com for status. Jen Videan"]
["Kristen Grace Schlemeyer, PA",1790315737,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Galaxy Health","In Process","Application Submitted","","","","2023-11-15","11/15/2023 Delegated roster submitted.  DCannon"]
["Kristen Grace Schlemeyer, PA",1790315737,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Galaxy Health","In Process","Application Submitted","","","","2023-11-15","11/15/2023 Delegated roster submitted.  DCannon"]
["Kristen Grace Schlemeyer, PA",1790315737,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","CAQH","Participating","CAQH Reattested","2023-10-04","","","2023-10-04",""]
["Kristen Grace Schlemeyer, PA",1790315737,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Sedgwick","In Process","Payor Follow Up","","","","2023-11-27","Per Sedgwick, your providers’ credentialing has been received & is currently under review at this time. Jen Videan"]
["Kristen Grace Schlemeyer, PA",1790315737,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Sedgwick","In Process","Payor Follow Up","","","","2023-11-27","Per Sedgwick, your providers’ credentialing has been received & is currently under review at this time. Jen Videan"]
["Jeremy Davis Dominguez, PA",1841508462,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","Scott&White (First Care)","In Process","Application Submitted","","","","2023-11-15","11/15/2023 Delegated roster submitted.  DCannon"]
["Jeremy Davis Dominguez, PA",1841508462,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Humana","In Process","Application Submitted","","","","2023-11-15","11/15/2023 Delegated roster submitted.  DCannon"]
["Jeremy Davis Dominguez, PA",1841508462,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Rail Road Medicare","In Process","Payor Follow Up","","","","2023-11-16","Still unable to process at this time. MS"]
["Jeremy Davis Dominguez, PA",1841508462,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Coventry Workers Comp","Panel Closed","Panel Closed","","","","2023-10-17","10/17/2023. We appreciate your interest in joining the Coventry Network.  At this time, our panels are closed, and we are not accepting new applications.  Please check back routinely to stay apprised of our panel status. We will update this site when we are open for new applicants. Gallagher, Hartford, Liberty Mutual, Travelers and Zurich fall under Coventry. Jen Videan"]
["Jeremy Davis Dominguez, PA",1841508462,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","Coventry Workers Comp","Panel Closed","Panel Closed","","","","2023-10-17","10/17/2023. We appreciate your interest in joining the Coventry Network.  At this time, our panels are closed, and we are not accepting new applications.  Please check back routinely to stay apprised of our panel status. We will update this site when we are open for new applicants. Gallagher, Hartford, Liberty Mutual, Travelers and Zurich fall under Coventry. Jen Videan"]
["Jeremy Davis Dominguez, PA",1841508462,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Amerigroup","In Process","Application Submitted","","","","2023-11-15","11/15/2023 Delegated roster submitted.  DCannon"]
["Jeremy Davis Dominguez, PA",1841508462,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Ambetter","Thru Other Payor","Pending Other Enrollment","","","","2023-11-09","11/9/2023 Pending Superior enrollment.  DCannon"]
["Jeremy Davis Dominguez, PA",1841508462,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","IMS","In Process","Application Submitted","","","","2023-11-15","11/15/2023 Delegated roster submitted.  DCannon"]
["Jeremy Davis Dominguez, PA",1841508462,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","IMS","In Process","Application Submitted","","","","2023-11-15","11/15/2023 Delegated roster submitted.  DCannon"]
["Jeremy Davis Dominguez, PA",1841508462,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","United Health Care","In Process","Payor Receipt Validated","","","","2023-11-15","11/15/2023 Rcvd confirmation email that November delegated roster was received.  Reference Number: PR-7842834.  DCannon"]
["Jeremy Davis Dominguez, PA",1841508462,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","HealthSmart PPO","In Process","Application Submitted","","","","2023-11-15","11/15/2023 Delegated roster submitted.  DCannon"]
["Jeremy Davis Dominguez, PA",1841508462,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Caprock (CapStar)","In Process","Application Submitted","","","","2023-11-15","11/15/2023 Delegated roster submitted.  DCannon"]
["Jeremy Davis Dominguez, PA",1841508462,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Tricare Prime","Panel Closed","Panel Closed","","","","2023-10-16","Payor has closed the enrollment panel until further notice. MS"]
["Jeremy Davis Dominguez, PA",1841508462,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","Tricare Prime","Panel Closed","Panel Closed","","","","2023-10-16","Payor has closed the enrollment panel until further notice. MS"]
["Jeremy Davis Dominguez, PA",1841508462,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Gallagher","Panel Closed","Panel Closed","","","","2023-10-20","10/17/2023. We appreciate your interest in joining the Coventry Network.  At this time, our panels are closed, and we are not accepting new applications.  Please check back routinely to stay apprised of our panel status. We will update this site when we are open for new applicants. Gallagher, Hartford, Liberty Mutual, Travelers and Zurich fall under Coventry. Jen Videan"]
["Jeremy Davis Dominguez, PA",1841508462,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Multiplan","In Process","Application Submitted","","","","2023-11-15","11/15/2023 Delegated roster submitted.  DCannon"]
["Jeremy Davis Dominguez, PA",1841508462,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","Multiplan","In Process","Application Submitted","","","","2023-11-15","11/15/2023 Delegated roster submitted.  DCannon"]
["Jeremy Davis Dominguez, PA",1841508462,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","TriCare Standard","In Process","Enrollment Complete","2023-10-26","","","2023-11-05","Provider is linked to Andrews Hwy location eff 10/26/23. MS"]
["Jeremy Davis Dominguez, PA",1841508462,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","TriCare Standard","In Process","Enrollment Complete","2023-10-26","","",45225,"Briarwood location is confirmed eff 10/16/23. MS"]
["Jeremy Davis Dominguez, PA",1841508462,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","TriCare Standard","In Process","Enrollment Complete","2023-10-26","","","2023-11-05","Provider is linked to Andrews Hwy location eff 10/26/23. MS"]
["Jeremy Davis Dominguez, PA",1841508462,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","TriCare Standard","In Process","Enrollment Complete","2023-10-26","","","2023-11-05","Provider is linked to Andrews Hwy location eff 10/26/23. MS"]
["Jeremy Davis Dominguez, PA",1841508462,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","TriCare Standard","In Process","Enrollment Complete","2023-10-26","","","2023-10-26","Briarwood location is confirmed eff 10/16/23. MS"]
["Jeremy Davis Dominguez, PA",1841508462,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","TriCare Standard","In Process","Enrollment Complete","2023-10-26","","",45225,"Provider is loaded to the Eastridge location eff 10/16/23. MS"]
["Jeremy Davis Dominguez, PA",1841508462,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","TriCare Standard","In Process","Enrollment Complete","2023-10-26","","","2023-10-26","Longview location is confirmed eff 10/16/23. MS"]
["Jeremy Davis Dominguez, PA",1841508462,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","Cigna","Participating","Enrollment Complete","","","","2023-10-27","Group has an ancillary contract in place, therefore, all services for midlevels will be billed under the group. no credentialing is required. MS"]
["Jeremy Davis Dominguez, PA",1841508462,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","CAQH","Participating","CAQH Reattested","2023-10-13","","","2023-10-13","10/13/23-CAQH Sweep completed - kavello"]
["Jeremy Davis Dominguez, PA",1841508462,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","CAQH","Participating","CAQH Reattested","2023-10-13","","","2023-10-13","10/13/23-CAQH Sweep completed - kavello"]
["Jeremy Davis Dominguez, PA",1841508462,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Wellmed","Thru Other Payor","Pending Other Enrollment","","","","2023-11-09","11/9/2023 Pending UHC enrollment.  DCannon"]
["Jeremy Davis Dominguez, PA",1841508462,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Galaxy Health","In Process","Application Submitted","","","","2023-11-15","11/15/2023 Delegated roster submitted.  DCannon"]
["Jeremy Davis Dominguez, PA",1841508462,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Galaxy Health","In Process","Application Submitted","","","","2023-11-15","11/15/2023 Delegated roster submitted.  DCannon"]
["Jeremy Davis Dominguez, PA",1841508462,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Omni PPO","In Process","Application Submitted","","","","2023-11-15","11/15/2023 Delegated roster submitted.  DCannon"]
["Jeremy Davis Dominguez, PA",1841508462,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Broadspire Services Inc.","Participating","Enrollment Complete","2023-05-23","","","2023-11-06","Per providerrelations@primehealthservices.com, provider has been added. effective date 05/23/2023. Jen Videan"]
["Jeremy Davis Dominguez, PA",1841508462,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Travelers WC","Panel Closed","Panel Closed","","","","2023-10-17","10/17/2023. We appreciate your interest in joining the Coventry Network.  At this time, our panels are closed, and we are not accepting new applications.  Please check back routinely to stay apprised of our panel status. We will update this site when we are open for new applicants. Gallagher, Hartford, Liberty Mutual, Travelers and Zurich fall under Coventry. Jen Videan"]
["Jeremy Davis Dominguez, PA",1841508462,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","First Health Coventry","In Process","Application Submitted","","","","2023-11-15","11/15/2023 Delegated roster submitted.  DCannon"]
["Jeremy Davis Dominguez, PA",1841508462,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","First Health Coventry","In Process","Application Submitted","","","","2023-11-15","11/15/2023 Delegated roster submitted.  DCannon"]
["Jeremy Davis Dominguez, PA",1841508462,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Zurich","Panel Closed","Panel Closed","","","","2023-10-17","10/17/2023. We appreciate your interest in joining the Coventry Network.  At this time, our panels are closed, and we are not accepting new applications.  Please check back routinely to stay apprised of our panel status. We will update this site when we are open for new applicants. Gallagher, Hartford, Liberty Mutual, Travelers and Zurich fall under Coventry. Jen Videan"]
["Jeremy Davis Dominguez, PA",1841508462,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Texas Mutual","In Process","Payor Follow Up","","","","2023-11-22","Emailed wwtxcontracts@texasmutual.com for status. Jen Videan"]
["Jeremy Davis Dominguez, PA",1841508462,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","Sedgwick","In Process","Payor Follow Up","","","","2023-11-27","Per Sedgwick, your providers’ credentialing has been received & is currently under review at this time. Jen Videan"]
["Jeremy Davis Dominguez, PA",1841508462,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Sedgwick","In Process","Payor Follow Up","","","","2023-11-27","Per Sedgwick, your providers’ credentialing has been received & is currently under review at this time. Jen Videan"]
["Jeremy Davis Dominguez, PA",1841508462,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","Boon Chapman","Thru Other Payor","Pending Other Enrollment","","","","2023-11-09","11/9/2023 Pending Multiplan enrollment.  DCannon"]
["Jeremy Davis Dominguez, PA",1841508462,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","Boon Chapman","Thru Other Payor","Pending Other Enrollment","","","","2023-11-09","11/9/2023 Pending Multiplan enrollment.  DCannon"]
["Jeremy Davis Dominguez, PA",1841508462,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","USA PPO","In Process","Payor Follow Up","","","","2023-11-27","11/27/2023 Per USA PPO provider portal provider is still not loaded under new locations.  Will allow more time, check back in 2 weeks.  \nDCannon"]
["Jeremy Davis Dominguez, PA",1841508462,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","Medicare","Participating","Enrollment Complete","2023-10-01","6C9153","","2023-11-08","Received welcome letter. MS"]
["Jeremy Davis Dominguez, PA",1841508462,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","BCBSTX","Participating","Enrollment Complete","2023-10-25","","","2023-10-24","Received confirmation provider is enrolled and participating with the following networks, eff. 10/25/2023:\nBAV - Blue Advantage HMO\t,\nHME - Health Select,\nBCA - BlueChoice PPO,\nHMO - Blue Essentials, and\nPMC - Medicare Advantage PPO\n- PA"]
["Jeremy Davis Dominguez, PA",1841508462,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Texas Municipal League","Thru Other Payor","Thru Other Payor","","","","2023-11-20","Please see Alliance status for enrollment. MS"]
["Jeremy Davis Dominguez, PA",1841508462,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Corvel Healthcare Corp.","In Process","Payor Follow Up","","","","2023-11-22","Per Karina Garcia at Corvel please allow up to 180 days for processing. Still within time frame...allow more time. Jen Videan"]
["Jeremy Davis Dominguez, PA",1841508462,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Corvel Healthcare Corp.","In Process","Payor Follow Up","","","","2023-11-22","Per Karina Garcia at Corvel please allow up to 180 days for processing. Still within time frame...allow more time. Jen Videan"]
["Jeremy Davis Dominguez, PA",1841508462,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Aetna","In Process","Application Submitted","","","","2023-11-15","11/15/2023 Delegated roster submitted.  DCannon"]
["Jeremy Davis Dominguez, PA",1841508462,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Liberty Mutual","Panel Closed","Panel Closed","","","","2023-10-17","10/17/2023. We appreciate your interest in joining the Coventry Network.  At this time, our panels are closed, and we are not accepting new applications.  Please check back routinely to stay apprised of our panel status. We will update this site when we are open for new applicants. Gallagher, Hartford, Liberty Mutual, Travelers and Zurich fall under Coventry. Jen Videan"]
["Jeremy Davis Dominguez, PA",1841508462,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Liberty Mutual","Panel Closed","Panel Closed","","","","2023-10-17","10/17/2023. We appreciate your interest in joining the Coventry Network.  At this time, our panels are closed, and we are not accepting new applications.  Please check back routinely to stay apprised of our panel status. We will update this site when we are open for new applicants. Gallagher, Hartford, Liberty Mutual, Travelers and Zurich fall under Coventry. Jen Videan"]
["Alma Martinez, APRN-FNP-BC",1376149153,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","First Health Coventry","In Process","Pending PSV","","","","2023-10-18",""]
["Alma Martinez, APRN-FNP-BC",1376149153,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","First Health Coventry","In Process","Pending PSV","","","","2023-10-18",""]
["Alma Martinez, APRN-FNP-BC",1376149153,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Zurich","Panel Closed","Panel Closed","","","","2023-11-17","11/17/2023. We appreciate your interest in joining the Coventry Network.  At this time, our panels are closed, and we are not accepting new applications.  Please check back routinely to stay apprised of our panel status. We will update this site when we are open for new applicants. Gallagher, Hartford, Liberty Mutual, Travelers and Zurich fall under Coventry. Jen Videan"]
["Alma Martinez, APRN-FNP-BC",1376149153,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","Sedgwick","In Process","Payor Follow Up","","","","2023-11-27","Per Sedgwick, your providers’ credentialing has been received & is currently under review at this time. Jen Videan"]
["Alma Martinez, APRN-FNP-BC",1376149153,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Tricare Prime","Panel Closed","Panel Closed","","","","2023-10-18","Payor is not accepting new enrollments until further notice. MS"]
["Alma Martinez, APRN-FNP-BC",1376149153,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Tricare Prime","Panel Closed","Panel Closed","","","","2023-10-18","Payor is not accepting new enrollments until further notice. MS"]
["Alma Martinez, APRN-FNP-BC",1376149153,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","Scott&White (First Care)","In Process","Pending PSV","","","","2023-10-18",""]
["Alma Martinez, APRN-FNP-BC",1376149153,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Cigna","Participating","Enrollment Complete","","","","2023-10-27","Group has an ancillary contract in place, therefore, all services for midlevels will be billed under the group. no credentialing is required. MS"]
["Alma Martinez, APRN-FNP-BC",1376149153,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","Cigna","Participating","Enrollment Complete","","","","2023-10-27","Group has an ancillary contract in place, therefore, all services for midlevels will be billed under the group. no credentialing is required. MS"]
["Alma Martinez, APRN-FNP-BC",1376149153,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","Alliance WC","In Process","Payor Follow Up","","","","2023-11-27","Per Michelle Killough, The application for this provider was received at the end of October after we had already closed October applications so it was put with November applications.\nWe process new applications once a month, at the end of the month.  Once a provider is approved or denied, you will hear from us the first or second week of the following month.  Depending on when the application is submitted, our review/approval process can take 4-6 weeks. Jen Videan"]
["Alma Martinez, APRN-FNP-BC",1376149153,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","USA PPO","In Process","Pending PSV","","","","2023-10-18",""]
["Alma Martinez, APRN-FNP-BC",1376149153,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","USA PPO","In Process","Pending PSV","","","","2023-10-18",""]
["Alma Martinez, APRN-FNP-BC",1376149153,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Omni PPO","In Process","Pending PSV","","","","2023-10-18",""]
["Alma Martinez, APRN-FNP-BC",1376149153,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","BCBSTX","Participating","Enrollment Complete","2023-11-22","","","2023-11-27","11/27/23: Received confirmation from BCBSTX per email, provider enrolled with the following networks, eff. 11/22/23:\nBAV - Blue Advantage HMO\nPMC - Medicare Advantage PPO\nBCA - BlueChoice PPO\t\nHME - Health Select\t\nHMO - Blue Essentials"]
["Alma Martinez, APRN-FNP-BC",1376149153,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Galaxy Health","In Process","Pending PSV","","","","2023-10-18",""]
["Alma Martinez, APRN-FNP-BC",1376149153,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Galaxy Health","In Process","Pending PSV","","","","2023-10-18",""]
["Alma Martinez, APRN-FNP-BC",1376149153,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Gallagher","Panel Closed","Panel Closed","","","","2023-11-17","11/17/2023. We appreciate your interest in joining the Coventry Network.  At this time, our panels are closed, and we are not accepting new applications.  Please check back routinely to stay apprised of our panel status. We will update this site when we are open for new applicants. Gallagher, Hartford, Liberty Mutual, Travelers and Zurich fall under Coventry. Jen Videan"]
["Alma Martinez, APRN-FNP-BC",1376149153,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Aetna","In Process","Pending PSV","","","","2023-11-06",""]
["Alma Martinez, APRN-FNP-BC",1376149153,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Aetna","In Process","Pending PSV","","","","2023-11-06",""]
["Alma Martinez, APRN-FNP-BC",1376149153,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Multiplan","In Process","Pending PSV","","","","2023-10-18",""]
["Alma Martinez, APRN-FNP-BC",1376149153,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","Multiplan","In Process","Pending PSV","","","","2023-10-18",""]
["Alma Martinez, APRN-FNP-BC",1376149153,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","IMS","In Process","Pending PSV","","","","2023-10-18",""]
["Alma Martinez, APRN-FNP-BC",1376149153,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Coventry Workers Comp","Panel Closed","Panel Closed","","","","2023-10-20","10/20/2023. We appreciate your interest in joining the Coventry Network.  At this time, our panels are closed, and we are not accepting new applications.  Please check back routinely to stay apprised of our panel status. We will update this site when we are open for new applicants. Gallagher, Hartford, Liberty Mutual, Travelers and Zurich fall under Coventry. Jen Videan"]
["Alma Martinez, APRN-FNP-BC",1376149153,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","Coventry Workers Comp","Panel Closed","Panel Closed","","","","2023-10-20","10/20/2023. We appreciate your interest in joining the Coventry Network.  At this time, our panels are closed, and we are not accepting new applications.  Please check back routinely to stay apprised of our panel status. We will update this site when we are open for new applicants. Gallagher, Hartford, Liberty Mutual, Travelers and Zurich fall under Coventry. Jen Videan"]
["Alma Martinez, APRN-FNP-BC",1376149153,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Travelers WC","Panel Closed","Panel Closed","","","","2023-10-20","10/20/2023. We appreciate your interest in joining the Coventry Network.  At this time, our panels are closed, and we are not accepting new applications.  Please check back routinely to stay apprised of our panel status. We will update this site when we are open for new applicants. Gallagher, Hartford, Liberty Mutual, Travelers and Zurich fall under Coventry. Jen Videan"]
["Alma Martinez, APRN-FNP-BC",1376149153,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","Boon Chapman","Thru Other Payor","Pending Other Enrollment","","","","2023-11-17","11/17/2023 Pending Multiplan enrollment.  DCannon"]
["Alma Martinez, APRN-FNP-BC",1376149153,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Boon Chapman","Thru Other Payor","Pending Other Enrollment","","","","2023-11-17","11/17/2023 Pending Multiplan enrollment.  DCannon"]
["Alma Martinez, APRN-FNP-BC",1376149153,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","HealthSmart PPO","In Process","Pending PSV","","","","2023-10-18",""]
["Alma Martinez, APRN-FNP-BC",1376149153,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","Caprock (CapStar)","In Process","Pending PSV","","","","2023-10-18",""]
["Alma Martinez, APRN-FNP-BC",1376149153,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","Caprock (CapStar)","In Process","Pending PSV","","","","2023-10-18",""]
["Alma Martinez, APRN-FNP-BC",1376149153,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","TriCare Standard","Participating","Enrollment Complete","2023-10-26","","","2023-11-05","Provider is linked to Andrews Hwy location eff 10/26/23. MS"]
["Alma Martinez, APRN-FNP-BC",1376149153,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","TriCare Standard","Participating","Enrollment on Hold","2023-10-26","","","2023-11-20","Main St. Location: Location not ready for enrollment until December. MS"]
["Alma Martinez, APRN-FNP-BC",1376149153,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","TriCare Standard","Participating","Enrollment Complete","2023-10-26","","","2023-11-05","Provider is linked to Longview, Briarwood, and Eastridge locations. MS"]
["Alma Martinez, APRN-FNP-BC",1376149153,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","TriCare Standard","Participating","Enrollment Complete","2023-10-26","","","2023-11-05","Provider is linked to Longview, Briarwood, and Eastridge locations. MS"]
["Alma Martinez, APRN-FNP-BC",1376149153,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Ambetter","Thru Other Payor","Pending Other Enrollment","","","","2023-11-17","11/17/2023 Pending Superior enrollment.  DCannon"]
["Alma Martinez, APRN-FNP-BC",1376149153,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","Ambetter","Thru Other Payor","Pending Other Enrollment","","","","2023-11-17","11/17/2023 Pending Superior enrollment.  DCannon"]
["Alma Martinez, APRN-FNP-BC",1376149153,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Amerigroup","In Process","Pending PSV","","","","2023-10-18",""]
["Alma Martinez, APRN-FNP-BC",1376149153,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Amerigroup","In Process","Pending PSV","","","","2023-10-18",""]
["Alma Martinez, APRN-FNP-BC",1376149153,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","Amerigroup","In Process","Pending PSV","","","","2023-10-18",""]
["Alma Martinez, APRN-FNP-BC",1376149153,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Wellmed","Thru Other Payor","Pending Other Enrollment","","","","2023-11-17","11/17/2023 Pending UHC enrollment.  DCannon"]
["Alma Martinez, APRN-FNP-BC",1376149153,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Wellmed","Thru Other Payor","Pending Other Enrollment","","","","2023-11-17","11/17/2023 Pending UHC enrollment.  DCannon"]
["Alma Martinez, APRN-FNP-BC",1376149153,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Broadspire Services Inc.","Participating","Enrollment Complete","2023-05-23","","","2023-11-06","Per providerrelations@primehealthservices.com, provider has been added. effective date 05/23/2023. Jen Videan"]
["Alma Martinez, APRN-FNP-BC",1376149153,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Humana","In Process","Pending PSV","","","","2023-10-18",""]
["Alma Martinez, APRN-FNP-BC",1376149153,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Humana","In Process","Pending PSV","","","","2023-10-18",""]
["Alma Martinez, APRN-FNP-BC",1376149153,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Texas Municipal League","Thru Other Payor","Thru Other Payor","","","","2023-11-27","See updates under Alliance WC payor line. Jen Videan"]
["Alma Martinez, APRN-FNP-BC",1376149153,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Texas Mutual","In Process","Payor Follow Up","","","","2023-11-22","Emailed wwtxcontracts@texasmutual.com for status. Jen Videan"]
["Alma Martinez, APRN-FNP-BC",1376149153,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","Texas Mutual","In Process","Payor Follow Up","","","","2023-11-22","Emailed wwtxcontracts@texasmutual.com for status. Jen Videan"]
["Alma Martinez, APRN-FNP-BC",1376149153,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","CAQH","Participating","CAQH Reattested","2023-11-02","15380393","","2023-11-02","11/2/2023 CAQH login revceived.  Reviewed, profile is current w/ all practice locations for WTUC are listed.  CAQH re-attested.  DCannon"]
["Alma Martinez, APRN-FNP-BC",1376149153,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","United Health Care","In Process","Pending PSV","","","","2023-10-18",""]
["Alma Martinez, APRN-FNP-BC",1376149153,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","United Health Care","In Process","Pending PSV","","","","2023-10-18",""]
["Alma Martinez, APRN-FNP-BC",1376149153,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Medicare","In Process","Pending Info/Document","","","","2023-11-27","Sent reminder to client the signature is still outstanding from the provider. MS"]
["Gerald Winemiller, APRN-NP",1316591522,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Texas Mutual","In Process","Application Submitted","","","","2023-11-21","TSCA and required documents emailed to wwtxcontracts@texasmutual.com. Jen Videan"]
["Gerald Winemiller, APRN-NP",1316591522,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","Texas Mutual","In Process","Application Submitted","","","","2023-11-21","TSCA and required documents emailed to wwtxcontracts@texasmutual.com. Jen Videan"]
["Gerald Winemiller, APRN-NP",1316591522,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Corvel Healthcare Corp.","In Process","Application Submitted","","","","2023-11-17","Emailed roster to Karina Garcia at Corvel. Jen Videan"]
["Gerald Winemiller, APRN-NP",1316591522,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Ambetter","Thru Other Payor","Pending Other Enrollment","","","",45247,""]
["Gerald Winemiller, APRN-NP",1316591522,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Ambetter","Thru Other Payor","Pending Other Enrollment","","","","2023-11-17",""]
["Gerald Winemiller, APRN-NP",1316591522,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Scott&White (First Care)","In Process","Pending PSV","","","","2023-11-17",""]
["Gerald Winemiller, APRN-NP",1316591522,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Caprock (CapStar)","In Process","Pending PSV","","","","2023-11-17",""]
["Gerald Winemiller, APRN-NP",1316591522,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","Caprock (CapStar)","In Process","Pending PSV","","","","2023-11-17",""]
["Gerald Winemiller, APRN-NP",1316591522,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","USA PPO","In Process","Pending PSV","","","","2023-11-17",""]
["Gerald Winemiller, APRN-NP",1316591522,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Broadspire Services Inc.","Participating","Enrollment Complete","","","","2023-11-27","Per providerrelations@primehealthservices.com, provider has been uploaded to our system with an effective date of 05/23/2023. Jen Videan"]
["Gerald Winemiller, APRN-NP",1316591522,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","Broadspire Services Inc.","Participating","Enrollment Complete","","","","2023-11-27","Per providerrelations@primehealthservices.com, provider has been uploaded to our system with an effective date of 05/23/2023. Jen Videan"]
["Gerald Winemiller, APRN-NP",1316591522,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","Galaxy Health","In Process","Pending PSV","","","","2023-11-17",""]
["Gerald Winemiller, APRN-NP",1316591522,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Liberty Mutual","Panel Closed","Panel Closed","","","","2023-11-17","11/17/2023. We appreciate your interest in joining the Coventry Network.  At this time, our panels are closed, and we are not accepting new applications.  Please check back routinely to stay apprised of our panel status. We will update this site when we are open for new applicants. Gallagher, Hartford, Liberty Mutual, Travelers and Zurich fall under Coventry. Jen Videan"]
["Gerald Winemiller, APRN-NP",1316591522,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","Liberty Mutual","Panel Closed","Panel Closed","","","","2023-11-17","11/17/2023. We appreciate your interest in joining the Coventry Network.  At this time, our panels are closed, and we are not accepting new applications.  Please check back routinely to stay apprised of our panel status. We will update this site when we are open for new applicants. Gallagher, Hartford, Liberty Mutual, Travelers and Zurich fall under Coventry. Jen Videan"]
["Gerald Winemiller, APRN-NP",1316591522,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Medicare","In Process","Application Submitted","","","","2023-11-17","Application submitted for reassignment. T111720230000827  MS"]
["Gerald Winemiller, APRN-NP",1316591522,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Zurich","Panel Closed","Panel Closed","","","","2023-11-17","11/17/2023. We appreciate your interest in joining the Coventry Network.  At this time, our panels are closed, and we are not accepting new applications.  Please check back routinely to stay apprised of our panel status. We will update this site when we are open for new applicants. Gallagher, Hartford, Liberty Mutual, Travelers and Zurich fall under Coventry. Jen Videan"]
["Gerald Winemiller, APRN-NP",1316591522,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","Zurich","Panel Closed","Panel Closed","","","","2023-11-17","11/17/2023. We appreciate your interest in joining the Coventry Network.  At this time, our panels are closed, and we are not accepting new applications.  Please check back routinely to stay apprised of our panel status. We will update this site when we are open for new applicants. Gallagher, Hartford, Liberty Mutual, Travelers and Zurich fall under Coventry. Jen Videan"]
["Gerald Winemiller, APRN-NP",1316591522,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","Wellcare","Thru Other Payor","Pending Other Enrollment","","","","2023-11-17","11/17/2023 Pending Superior enrollment.  DCannon"]
["Gerald Winemiller, APRN-NP",1316591522,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Sedgwick","In Process","Application Submitted","","","","2023-11-21","TSCA and required documents emailed to spneast@sedgwickcms.com. Jen Videan"]
["Gerald Winemiller, APRN-NP",1316591522,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","Sedgwick","In Process","Application Submitted","","","","2023-11-21","TSCA and required documents emailed to spneast@sedgwickcms.com. Jen Videan"]
["Gerald Winemiller, APRN-NP",1316591522,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","HealthSmart PPO","In Process","Pending PSV","","","","2023-11-17",""]
["Gerald Winemiller, APRN-NP",1316591522,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Boon Chapman","Thru Other Payor","Pending Other Enrollment","","","","2023-11-17","11/17/2023 Pending Multiplan enrollment.  DCannon"]
["Gerald Winemiller, APRN-NP",1316591522,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","TriCare Standard","In Process","Application Submitted","","","","2023-11-17","Applications to link provider to: Longview, Briarwood, Andrews, and Eastridge. MS"]
["Gerald Winemiller, APRN-NP",1316591522,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","TriCare Standard","In Process","Application Submitted","","","","2023-11-17","Applications to link provider to: Longview, Briarwood, Andrews, and Eastridge. MS"]
["Gerald Winemiller, APRN-NP",1316591522,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","TriCare Standard","In Process","Application Submitted","","","","2023-11-17","Applications to link provider to: Longview, Briarwood, Andrews, and Eastridge. MS"]
["Gerald Winemiller, APRN-NP",1316591522,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","TriCare Standard","In Process","Application Submitted","","","","2023-11-17","Applications to link provider to: Longview, Briarwood, Andrews, and Eastridge. MS"]
["Gerald Winemiller, APRN-NP",1316591522,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Tricare Prime","Panel Closed","Panel Closed","2023-11-14","","","2023-11-15","Panel is closed at the current time. MS"]
["Gerald Winemiller, APRN-NP",1316591522,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","Tricare Prime","Panel Closed","Panel Closed","2023-11-14","","","2023-11-15","Panel is closed at the current time. MS"]
["Gerald Winemiller, APRN-NP",1316591522,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","Amerigroup","In Process","Pending PSV","","","","2023-11-17",""]
["Gerald Winemiller, APRN-NP",1316591522,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","IMS","In Process","Pending PSV","","","","2023-11-17",""]
["Gerald Winemiller, APRN-NP",1316591522,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Aetna","In Process","Pending PSV","","","","2023-11-17",""]
["Gerald Winemiller, APRN-NP",1316591522,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","Aetna","In Process","Pending PSV","","","",45247,""]
["Gerald Winemiller, APRN-NP",1316591522,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","Multiplan","In Process","Pending PSV","","","","2023-11-17",""]
["Gerald Winemiller, APRN-NP",1316591522,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","First Health Coventry","In Process","Pending PSV","","","","2023-11-17",""]
["Gerald Winemiller, APRN-NP",1316591522,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","First Health Coventry","In Process","Pending PSV","","","","2023-11-17",""]
["Gerald Winemiller, APRN-NP",1316591522,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","United Health Care","In Process","Pending PSV","","","","2023-11-17",""]
["Gerald Winemiller, APRN-NP",1316591522,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Humana","In Process","Pending PSV","","","","2023-11-17",""]
["Gerald Winemiller, APRN-NP",1316591522,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","Humana","In Process","Pending PSV","","","","2023-11-17",""]
["Gerald Winemiller, APRN-NP",1316591522,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Cigna","In Process","Payor Receipt Validated","","","","2023-11-17","Received confirmation of receipt of application. MS"]
["Gerald Winemiller, APRN-NP",1316591522,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Cigna","In Process","Payor Receipt Validated","","","","2023-11-17","Received confirmation of receipt of application. MS"]
["Gerald Winemiller, APRN-NP",1316591522,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","Alliance WC","In Process","Application Submitted","","","","2023-11-21","Application submitted on-line at pswca.org. Jen Videan"]
["Gerald Winemiller, APRN-NP",1316591522,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Gallagher","Panel Closed","Panel Closed","","","","2023-11-17","11/17/2023. We appreciate your interest in joining the Coventry Network.  At this time, our panels are closed, and we are not accepting new applications.  Please check back routinely to stay apprised of our panel status. We will update this site when we are open for new applicants. Gallagher, Hartford, Liberty Mutual, Travelers and Zurich fall under Coventry. Jen Videan"]
["Gerald Winemiller, APRN-NP",1316591522,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Gallagher","Panel Closed","Panel Closed","","","","2023-11-17","11/17/2023. We appreciate your interest in joining the Coventry Network.  At this time, our panels are closed, and we are not accepting new applications.  Please check back routinely to stay apprised of our panel status. We will update this site when we are open for new applicants. Gallagher, Hartford, Liberty Mutual, Travelers and Zurich fall under Coventry. Jen Videan"]
["Gerald Winemiller, APRN-NP",1316591522,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Wellmed","Thru Other Payor","Pending Other Enrollment","","","","2023-11-17","11/17/2023 Pending UHC enrollment.  DCannon"]
["Gerald Winemiller, APRN-NP",1316591522,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Wellmed","Thru Other Payor","Pending Other Enrollment","","","","2023-11-17","11/17/2023 Pending UHC enrollment.  DCannon"]
["Gerald Winemiller, APRN-NP",1316591522,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","CAQH","Participating","CAQH Reattested","2023-11-21","","","2023-11-21","11/21/2023 CAQH Sweep added 5 locations, cred contact and added demo tab info"]
["Gerald Winemiller, APRN-NP",1316591522,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Coventry Workers Comp","Panel Closed","Panel Closed","","","","2023-11-17","11/17/2023. We appreciate your interest in joining the Coventry Network.  At this time, our panels are closed, and we are not accepting new applications.  Please check back routinely to stay apprised of our panel status. We will update this site when we are open for new applicants. Gallagher, Hartford, Liberty Mutual, Travelers and Zurich fall under Coventry. Jen Videan"]
["Gerald Winemiller, APRN-NP",1316591522,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","BCBSTX","In Process","Application Submitted","","","","2023-11-16","Application submitted via portal. NGaneshraj"]
["Gerald Winemiller, APRN-NP",1316591522,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","BCBSTX","In Process","Payor Follow Up","","","","","11/21/2023- BCBSTX application, case# 07427745 in progress. PA"]
["Gerald Winemiller, APRN-NP",1316591522,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","BCBSTX","In Process","Payor Follow Up","","","","","11/21/2023- BCBSTX application, case# 07427745 in progress. PA"]
["Lawrence A Wilson, MD",1518951342,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Aetna","Participating","Enrollment Complete","2021-07-26","","","2023-09-07","9/7/2023 Per email response from Mary Hanna at Aetna, May delegated roster is complete.  Provider is PAR and linked to group TIN/location effective 7/26/2021.  DCannon"]
["Lawrence A Wilson, MD",1518951342,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","First Health Coventry","Participating","Enrollment Complete","2021-08-01","1103233","",45174,"9/5/2023 Per First Health web portal provider is PAR and linked to group TIN/location effective 8/1/2021.  PID #1103233  DCannon"]
["Lawrence A Wilson, MD",1518951342,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","Zurich","Panel Closed","Panel Closed","","","","2023-09-02","9/2/2023 Coventry panel closed at this time."]
["Lawrence A Wilson, MD",1518951342,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","First Health Coventry","Participating","Enrollment Complete","2021-08-01","1103233","","2023-09-20","09.20.2023 S/W Teresita of First Health @ 800-226-5116. Per rep, provider is showing participating and link under the Group and TIN with an Effective date 08/01/2021. Provider ID 1103233. Service location is on file. Call ref#:761417. - Danico Gabriel Melendres"]
["Lawrence A Wilson, MD",1518951342,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Medicare","Participating","Enrollment Complete","2021-07-26","","","2023-09-08","Provider is enrolled with all locations under WesTex. MS"]
["Lawrence A Wilson, MD",1518951342,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Corvel Healthcare Corp.","Participating","Enrollment Complete","","","","2023-11-27","Per Karina Garcia at Corvel, Lawrence Wilson, MD NPI: 1518951342- credentialing approved since 01/19/2022, renewal 01/19/2025. For billing purposes we always reflect back to the contract date which for this group is 7/20/2020. Jen Videan"]
["Lawrence A Wilson, MD",1518951342,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Cigna","Participating","Enrollment Complete","2021-07-26","9800227","","2021-08-31","8/31/2021 Received an email from pdmcogz@cigna.com with confirmation provider has been loaded under group Tax ID and all practice locations effective 7/26/2021 and assigned provider ID 9800227. KFrazier"]
["Lawrence A Wilson, MD",1518951342,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Wellmed","Participating","Enrollment Complete","2021-11-16","002438204","","2023-11-17","11/17/2023 Per email rcvd from UHC provider is PAR and linked to group TIN and location effective 11/16/2021.  MPIN # 002438204.  DCannon"]
["Lawrence A Wilson, MD",1518951342,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Texas Mutual","Participating","Enrollment Complete","2022-08-01","","","2022-08-04","8/4/2022 Received approval letter for TX Mutual/Workwell.  Provider is PAR effective 8/1/2022.  DCannon"]
["Lawrence A Wilson, MD",1518951342,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","IMS","Participating","Enrollment Complete","2023-10-02","","","2023-09-05","9/5/2023 Per email received from IMS/OMNI May delegated roster has been processed and provider is PAR and linked to group effective 10/2/2023.  DCannon"]
["Lawrence A Wilson, MD",1518951342,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Liberty Mutual","Panel Closed","Panel Closed","","","","2023-09-02","9/2/2023 Coventry panel closed at this time.  DCannon"]
["Lawrence A Wilson, MD",1518951342,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Liberty Mutual","Panel Closed","Panel Closed","","","","2023-09-02","9/2/2023 Coventry panel closed at this time.  DCannon"]
["Lawrence A Wilson, MD",1518951342,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","Gallagher","Panel Closed","Panel Closed","","","","2023-09-02","9/2/2023 Coventry Panel closed at this time.  DCannon"]
["Lawrence A Wilson, MD",1518951342,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Multiplan","Participating","Enrollment Complete","2023-05-01","","","2023-09-07","9/7/2023 Per email received from Jessica Bess at Multiplan provider is PAR and linked to group TIN/location effective 5/1/2023.  DCannon"]
["Lawrence A Wilson, MD",1518951342,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Caprock (CapStar)","Participating","Enrollment Complete","2023-05-01","","","2023-09-02",""]
["Lawrence A Wilson, MD",1518951342,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Travelers WC","Panel Closed","Panel Closed","","","","2023-09-02","9/2/2023 Coventry panel is closed at this time.  DCannon"]
["Lawrence A Wilson, MD",1518951342,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Travelers WC","Panel Closed","Panel Closed","","","","2023-09-02","9/2/2023 Coventry panel is closed at this time.  DCannon"]
["Lawrence A Wilson, MD",1518951342,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","CAQH","Participating","CAQH Reattested","2023-11-27","","","2023-11-27","11/27/2023 Updated mailing address for all WesTex locations.  WT"]
["Lawrence A Wilson, MD",1518951342,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Galaxy Health","Participating","Enrollment Complete","2021-07-26","","","2021-10-06","10/6/2021 Rcvd email from Karen Avalos at Galaxy confirming that the August delegated roser provider load has been completed and providers are loaded under TIN/locations effective 7/26/2021.  DCannon"]
["Lawrence A Wilson, MD",1518951342,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Scott&White (First Care)","Participating","Enrollment Complete","2023-05-01","","","2023-09-04","9/4/2023 Received email from Scott & White HPDELEGATION@BSWHealth.org that provider load from May has been completed and provider is PAR effective 5/1/2023.  DCannon"]
["Lawrence A Wilson, MD",1518951342,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Sedgwick","In Process","Payor Follow Up","","","","2023-11-27","Per Sedgwick, Mr. Wilson’s credentialing has been completed & is on the December 2023 credentialing meeting.  It is tentatively scheduled for 12/20/2023. 11/27/2023 Jen Videan \n\nEmailed spneast@sedgwickcms.com for status. Jen Videan"]
["Lawrence A Wilson, MD",1518951342,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Sedgwick","In Process","Payor Follow Up","","","","2023-11-27","Per Sedgwick, Mr. Wilson’s credentialing has been completed & is on the December 2023 credentialing meeting.  It is tentatively scheduled for 12/20/2023. 11/27/2023 Jen Videan \n\nEmailed spneast@sedgwickcms.com for status. Jen Videan"]
["Lawrence A Wilson, MD",1518951342,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Rail Road Medicare","Participating","Enrollment Complete","2021-07-26","Q00177598","DX4335","2021-12-08","12/8/2021 Rcvd RR Medicare PTAN Approval letter instantly.  RR Medicare PTAN#  Q00177598 - effective 7/26/2021.  DCannon"]
["Lawrence A Wilson, MD",1518951342,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","Texas Mutual","In Process","Payor Follow Up","","","","2023-11-22","Emailed wwtxcontracts@texasmutual.com to check status of 6301 Andrews Hwy. Jen Videan"]
["Lawrence A Wilson, MD",1518951342,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Omni PPO","Participating","Enrollment Complete","2023-05-01","","","2023-07-20","7/20/2023 Per email received from IMS/OMNI May delegated roster has been processed and provider is PAR and linked to group effective 5/1/2023.  DCannon"]
["Lawrence A Wilson, MD",1518951342,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","TriCare Standard","Participating","Enrollment Complete","2023-09-20","","","2023-09-25","Confirmed provider is linked to Briarwood location effective 9/20/2023. MS"]
["Lawrence A Wilson, MD",1518951342,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","TriCare Standard","Participating","Enrollment Complete","2023-09-20","","",45194,"Confirmed provider is linked to Briarwood location effective 9/20/2023. MS"]
["Lawrence A Wilson, MD",1518951342,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","TriCare Standard","Participating","Enrollment Complete","2023-09-20","","","2023-09-25","Confirmed provider is linked to Briarwood location effective 9/20/2023. MS"]
["Lawrence A Wilson, MD",1518951342,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Texas Municipal League","Thru Other Payor","Thru Other Payor","","","",45250,"Still pending Alliance WC enrollment. Please see that payor line for updates. MS"]
["Lawrence A Wilson, MD",1518951342,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","Galaxy Health","Participating","Enrollment Complete","2023-10-02","","","2023-09-19","9/19/2023 Per email received from Galaxy August delegated roster has been processed and provider is PAR and linked to group/location effective 10/2/2023.  DCannon"]
["Lawrence A Wilson, MD",1518951342,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","HealthSmart PPO","In Process","Payor Follow Up","","","","2023-11-14","11/14/2023 Per Healthsmart provider portal provider is still not loaded under group TIN.  Per phone conversation with Lee Kinard at Healthsmart provider portal should be updated  by 11/27/2023.  Will allow more time, check back in 2 weeks.   DCannon"]
["Lawrence A Wilson, MD",1518951342,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","United Health Care","Participating","Enrollment Complete","2021-11-16","002438204","","2023-11-17","11/17/2023 Per email rcvd from UHC provider is PAR and linked to group TIN and location effective 11/16/2021.  MPIN # 002438204.  DCannon"]
["Terry L Beck, MD",1912991084,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Aetna","Participating","Enrollment Complete","2019-08-01","1912991084","","2020-04-15","04/15/2020 - Rec'd notification from the follow up team stating : \"S/W Mark of Aetna @ 18003531232, provider NPI# is on file for the provider and is participating effective 08/01/2019 under the group and TIN#. Physical location is on file Call ref# 5224430323. \"  THIS PROVIDER IS PART OF THE PRIMED DELEGATED CONTRACT - Stacey Hudak"]
["Terry L Beck, MD",1912991084,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Liberty Mutual","Participating","Enrollment Complete","2016-05-01","","","2021-01-27","1/27/2021 - Per follow-up notes provider is on file and participating at location and under TIN effective 5/1/2016.  DCannon"]
["Terry L Beck, MD",1912991084,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Liberty Mutual","Panel Closed","Panel Closed","","","","2023-08-10","Per Liberty Mutual any updates to the provider record would need to be processed through Coventry and Coventry panel is closed. Jen Videan"]
["Terry L Beck, MD",1912991084,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Scott&White (First Care)","Participating","Enrollment Complete","2023-05-01","","","2023-08-17","8/17/2023 Received email from Scott & White HPDELEGATION@BSWHealth.org that provider load from May has been completed and provider is PAR effective 5/1/2023.  DCannon"]
["Terry L Beck, MD",1912991084,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","USA PPO","In Process","Payor Follow Up","","","","2023-11-27","11/27/2023 Per USA PPO provider portal provider is still not loaded under new locations.  Will allow more time, check back in 2 weeks.  \nDCannon"]
["Terry L Beck, MD",1912991084,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Omni PPO","Participating","Enrollment Complete","2023-05-01","","","2023-07-20","7/20/2023 Per email received from IMS/OMNI May delegated roster has been processed and provider is PAR and linked to group effective 5/1/2023.  DCannon"]
["Terry L Beck, MD",1912991084,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","IMS","Participating","Enrollment Complete","2023-05-01","","","2023-07-20","7/20/2023 Per email received from IMS/OMNI May delegated roster has been processed and provider is PAR and linked to group effective 5/1/2023.  DCannon"]
["Terry L Beck, MD",1912991084,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","United Health Care","Participating","Enrollment Complete","2020-01-01","00002067277","","2023-10-13","10/13/2023 Per email received from  from UHC monthly delegated roster submission has been completed and provider is PAR and in linked to group TIN effective 1/1/2020.   MPIN# 00002067277.   DCannon"]
["Terry L Beck, MD",1912991084,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Texas Mutual","In Process","Payor Follow Up","","","","2023-11-22","Emailed wwtxcontracts@texasmutual.com to check status of 6301 Andrews Hwy. Jen Videan"]
["Terry L Beck, MD",1912991084,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","Galaxy Health","Participating","Enrollment Complete","2023-10-02","","","2023-09-19","9/19/2023 Per email received from Galaxy August delegated roster has been processed and provider is PAR and linked to group/location effective 10/2/2023.  DCannon"]
["Terry L Beck, MD",1912991084,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Triwest VA","In House Enrollment","In House Enrollment","","","","2023-06-14","6/14/2023 Add new locations - 4705 Briarwood Ave, 6950 Eastridge Rd. and 6301 Andrews Hwy.   DCannon"]
["Terry L Beck, MD",1912991084,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","USA PPO","Participating","Enrollment Complete","2016-10-26","1912991084","473465832","2020-08-19","Confirmed provider is participating with PPO and H&W networks (list of networks attached). Kimberly Frazier"]
["Terry L Beck, MD",1912991084,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","Caprock (CapStar)","Participating","Enrollment Complete","2023-10-02","","","2023-09-12","9/12/2023 Per email received from Caprock provider has been added to new location 6301 Andrews Hwy effective 10/2/2023.  DCannon"]
["Terry L Beck, MD",1912991084,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","CAQH","Participating","CAQH Reattested","2023-10-04","","","2023-10-04","10/04/2023 - Updated Primary Mail, Practice Location, DEA, Insurance, Cred contact and Re-attested - Mkhan"]
["Terry L Beck, MD",1912991084,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","Sedgwick","Participating","Enrollment Complete","2023-08-02","","","2023-09-26","Per providerdata@careworks.com all three locations added Effective 08/02/2023. Jen Videan"]
["Terry L Beck, MD",1912991084,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Rail Road Medicare","Participating","Enrollment Complete","2015-05-09","P01841282","DX4335","2020-07-10","07/10/2020 - was able to confirm EFF info through payer site - Stacey Hudak"]
["Terry L Beck, MD",1912991084,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Rail Road Medicare","Participating","Enrollment Complete","2015-05-09","P01841282","DX4335","2020-07-10","07/10/2020 - was able to confirm EFF info through payer site - Stacey Hudak"]
["Terry L Beck, MD",1912991084,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Gallagher","Panel Closed","Panel Closed","","","","2023-08-15","We appreciate your interest in joining the Coventry Network.  At this time, our panels are closed, and we are not accepting new applications.  Please check back routinely to stay apprised of our panel status. We will update this site when we are open for new applicants. Gallagher, Hartford, Liberty Mutual, Travelers and Zurich fall under Coventry. Jen Videan"]
["Terry L Beck, MD",1912991084,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","TriCare Standard","Participating","Enrollment Complete","2023-07-28","","","2023-08-23","Confirmed Briarwood location is linked to provider. effective 7/28. MS"]
["Terry L Beck, MD",1912991084,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","TriCare Standard","Participating","Enrollment Complete","2023-07-28","","","2023-10-26","Eastridge location confirmed effective 10/9/2023. MS"]
["Terry L Beck, MD",1912991084,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","TriCare Standard","Participating","Enrollment Complete","2023-07-28","","","2023-11-05","Provider linked to Andrews Hwy location eff 10.26.2023"]
["Terry L Beck, MD",1912991084,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Aetna","Participating","Enrollment Complete","2015-09-01","","","2023-08-18","8/18/2023 Per email from Priscilla Albertine at MQA she received confirmation that provider is PAR and linked to group TIN/location effective 9/1/2015.  DCannon"]
["Terry L Beck, MD",1912991084,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","BCBSTX","Participating","Enrollment Complete","2015-07-28","","","2023-10-02","10/2/2023 Per BCBS TX roster received from Priscilla Albertine at MQA provider is PAR and linked to group effective 7/28/2015.  DCannon"]
["Terry L Beck, MD",1912991084,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Amerigroup","In Process","Payor Follow Up","","","","2023-10-13","10/13/2023 Sent follow-up email to Cassandra Dunagon-Smith and Vanessa Christensen at Amerigroup to check status of follow-up request sent on 9/9/2023.  DCannon"]
["Terry L Beck, MD",1912991084,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Humana","Participating","Enrollment Complete","2015-08-28","","","2023-09-15","9/15/2023 Per email received from Humana provider is PAR and linked to group TIN/locations effective 8/28/2015.  DCannon"]
["Terry L Beck, MD",1912991084,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Galaxy Health","Participating","Enrollment Complete","2019-09-01","1912991084","","2020-08-24",""]
["Karen Ward, NP-C, CNOR, RNFA",1790831493,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","Liberty Mutual","Panel Closed","Panel Closed","","","","2023-09-01","9/1/2023 Pending Coventry enrollment.  Coventry panel is closed at this time.  DCannon"]
["Karen Ward, NP-C, CNOR, RNFA",1790831493,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Galaxy Health","Participating","Enrollment Complete","2023-05-01","","","2023-07-20","7/20/2023 Per email received from Galaxy May delegated roster has been processed and provider is PAR and linked to group effective 5/1/2023.  DCannon"]
["Karen Ward, NP-C, CNOR, RNFA",1790831493,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Rail Road Medicare","Participating","Enrollment Complete","2022-05-01","Q00306896","DX4335","2022-08-11","8/11/2022 Rcvd RR Medicare approval letter.  PTAN # Q00306896 - effective 5/1/2022.  DCannon"]
["Karen Ward, NP-C, CNOR, RNFA",1790831493,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Texas Mutual","In Process","Payor Follow Up","","","","2023-11-22","Emailed wwtxcontracts@texasmutual.com to check status of 6301 Andrews Hwy. Jen Videan"]
["Karen Ward, NP-C, CNOR, RNFA",1790831493,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Amerigroup","Participating","Enrollment Complete","2022-08-26","","","2022-11-16","11/16/2022 Per email from Priscilla Albertine at MQA she received an update from Joe Rodriguez at Amerigroup.  Provider is PAR and linked to group TIN/location effective 8/29/2022.  DCannon"]
["Karen Ward, NP-C, CNOR, RNFA",1790831493,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","Texas Municipal League","Participating","Enrollment Complete","","","","2023-11-20","participating, please see Alliance WC for details. MS"]
["Karen Ward, NP-C, CNOR, RNFA",1790831493,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Humana","Participating","Enrollment Complete","2022-07-01","","","2022-11-01","11/1/2022 Per email received from Vernita Young July monthly delegated roster is complete and provider is PAR and linked to group TIN/location effective 7/1/2022.  DCannon"]
["Karen Ward, NP-C, CNOR, RNFA",1790831493,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Cigna","Participating","Enrollment Complete","2023-05-01","","","2023-07-18","7/18/2023 Rcvd email from Cigna that provider is PAR and linked to new practice locations effective 5/1/2023.  PID # 8228233 DCannon"]
["Karen Ward, NP-C, CNOR, RNFA",1790831493,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","Tricare Prime","Panel Closed","Panel Closed","","","","2023-09-01","9/1/2023 Unfortunately, at this time the network is closed. Humana Military thanks you for your interest in joining the TRICARE East Region network to provide care for our beneficiaries. At this time, we are not currently expanding our network based on your specialty and location within the East Region. Please understand that every market is different based on the beneficiary population and the types of services needed in a particular location. Thank you again for your inquiry.   You can monitor the link below for network opening status.    Join the TRICARE East network (humanamilitary.com)   Humana Military is currently not accepting requests to join the medical surgical network. We apologize for the inconvenience, but we hope you check back soon to see if we are accepting network providers.  DCannon"]
["Karen Ward, NP-C, CNOR, RNFA",1790831493,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Tricare Prime","Panel Closed","Panel Closed","","","","2023-09-01","9/1/2023 Unfortunately, at this time the network is closed. Humana Military thanks you for your interest in joining the TRICARE East Region network to provide care for our beneficiaries. At this time, we are not currently expanding our network based on your specialty and location within the East Region. Please understand that every market is different based on the beneficiary population and the types of services needed in a particular location. Thank you again for your inquiry.   You can monitor the link below for network opening status.    Join the TRICARE East network (humanamilitary.com)   Humana Military is currently not accepting requests to join the medical surgical network. We apologize for the inconvenience, but we hope you check back soon to see if we are accepting network providers.  DCannon"]
["Karen Ward, NP-C, CNOR, RNFA",1790831493,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","Travelers WC","Panel Closed","Panel Closed","","","","2023-09-01","9/1/2023 Pending Coventry enrollment.  Coventry panel is closed at this time."]
["Karen Ward, NP-C, CNOR, RNFA",1790831493,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Boon Chapman","Participating","Enrollment Complete","2023-05-01","","","2023-09-07","9/7/2023 Per email received from Jessica Bess at Multiplan provider is PAR and linked to group TIN/location effective 5/1/2023.  DCannon"]
["Karen Ward, NP-C, CNOR, RNFA",1790831493,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","United Health Care","Participating","Enrollment Complete","2023-05-01","","","2023-09-07","9/7/2023 Per email from UHC May delegated roster has been completed.  Provider is PAR and linked to group TIN/locations effective 5/1/2023.  DCannon"]
["Karen Ward, NP-C, CNOR, RNFA",1790831493,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Humana","Participating","Enrollment Complete","2023-05-01","","","2023-09-27","9/27/2023 Per email response from Marcus Wester at Humana May delegated roster has bee completed.  Provider is PAR and linked to group/location effective 5/1/2023.  DCannon"]
["Karen Ward, NP-C, CNOR, RNFA",1790831493,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Broadspire Services Inc.","Participating","Enrollment Complete","2022-05-01","","","2022-09-16","9/16/2022 Per Prime Health Services web portal provider is PAR and linked to group TIN effective 5/1/2022.  DCannon"]
["Karen Ward, NP-C, CNOR, RNFA",1790831493,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","First Health Coventry","Participating","Enrollment Complete","2022-07-01","2703063","","2023-09-05","9/5/2023 Per First Health web portal provider is PAR and linked to group TIN/location effective 7/1/2022.  PID #2703063  DCannon"]
["Karen Ward, NP-C, CNOR, RNFA",1790831493,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Multiplan","Participating","Enrollment Complete","2022-05-01","","",44766,"7/24/2022 Per email from Marcie Eckhart-Havens Multiplan July delegated roster has been completed  and provider is PAR and linked to group TIN effective 5/1/2022.  DCannon"]
["Karen Ward, NP-C, CNOR, RNFA",1790831493,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Medicare","Participating","Enrollment Complete","2022-05-01","","","2023-09-08","Confirmed enrollment with all locations under WesTex. MS"]
["Karen Ward, NP-C, CNOR, RNFA",1790831493,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Amerigroup","Participating","Enrollment Complete","2023-05-01","","","2023-10-18","10/18/2023 Per email received from Jessica Bess at  Multiplan provider is PAR with Amerigroup and linked to group TIN/locations thru Multiplan enrollment effective 5/1/2023.  DCannon"]
["Karen Ward, NP-C, CNOR, RNFA",1790831493,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Scott&White (First Care)","Participating","Enrollment Complete","2023-05-14","","","2023-09-04","9/4/2023 Received email from Scott & White HPDELEGATION@BSWHealth.org that provider load from May has been completed and provider is PAR effective 5/14/2023.  DCannon"]
["Karen Ward, NP-C, CNOR, RNFA",1790831493,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Texas Mutual","Participating","Enrollment Complete","2023-05-01","","","2023-05-10","5/10/2023 Rcvd TX Mutual - WorkWell approval letter.  Provider is PAR and linked to group effective 5/1/2023.  DCannon"]
["Karen Ward, NP-C, CNOR, RNFA",1790831493,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Wellmed","Thru Other Payor","Pending Other Enrollment","","","","2023-11-17","11/17/2023 Pending UHC enrollment.  DCannon"]
["Karen Ward, NP-C, CNOR, RNFA",1790831493,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Wellmed","Thru Other Payor","Pending Other Enrollment","","","","2023-11-17","11/17/2023 Pending UHC enrollment.  DCannon"]
["Karen Ward, NP-C, CNOR, RNFA",1790831493,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Alliance WC","Participating","Enrollment Complete","2022-08-26","","","2023-11-13","Per Michelle Killough @ Alliance WC provider is effective 08/26/2022.  Providers are paid via tax ID number, so they are paid no matter what location they provide services from.  The Alliance will only list two locations per provider on our website.  Jen Videan"]
["Karen Ward, NP-C, CNOR, RNFA",1790831493,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","TriCare Standard","Participating","Enrollment Complete","2023-09-20","","","2023-09-26","Confirmed provider is linked to Briarwood location effective 9/20/23. MS"]
["Karen Ward, NP-C, CNOR, RNFA",1790831493,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","TriCare Standard","Participating","Enrollment Complete","2023-09-20","","","2023-10-26","Eastridge location confirmed eff 10/9/23. MS"]
["Karen Ward, NP-C, CNOR, RNFA",1790831493,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","TriCare Standard","Participating","Enrollment Complete","2023-09-20","","","2023-11-05","Provider is linked to Andrews Hwy location eff 10/26/23. MS"]
["Karen Ward, NP-C, CNOR, RNFA",1790831493,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","HealthSmart PPO","In Process","Payor Follow Up","","","","2023-11-14","11/14/2023 Per Healthsmart provider portal provider is still not loaded under group TIN.  Per phone conversation with Lee Kinard at Healthsmart provider portal should be updated  by 11/27/2023.  Will allow more time, check back in 2 weeks.   DCannon"]
["Karen Ward, NP-C, CNOR, RNFA",1790831493,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","HealthSmart PPO","In Process","Payor Follow Up","","","","2023-11-14","11/14/2023 Per Healthsmart provider portal provider is still not loaded under group TIN.  Per phone conversation with Lee Kinard at Healthsmart provider portal should be updated  by 11/27/2023.  Will allow more time, check back in 2 weeks.   DCannon"]
["Karen Ward, NP-C, CNOR, RNFA",1790831493,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","Broadspire Services Inc.","Participating","Enrollment Complete","2023-05-23","","","2023-09-15","Rcvd confirmation from providerrelations@primehealthservices.com provider has been loaded to roster, with effective date 05/23/2023. Jen Videan"]
["Karen Ward, NP-C, CNOR, RNFA",1790831493,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","BCBSTX","Participating","Enrollment Complete","2021-05-23","","","2023-10-02","10/2/2023 Per BCBS TX roster received from Priscilla Albertine at MQA provider is PAR and linked to group effective 5/23/2021.  DCannon"]
["Johnny L Flitton, PA-C",1437356730,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Caprock (CapStar)","Participating","Enrollment Complete","2014-02-05","","","2020-09-14",""]
["Johnny L Flitton, PA-C",1437356730,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Aetna","Participating","Enrollment Complete","2023-05-01","9326179","","2023-10-24","10.24.2023 S/W JoeO of Aetna @ 1-800-353-1232. Per rep, Provider is in network with Aetna and linked to the group and TIN# effective 05/01/2023. No next recredentialing date available. PIN: 9326179. Servicing location is on file. Payer# 60054. Call ref# 6167817975. - Willie Ravas"]
["Johnny L Flitton, PA-C",1437356730,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","Cigna","Participating","Enrollment Complete","2023-08-01","","","2023-10-10","Received confirmation of the locations being added. MS"]
["Johnny L Flitton, PA-C",1437356730,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","Humana","In Process","Payor Follow Up","","","","2023-11-17","11/17/2023 Sent follow-up email to Marcus Wester at Humana to check status of September monthly delegated roster submission.  Provider Add - CO16127988, Provider Changes - CO-16128096,  Provider Terms - CO-16128221.  DCannon"]
["Johnny L Flitton, PA-C",1437356730,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","United Health Care","Participating","Enrollment Complete","2023-09-06","002854139","","2023-09-28","9/28/2023 Rcvd email confirmation from UHC that September delegated roster has been completed.  Provider is PAR and linked to group/location effective 9/6/2023.  DCannon"]
["Johnny L Flitton, PA-C",1437356730,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Medicare","Participating","Enrollment Complete","","","","2023-09-08","Provider is enrolled with all locations under WesTex. MS"]
["Johnny L Flitton, PA-C",1437356730,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Sedgwick","In Process","Payor Follow Up","","","","2023-11-27","Per Sedgwick, Mr. Flitton’s credentialing has been completed & is on the December 2023 credentialing meeting.  It is tentatively scheduled for 12/20/2023. 11/27/2023 Jen Videan \n\nEmailed spneast@sedgwickcms.com for status. Jen Videan"]
["Johnny L Flitton, PA-C",1437356730,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Texas Mutual","In Process","Payor Follow Up","","","","2023-11-22","Emailed wwtxcontracts@texasmutual.com to check status of 6301 Andrews Hwy. Jen Videan"]
["Johnny L Flitton, PA-C",1437356730,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","TriCare Standard","Participating","Enrollment Complete","2023-09-20","","","2023-09-26","Confirmation received  the provider is linked to Briarwood location effective 9/20/23. MS"]
["Johnny L Flitton, PA-C",1437356730,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","TriCare Standard","Participating","Enrollment Complete","2023-09-20","","","2023-10-26","Eastridge location approved eff 10/9/23. MS"]
["Johnny L Flitton, PA-C",1437356730,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","TriCare Standard","Participating","Enrollment Complete","2023-09-20","","","2023-10-26","Eastridge location approved eff 10/9/23. MS"]
["Johnny L Flitton, PA-C",1437356730,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Galaxy Health","Participating","Enrollment Complete","2023-09-06","","","2023-10-11","10/11/2023 Per email received from Galaxy September delegated roster has been processed and provider is PAR and linked to group/location effective 9/6/2023.  DCannon"]
["Johnny L Flitton, PA-C",1437356730,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","USA PPO","In Process","Payor Follow Up","","","","2023-11-27","11/27/2023 Per USA PPO provider portal provider is still not loaded under new locations.  Will allow more time, check back in 2 weeks.  \nDCannon"]
["Johnny L Flitton, PA-C",1437356730,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","BCBSTX","Participating","Enrollment Complete","2023-10-10","","","2023-10-09","10/9/2023 Rcvd email from Priscilla at MQA confirming provider is PAR and linked to group effective 10/10/2023.  DCannon"]
["Johnny L Flitton, PA-C",1437356730,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","Wellmed","Participating","Enrollment Complete","2022-01-01","","","2023-10-13","10/13/2023 Provider is PAR and linked to group TIN effective 1/1/2022.  DCannon"]
["Johnny L Flitton, PA-C",1437356730,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","Caprock (CapStar)","Participating","Enrollment Complete","2023-09-06","","","2023-09-27","9/27/2023 Rcvd email confirmation from Caprock that the September roster has been completed.  Provider is PAR and linked to group/location effective 9/6/2023.  DCannon"]
["Johnny L Flitton, PA-C",1437356730,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Caprock (CapStar)","Participating","Enrollment Complete","2023-09-06","","","2023-09-27","9/27/2023 Rcvd email confirmation from Caprock that the September roster has been completed.  Provider is PAR and linked to group/location effective 9/6/2023.  DCannon"]
["Johnny L Flitton, PA-C",1437356730,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Boon Chapman","Participating","Enrollment Complete","2020-04-03","","","2023-10-12","10/12/2023 Per email received from Jessica Bess at  Multiplan provider is PAR and linked to group TIN/locations effective 4/3/2020.  DCannon"]
["Johnny L Flitton, PA-C",1437356730,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","Boon Chapman","Participating","Enrollment Complete","2020-04-03","","","2023-10-12","10/12/2023 Per email received from Jessica Bess at  Multiplan provider is PAR and linked to group TIN/locations effective 4/3/2020.  DCannon"]
["Johnny L Flitton, PA-C",1437356730,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","Scott&White (First Care)","Participating","Enrollment Complete","2018-12-01","","","2023-10-12","10/12/2023 Per email received from Scott & White provider is PAR and linked to group TIN/locations effective 12/1/2018.  DCannon"]
["Johnny L Flitton, PA-C",1437356730,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Triwest VA","In House Enrollment","In House Enrollment","","","","2021-01-13","1/6/2021 MQA Team is working with Representatives at BCBS-TX to ensure all providers are enrolled and loaded to participate with the VACCN network in a timely manner. However, we are currently awaiting a full roster of providers currently participating and will update all records accordingly upon receipt. Kfrazier"]
["Johnny L Flitton, PA-C",1437356730,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Amerigroup","In Process","Payor Follow Up","","","","2023-10-27","10/27/2023 Sent follow-up email to Amerigroup to check status of September delegated roster submission.  DCannon"]
["Johnny L Flitton, PA-C",1437356730,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","Gallagher","Panel Closed","Panel Closed","","","","2023-09-02","9/2/2023 Pending Coventry enrollment.  Coventry panel closed at this time.  DCannon"]
["Johnny L Flitton, PA-C",1437356730,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Zurich","Panel Closed","Panel Closed","","","","2023-09-02","9/2/2023 Pending Coventry enrollment.  Coventry panel closed at this time."]
["Johnny L Flitton, PA-C",1437356730,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","Zurich","Panel Closed","Panel Closed","","","","2023-09-02","9/2/2023 Pending Coventry enrollment.  Coventry panel closed at this time."]
["Johnny L Flitton, PA-C",1437356730,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Medicare","Participating","Enrollment Complete","2015-05-09","423893ZP5M","","2020-06-15","06/15/2020 - Rec'd spreadsheet from the clinic stating this provider is EFF - Stacey Hudak"]
["Johnny L Flitton, PA-C",1437356730,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","IMS","Participating","Enrollment Complete","2023-09-06","","","2023-10-09","10/9/2023 Per email received from G. Aviles at IMS/OMNI September delegation roster has been completed.  Provider is PAR and linked to group/location effective 9/6/2023.  DCannon"]
["Jeffrey Limbacher, PA-C",1376723361,"47-3465832","TX","","Aetna","Participating","Enrollment Complete","2019-01-01","1376723361","","2020-04-15","04/15/2020 - Rec'd email from the follow up team stating \"S/W Ron of Aetna @ 800-353-1232. Per rep the Provider is on file, linked & participating under the GRP & TIN effective 1/1/2019. Physical Location is on file. Provider ID #9469407. Call ref # 5226062453\"\nIt's clearly stated that THIS PROVIDER HAS DIRECT CONTRACT - Stacey Hudak"]
["Jeffrey Limbacher, PA-C",1376723361,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Boon Chapman","Participating","Enrollment Complete","2023-05-01","","","2023-09-07","9/7/2023 Per email received from Jessica Bess at Multiplan provider is PAR and linked to group TIN/location effective 5/1/2023.  DCannon"]
["Jeffrey Limbacher, PA-C",1376723361,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","First Health Coventry","Participating","Enrollment Complete","2014-12-01","2681483","","2023-09-05","9/5/2023 Per First Health web portal provider is PAR and linked to group TIN/location effective 12/1/2014.  PID #2681483  DCannon"]
["Jeffrey Limbacher, PA-C",1376723361,"47-3465832","TX","","USA PPO","Participating","Enrollment Complete","2018-02-04","","","2020-09-09","Confirmed provider is participating with PPO and H&W networks (list of networks attached). Kimberly Frazier"]
["Jeffrey Limbacher, PA-C",1376723361,"47-3465832","TX","","Aetna","Participating","Enrollment Complete","2019-10-01","9469407","","2023-09-05","9/5/2023 Per email from Priscilla Albertine at MQA she received a roster confirming that provider is PAR and linked to group TIN/location effective 10/1/2019.  DCannon"]
["Jeffrey Limbacher, PA-C",1376723361,"47-3465832","tx","","Caprock (CapStar)","Participating","Enrollment Complete","2023-10-02","","","2023-09-12","9/12/2023 Per email received from Caprock provider has been added to new location 6301 Andrews Hwy effective 10/2/2023.  DCannon"]
["Jeffrey Limbacher, PA-C",1376723361,"47-3465832","TX","","TriCare Standard","Participating","Enrollment Complete","2020-01-30","1376723361","","2020-06-25","06/25/2020 - Verified this provider is participating with this group through payer portal. This group is NON NETWORKED, but this provider is certified - Stacey Hudak"]
["Jeffrey Limbacher, PA-C",1376723361,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","HealthSmart PPO","Participating","Enrollment Complete","2016-04-25","13512484","","2020-07-21","07/21/2020 - rec'd spreadsheet from the payer stating this provider/TIN/service location is EFF - Stacey Hudak"]
["Jeffrey Limbacher, PA-C",1376723361,"47-3465832","TX","","Gallagher","Participating","Enrollment Complete","2015-12-01","","","2021-08-06","8/6/2021 Moved to enrollment complete per notes from First Health/Coventry. Provider is effective 12/1/2015. Kfrazier"]
["Jeffrey Limbacher, PA-C",1376723361,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Wellmed","Participating","Enrollment Complete","2022-01-01","003026419","","2023-11-17","11/17/2023 Per email rcvd from UHC provider is PAR and linked to group TIN and location effective 1/1/2022.  MPIN # 003026419.  DCannon"]
["Jeffrey Limbacher, PA-C",1376723361,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","Wellmed","Participating","Enrollment Complete","2022-01-01","003026419","","2023-11-17","11/17/2023 Per email rcvd from UHC provider is PAR and linked to group TIN and location effective 1/1/2022.  MPIN # 003026419.  DCannon"]
["Jeffrey Limbacher, PA-C",1376723361,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","Wellmed","Participating","Enrollment Complete","2022-01-01","003026419","","2023-11-17","11/17/2023 Per email rcvd from UHC provider is PAR and linked to group TIN and location effective 1/1/2022.  MPIN # 003026419.  DCannon"]
["Jeffrey Limbacher, PA-C",1376723361,"47-3465832","TX","","USA PPO","In Process","Payor Follow Up","","","","2023-11-27","11/27/2023 Per USA PPO provider portal provider is still not loaded under new locations.  Will allow more time, check back in 2 weeks.  \nDCannon"]
["Jeffrey Limbacher, PA-C",1376723361,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","United Health Care","Participating","Enrollment Complete","2020-08-22","003026419","","2023-11-17","11/17/2023 Per email rcvd from UHC provider is PAR and linked to group TIN and location effective 8/22/2020.  MPIN # 003026419.  DCannon"]
["Jeffrey Limbacher, PA-C",1376723361,"47-3465832","TX","","United Health Care","Participating","Enrollment Complete","2020-08-22","003026419","","2023-11-17","11/17/2023 Per email rcvd from UHC provider is PAR and linked to group TIN and location effective 8/22/2020.  MPIN # 003026419.  DCannon"]
["Jeffrey Limbacher, PA-C",1376723361,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","TriCare Standard","Participating","Enrollment Complete","2023-09-20","","","2023-10-26","Eastridge location confirmed eff 10/9/23. MS"]
["Jeffrey Limbacher, PA-C",1376723361,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","TriCare Standard","Participating","Enrollment Complete","2023-09-20","","","2023-11-05","Provider is linked to Andrews Hwy location eff 10/26/23. MS"]
["Jeffrey Limbacher, PA-C",1376723361,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","TriCare Standard","Participating","Enrollment Complete","2023-09-20","","","2023-11-05","Provider is linked to Andrews Hwy location eff 10/26/23. MS"]
["Jeffrey Limbacher, PA-C",1376723361,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","TriCare Standard","Participating","Enrollment Complete","2023-09-20","","","2023-11-05","Provider is linked to Andrews Hwy location eff 10/26/23. MS"]
["Jeffrey Limbacher, PA-C",1376723361,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","CAQH","Participating","CAQH Reattested","2023-11-17","13780299","","2023-11-17","11/17/2023 Updated mailing addresses."]
["Jeffrey Limbacher, PA-C",1376723361,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","CAQH","Participating","CAQH Reattested","2023-11-17","13780299","","2023-11-17","11/17/2023 Updated mailing addresses."]
["Jeffrey Limbacher, PA-C",1376723361,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","CAQH","Participating","CAQH Reattested","2023-11-17","13780299","","2023-11-17","11/17/2023 Updated mailing addresses."]
["Jeffrey Limbacher, PA-C",1376723361,"47-3465832","TX","","Amerigroup","Participating","Enrollment Complete","2023-05-01","","","2023-10-18","10/18/2023 Per email received from Jessica Bess at  Multiplan provider is PAR with Amerigroup and linked to group TIN/locations thru Multiplan enrollment effective 5/1/2023.  DCannon"]
["Jeffrey Limbacher, PA-C",1376723361,"47-3465832","TX","","IMS","Participating","Enrollment Complete","2023-05-01","","","2023-07-20","7/20/2023 Per email received from IMS/OMNI May delegated roster has been processed and provider is PAR and linked to group effective 5/1/2023.  DCannon"]
["Jeffrey Limbacher, PA-C",1376723361,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","HealthSmart PPO","In Process","Payor Follow Up","","","","2023-11-14","11/14/2023 Per Healthsmart provider portal provider is still not loaded under group TIN.  Per phone conversation with Lee Kinard at Healthsmart provider portal should be updated  by 11/27/2023.  Will allow more time, check back in 2 weeks.   DCannon"]
["Jeffrey Limbacher, PA-C",1376723361,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Scott&White (First Care)","Participating","Enrollment Complete","2023-05-01","","","2023-09-04","9/4/2023 Received email from Scott & White HPDELEGATION@BSWHealth.org that provider load from May has been completed and provider is PAR effective 5/1/2023.  DCannon"]
["Jeffrey Limbacher, PA-C",1376723361,"47-3465832","TX","","Scott&White (First Care)","Participating","Enrollment Complete","2023-05-01","","","2023-09-04","9/4/2023 Received email from Scott & White HPDELEGATION@BSWHealth.org that provider load from May has been completed and provider is PAR effective 5/1/2023.  DCannon"]
["Jeffrey Limbacher, PA-C",1376723361,"47-3465832","TX","","Galaxy Health","Participating","Enrollment Complete","2023-05-01","","","2023-07-20","7/20/2023 Per email received from Galaxy May delegated roster has been processed and provider is PAR and linked to group effective 5/1/2023.  DCannon"]
["Jeffrey Limbacher, PA-C",1376723361,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Liberty Mutual","Panel Closed","Panel Closed","","","","2023-09-02","9/2/2023 Pending Coventry enrollment.  Coventry panel is closed at this time.  DCannon"]
["Jeffrey Limbacher, PA-C",1376723361,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","Liberty Mutual","Panel Closed","Panel Closed","","","","2023-09-02","9/2/2023 Pending Coventry enrollment.  Coventry panel is closed at this time.  DCannon"]
["Jeffrey Limbacher, PA-C",1376723361,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","Medicare","Participating","Enrollment Complete","2017-09-01","","","2023-09-08","Provider is enrolled with all locations under WesTex. MS"]
["Jeffrey Limbacher, PA-C",1376723361,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Rail Road Medicare","Participating","Enrollment Complete","2017-09-06","P01938882","DX4335","2020-07-10","07/10/2020 - was able to confirm EFF info through payer site - Stacey Hudak"]
["Jeffrey Limbacher, PA-C",1376723361,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Rail Road Medicare","Participating","Enrollment Complete","2017-09-06","P01938882","DX4335","2020-07-10","07/10/2020 - was able to confirm EFF info through payer site - Stacey Hudak"]
["Jeffrey Limbacher, PA-C",1376723361,"47-3465832","TX","","Sedgwick","Participating","Enrollment Complete","2018-12-14","1214700","","2021-01-26","1/26/2021 - Per follow-up notes provider is par with TIN and location effective 12/14/2018.  DCannon"]
["Jeffrey Limbacher, PA-C",1376723361,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","BCBSTX","Participating","Enrollment Complete","2017-03-09","","","2023-10-02","10/2/2023 Per BCBS TX roster received from Priscilla Albertine at MQA provider is PAR and linked to group effective 3/9/2017.  DCannon"]
["Jeffrey Limbacher, PA-C",1376723361,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","BCBSTX","Participating","Enrollment Complete","2017-03-09","","","2023-10-02","10/2/2023 Per BCBS TX roster received from Priscilla Albertine at MQA provider is PAR and linked to group effective 3/9/2017.  DCannon"]
["Jeffrey Limbacher, PA-C",1376723361,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","BCBSTX","Participating","Enrollment Complete","2017-03-09","","","2023-10-02","10/2/2023 Per BCBS TX roster received from Priscilla Albertine at MQA provider is PAR and linked to group effective 3/9/2017.  DCannon"]
["Jeffrey Limbacher, PA-C",1376723361,"47-3465832","tx","","Scott&White (First Care)","Participating","Enrollment Complete","2023-09-14","","","2023-09-29","9/29/2023 Rcvd confirmation from Scott & White that provider has been loaded at all locations effective 9/14/2023.  DCannon"]
["Jeffrey Limbacher, PA-C",1376723361,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Caprock (CapStar)","Participating","Enrollment Complete","2014-12-01","","","2020-09-14",""]
["Jeffrey Limbacher, PA-C",1376723361,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Zurich","Panel Closed","Panel Closed","","","","2023-09-02","9/2/2023 Pending Coventry enrollment.  Coventry panel is closed at this time.   DCannon"]
["Jeffrey Limbacher, PA-C",1376723361,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Multiplan","Participating","Enrollment Complete","2022-01-03","","","2022-03-10","3/10/2022 Rcvd roster from Multiplan listing provider as PAR and listed under group TIN/location effective 1/3/2022.  DCannon"]
["Jeffrey Limbacher, PA-C",1376723361,"47-3465832","TX","","Medicare","Participating","Enrollment Complete","2017-09-01","615599ZP5M","","2020-06-15","06/15/2020 - Rec'd spreadsheet from the clinic stating this proivder is EFF - Stacey Hudak"]
["Jeffrey Limbacher, PA-C",1376723361,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Texas Mutual","In Process","Payor Follow Up","","","","2023-11-22","Emailed wwtxcontracts@texasmutual.com to check status of 6301 Andrews Hwy. Jen Videan"]
["Jeffrey Limbacher, PA-C",1376723361,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Gallagher","Panel Closed","Panel Closed","","","","2023-09-02","9/2/2023 Pending Coventry enrollment.   Coventry panel closed at this time.  DCannon"]
["Jeffrey Limbacher, PA-C",1376723361,"47-3465832","TX","","Rail Road Medicare","Participating","Enrollment Complete","2017-09-06","P01938882","DX4335","2020-07-10","07/10/2020 - was able to confirm EFF info through payer site - Stacey Hudak"]
["Jeffrey Limbacher, PA-C",1376723361,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Cigna","Participating","Enrollment Complete","2023-05-01","","","2023-07-18","7/18/2023 Rcvd email from Cigna that provider is PAR and linked to new practice locations effective 5/1/2023.  PID # 8867748 DCannon"]
["Jeffrey Limbacher, PA-C",1376723361,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Sedgwick","In Process","Application Submitted","","","",45251,"Emailed roster to cynthia.clancy@sedgwick.com to add 6301 Andrews Hwy to provider's profile. Jen Videan"]
["Jeffrey Limbacher, PA-C",1376723361,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","Sedgwick","In Process","Application Submitted","","","","2023-11-21","Emailed roster to cynthia.clancy@sedgwick.com to add 6301 Andrews Hwy to provider's profile. Jen Videan"]
["Jeffrey Limbacher, PA-C",1376723361,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Humana","Participating","Enrollment Complete","2017-11-30","","","2023-09-15","9/15/2023 Per email received from Humana provider is PAR and linked to group TIN/locations effective 11/30/2017.  DCannon"]
["Jeffrey Limbacher, PA-C",1376723361,"47-3465832","TX","","First Health Coventry","Participating","Enrollment Complete","2014-12-01","2681483","","2020-03-20","3/20/2020-receieved email with roster stating provider PAR 12/1/2014 PID # 2681483\ntisha rader"]
["Jeffrey Limbacher, PA-C",1376723361,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","Multiplan","Participating","Enrollment Complete","2023-10-02","","","2023-09-20","9/20/2023 Per email received from Jessica Bess at Multiplan August roster has been completed.  Provider is PAR and linked to group TIN/location effective 10/2/2023.  DCannon"]
["Gautham S Gadiraju, MD",1649462987,"47-5554737","TX","PE - Midland Inpatient Medical Association","Galaxy Health","Participating","Enrollment Complete","2018-10-26","1649462987","","2020-07-10","07/10/2020 - updated payer line to enrollment complete status instead of \"Delegated status\" for report running purposes - Stacey Hudak"]
["Gautham S Gadiraju, MD",1649462987,"47-5554737","TX","PE - Midland Inpatient Medical Association","Wellmed","Participating","Enrollment Complete","2020-06-01","","","2023-03-23","3/23/2023 Rcvd roster from UHC w/ all Wellmed participating providers.  Provider is PAR effective 6/1/2020.  DCannon"]
["Vamsi K Korrapati, MD",1407149883,"47-5554737","TX","PE - Midland Inpatient Medical Association","Caprock (CapStar)","Participating","Enrollment Complete","2018-10-22","1407149883","","2020-06-02","06/02/2020 - rec'd spreadsheet back from the payer Mary Rodriguez <MRodriguez@caprockhp.com> confirming this provider/service location is EFF with this payer - Stacey Hudak"]
["Vamsi K Korrapati, MD",1407149883,"47-5554737","TX","PE - Midland Inpatient Medical Association","Rail Road Medicare","Participating","Enrollment Complete","2018-09-01","P02262526","","2020-03-25","3/25/2020--Per online check, provider is now PAR effective 09/01/2018 with provider number P02262526. Attached welcome letter to payor line\n--tisha rader"]
["Vamsi K Korrapati, MD",1407149883,"47-5554737","TX","PE - Midland Inpatient Medical Association","HealthSmart PPO","Participating","Enrollment Complete","2018-10-26","1407149883","","2020-06-05","060/5/2020 - Rec'd email from the payer stating this provider is EFF - Stacey HUdak"]
["Vamsi K Korrapati, MD",1407149883,"47-5554737","TX","PE - Midland Inpatient Medical Association","USA PPO","Participating","Enrollment Complete","2018-10-26","1407149883","475554737","2020-08-18","Confirmed provider is participating with PPO and H&W networks (list of networks attached). Kimberly Frazier"]
["Purshotham R Ginne, MD",1255584397,"47-5554737","TX","PE - Midland Inpatient Medical Association","TriCare Standard","Participating","Enrollment Complete","2019-09-01","1255584397","","2020-03-03","03/03/2020 - This provider is linked to this group and service location, however, this group/provider is NON NETWORK. This payer is not currently open to accepting new groups/providers in network.  - Stacey Hudak"]
["Purshotham R Ginne, MD",1255584397,"47-5554737","TX","PE - Midland Inpatient Medical Association","Rail Road Medicare","Participating","Enrollment Complete","2019-07-01","P02326890","","2020-03-30","3/25/2020--Per online check, provider is now PAR effective 07/01/2019 with provider number P02326890. Attached welcome letter to payor line\ntisha rader"]
["Purshotham R Ginne, MD",1255584397,"47-5554737","TX","PE - Midland Inpatient Medical Association","Triwest VA","Enrollment Stopped","Enrollment Stopped","","","","","Practice is hospital-based; not eligible for TriWest VA enrollment"]
["Olufemi Aduroja, MD",1366762874,"47-5554737","TX","PE - Midland Inpatient Medical Association","USA PPO","Participating","Enrollment Complete","2020-01-23","1276203","","2020-09-04","Confirmed provider is participating with PPO and H&W networks (see attached list of networks). Kimberly Frazier"]
["Olufemi Aduroja, MD",1366762874,"47-5554737","TX","","USA PPO","Participating","Enrollment Complete","2020-01-23","1276203","","2020-09-04","Confirmed provider is participating with PPO and H&W networks (see attached list of networks). Kimberly Frazier"]
["Olufemi Aduroja, MD",1366762874,"47-5554737","TX","PE - Midland Inpatient Medical Association","HealthSmart PPO","Participating","Enrollment Complete","2020-01-31","1366762874","","2020-06-05","06/05/2020 - Rec'd email from the payer stating this provider is EFF - Stacey Hudak+"]
["Olufemi Aduroja, MD",1366762874,"47-5554737","TX","PE - Midland Inpatient Medical Association","Scott&White (First Care)","Participating","Enrollment Complete","2020-01-10","","","2021-01-14","1/14/2021 - Rcvd email from payer that provider is participating and loaded under tax ID effective 1/10/2020.  DCannon"]
["Olufemi Aduroja, MD",1366762874,"47-5554737","TX","","Scott&White (First Care)","Participating","Enrollment Complete","2020-01-10","","","2021-01-14","1/14/2021 - Rcvd email from payer that provider is participating and loaded under tax ID effective 1/10/2020.  DCannon"]
["Olufemi Aduroja, MD",1366762874,"47-5554737","TX","","Triwest VA","Enrollment Stopped","Enrollment Stopped","","","","","Practice is hospital-based; not eligible for TriWest VA enrollment"]
["Olufemi Aduroja, MD",1366762874,"47-5554737","TX","","IMS","Participating","Enrollment Complete","2020-01-31","1366762874","","2020-06-22","06/22/2020- Rec'd email from the payer confirming this provider is PAR with this group/service location - Stacey Hudak"]
["Olufemi Aduroja, MD",1366762874,"47-5554737","TX","","Superior","Participating","Enrollment Complete","2020-03-01","1366762874","","2020-07-14","07/14/2020 - Rec'd email from the payer stating this provider is EFF under PRIMED DELEGATED agreement - Stacey Hudak"]
["Hagos Z Aymut, MD",1922548890,"47-5554737","TX","PE - Midland Inpatient Medical Association","Ambetter","Participating","Enrollment Complete","2022-04-01","","","2022-06-13","6/13/2022 Received April Monthly Validation roster from Superior and provider is PAR and linked effective 4/1/2022.  DCannon"]
["Hagos Z Aymut, MD",1922548890,"47-5554737","TX","PE - Midland Inpatient Medical Association","Humana","Participating","Enrollment Complete","2021-09-01","","","2021-11-18","11/18/2021 Rcvd full roster from Humana listing provider as PAR and linked to group TIN/location effective 9/1/2021.  DCannon"]
["Hagos Z Aymut, MD",1922548890,"47-5554737","TX","PE - Midland Inpatient Medical Association","United Health Care","Participating","Enrollment Complete","2020-07-15","1922548890","","2020-09-24","09/24/2020 - Rec'd email from the payer stating \"Good news! We’ve completed the provider/group updates you requested on Sep 9, 2020 8:14:13 AM. Your request was assigned reference number PR-5483219 .\"  - Stacey Hudak"]
["Suresh K Ravuri, MD",1750539268,"47-5554737","TX","PE - Midland Inpatient Medical Association","TriCare Standard","Participating","Enrollment Complete","2020-07-29","","","2020-09-24","Confirmed via self-service portal, provider is a certified non-network provider under group Tax ID and appropriate location. Group is not contracted as 'participating' only non-network.  Kimberly Frazier"]
["Suresh K Ravuri, MD",1750539268,"47-5554737","TX","PE - Midland Inpatient Medical Association","Cigna","Participating","Enrollment Complete","2019-09-01","3176267","","2020-05-19","05/19/2020 - Rec'd email from the payer stating \"This is to confirm that your request has been completed\" _ Stacey Hudak"]
["Suresh K Ravuri, MD",1750539268,"47-5554737","TX","PE - Midland Inpatient Medical Association","Scott&White (First Care)","Participating","Enrollment Complete","2020-09-28","","",44210,"1/14/2021 - Rcvd email from payer that provider is participating and loaded under tax ID effective 9/28/2020.  DCannon"]
["Suresh K Ravuri, MD",1750539268,"47-5554737","TX","PE - Midland Inpatient Medical Association","Humana","Participating","Enrollment Complete","2021-09-01","","","2021-11-18","11/18/2021 Rcvd full roster from Humana listing provider as PAR and linked to group TIN/location effective 9/1/2021.  DCannon"]
["Bola O Jaiyeola, NP",1235605064,"47-5554737","TX","PE - Midland Inpatient Medical Association","TriCare Standard","Participating","Enrollment Complete","2021-02-17","","","2021-04-02","4/2/2021 Per Humana Millitary portal provider is certified and linked to TIN and location effective 2/17/2021.   Also rcvd approval letter confirming certification.  DCannon"]
["Bola O Jaiyeola, NP",1235605064,"47-5554737","TX","PE - Midland Inpatient Medical Association","HealthSmart PPO","Participating","Enrollment Complete","2021-02-08","","","2021-05-04","5/4/2021 Rcvd confirmation from Healthsmart <cgc.data@healthsmart.com> that provider is PAR and loaded under TIN and location effective 2/8/2021.  DCannon"]
["Bola O Jaiyeola, NP",1235605064,"47-5554737","TX","PE - Midland Inpatient Medical Association","Multiplan","Participating","Enrollment Complete","2021-02-08","","","2022-07-24","7/24/2022 Per email from Marcie Eckhart-Havens Multiplan July delegated roster has been completed  and provider is PAR and linked to group TIN effective 2/8/2021.  DCannon"]
["Bola O Jaiyeola, NP",1235605064,"47-5554737","TX","PE - Midland Inpatient Medical Association","United Health Care","Participating","Enrollment Complete","2021-02-18","","","2021-05-10","5/10/2021 Received an email response from Rep jean.lambert@optum.com with confirmation provider has been approved under group Tax ID effective 2/18/2021. KFrazier"]
["Rebecca McClay, DNP",1629613070,"47-5554737","TX","PE - Midland Inpatient Medical Association","Cigna","Participating","Enrollment Complete","2021-02-08","1427518","","2021-05-04","5/4/2021 Received an email from PDMCOGZ@Cigna.com confirming provider is participating under group Tax ID effective 2/8/2021 with PID number 1427518. KFrazier"]
["Rebecca McClay, DNP",1629613070,"47-5554737","TX","PE - Midland Inpatient Medical Association","Multiplan","Participating","Enrollment Complete","2021-03-15","","","2022-07-24","7/24/2022 Per email from Marcie Eckhart-Havens Multiplan July delegated roster has been completed  and provider is PAR and linked to group TIN effective 3/15/2021.  DCannon"]
["Rebecca McClay, DNP",1629613070,"47-5554737","TX","PE - Midland Inpatient Medical Association","Ambetter","Participating","Enrollment Complete","2022-04-01","","","2022-06-13","6/13/2022 Per roster received from Superior provider is PAR and linked to group delegation roster effective 4/1/2022."]
["Karthik Chakrala, DO",1043633233,"47-5554737","TX","PE - Midland Inpatient Medical Association","Wellmed","Participating","Enrollment Complete","2021-07-09","","","2023-03-23","3/23/2023 Rcvd roster from UHC w/ all Wellmed participating providers.  Provider is PAR effective 7/9/2021.  DCannon"]
["Karthik Chakrala, DO",1043633233,"47-5554737","TX","PE - Midland Inpatient Medical Association","Ambetter","Participating","Enrollment Complete","2022-04-01","","","2022-06-13","6/13/2022 Received April Monthly Validation roster from Superior and provider is PAR and linked effective 4/1/2022.  DCannon"]
["Karthik Chakrala, DO",1043633233,"47-5554737","TX","PE - Midland Inpatient Medical Association","Humana","Participating","Enrollment Complete","2021-09-01","","","2021-11-18","11/18/2021 Rcvd full roster from Humana listing provider as PAR and linked to group TIN/location effective 9/1/2021.  DCannon"]
["Karthik Chakrala, DO",1043633233,"47-5554737","TX","PE - Midland Inpatient Medical Association","First Health Coventry","Participating","Enrollment Complete","2021-05-15","","","2023-06-02","06.02.2023 S/W Trina of First Health @ 800-226-5116. Rep advised to call aetna first to see if provider is credentialed with aetna. S/W Chris of Aetna @ 1-800-353-1232. Per rep, provider is showing participating with First Health and link under the Group and TIN with an Effective date 05/15/2021. Provider ID 4722352, Payer ID 60025 and Recredentialing date 05/15/2024. Service location is on file. Call ref#:6149441125. - Danico Gabriel Melendres"]
["Brenda Campos-Ilesanmi, APRN-NP",1740807304,"47-5554737","TX","PE - Midland Inpatient Medical Association","Scott&White (First Care)","Participating","Enrollment Complete","2021-10-20","","","2021-10-06","10/6/2021 Received an email from swhpexpedites@bswhealth.org confirming provider is participating under group Tax ID effective 10/20/2021. KFrazier"]
["Brenda Campos-Ilesanmi, APRN-NP",1740807304,"47-5554737","TX","PE - Midland Inpatient Medical Association","Cigna","Participating","Enrollment Complete","2021-09-13","3896115","","2021-10-09","10/9/21 Received email from pdmcogz@cigna.com Update has been made. provider effective as of 9/13/21, PID 3896115. Cbankston"]
["Brenda Campos-Ilesanmi, APRN-NP",1740807304,"47-5554737","TX","PE - Midland Inpatient Medical Association","First Health Coventry","Participating","Enrollment Complete","2021-12-01","3546219","","2022-08-10","8/10/2022 Per First Health web portal provider is PAR and linked to group TIN/location effective 12/1/2021.  PID # 3546219.  DCannon"]
["Addis Getahun, MD",1548765183,"47-5554737","TX","PE - Midland Inpatient Medical Association","Aetna","Participating","Enrollment Complete","2021-11-01","6261482","","2022-02-24","2/24/2022 Per follow-up note from 2/17/2022  Provider NPI# is on file for the provider and is participating effective 11/1/21 under the group and TIN#. PIN 6261482. Physical location is on file. Ref# 6075333572.  -DCannon"]
["Addis Getahun, MD",1548765183,"47-5554737","TX","PE - Midland Inpatient Medical Association","Cigna","Participating","Enrollment Complete","2021-10-21","4000052","","2021-10-28","10/28/2021 Per follow-up notes.  Provider NPI# is on file for the provider and is participating effective 10/21/2021 under the group and TIN#. PIN 4000052. Physical location is on file. Call ref# Roberts10272021."]
["Addis Getahun, MD",1548765183,"47-5554737","TX","PE - Midland Inpatient Medical Association","Medicare","Participating","Enrollment Complete","2021-10-21","1V7718","519061","2021-10-25","10/25/2021 Rcvd email from Medicare that provider's app has been approved.  Per PECOS provider's PTAN 1V7718 - Effective 10/21/2021.  DCannon"]
["Addis Getahun, MD",1548765183,"47-5554737","TX","PE - Midland Inpatient Medical Association","Galaxy Health","Participating","Enrollment Complete","2021-11-01","","","2021-12-12","12/12/2021 Sent f/u email to Michelle Monroe at Galaxy to check status of November Delegated Roster load.  Per email response November Delegated Roster load has been completed and provider is PAR w/ group/location effective 11/1/2021.  DCannon"]
["Martha Denise Mourning, NP",1922552959,"47-5554737","TX","PE - Midland Inpatient Medical Association","Ambetter","Participating","Enrollment Complete","2022-04-01","","","2022-06-13","6/13/2022 Per roster received from Superior provider is PAR and linked to group delegation roster effective 4/1/2022."]
["Martha Denise Mourning, NP",1922552959,"47-5554737","TX","PE - Midland Inpatient Medical Association","Humana","Participating","Enrollment Complete","2021-10-29","","","2023-02-17","2/17/2023 Per email received from Priscilla Albertine at MQA she received confirmation from Humana that provider is PAR and linked to group TIN/location effective 10/29/2021.  DCannon"]
["Martha Denise Mourning, NP",1922552959,"47-5554737","TX","PE - Midland Inpatient Medical Association","Medicaid","Participating","Enrollment Complete","2017-04-01","1922552959","","2022-03-23","3/23/2022 Per TMHP provider portal provider is PAR and linked to group effective 4/1/2017.  DCannon"]
["Daniel Gellan, MD",1811315880,"47-5554737","TX","PE - Midland Inpatient Medical Association","Galaxy Health","Participating","Enrollment Complete","2021-11-18","","","2022-03-10","3/10/2022 Rcvd email from K. Avalos @ Galaxy that provider is PAR and linked to group TIN/location effective 11/18/2021.  DCannon"]
["Daniel Gellan, MD",1811315880,"47-5554737","TX","PE - Midland Inpatient Medical Association","Boon Chapman","Participating","Enrollment Complete","2021-11-18","","","2022-03-10","3/10/2022 Rcvd roster from Multiplan listing provider as PAR and listed under group TIN/location effective 11/18/2021.  DCannon"]
["Daniel Gellan, MD",1811315880,"47-5554737","TX","PE - Midland Inpatient Medical Association","CAQH","Participating","CAQH Reattested","2023-11-07","","","2023-11-07","11/7/2023 CAQH reviewed and re-attested.  Uploaded current malpractice COI.  DCannon"]
["Daniel Gellan, MD",1811315880,"47-5554737","TX","PE - Midland Inpatient Medical Association","TriCare Standard","Participating","Enrollment Complete","2021-12-15","","","2022-02-24","2/24/2022 Per Humana Tricare portal provider is PAR and linked to group TIN/location effective 12/15/2021.  DCannon"]
["Venkatasubbaraya Achanta, MD",1780693648,"47-5554737","TX","PE - Midland Inpatient Medical Association","Omni PPO","Participating","Enrollment Complete","2022-01-10","","","2022-02-04","2/4/2022 Rcvd email from G. Aviles @ IMS/Omni that provider is PAR and linked to group TIN/location effective 1/10/2022.  DCannon"]
["Venkatasubbaraya Achanta, MD",1780693648,"47-5554737","TX","PE - Midland Inpatient Medical Association","Humana","Participating","Enrollment Complete","2022-01-10","","","2022-06-19","6/19/2022 Per email received from Priscilla Albertine at MQA from a follow-up email she received from Humana provider is PAR and linked to group TIN effective 1/10/2022.  DCannon"]
["Venkatasubbaraya Achanta, MD",1780693648,"47-5554737","TX","PE - Midland Inpatient Medical Association","Boon Chapman","Participating","Enrollment Complete","2022-01-15","","","2022-01-24","1/24/2022 Rcvd Multiplan approval letter, provider is PAR and linked to group/location effective 1/15/2022.  DCannon"]
["Kendra Cooper, APRN-FNP-BC",1780334193,"47-5554737","TX","PE - Midland Inpatient Medical Association","Wellmed","Participating","Enrollment Complete","2022-05-09","","","2023-03-23","3/23/2023 Rcvd roster from UHC w/ all Wellmed participating providers.  Provider is PAR effective 5/9/2022.  DCannon"]
["Kendra Cooper, APRN-FNP-BC",1780334193,"47-5554737","TX","PE - Midland Inpatient Medical Association","Medicaid","Enrollment Stopped","Enrollment Stopped","","","","2022-09-22","9/22/2022 Per Candace Wynne provider is not practicing under MIMA TIN.  DCannon"]
["Kendra Cooper, APRN-FNP-BC",1780334193,"47-5554737","TX","PE - Midland Inpatient Medical Association","TriCare Standard","Participating","Enrollment Complete","2022-07-12","","","2022-07-14","7/14/2022 Per Humana Military provider portal provider is PAR and linked to group TIN/location effective 7/12/2022.  DCannon"]
["Suresh K Kota, MD",1609921782,"47-5554737","TX","PE - Midland Inpatient Medical Association","First Health Coventry","Participating","Enrollment Complete","2023-09-08","","","2023-11-07","11/7/2023 S/W Bridgette of First Health @ 800-226-5116. Per rep, provider is PAR and linked to group TIN and location effective 9/8/2023.  PID # 1037148.  DCannon"]
["Suresh K Kota, MD",1609921782,"47-5554737","TX","PE - Midland Inpatient Medical Association","Omni PPO","Participating","Enrollment Complete","2023-09-08","","","2023-10-09","10/9/2023 Per email received from G. Aviles at IMS/OMNI September delegation roster has been completed.  Provider is PAR and linked to group/location effective 9/8/2023.  DCannon"]
["Suresh K Kota, MD",1609921782,"47-5554737","TX","PE - Midland Inpatient Medical Association","Wellmed","Participating","Enrollment Complete","2023-09-08","","","2023-09-28","9/28/2023 Rcvd email confirmation from UHC that September delegated roster has been completed.  Provider is PAR and linked to group/location effective 9/8/2023.  DCannon"]
["Suresh K Kota, MD",1609921782,"47-5554737","TX","PE - Midland Inpatient Medical Association","Multiplan","Participating","Enrollment Complete","2023-09-08","","","2023-10-12","10/12/2023 Per email received from Jessica Bess at  Multiplan provider is PAR and linked to group TIN/locations effective 9/8/2023.  DCannon"]
["Rajnarsing R Chennamaneni, MD",1164689634,"47-5554737","TX","PE - Midland Inpatient Medical Association","United Health Care","In Process","Payor Receipt Validated","","","","2023-11-15","11/15/2023 Rcvd confirmation email that November delegated roster was received.  Reference Number: PR-7842834.  DCannon"]
["Rajnarsing R Chennamaneni, MD",1164689634,"47-5554737","TX","PE - Midland Inpatient Medical Association","Wellmed","Thru Other Payor","Pending Other Enrollment","","","","2023-11-09","11/9/2023 Pending UHC enrollment.  DCannon"]
["Rajnarsing R Chennamaneni, MD",1164689634,"47-5554737","TX","PE - Midland Inpatient Medical Association","Omni PPO","In Process","Application Submitted","","","","2023-11-15","11/15/2023 Delegated roster submitted.  DCannon"]
["Sudhir K Chiluka, MD",1912452053,"47-5554737","TX","PE - Midland Inpatient Medical Association","Aetna","In Process","Pending PSV","","","","2023-11-09",""]
["Sudhir K Chiluka, MD",1912452053,"47-5554737","TX","PE - Midland Inpatient Medical Association","Medicaid","Pending Other Enrollment","Pending Medicare","","","","2023-11-15",""]
["Sudhir K Chiluka, MD",1912452053,"47-5554737","TX","PE - Midland Inpatient Medical Association","Cigna","In Process","Application Submitted","","","","2023-11-15","Application submitted to MedicalOnboarding. MS"]
["Maung K Hlaing, MD",1306167309,"47-5554737","TX","PE - Midland Inpatient Medical Association","Boon Chapman","Participating","Enrollment Complete","2020-03-20","","","2022-07-24","7/24/2022 Per email from Marcie Eckhart-Havens Multiplan July delegated roster has been completed  and provider is PAR and linked to group TIN effective 3/20/2020.  DCannon"]
["Maung K Hlaing, MD",1306167309,"47-5554737","TX","PE - Midland Inpatient Medical Association","Medicaid","Participating","Enrollment Complete","2016-06-22","341272802","364596201","2022-02-08","2/8/2022 Per TMHP web portal revalidation has been completed.  Revalidation date:  10/24/2026.  DCannon"]
["Maung K Hlaing, MD",1306167309,"47-5554737","TX","","Triwest VA","Enrollment Stopped","In House Enrollment","","","","2021-01-14","1/6/2021 MQA Team is working with Representatives at BCBS-TX to ensure all providers are enrolled and loaded to participate with the VACCN network in a timely manner. However, we are currently awaiting a full roster of providers currently participating and will update all records accordingly upon receipt. Kfrazier"]
["Maung K Hlaing, MD",1306167309,"47-5554737","TX","PE - Midland Inpatient Medical Association","Medicare","Participating","Enrollment Complete","2016-06-22","355008ZV0W","519061","2020-04-20","04/20/2020 - found EFF info through group PECOS to update payer lines - Stacey Hudak"]
["Alaaedin Alhomosh, MD",1063709913,"47-5554737","TX","PE - Midland Inpatient Medical Association","Wellcare","Participating","Enrollment Complete","2021-11-01","","","2022-11-15","11/15/2022 Per roster received from Wellcare provider is PAR and linked to group TIN/location effective 11/1/2021.  DCannon"]
["Alaaedin Alhomosh, MD",1063709913,"47-5554737","TX","PE - Midland Inpatient Medical Association","Humana","Participating","Enrollment Complete","2021-09-01","","","2021-11-18","11/18/2021 Rcvd full roster from Humana listing provider as PAR and linked to group TIN/location effective 9/1/2021.  DCannon"]
["Alaaedin Alhomosh, MD",1063709913,"47-5554737","TX","PE - Midland Inpatient Medical Association","Triwest VA","Enrollment Stopped","Enrollment Stopped","","","","","Practice is hospital-based; not eligible for TriWest VA enrollment"]
["Alaaedin Alhomosh, MD",1063709913,"47-5554737","TX","PE - Midland Inpatient Medical Association","Omni PPO","Participating","Enrollment Complete","2021-01-07","","","2021-01-01","4/1/2021 Rcvd confirmation email from payor that providers have been loaded according to the monthly delegation roster.  DCannon"]
["Nancy Asamoa, MD",1023135639,"47-5554737","TX","PE - Midland Inpatient Medical Association","HealthSmart PPO","Participating","Enrollment Complete","2021-03-15","","","2021-05-04","5/4/2021 Rcvd confirmation from Healthsmart <cgc.data@healthsmart.com> that provider is PAR and loaded under TIN and location effective 3/15/2021.  DCannon"]
["Nancy Asamoa, MD",1023135639,"47-5554737","TX","PE - Midland Inpatient Medical Association","Rail Road Medicare","Participating","Enrollment Complete","2016-09-15","P01732061","DW7662","2021-03-09","3/9/2021 Rcvd RR Medicare PTAN approval letter.  DCannon"]
["Nancy Asamoa, MD",1023135639,"47-5554737","TX","PE - Midland Inpatient Medical Association","Medicare","Participating","Enrollment Complete","2016-09-15","469348ZV0W","519016","2021-02-19","2/19/2021 Received rejection notice stating provider is already assigned PTAN under group, which is 469348ZV0W, effective 9/15/2016. KFrazier"]
["Nancy Asamoa, MD",1023135639,"47-5554737","TX","PE - Midland Inpatient Medical Association","Superior","Participating","Enrollment Complete","2021-05-01","","","2021-05-04","5/4/2021 Rcvd email from Superior confirming that the providers are PAR and loaded under TIN/locations effective 5/1/2021.  DCannon"]
["Karen Ward, NP-C, CNOR, RNFA",1790831493,"47-5554737","TX","PE - Midland Inpatient Medical Association","HealthSmart PPO","Participating","Enrollment Complete","2021-04-13","","","2021-06-03","6/1/2021 Per Healthsmart website provider is PAR and loaded under TIN/location effective 4/13/2021.  DCannon"]
["Karen Ward, NP-C, CNOR, RNFA",1790831493,"47-5554737","TX","PE - Midland Inpatient Medical Association","Medicaid","Participating","Enrollment Complete","2020-12-19","367241202","364596201","2021-04-12","4/12/2021 Upon review of group TMHP portal, provider has been approved effective 12/19/2020 with assigned TPI 367241202. KFrazier"]
["Karen Ward, NP-C, CNOR, RNFA",1790831493,"47-5554737","TX","PE - Midland Inpatient Medical Association","Wellcare","Participating","Enrollment Complete","2021-11-01","","","2022-12-01","12/1/2022 Per roster received from Wellcare provider is PAR and linked to group TIN/location effective 11/1/2021.  DCannon"]
["Allen E Gibson, MD",1912068446,"47-5554737","TX","PE - Midland Inpatient Medical Association","TriCare Standard","Participating","Enrollment Complete","2019-09-01","1912068446","","2020-03-03","03/03/2020 - This provider is linked to this group and service location, however, this group/provider is NON NETWORK. This payer is not currently open to accepting new groups/providers in network.  - Stacey Hudak"]
["Allen E Gibson, MD",1912068446,"47-5554737","TX","PE - Midland Inpatient Medical Association","IMS","Participating","Enrollment Complete","2019-09-01","1912068446","","2020-07-27","07/27/2020 - Rec'd roster response back from the payer regarding 7/15/2020 submission stating that all requested providers/service locations have been added to PriMed agreement - Stacey Hudak"]
["Allen E Gibson, MD",1912068446,"47-5554737","TX","PE - Midland Inpatient Medical Association","Rail Road Medicare","Participating","Enrollment Complete","2016-08-02","P01752740","DW7662","2020-05-04","05/04/2020 - verified and marked EFF - Stacey Hudak"]
["Allen E Gibson, MD",1912068446,"47-5554737","TX","PE - Midland Inpatient Medical Association","First Health Coventry","Participating","Enrollment Complete","2020-11-01","1901814","","2020-12-17","12/17/2020 - Rcvd confirmation email from payor that credentialing has been completed.  CPID 1901814 effective 11/1/2020.  DCannon"]
["Ajay K Vaikuntam, MD",1447415476,"47-5554737","TX","PE - Midland Inpatient Medical Association","Humana","Participating","Enrollment Complete","2020-01-01","1447415476","","2020-07-15","7/15/2020 - Received email spreadsheet from the payor confirming that this provider is EFF at this service location and PAR with the PRIMED DELEGATED agreement - Pam Porter"]
["Ajay K Vaikuntam, MD",1447415476,"47-5554737","TX","PE - Midland Inpatient Medical Association","Caprock (CapStar)","Participating","Enrollment Complete","2020-03-01","1447415476","","",""]
["Ajay K Vaikuntam, MD",1447415476,"47-5554737","TX","PE - Midland Inpatient Medical Association","Rail Road Medicare","Participating","Enrollment Complete","2017-07-10","P01909454","","2020-03-25","3/25/2020--Per online check, provider is now PAR effective 07/10/2017 with provider number P01909454. Attached welcome letter to payor line\ntisha rader"]
["Adriana E Nur, MD",1619982584,"47-5554737","TX","","Multiplan","Participating","Enrollment Complete","2020-05-01","","","2022-07-24","7/24/2022 Per email from Marcie Eckhart-Havens Multiplan July delegated roster has been completed  and provider is PAR and linked to group TIN effective 5/1/2020.   DCannon"]
["Adriana E Nur, MD",1619982584,"47-5554737","TX","","IMS","Participating","Enrollment Complete","2019-09-01","1619982584","","2020-07-27","07/27/2020 - Rec'd roster response back from the payer regarding 7/15/2020 submission stating that all requested providers/service locations have been added to PriMed agreement - Stacey Hudak"]
["Adriana E Nur, MD",1619982584,"47-5554737","TX","","Humana","Participating","Enrollment Complete","2020-01-01","1619982584","","2020-07-02","7/2/2020 - Received email spreadsheet from the payor confirming that this provider is EFF at this service location and PAR with the PRIMED DELEGATED agreement - Pam Porter"]
["Adriana E Nur, MD",1619982584,"47-5554737","TX","PE - Midland Inpatient Medical Association","First Health Coventry","Participating","Enrollment Complete","2020-08-01","","","2021-10-13","10/13/2021  Per First Health online provider directory provider is PAR and linked to group/locations  effective 8/1/2020.  DCannon"]
["Adriana E Nur, MD",1619982584,"47-5554737","TX","PE - Midland Inpatient Medical Association","Scott&White (First Care)","Participating","Enrollment Complete","2020-09-28","","","2021-01-29","1/29/2021 - Rcvd roster from Scott&White (First Care) confirming participation of provider with TIN and location effective dates.  DCannon"]
["Adriana E Nur, MD",1619982584,"47-5554737","TX","PE - Midland Inpatient Medical Association","TriCare Standard","Participating","Enrollment Complete","2018-11-30","","","2020-10-23","10/23/2020 Upon review of the self-service portal, provider is participating under group Tax ID and location effective 11/30/2018; therefore, this also confirms provider is certified as a non-network provider since it's required prior to participation. Kimberly Frazier"]
["Adriana E Nur, MD",1619982584,"47-5554737","TX","PE - Midland Inpatient Medical Association","Superior","Participating","Enrollment Complete","2020-08-01","1619982584","","2020-08-06","8/6/2020 - Rec'd an email from the payer stating this provider was added to their database EFF: 8-1-2020 after receiving/processing the July roster - Stacey Hudak"]
["Juan C Gil, MD",1558392779,"47-5554737","TX","PE - Midland Inpatient Medical Association","IMS","Participating","Enrollment Complete","2020-07-20","","","2020-08-25","Confirmed provider is participating under delegation with this location effective 7/20/2020. Kimberly Frazier"]
["Juan C Gil, MD",1558392779,"47-5554737","TX","PE - Midland Inpatient Medical Association","First Health Coventry","Participating","Enrollment Complete","2020-04-01","","","2022-05-24","5/24/2022 Rcvd email from First Health confirming provider is PAR and linked to group TIN/location effective 4/1/2020.  DCannon"]
["Juan C Gil, MD",1558392779,"47-5554737","TX","PE - Midland Inpatient Medical Association","Caprock (CapStar)","Participating","Enrollment Complete","2012-01-01","","","2020-09-14",""]
["Juan C Gil, MD",1558392779,"47-5554737","TX","PE - Midland Inpatient Medical Association","USA PPO","Participating","Enrollment Complete","2021-01-26","1082380","","2021-03-12","3/12/2021 Per verification on payor website USAMCO.com provider is loaded as participating.  Rcvd Roster LeNetrice Myart with provider numbers and effective dates for providers.  DCannon"]
["Kavitha Bagadi, MD",1871782961,"47-5554737","TX","PE - Midland Inpatient Medical Association","Wellcare","Participating","Enrollment Complete","2021-11-01","","","2022-11-15","11/15/2022 Per roster received from Wellcare provider is PAR and linked to group TIN/location effective 11/1/2021.  DCannon"]
["Kavitha Bagadi, MD",1871782961,"47-5554737","TX","PE - Midland Inpatient Medical Association","IMS","Participating","Enrollment Complete","2019-09-01","1871782961","","2020-07-27","07/27/2020 - Rec'd roster response back from the payer regarding 7/15/2020 submission stating that all requested providers/service locations have been added to PriMed agreement - Stacey Hudak"]
["Kavitha Bagadi, MD",1871782961,"47-5554737","TX","PE - Midland Inpatient Medical Association","Scott&White (First Care)","Participating","Enrollment Complete","2016-12-15","1871782961","","2020-02-13","02/13/2020 - Rec'd emailed confirmation from the payer that this provider is EFF and DIRECT CONTRACTED under this TIN - Stacey Hudak"]
["Kavitha Bagadi, MD",1871782961,"47-5554737","TX","PE - Midland Inpatient Medical Association","Aetna","Participating","Enrollment Complete","2020-10-01","","","2020-12-04","12/4/2020 - Rcvd completed PRIMED ROSTER back from the payer. This provider is PAR at this service location eff 10/1/2020.  DCannon"]
["Jeffrey Hunter Atkins, MD",1760860720,"47-5554737","TX","PE - Midland Inpatient Medical Association","Medicaid","Participating","Enrollment Complete","2018-08-01","386494401","364596201","2020-02-19","02/19/2020 - Per payer portal, this provider is PAR with group TPI 364596201 and linked to the following plans: \nTRADITIONAL MEDICAID, Amerigroup - MRSA West, Amerigroup Texas, Inc. - MRSA West - Stacey Hudak"]
["Jeffrey Hunter Atkins, MD",1760860720,"47-5554737","TX","PE - Midland Inpatient Medical Association","United Health Care","Participating","Enrollment Complete","2020-01-01","1760860720","","2020-08-31","08/31/2020 - moved to completed status after reviewing the follow up completed note - Stacey Hudak"]
["Jeffrey Hunter Atkins, MD",1760860720,"47-5554737","TX","PE - Midland Inpatient Medical Association","Galaxy Health","Participating","Enrollment Complete","2019-09-01","1760860720","","2020-08-21","08/21/2020 - Rec'd email confirmation that this roster was processed and this provider was made effective with the requested eff date of 9-1-2019 - Stacey Hudak"]
["Amber J White, PA",1255614970,"47-5554737","TX","PE - Midland Inpatient Medical Association","TriCare Standard","Participating","Enrollment Complete","2019-03-01","1255614970","","2020-09-09","09/09/2020 - moved to completed status after reviewing last note - Stacey Hudak"]
["Amber J White, PA",1255614970,"47-5554737","TX","PE - Midland Inpatient Medical Association","USA PPO","Participating","Enrollment Complete","2020-04-03","","","2022-02-24","2/24/2022 Per follow-up not on 2/17/2022 - S/W Provider NPI# is on file for the provider and is participating under the group and TIN effective 04/03/2020. PIN# 1172922. Next recredentialing date is on 04/03/2023. Physical location is on file. DCannon"]
["Amber J White, PA",1255614970,"47-5554737","TX","PE - Midland Inpatient Medical Association","Boon Chapman","Participating","Enrollment Complete","2020-04-03","","","2022-07-24","7/24/2022 Per email from Marcie Eckhart-Havens Multiplan July delegated roster has been completed  and provider is PAR and linked to group TIN effective 4/3/2020.   DCannon"]
["Amber J White, PA",1255614970,"47-5554737","TX","PE - Midland Inpatient Medical Association","Amerigroup","Participating","Enrollment Complete","2017-01-10","1255614970","","2020-03-20","03/20/2020 - Rec'd email from the payer (multiplan/true texas choice) stating this provider/service location is EFF with amerigroup - Stacey Hudak"]
["Luis F Hernandez, DO",1447412895,"47-5554737","TX","PE - Midland Inpatient Medical Association","Galaxy Health","Participating","Enrollment Complete","2020-01-01","1447412895","","2020-10-05","10/5/2020 - Rec'd email back from the payer stating this enrollment has been completed - Stacey"]
["Luis F Hernandez, DO",1447412895,"47-5554737","TX","PE - Midland Inpatient Medical Association","Ambetter","Participating","Enrollment Complete","2022-04-01","","","2022-06-13","6/13/2022 Received April Monthly Validation roster from Superior and provider is PAR and linked effective 4/1/2022.  DCannon"]
["Luis F Hernandez, DO",1447412895,"47-5554737","TX","PE - Midland Inpatient Medical Association","Triwest VA","Enrollment Stopped","Enrollment Stopped","","","","","Practice is hospital-based; not eligible for TriWest VA enrollment"]
["Jaya Krishna Chadalavada, MD",1710180666,"47-5554737","TX","PE - Midland Inpatient Medical Association","USA PPO","Participating","Enrollment Complete","2021-01-26","1216979","","2021-03-13","3/12/2021 Per verification on payor website USAMCO.com provider is loaded as participating.  Rcvd Roster LeNetrice Myart with provider numbers and effective dates for providers.  DCannon"]
["Jaya Krishna Chadalavada, MD",1710180666,"47-5554737","TX","PE - Midland Inpatient Medical Association","TriCare Standard","Participating","Enrollment Complete","2021-09-28","","","2021-12-14","12/14/2021 Update from note made on 10/29/2021. Provider certified as of 9/28/2021. Cbankston"]
["Jaya Krishna Chadalavada, MD",1710180666,"47-5554737","TX","PE - Midland Inpatient Medical Association","HealthSmart PPO","Participating","Enrollment Complete","2016-09-15","1710180666","","2020-06-05","06/05/2020 - Rec'd email from the payer stating this provider is EFF -Stacey Hudak"]
["Jaya Krishna Chadalavada, MD",1710180666,"47-5554737","TX","PE - Midland Inpatient Medical Association","Superior","Participating","Enrollment Complete","2020-08-01","1710180666","","2020-08-06","8/6/2020 - Rec'd an email from the payer stating this provider was added to their database EFF: 8-1-2020 after receiving/processing the July roster - Stacey Hudak"]
["Ali R Khan, MD",1760714380,"47-5554737","TX","PE - Midland Inpatient Medical Association","Humana","Participating","Enrollment Complete","2021-09-01","","","2021-11-18","11/18/2021 Rcvd full roster from Humana listing provider as PAR and linked to group TIN/location effective 9/1/2021.  DCannon"]
["Ali R Khan, MD",1760714380,"47-5554737","TX","PE - Midland Inpatient Medical Association","Aetna","Participating","Enrollment Complete","2021-01-07","9896886","","2021-04-18","4/18/2021 Rcvd complete roster from Jamie Roberts <robertsj6@aetna.com> at Aetna listing provider as participating at TIN and locations.  DCannon"]
["Ali R Khan, MD",1760714380,"47-5554737","TX","PE - Midland Inpatient Medical Association","Omni PPO","Participating","Enrollment Complete","2021-01-07","","","2021-02-02","2/2/2021 Rcvd confirmation email from German Aviles that providers have been loaded according to the monthly delegation roster.  DCannon"]
["Deepika Devalla, MD",1265872592,"47-5554737","TX","PE - Midland Inpatient Medical Association","Humana","Participating","Enrollment Complete","2020-01-01","1265872592","","2020-07-15","7/15/2020 - Received email spreadsheet from the payor confirming that this provider is EFF at this service location and PAR with the PRIMED DELEGATED agreement - Pam Porter"]
["Deepika Devalla, MD",1265872592,"47-5554737","TX","PE - Midland Inpatient Medical Association","United Health Care","Participating","Enrollment Complete","2018-03-08","6290221","","2020-07-30","7/30/2020 - moved to completed status after reviewing follow up complete note - Stacey Hudak"]
["Deepika Devalla, MD",1265872592,"47-5554737","TX","PE - Midland Inpatient Medical Association","Wellmed","Participating","Enrollment Complete","2022-01-01","","","2023-03-23","3/23/2023 Rcvd roster from UHC w/ all Wellmed participating providers.  Provider is PAR effective 1/1/2022.  DCannon"]
["Deepika Devalla, MD",1265872592,"47-5554737","TX","PE - Midland Inpatient Medical Association","Medicaid","Participating","Enrollment Complete","","363331502","364596201","2020-02-19","02/19/2020 - Per payer portal, this provider is effective with this group TPI 364596201 and linked to the following plans: FirstCare - Lubbock, TRADITIONAL MEDICAID, Amerigroup - MRSA West, Amerigroup - MRSA West, FirstCare - MRSA West, Amerigroup Texas, Inc. - MRSA West - stacey Hudak"]
["Jeremiah L Stewart, APRN-FNP-BC",1649713595,"47-5554737","TX","PE - Midland Inpatient Medical Association","Galaxy Health","Participating","Enrollment Complete","2020-01-01","1649713595","","2020-10-05","10/5/2020 - Rec'd email back from the payer stating this enrollment has been completed - Stacey"]
["Jeremiah L Stewart, APRN-FNP-BC",1649713595,"47-5554737","TX","PE - Midland Inpatient Medical Association","Scott&White (First Care)","Participating","Enrollment Complete","2016-11-17","1649713595","","2020-02-13","02/13/2020 - Rec'd emailed confirmation from the payer that this provider is EFF and DIRECT CONTRACTED under this TIN - Stacey Hudak"]
["Jeremiah L Stewart, APRN-FNP-BC",1649713595,"47-5554737","TX","PE - Midland Inpatient Medical Association","Boon Chapman","Participating","Enrollment Complete","2020-04-03","","","2022-07-24","7/24/2022 Per email from Marcie Eckhart-Havens Multiplan July delegated roster has been completed  and provider is PAR and linked to group TIN effective 4/3/2020.   DCannon"]
["Gypsy J Jasso, APRN, FNP-C",1013456649,"47-5554737","TX","PE - Midland Inpatient Medical Association","Medicare","Participating","Enrollment Complete","2017-05-14","579253ZV0W","519061","2020-04-20","04/20/2020 -confirmed provider is EFF through group enrollment in PECOS - Stacey Hduak"]
["Gypsy J Jasso, APRN, FNP-C",1013456649,"47-5554737","TX","PE - Midland Inpatient Medical Association","First Health Coventry","Participating","Enrollment Complete","2022-12-15","3546231","","2023-03-06","03.06.2023 Per follow-up note - Provider is in network and linked under the TIN effective 12/15/2022. Next recredentialing is every 3 yrs from the effective date. Provider ID# 3546231. Physical location is on file. - DCannon"]
["Gypsy J Jasso, APRN, FNP-C",1013456649,"47-5554737","TX","PE - Midland Inpatient Medical Association","United Health Care","Participating","Enrollment Complete","2019-09-01","","","2020-11-06","11/6/2020 Received email from United_Healthcare_Provider_Operations@uhc.com confirming provider is loaded under Group Tax ID and location for reference number PR-5512953 and assigned internal MPIN 006569937. Kimberly Frazier"]
["Gypsy J Jasso, APRN, FNP-C",1013456649,"47-5554737","TX","PE - Midland Inpatient Medical Association","Caprock (CapStar)","Participating","Enrollment Complete","2020-03-01","1013456649","","",""]
["Ayodele Olowookere, MD",1124350442,"49-4110931","TX","PE - Ayodele O Olowookere MD, PA","Wellcare","Participating","Enrollment Complete","2021-11-01","","","2022-12-01","12/1/2022 Per roster received from Wellcare provider is PAR and linked to group TIN/location effective 11/1/2021.  DCannon"]
["Ayodele Olowookere, MD",1124350442,"49-4110931","TX","PE - Ayodele O Olowookere MD, PA","TriCare Standard","Participating","Enrollment Complete","2014-06-17","","","2022-07-20","7/20/2022 Per Tricare portal provider is PAR and linked to group TIN/location effective 6/17/2014.  DCannon"]
["Ayodele Olowookere, MD",1124350442,"49-4110931","TX","PE - Ayodele O Olowookere MD, PA","HealthSmart PPO","Participating","Enrollment Complete","2011-02-01","1124350442","","2020-06-04","06/04/2020 - rec'd email from the payer stating this provider is EFF - Stacey Hudak"]
["Sandra Maerzacker, MD",1396190823,"54-2080139","TX","PE - Sari Nabulsi, MD, LTD, LLP","Superior","Participating","Enrollment Complete","2021-09-01","","","2021-10-06","10/6/2021 Rcvd email from Superior that monthly delegation roster for August/September is complete and providers are loaded under TIN/locations effective 9/1/2021.  DCannon"]
["Sandra Maerzacker, MD",1396190823,"54-2080139","TX","PE - Sari Nabulsi, MD, LTD, LLP","United Health Care","Participating","Enrollment Complete","2019-11-14","","","2022-02-22","2/22/2022 Received email from NMRT networkhelp@uhc.com, provider is par with location as of 11/14/2019. Cbankston"]
["Sandra Maerzacker, MD",1396190823,"54-2080139","TX","PE - Sari Nabulsi, MD, LTD, LLP","Aetna","Participating","Enrollment Complete","2021-09-01","6162182","","2021-09-09","9/9/2021 Rcvd full roster from Jamie Roberts at Aetna on 9/8/2021 confirming that provider is PAR and linked to group TIN/locations effective 9/1/2021.  PID # 6962182 DCannon"]
["Sari A Nabulsi, MD",1740289297,"54-2080139","TX","PE - Sari Nabulsi, MD, LTD, LLP","HealthSmart PPO","Participating","Enrollment Complete","2011-02-01","1740289297","","2020-06-10","06/10/2020 - Rec'd email from the payer stating this provider is EFF - Stacey Hudak"]
["Sari A Nabulsi, MD",1740289297,"54-2080139","TX","PE - Sari Nabulsi, MD, LTD, LLP","Omni PPO","Participating","Enrollment Complete","2019-09-01","1740289297","","2020-07-27","IMS complete"]
["Sari A Nabulsi, MD",1740289297,"54-2080139","TX","PE - Sari Nabulsi, MD, LTD, LLP","Galaxy Health","Participating","Enrollment Complete","1998-11-16","1740289297","","2020-07-17","7/17/2020 - Received a spreadsheet from the payer stating this provider is effective as of 11/16/1998 - Jesriel Segovia"]
["Rajanikant P Pandya, MD",1316965403,"56-2697415","TX","PE - Rajanikant P. Pandya","Ambetter","Participating","Enrollment Complete","2022-04-01","","","2022-06-13","6/13/2022 Per roster received from Superior provider is PAR and linked to group delegation roster effective 4/1/2022."]
["Rajanikant P Pandya, MD",1316965403,"56-2697415","TX","PE - Rajanikant P. Pandya","CAQH","Participating","CAQH Reattested","2023-10-31","12031991","","2023-10-31","10/31/2023 - CAQH Re-attested, updated and uploaded liability documents - dkonar"]
["Rajanikant P Pandya, MD",1316965403,"56-2697415","TX","PE - Rajanikant P. Pandya","Superior","Participating","Enrollment Complete","2020-09-01","1316965403","","2020-09-02","09/02/2020 - Rec'd email from the payer stating this delegated update has been made - Stacey Hudak"]
["Rajanikant P Pandya, MD",1316965403,"56-2697415","TX","PE - Rajanikant P. Pandya","Rail Road Medicare","Participating","In House Enrollment","","","","2020-10-26","10/26/2020 - This clinic performs their own medicare enrollment in house. They have not provided me with the proper information to check the status of this RR Medicare enrollment through the portal. Moved to IN HOUSE ENROLLMENT to remove from work list - Stacey Hudak"]
["Satish Nayak, MD",1518053149,"57-1157825","TX","PE - Satish Nayak","Superior","Participating","Enrollment Complete","2017-01-01","1518053149","","2020-07-14","07/14/2020 - Rec'd email from the payer stating this provider is EFF under PRIMED DELEGATED agreement - Stacey Hudak"]
["Satish Nayak, MD",1518053149,"57-1157825","TX","PE - Satish Nayak","First Health Coventry","Participating","Enrollment Complete","2008-09-01","1518053149","","2020-06-12","06/12/2020 - Rec'd email from the payer stating this provider is EFF - PID# 1091293 - Stacey Hudak"]
["Satish Nayak, MD",1518053149,"57-1157825","TX","PE - Satish Nayak","First Health Coventry","Participating","Enrollment Complete","2021-07-06","","","2021-10-13","10/13/2021  Per First Health online provider directory provider is PAR and linked to group/locations  effective 7/6/2021  DCannon"]
["Daniel J Dominguez, APRN-FNP-BC",1720610447,"74-2348334","TX","PE - Permian Gastroenterology PA","Cigna","Participating","Enrollment Complete","2023-09-01","3330657","","2023-10-31","Received confirmation email.. MS"]
["Daniel J Dominguez, APRN-FNP-BC",1720610447,"74-2348334","TX","PE - Permian Gastroenterology PA","Boon Chapman","Participating","Enrollment Complete","2023-07-17","","","2023-11-09","11/9/2023 Rcvd email confirmation from Jessica Bess at Multiplan that October roster has been processed and provider is PAR w/ group effective 7/17/2023.  DCannon"]
["Daniel J Dominguez, APRN-FNP-BC",1720610447,"74-2348334","TX","PE - Permian Gastroenterology PA","Humana","In Process","Payor Receipt Validated","","","","2023-10-25","10/25/2023 Rcvd confirmation email from Marcus Wester that October Delegation roster has been received and sent for processing.   Assigned the following case #'s Provider adds CO-16142269\nProvider changes CO-16142352\nProvider terms CO-16142430\nDCannon"]
["Mrunal C Patel, MD",1528000734,"74-2348334","TX","PE - Permian Gastroenterology PA","Rail Road Medicare","Participating","Enrollment Complete","1997-10-01","100012286","","2020-10-09","10/9/2020 - called payer at 877-228-7600 and spoke with Stephanie in provider enrollment who said this provider medicare PTAN was not linked properly. She went into the system and requested the PTAN to be linked. It should take 5 business days before this will generate on RRMCR site. Stephanie shared provider RRPTAN and EFF date with me over the phone  REF# 20283003000279 - Stacey Hudak"]
["Mrunal C Patel, MD",1528000734,"74-2348334","TX","PE - Permian Gastroenterology PA","TriCare Standard","Participating","Enrollment Complete","2004-10-01","1528000734","","2020-04-06","04/06/2020 - Rec'd access to provider through payer portal and I was able to confirm provider certification with this TIN at this service location. This group is NON NETWORKED, therefore no credentialing is required. - Stacey Hudak"]
["Mrunal C Patel, MD",1528000734,"74-2348334","TX","PE - Permian Gastroenterology PA","Triwest VA","Facility Enrollment","Facility Enrollment","","","","2022-10-17","10/17/2022 - Received roster from Scarlett; provider status: \"No Action.  TIN is CCN participating under own DCN.\""]
["Govind B Patel, MD",1073555249,"74-2348334","TX","PE - Permian Gastroenterology PA","Aetna","Participating","Enrollment Complete","2019-12-13","1073555249","","2020-03-25","3/25/2020--S/W Ella of Aetna 8003531232, provider NPI# is on file for the provider and is participating effective 12/13/2019 under the group and TIN#. Physical location is on file. DIRECT CONTRACT--Call ref#: 5194745657. --tisha rader"]
["Govind B Patel, MD",1073555249,"74-2348334","TX","PE - Permian Gastroenterology PA","Scott&White (First Care)","Participating","Enrollment Complete","2016-02-29","1073555249","","2020-04-16","04/16/2020 - Rec'd confirmation from the payer stating this provider is EFF under the DELEGATED PRIMED agreement with ALL products (except Medicaid) with this TIN/Service Location- Stacey Hudak"]
["Govind B Patel, MD",1073555249,"74-2348334","TX","PE - Permian Gastroenterology PA","Multiplan","Participating","Enrollment Complete","1996-10-01","1073555249","","2020-02-12","02/12/2020 - rec'd confirmation through payer portal that this provider is EFF through and INDIVIDUAL CONTRACT as of 10-1-1996. Provider is in network with multiplan - Stacey Hudak"]
["Ubaldo Estrada, FNP",1740723725,"75-1997880","TX","PE - Andrews County Hospital District","Amerigroup","Participating","Enrollment Complete","2020-07-17","","","2021-08-26","8/26/2021 Rcvd full roster from Joe Rodriguez at Amerigroup listing provider as PAR w/ group TIN and location effective 7/17/2020.  DCannon"]
["Ubaldo Estrada, FNP",1740723725,"75-1997880","TX","PE - Andrews County Hospital District","USA PPO","Participating","Enrollment Complete","2021-01-26","1312289","","2021-03-12","3/12/2021 Per verification on payor website USAMCO.com provider is loaded as participating.  Rcvd Roster LeNetrice Myart with provider numbers and effective dates for providers.  DCannon"]
["Ubaldo Estrada, FNP",1740723725,"75-1997880","TX","PE - Andrews County Hospital District","Aetna","Participating","Enrollment Complete","2020-09-01","","","2020-12-04","12/4/2020 - Rcvd completed PRIMED ROSTER back from the payer. This provider is PAR at this service location eff 9/1/2020.  DCannon"]
["Ubaldo Estrada, FNP",1740723725,"75-1997880","TX","PE - Andrews County Hospital District","CAQH","Participating","CAQH Reattested","2023-10-31","","","2023-10-31","10/31/2023 CAQH reviewed/reattested.  DCannon"]
["Carlos Molina, DO",1225277833,"75-1997880","TX","PE - Andrews County Hospital District","CAQH","Participating","CAQH Reattested","2023-11-07","","","2023-11-07","11/7/2023 CAQH reviewed and re-attested.  Uploaded current malpractice COI.  DCannon"]
["Carlos Molina, DO",1225277833,"75-1997880","TX","PE - Andrews County Hospital District","USA PPO","Participating","Enrollment Complete","2017-04-03","1225277833","751997880","2020-08-19","Confirmed provider is participating with PPO and H&W networks (list of networks attached). Kimberly Frazier"]
["Carlos Molina, DO",1225277833,"75-1997880","TX","PE - Andrews County Hospital District","Alliance WC","Participating","Enrollment Complete","2023-07-21","","","2023-08-15","Per Michelle Killough @ PSWCA Dr. Molina is par effective 07/21/2023. Jen Videan"]
["Carlos Molina, DO",1225277833,"75-1997880","TX","PE - Andrews County Hospital District","Caprock (CapStar)","Participating","Enrollment Complete","2017-03-30","","","2020-09-14",""]
["Alyssa Tochterman, MD",1972942209,"75-1997880","TX","PE - Andrews County Hospital District","Alliance WC","Participating","Enrollment Complete","","","","2023-09-27","Rcvd Welcome Ltr from Barry Harris at pswca.org. Provider is effective 09/22/2023. Jen Videan"]
["Alyssa Tochterman, MD",1972942209,"75-1997880","TX","PE - Andrews County Hospital District","Triwest VA","Participating","Enrollment Complete","2022-08-01","","","2022-11-14","11/14/22- Per Scarlett Abigail, TIN has active 400TX DCN.  TIN has association of RHC."]
["Alyssa Tochterman, MD",1972942209,"75-1997880","TX","","CAQH","Participating","CAQH Reattested","2023-10-06","","","2023-07-05","6/5/2023- CAQH Reattested by Data Services - kavello"]
["Alyssa Tochterman, MD",1972942209,"75-1997880","TX","PE - Andrews County Hospital District","Coventry Workers Comp","Panel Closed","Panel Closed","","","","2023-07-24"," We appreciate your interest in joining the Coventry Network.  At this time, our panels are closed, and we are not accepting new applications.  Please check back routinely to stay apprised of our panel status. We will update this site when we are open for new applicants. Gallagher, Hartford, Liberty Mutual, Travelers and Zurich fall under Coventry. Jen Videan"]
["Alyssa Tochterman, MD",1972942209,"75-1997880","TX","PE - Andrews County Hospital District","Humana","Participating","Enrollment Complete","2016-10-26","1972942209","","2021-11-18","11/18/2021 Rcvd full roster from Humana listing provider as PAR and linked to group TIN/location effective 10/26/2016.  DCannon"]
["Margaret Merriam, DO",1083867147,"75-1997880","TX","PE - Andrews County Hospital District","Gallagher","Panel Closed","Panel Closed","","","","2023-07-25","We appreciate your interest in joining the Coventry Network.  At this time, our panels are closed, and we are not accepting new applications.  Please check back routinely to stay apprised of our panel status. We will update this site when we are open for new applicants. Gallagher, Hartford, Liberty Mutual, Travelers and Zurich fall under Coventry. Jen Videan"]
["Margaret Merriam, DO",1083867147,"75-1997880","TX","PE - Andrews County Hospital District","Coventry Workers Comp","Panel Closed","Panel Closed","","","","2023-07-25","We appreciate your interest in joining the Coventry Network.  At this time, our panels are closed, and we are not accepting new applications.  Please check back routinely to stay apprised of our panel status. We will update this site when we are open for new applicants. Gallagher, Hartford, Liberty Mutual, Travelers and Zurich fall under Coventry. Jen Videan"]
["Margaret Merriam, DO",1083867147,"75-1997880","TX","PE - Andrews County Hospital District","Broadspire Services Inc.","Enrollment Stopped","Enrollment Stopped","","","","2023-10-04","Per Melody Starcher, they would like to hold off on Broadspire WC enrollment at this time. If they start to see a large amount of patients coming in with it, then they will reassess. 10/04/2023 Jen Videan"]
["Margaret Merriam, DO",1083867147,"75-1997880","TX","PE - Andrews County Hospital District","First Health Coventry","Participating","Enrollment Complete","2017-06-15","2680644","","2023-05-02","5/2.2023 Per confirm par status -  Per rep, provider is showing participating with an effective date 12/1/2021 and link under the Group and TIN. Provider ID 2680644.  Service location is on file. Call ref#:610334. DCannon"]
["Margaret Merriam, DO",1083867147,"75-1997880","TX","PE - Andrews County Hospital District","Humana","Participating","Enrollment Complete","2017-06-05","","","2021-11-18","11/18/2021 Rcvd full roster from Humana listing provider as PAR and linked to group TIN/location effective 6/5/2017.  DCannon"]
["Margaret Merriam, DO",1083867147,"75-1997880","TX","PE - Andrews County Hospital District","TriCare Standard","Participating","Enrollment Complete","2017-07-08","1083867147","","2020-09-23","09/23/2020 - moved to completed status after reviewing follow up complete note - Stacey Hudak"]
["Jennifer B Hada-Ondriezek, DNP",1669617981,"75-1997880","TX","PE - Andrews County Hospital District","USA PPO","Participating","Enrollment Complete","2019-08-30","","","2020-09-09","Confirmed provider is participating with PPO and H&W networks (list of networks attached). Kimberly Frazier"]
["Jennifer B Hada-Ondriezek, DNP",1669617981,"75-1997880","TX","PE - Andrews County Hospital District","Medicaid","Facility Enrollment","Facility Enrollment","","112273103","","2020-09-23","09/23/2020 - Rec'd email from the clinic with the group RHC TPI# 112273103.  Moved to effective status to bring payer line to a desired status. THIS IS A FACILITY ENROLLMENT - Stacey Hudak"]
["Jennifer B Hada-Ondriezek, DNP",1669617981,"75-1997880","TX","PE - Andrews County Hospital District","TriCare Standard","Participating","Enrollment Complete","2015-06-23","1669617981","","2020-09-23","09/23/2020 - Confirmed via self-service portal, provider is certified as non-network provider under group Tax ID. KFrazier"]
["Shannan Clawson, NP",1972073906,"75-1997880","TX","PE - Andrews County Hospital District","Multiplan","Participating","Enrollment Complete","2020-08-05","1972073906","Contract Source Individual","2022-07-23","7/23/2022 Per email from Marcie Eckhart-Haven at Multiplan provider is PAR and linked to group TIN effective 8/5/2020.  DCannon"]
["Shannan Clawson, NP",1972073906,"75-1997880","TX","PE - Andrews County Hospital District","Wellcare","Participating","Enrollment Complete","2021-11-01","","","2022-11-15","11/15/2022 Per roster received from Wellcare provider is PAR and linked to group TIN/location effective 11/1/2021.  DCannon"]
["Shannan Clawson, NP",1972073906,"75-1997880","TX","PE - Andrews County Hospital District","First Health Coventry","Participating","Enrollment Complete","2023-07-01","","","2023-08-10","Confirmed active via online portal. MS"]
["Shannan Clawson, NP",1972073906,"75-1997880","TX","PE - Andrews County Hospital District","HealthSmart PPO","Participating","Enrollment Complete","2020-08-05","","","2021-12-03","12/3/2021 Per Healthsmart website provider is PAR and loaded under TIN/location effective 8/5/2020.  DCannon"]
["Peggy Thurston, NP",1205941564,"75-1997880","TX","PE - Andrews County Hospital District","Caprock (CapStar)","Participating","Enrollment Complete","2020-07-14","","","2021-04-09","4/9/2020 Rcvd roster from Mary Rodriguez <mary.rodriguez@90degreebenefits.com> at Caprock listing provider as participating under TIN.  DCannon"]
["Peggy Thurston, NP",1205941564,"75-1997880","TX","PE - Andrews County Hospital District","Superior","Participating","Enrollment Complete","2020-10-01","1205941564","","2020-10-02","10/02/2020 - rec'd email from the payer stating this provider has been added to the primed roster - Stacey Hudak"]
["Peggy Thurston, NP",1205941564,"75-1997880","TX","PE - Andrews County Hospital District","CAQH","Participating","CAQH Reattested","2023-10-06","","","2023-10-20","10/20/2023 CAQH Reattested"]
["Peggy Thurston, NP",1205941564,"75-1997880","TX","PE - Andrews County Hospital District","Multiplan","Participating","Enrollment Complete","2020-07-13","","","2022-07-23","7/23/2022 Per email from Marcie Eckhart-Haven at Multiplan provider is PAR and linked to group TIN effective 7/13/2020.  DCannon"]
["Barbara Norris, NP-C",1720353592,"75-1997880","TX","PE - Andrews County Hospital District","HealthSmart PPO","Participating","Enrollment Complete","2014-04-29","1720353592","","2020-09-23","09/23/2020 - moved to completed status after reviewing follow up complete - Stacey Hudak"]
["Barbara Norris, NP-C",1720353592,"75-1997880","TX","PE - Andrews County Hospital District","Medicare","Participating","Enrollment Complete","2020-05-01","1D0572","290001","2020-07-24","7/24/2020 - Signed into group enrollment and was able to confirm that this provider is linked to Quick Care Clinic group PTAN 290001 part B.  - Stacey Hudak"]
["Barbara Norris, NP-C",1720353592,"75-1997880","TX","PE - Andrews County Hospital District","First Health Coventry","Participating","Enrollment Complete","2014-04-01","","","2023-05-02","5/2.2023 Per confirm par status note.   Per rep, provider is showing participating with an effective date 4/1/2014 and link under the Group and TIN. Provider ID 2609103.  Service location is on file. Call ref#:610334. DCannon"]
["Stephanie Jean Fitzgerald, MD",1184035313,"75-1997880","TX","PE - Andrews County Hospital District","Travelers WC","Panel Closed","Panel Closed","","","","2023-01-25","1.25.23 Confirmed with Jennifer Hoffman <JMHOFFMA@travelers.com> that providers must first be enrolled in Coventry's network before they can be considered for Travelers WC. Provider placed in 'Pending other enrollment' status. ABoles"]
["Stephanie Jean Fitzgerald, MD",1184035313,"75-1997880","TX","PE - Andrews County Hospital District","Caprock (CapStar)","Participating","Enrollment Complete","2020-08-05","","","2021-04-09","4/9/2020 Rcvd roster from Mary Rodriguez <mary.rodriguez@90degreebenefits.com> at Caprock listing provider as participating under TIN.  DCannon"]
["Stephanie Jean Fitzgerald, MD",1184035313,"75-1997880","TX","PE - Andrews County Hospital District","Sedgwick","Pending Other Enrollment","Pending Contracting","","","","2023-11-28","Per Debbie Mason at Sedgwick TIN is not contracted/enrolled. Emailed roster and W9 per her request and she is looking into available contract opportunities. See group enrollment payor line for status/updates. Jen Videan"]
["Cynthia A Hill, CNS",1225271224,"75-1997880","TX","PE - Andrews County Hospital District","Ambetter","Participating","Enrollment Complete","2022-04-01","","","2022-06-13","6/13/2022 Received April Monthly Validation roster from Superior and provider is PAR and linked effective 4/1/2022.  DCannon"]
["Cynthia A Hill, CNS",1225271224,"75-1997880","TX","PE - Andrews County Hospital District","Boon Chapman","Participating","Enrollment Complete","2020-07-17","","","2022-07-23","7/23/2022 Per email from Marcie Eckhart-Haven at Multiplan provider is PAR and linked to group TIN effective  7/17/2020. DCannon"]
["Cynthia A Hill, CNS",1225271224,"75-1997880","TX","PE - Andrews County Hospital District","First Health Coventry","Participating","Enrollment Complete","2022-12-01","3628670","","2023-01-19","1.19.2023 S/W Britney of First Health @ 800-226-5116. Transferred the call and spoke with Courtney. Provider is on file and participating. Link under the group and TIN effective 12/1/2022. Location is on file. Provider ID is 3628670. Next recredentialing date is every 3 years (12/1/2025) No information for the payer#. -Kim Monique Fabian"]
["Cynthia A Hill, CNS",1225271224,"75-1997880","TX","PE - Andrews County Hospital District","Galaxy Health","Participating","Enrollment Complete","2020-01-01","1225271224","","2020-10-05","10/5/2020 - Rec'd email back from the payer stating this enrollment has been completed - Stacey"]
["Rahul Dinesh Puri, MD",1306928098,"75-1997880","TX","","Liberty Mutual","Enrollment Stopped","Enrollment Stopped","","","","2021-08-05","8/4/2021 Provider does not see WC patients; therefore, enrollment has stopped. KFrazier"]
["Rahul Dinesh Puri, MD",1306928098,"75-1997880","TX","","CAQH","Participating","CAQH Reattested","2023-11-01","","","2023-11-01","11/01/2023 - Updated Primary email add, Cred contact, PLI and uploaded documents and re-attested - rkedare"]
["Rahul Dinesh Puri, MD",1306928098,"75-1997880","TX","PE - Andrews County Hospital District","Medicaid","Facility Enrollment","Facility Enrollment","","112273103","","2020-09-23"," 09/23/2020 - Rec'd email from the clinic with the group RHC TPI# 112273103.  Moved to effective status to bring payer line to a desired status. THIS IS A FACILITY ENROLLMENT - Stacey Hudak"]
["Rahul Dinesh Puri, MD",1306928098,"75-1997880","TX","","HealthSmart PPO","Participating","Enrollment Complete","2011-11-01","","","2021-04-11","4/11/2021 Rcvd email from HealthSmart <mdipsupport@healthsmart.com> confirming participation of provider under TIN and location effective 11/01/2011.  DCannon"]
["Rahul Dinesh Puri, MD",1306928098,"75-1997880","TX","","Cigna","Participating","Enrollment Complete","2016-04-01","1306928098","","2020-07-23","07/23/2020 - moved to completed status after reviewing follow up complete status - Stacey Hudak"]
["Rahul Dinesh Puri, MD",1306928098,"75-1997880","TX","PE - Andrews County Hospital District","First Health Coventry","Participating","Enrollment Complete","","","","2023-07-24","Confirmed enrollment via online directory. MS"]
["Rahul Dinesh Puri, MD",1306928098,"75-1997880","TX","","First Health Coventry","Participating","Enrollment Complete","","","","2023-07-24","Confirmed enrollment via online directory. MS"]
["Paul Slaughter, DO",1184626749,"75-1997880","TX","PE - Andrews County Hospital District","Medicare","Participating","Enrollment Complete","2013-08-26","315563YSCJ","290001","2020-07-24","07/24/2020 - moved to completed status after confirming through group PECOS that this provider is linked to Part B Quick Care Clinic Group PTAN 290001. - Stacey Hudak"]
["Paul Slaughter, DO",1184626749,"75-1997880","TX","PE - Andrews County Hospital District","First Health Coventry","Participating","Enrollment Complete","2014-05-01","1098076","","2023-05-02","5/2/2023 Per confirm par status note - Per rep, provider is showing participating with an effective date 05/01/2014 and link under the Group and TIN. Provider ID 1098076. As per Donna from Credentialing Dept they don't have the provider's next recredentialing date then advised that their Network Team will inform the provider if the recredentialing date is available. Service location is on file. Call ref#:610344. DCannon"]
["Paul Slaughter, DO",1184626749,"75-1997880","TX","PE - Andrews County Hospital District","Cigna","Participating","Enrollment Complete","2018-03-01","1184626749","","2020-07-30","7/30/2020 - Moved to completed status after reviewing follow up complete note - Stacey Hudak"]
["Christopher Stansell, FNP",1285065946,"75-1997880","TX","PE - Andrews County Hospital District","Medicare","Participating","Enrollment Complete","2013-12-25","333694YSCJ","290001","2020-07-31","07/31/2020 - was able to log into group enrollment for Quick Care and confirm that this provider is linked to the correct group PTAN/service location - Stacey Hudak"]
["Christopher Stansell, FNP",1285065946,"75-1997880","TX","PE - Andrews County Hospital District","CAQH","Participating","CAQH Reattested","2023-10-06","","","2023-10-06","10/6/2023 CAQH reviewed/reattested by provider.  DCannon"]
["Christopher Stansell, FNP",1285065946,"75-1997880","TX","PE - Andrews County Hospital District","TriCare Standard","Participating","Enrollment Complete","2013-11-01","","","2020-12-24","12/24/2020 Provider is certified as non-network provider under Group Tax ID and location. KFrazier"]
["Eliana Kelley, APRN-FNP-BC",1184278251,"75-1997880","TX","PE - Andrews County Hospital District","Caprock (CapStar)","Participating","Enrollment Complete","2021-01-07","","","2021-04-09","4/9/2020 Rcvd roster from Mary Rodriguez <mary.rodriguez@90degreebenefits.com> at Caprock listing provider as participating under TIN.  DCannon"]
["Eliana Kelley, APRN-FNP-BC",1184278251,"75-1997880","TX","","Triwest VA","Enrollment on Hold","Enrollment on Hold","","","","","RHC."]
["Eliana Kelley, APRN-FNP-BC",1184278251,"75-1997880","TX","PE - Andrews County Hospital District","Medicare","Participating","No Enrollment Required","2019-10-01","","","2020-12-09","12/9/2020 Enrollment not required for adding provider under RHC. KFrazier"]
["Eliana Kelley, APRN-FNP-BC",1184278251,"75-1997880","TX","PE - Andrews County Hospital District","United Health Care","Participating","Enrollment Complete","2021-01-28","","","2021-08-07","7/14/2021 Received email response from networkhelp@uhc.com stating provider is participating under group Tax ID effective 1/28/2021. KFrazier"]
["Julie Parker, APRN-NP",1720538606,"75-1997880","TX","PE - Andrews County Hospital District","Superior","Participating","Enrollment Complete","2021-02-01","","","2021-02-02","2/2/2021 - Rcvd confirmation from payer that provider is participating and linked to TIN effective 12/1/2020.  DCannon"]
["Julie Parker, APRN-NP",1720538606,"75-1997880","TX","PE - Andrews County Hospital District","CAQH","Participating","CAQH Reattested","2023-10-26","","","2023-06-05","6/5/2023- CAQH Reattested by Data Services - kavello"]
["Julie Parker, APRN-NP",1720538606,"75-1997880","TX","PE - Andrews County Hospital District","Aetna","Participating","Enrollment Complete","2021-01-07","6945139","","2021-04-18","4/18/2021 Rcvd complete roster from Jamie Roberts <robertsj6@aetna.com> at Aetna listing provider as participating at TIN and locations.  DCannon"]
["Julie Parker, APRN-NP",1720538606,"75-1997880","TX","","Triwest VA","Enrollment on Hold","In House Enrollment","","","","2021-01-14","1/6/2021 MQA Team is working with Representatives at BCBS-TX to ensure all providers are enrolled and loaded to participate with the VACCN network in a timely manner. However, we are currently awaiting a full roster of providers currently participating and will update all records accordingly upon receipt. Kfrazier"]
["Meagan Leighann Cunningham, APRN-FNP-BC",1891302931,"75-1997880","TX","PE - Andrews County Hospital District","Aetna","Participating","Enrollment Complete","2021-01-07","","","2021-03-26","3/26/2021 Rcvd confirmation email from Jamie Roberts that February delegation roster adds have been completed.  DCannon"]
["Meagan Leighann Cunningham, APRN-FNP-BC",1891302931,"75-1997880","TX","PE - Andrews County Hospital District","HealthSmart PPO","Participating","Enrollment Complete","2021-01-07","","","2021-04-11","4/11/2021 Rcvd email from HealthSmart <mdipsupport@healthsmart.com> confirming participation of provider under TIN and location effective 01/07/2021.  DCannon"]
["Meagan Leighann Cunningham, APRN-FNP-BC",1891302931,"75-1997880","TX","PE - Andrews County Hospital District","Multiplan","Participating","Enrollment Complete","2021-09-02","","","2022-07-23","7/23/2022 Per email from Marcie Eckhart-Haven at Multiplan provider is PAR and linked to group TIN effective 9/2/2021.  DCannon"]
["Amanda Compton, MD",1679953517,"75-1997880","TX","PE - Andrews County Hospital District","Sedgwick","Pending Other Enrollment","Pending Contracting","","","","2023-11-28","Per Debbie Mason at Sedgwick TIN is not contracted/enrolled. Emailed roster and W9 per her request and she is looking into available contract opportunities. See group enrollment payor line for status/updates. Jen Videan"]
["Amanda Compton, MD",1679953517,"75-1997880","TX","PE - Andrews County Hospital District","Tricare Prime","Participating","Enrollment Complete","2021-07-08","","","2022-02-17","2/17/2022 Per Tricare portal, provider is linked to location eff 7/8/2021. Cbankston"]
["Amanda Compton, MD",1679953517,"75-1997880","TX","PE - Andrews County Hospital District","Medicare","No Enrollment Required","No Enrollment Required","2021-04-02","","","2022-04-01","No enrollment required due to this being a RHC. DCannon"]
["Amanda Compton, MD",1679953517,"75-1997880","TX","PE - Andrews County Hospital District","Wellcare","Participating","Enrollment Complete","2021-11-01","","","2022-11-15","7/1/2022 Received April Monthly Validation roster from Superior and provider is PAR and linked effective 4/1/2022.  DCannon"]
["Ragini Sastry, DO",1942568431,"75-1997880","TX","PE - Andrews County Hospital District","United Health Care","Participating","Enrollment Complete","2022-05-09","","","2023-08-14","8/14/2023 Rcvd email from Priscilla Albertine at MQA that providers effective date should be 5/9/2022 per confirmation from Kelly at UHC. \nDCannon"]
["Ragini Sastry, DO",1942568431,"75-1997880","TX","PE - Andrews County Hospital District","Sedgwick","Pending Other Enrollment","Pending Contracting","","","","2023-11-28","Per Debbie Mason at Sedgwick TIN is not contracted/enrolled. Emailed roster and W9 per her request and she is looking into available contract opportunities. See group enrollment payor line for status/updates. Jen Videan"]
["Ragini Sastry, DO",1942568431,"75-1997880","TX","PE - Andrews County Hospital District","HealthSmart PPO","Participating","Enrollment Complete","2022-05-09","","","2022-07-14","7/14/2022 Per Healthsmart website provider is PAR and loaded under TIN/location effective 5/9/2022.  DCannon"]
["Ragini Sastry, DO",1942568431,"75-1997880","TX","PE - Andrews County Hospital District","Broadspire Services Inc.","Enrollment Stopped","Enrollment Stopped","","","","2023-10-04","Per Melody Starcher, they would like to hold off on Broadspire WC enrollment at this time. If they start to see a large amount of patients coming in with it, then they will reassess. 10/04/2023 Jen Videan"]
["Ragini Sastry, DO",1942568431,"75-1997880","TX","PE - Andrews County Hospital District","Medicare","Facility Enrollment","Facility Enrollment","","","","2022-02-17","2/17/2022 This is an RHC location and providers cannot be enrolled/linked to this location. Therefore no enrollment is required.  DCannon"]
["Richard Glenn Eby, MD",1598260325,"75-1997880","TX","PE - Andrews County Hospital District","Tricare Prime","Panel Closed","Panel Closed","","","","2022-10-28","10/28/2022 Per Tricare/Humana Military is currently not accepting requests to join the medical surgical network. Will check back soon to see if we are accepting network providers.  DCannon"]
["Richard Glenn Eby, MD",1598260325,"75-1997880","TX","PE - Andrews County Hospital District","Amerigroup","Participating","Enrollment Complete","2022-09-26","14614970","","2023-02-01","2/1/2023 Per email response from Amerigroup Provider Relations-Texas provider is PAR and linked to group effective 9/26/2022.  PID# 14614970.  DCannon"]
["Richard Glenn Eby, MD",1598260325,"75-1997880","TX","PE - Andrews County Hospital District","Triwest VA","Enrollment on Hold","Enrollment on Hold","","","","","RHC."]
["Richard Glenn Eby, MD",1598260325,"75-1997880","TX","PE - Andrews County Hospital District","IMS","Participating","Enrollment Complete","2022-09-26","","","2022-10-17","10/17/2022 Per email received from German Aviles at IMS/OMNI monthly delegation roster provider load for October has been completed.  Provider is PAR and linked to group TIN effective 9/26/2022.   DCannon"]
["Richard Glenn Eby, MD",1598260325,"75-1997880","TX","PE - Andrews County Hospital District","Superior","Participating","Enrollment Complete","2022-11-01","","","2022-12-08","12/08/2022 Rcvd confirmation email from Superior that October delegation roster has been processed and provider has been loaded to delegation roster and PAR w/ group effective 11/1/2022.  DCannon"]
["Richard Glenn Eby, MD",1598260325,"75-1997880","TX","PE - Andrews County Hospital District","Coventry Workers Comp","Panel Closed","Panel Closed","","","","2023-05-18","Coventry panel is currently closed for new enrollments. MS"]
["Rand E Waddingham, M.D.",1730181389,"75-1997880","TX","PE - Andrews County Hospital District","Scott&White (First Care)","Participating","Enrollment Complete","2020-07-14","","","2021-08-30","8/30/2021 Rcvd email from Scott & White (First Care) <SWHPDELEGATION@BSWHealth.org>that provider is PAR and linked to group TIN/locations effective 7/14/2020.  DCannon"]
["Rand E Waddingham, M.D.",1730181389,"75-1997880","TX","PE - Andrews County Hospital District","Multiplan","Participating","Enrollment Complete","2021-09-02","1730181389","","2022-07-23","7/23/2022 Per email from Marcie Eckhart-Haven at Multiplan provider is PAR and linked to group TIN effective 9/2/2021.  DCannon"]
["Rand E Waddingham, M.D.",1730181389,"75-1997880","TX","PE - Andrews County Hospital District","Texas Mutual","In Process","Application Submitted","","","","2023-11-22","TSCA and required documents emailed to wwtxcontracts@texasmutual.com. Jen Videan"]
["Rand E Waddingham, M.D.",1730181389,"75-1997880","TX","PE - Andrews County Hospital District","Alliance WC","Participating","Enrollment Complete","2023-11-03","","","2023-11-20","Rcvd approval ltr. Provider effective 11/03/2023. Jen Videan"]
["Rand E Waddingham, M.D.",1730181389,"75-1997880","TX","PE - Andrews County Hospital District","Aetna","Participating","Enrollment Complete","2009-04-01","4266535","","2020-07-10","07/10/2020 - moved to completed status per notes in Follow Up Complete  - Stacey Hudak"]
["Rand E Waddingham, M.D.",1730181389,"75-1997880","TX","","Triwest VA","Participating","Enrollment Complete","2022-08-01","","","2022-11-14","11/14/22- TIN is active and has direct contract, provider in network due to association with TIN"]
["Rand E Waddingham, M.D.",1730181389,"75-1997880","TX","","Coventry Workers Comp","Panel Closed","Panel Closed","","","","2023-07-25","We appreciate your interest in joining the Coventry Network.  At this time, our panels are closed, and we are not accepting new applications.  Please check back routinely to stay apprised of our panel status. We will update this site when we are open for new applicants. Gallagher, Hartford, Liberty Mutual, Travelers and Zurich fall under Coventry. Jen Videan"]
["Rand E Waddingham, M.D.",1730181389,"75-1997880","TX","","TriCare Standard","Participating","Enrollment Complete","2004-11-01","1730181389","","2020-07-31","7/31/2020 - Rec'd email from the payer stating \"I also show Rand attached to Permian, effective 11/1/04. \" - Stacey Hudak"]
["Rand E Waddingham, M.D.",1730181389,"75-1997880","TX","","Medicare","Facility Enrollment","Facility Enrollment","","RHC Part A Only","","2020-09-01","09/01/2020 - RHC - Part A Only. Provider cannot be enrolled under the group, as this would be billed under the facility - Stacey Hudak"]
["Coby R Robins, MD",1104237015,"75-2133441","TX","PE - Midland Pediatric Associates, PLLC","CAQH","Participating","CAQH Reattested","2023-09-27","14218808","","2023-06-05","6/5/2023- CAQH Reattested by Data Services - kavello"]
["Coby R Robins, MD",1104237015,"75-2133441","TX","PE - Midland Pediatric Associates, PLLC","Humana","Participating","Enrollment Complete","2018-07-18","1104237015","","2020-07-15","07/15/2020 - Rec'd email through Humana Secure Mailbox stating \"i have attached a small roster with providers still active under that tin but also not on your roster.\"  I confirmed that this provider does remain effective with our group - Stacey Hudak"]
["Kevin W Benson, MD",1326061086,"75-2133441","TX","PE - Midland Pediatric Associates, PLLC","Scott&White (First Care)","Participating","Enrollment Complete","2015-12-17","1326061086","","2020-04-16","04/16/2020 - Rec'd confirmation from the payer stating this provider is EFF under the DELEGATED PRIMED agreement with this TIN/Service Location- Stacey Hudak\n\n**Verified with the payer that this provider is networked with: \nFirstCare MyChoice PPO\nCHIP\nFirstCare Select Benefit Network\nHMO Enhanced Benefit Network\nMedicare (FC)\nPPO Limited Benefit Network"]
["Kevin W Benson, MD",1326061086,"75-2133441","TX","PE - Midland Pediatric Associates, PLLC","TriCare Standard","Participating","Enrollment Complete","2018-12-19","","","2020-11-03","11/3/2020 Confirmed via self-service portal provider has been completed effective 12/19/2018. Kimberly Frazier"]
["Tokkie Orogbemi, CPNP",1790435014,"75-2133441","TX","PE - Midland Pediatric Associates, PLLC","HealthSmart PPO","In Process","Payor Follow Up","","","","2023-11-14","11/14/2023 Per Healthsmart provider portal provider is still not loaded under group TIN.  Per phone conversation with Lee Kinard at Healthsmart provider portal should be updated  by 11/27/2023.  Will allow more time, check back in 2 weeks.   DCannon"]
["Tokkie Orogbemi, CPNP",1790435014,"75-2133441","TX","PE - Midland Pediatric Associates, PLLC","Multiplan","Participating","Enrollment Complete","2023-06-01","","","2023-07-25","7/25/2023 Rcvd email confirmation from Jessica Bess at Multiplan that June roster has been processed and provider is PAR w/ group effective 6/1/2023.  DCannon"]
["Tokkie Orogbemi, CPNP",1790435014,"75-2133441","TX","PE - Midland Pediatric Associates, PLLC","United Health Care","Participating","Enrollment Complete","2023-06-01","00008736952","","2023-10-13","10/13/2023 Per email received from  from UHC monthly delegated roster submission has been completed and provider is PAR and in linked to group TIN effective 6/1/2023.   MPIN# 00008736952.   DCannon"]
["Willie Clyde Watson, III, MD",1659366433,"75-2133441","TX","PE - Midland Pediatric Associates, PLLC","USA PPO","Participating","Enrollment Complete","2002-11-15","1659366433","752133441","2020-08-19","Confirmed provider is participating with PPO and H&W networks (list of networks attached). Kimberly Frazier"]
["Willie Clyde Watson, III, MD",1659366433,"75-2133441","TX","PE - Midland Pediatric Associates, PLLC","Scott&White (First Care)","Participating","Enrollment Complete","2018-01-01","1659366433","","2020-04-16","04/16/2020 - Rec'd confirmation from the payer stating this provider is EFF under the DELEGATED PRIMED agreement with HMO/PPO only products with this TIN/Service Location- Stacey Hudak"]
["Willie Clyde Watson, III, MD",1659366433,"75-2133441","TX","PE - Midland Pediatric Associates, PLLC","Boon Chapman","Participating","Enrollment Complete","2017-04-15","1659366433","","2020-10-05","enrolled thru PHCS"]
["Debbie P Reese, MD",1629074984,"75-2133441","TX","PE - Midland Pediatric Associates, PLLC","Aetna","Participating","Enrollment Complete","2019-01-01","1629074984","","2020-03-25","3/25/2020--S/W Mary of Aetna @ 8003531232,  provider NPI# is on file for the provider and is participating effective 01/01/2019 under the group and TIN#. Physical location is on file. DIRECT CONTRACT--Call ref#: 5194781237. \ntisha rader"]
["Debbie P Reese, MD",1629074984,"75-2133441","TX","PE - Midland Pediatric Associates, PLLC","Humana","Participating","Enrollment Complete","2011-03-01","","","2023-02-17","2/17/2023 Per email received from Priscilla Albertine at MQA she received confirmation from Humana that provider is PAR and linked to group TIN/location effective 3/1/2011.  DCannon"]
["Wayne L Sager, MD",1225182314,"75-2133441","TX","PE - Midland Pediatric Associates, PLLC","Tricare Prime","Participating","Enrollment Complete","2009-04-30","","","2020-10-08","10/8/2020 Confirmed via Self-Service Portal provider is participating under Tax ID and location. Kimberly Frazier"]
["Wayne L Sager, MD",1225182314,"75-2133441","TX","PE - Midland Pediatric Associates, PLLC","Multiplan","Participating","Enrollment Complete","2017-04-15","1225182314","","2020-08-27","08/27/2020 -Rec'd email from the payer stating \"\nThank you for contacting our Customer Service Department with Multiplan/PHCS. We received your request have confirmed that the following providers are participating with Multiplan and PHCS through Midland Pediatric Associates: - Wayne Sager-Effective 04/15/2017\" - Stacey Hudak"]
["Wayne L Sager, MD",1225182314,"75-2133441","TX","PE - Midland Pediatric Associates, PLLC","Aetna","Participating","Enrollment Complete","2009-09-15","1225182314","","2020-06-09","06/09/2020 - S/W Bella of Aetna @ 8003531232, provider NPI# is on file for the provider and is participating effective 09/15/2009 under the group and TIN#. Provider is delegated to Primed Health Network. Physical location is on file. Call ref# 5309719262. - Stacey Hudak"]
["Kristin M Moose, FNP",1215213970,"75-2182177","TX","PE - Debbie P. Reese, MD PA","Humana","Participating","Enrollment Complete","2021-09-01","","","2021-11-18","11/18/2021 Rcvd full roster from Humana listing provider as PAR and linked to group TIN/location effective 9/1/2021.  DCannon"]
["Kristin M Moose, FNP",1215213970,"75-2182177","TX","PE - Debbie P. Reese, MD PA","Omni PPO","Participating","Enrollment Complete","2021-06-10","","","2021-07-09","7/9/2021 Rcvd email from German Aviles <german.aciles@imsm.net> at IMS/OMNI stating that the monthly delegated roster provider loads for June have been completed.  Provider is PAR and linked to location/TIN effective 6/10/2021. DCannon"]
["Kristin M Moose, FNP",1215213970,"75-2182177","TX","PE - Debbie P. Reese, MD PA","USA PPO","Participating","Enrollment Complete","2021-06-10","","","2021-07-01","7/1/2021  In following up with USAMCO (800-872-3860) I was told that you can confirm participating via the USA MCO website  https://providersearch.usamco.com/hwprovsearch.  Provider is PAR and linked to location/TIN effective 6/10/2021.  DCannon"]
["Taylor Allison Arrington, APRN-FNP-BC",1619603255,"75-2182177","TX","PE - Debbie P. Reese, MD PA","Multiplan","Participating","Enrollment Complete","2023-02-06","","","2023-06-21","Rcvd effective date of 2/6/2023 from jessica.bess@MultiPlan.com.\nJen Videan"]
["Taylor Allison Arrington, APRN-FNP-BC",1619603255,"75-2182177","TX","PE - Debbie P. Reese, MD PA","CAQH","In House Enrollment","In House Enrollment","","","","2022-11-28","11/28/2022 Provider refused to provide login.  Provider will maintain CAQH profile.  DCannon"]
["Taylor Allison Arrington, APRN-FNP-BC",1619603255,"75-2182177","TX","PE - Debbie P. Reese, MD PA","Boon Chapman","Participating","Enrollment Complete","2023-02-06","","","2023-07-21","7/21/2023 Per email from Multiplan provider is PAR and linked to group/TIN effective 2/6/2023.  DCannon"]
["Debbie P Reese, MD",1629074984,"75-2182177","TX","PE - Debbie P. Reese, MD PA","Medicaid","Participating","Enrollment Complete","2016-08-11","132863503","132863501","2020-06-25","06/25/2020 - rec'd welcome letter from the clinic showing - Stacey Hudak"]
["Debbie P Reese, MD",1629074984,"75-2182177","TX","PE - Debbie P. Reese, MD PA","HealthSmart PPO","Participating","Enrollment Complete","2011-02-01","10120298","","2020-07-21","07/21/2020 - Rec'd email from the payer indicating this provider/service location/TIN are affiliated under PRIMED delegation - Stacey Hudak"]
["Douglas J Colson, MD",1790767119,"75-2656723","TX","PE - Premier Family Care, Inc","TriCare Standard","Participating","Enrollment Complete","2023-10-17","","","2023-10-27","Ste. 102 and 103 effective 10/17/2023 has been approved. MD"]
["Douglas J Colson, MD",1790767119,"75-2656723","TX","PE - Premier Family Care, Inc","Cigna","Participating","Enrollment Complete","2023-07-19","6670877","","2023-11-08","Received confirmation of update. MS"]
["Douglas J Colson, MD",1790767119,"75-2656723","TX","PE - Premier Family Care, Inc","Aetna","In Process","Add Info Submitted","","","","2023-11-13","11/13/2023 Additional information submitted to Aetna.  Demo update letter and W-9 to update suite #.  DCannon"]
["Douglas J Colson, MD",1790767119,"75-2656723","TX","PE - Premier Family Care, Inc","Caprock (CapStar)","Participating","Enrollment Complete","2023-07-19","","","2023-10-19","10/19/2023 Rcvd email  confirmation from Caprock that provider is PAR and linked to group TIN/locations effective 7/19/2023.  DCannon"]
["Lori Ann Reeves, APRN-FNP-BC",1023520830,"75-2656723","TX","PE - Premier Family Care, Inc","USA PPO","Participating","Enrollment Complete","2013-12-27","1023520830","463131679","2020-08-18","Confirmed provider is participating under delegated agreement for PPO and H&W Networks (list of networks attached). Kim Frazier"]
["Lori Ann Reeves, APRN-FNP-BC",1023520830,"75-2656723","TX","PE - Premier Family Care, Inc","IMS","Participating","Enrollment Complete","2019-09-01","1023520830","","2020-07-27","07/27/2020 - Rec'd roster response back from the payer regarding 7/15/2020 submission stating that all requested providers/service locations have been added to PriMed agreement - Stacey Hudak"]
["Lori Ann Reeves, APRN-FNP-BC",1023520830,"75-2656723","TX","PE - Premier Family Care, Inc","Scott&White (First Care)","Participating","Enrollment Complete","2018-07-11","1023520830","","2020-02-19","2/19/2020--Per payer roster received from Irma Henson, this provider is participating with this service location and TIN--tisha rader"]
["Lori Ann Reeves, APRN-FNP-BC",1023520830,"75-2656723","TX","PE - Premier Family Care, Inc","Multiplan","Participating","Enrollment Complete","2018-06-15","1023520830","52669: West Texas Physicians Alliance Group Cntrct","2020-03-11","03/11/2020 - Rec'd email response from the payer stating provider is effective with different networks/effective dates as follows:\n\"Network:  MPI \nNetwork Participation effective: 10/01/2019 Group contract through: West Texas Physicians Alliance\n\nNetwork:  PHCS\nNetwork Participation effective: 06/15/2018 Group contract through: West Texas Physicians Alliance\n\nNetwork:  Beech St.\nNetwork Participation effective: 11/27/2019 Group contract through: West Texas Physicians Alliance\"\n\nAll are linked to group TIN - Stacey Hudak"]
["Anusha Ammu, MD",1386135713,"75-2656723","TX","PE - Premier Family Care, Inc","Caprock (CapStar)","Provider Load","Provider Load","","","","2023-11-27",""]
["Anusha Ammu, MD",1386135713,"75-2656723","TX","PE - Premier Family Care, Inc","Aetna","In Process","Application Submitted","","","","2023-11-28","Application submitted via online portal. Request ID 51222024. MS"]
["Anusha Ammu, MD",1386135713,"75-2656723","TX","PE - Premier Family Care, Inc","Medicaid","Provider Load","Provider Load","","","","2023-11-27",""]
["Rachel K Longacre, FNP-C",1639524861,"75-2656723","TX","PE - Premier Family Care, Inc","Multiplan","Participating","Enrollment Complete","2019-04-16","1639524861","52669: West Texas Physicians Alliance Group Cntrct","2020-02-13","02/13/2020 - Rec'd roster stating this provider is linked to DIRECT GROUP CONTRACT as of 4-16-2019. Provider is networked with Beechstreet. - Stacey Hudak"]
["Rachel K Longacre, FNP-C",1639524861,"75-2656723","TX","PE - Premier Family Care, Inc","CAQH","Participating","CAQH Reattested","2023-11-01","13859704","","2023-11-01","11/01/2023 - CAQH Re-attested, updated and uploaded, license and COI - dkonar"]
["Rachel K Longacre, FNP-C",1639524861,"75-2656723","TX","PE - Premier Family Care, Inc","Amerigroup","Participating","Enrollment Complete","2023-07-19","","","2023-10-19","10/19/2023 Per email received from Jessica Bess at  Multiplan provider is PAR with Amerigroup and linked to group TIN/locations thru Multiplan enrollment effective 7/19/2023.  DCannon"]
["Rachel K Longacre, FNP-C",1639524861,"75-2656723","TX","PE - Premier Family Care, Inc","Caprock (CapStar)","Participating","Enrollment Complete","2019-05-21","1639524861","","2020-06-02","06/02/2020 - rec'd spreadsheet back from the payer Mary Rodriguez <MRodriguez@caprockhp.com> confirming this provider/service location is EFF with this payer - Stacey Hudak"]
["Rachel K Longacre, FNP-C",1639524861,"75-2656723","TX","PE - Premier Family Care, Inc","Cigna","Participating","Enrollment Complete","2023-04-17","","","2023-09-13","Received confirmation of enrollment via email. MS"]
["Rachel K Longacre, FNP-C",1639524861,"75-2656723","TX","PE - Premier Family Care, Inc","Medicaid","Participating","Enrollment Complete","","360348204","079837301","2020-01-29","01/29/2020 - found provider through payer portal. Provider is linked to the following plans: TRADITIONAL MEDICAID, Texas Children's Health Plan - MRSA Northeast, Amerigroup - MRSA West, Amerigroup Texas, Inc. - MRSA West - Stacey Hudak"]
["Rachel K Longacre, FNP-C",1639524861,"75-2656723","TX","PE - Premier Family Care, Inc","Cigna","Participating","Enrollment Complete","2021-03-31","2017791","","2021-08-04","8/4/2021 Received an email from PDMCOGZ@cigna.com with confirmation provider is now participating under group Tax ID effective 3/31/2021 with assigned provider ID number 2017791. KFrazier"]
["Rachel K Longacre, FNP-C",1639524861,"75-2656723","TX","PE - Premier Family Care, Inc","Amerigroup","Participating","Enrollment Complete","2019-05-31","1639524861","","2020-02-11","2/11/2020 – Received Roster from Amerigroup and provider is now PAR- Tisha Rader\n\n3-19-2020 - Rec'd email from Multiplan/Texas True Choice confirming that this EFF information is true - Stacey Hudak"]
["Madhavi Gadiraju, MD",1932541406,"75-2656723","TX","PE - Premier Family Care, Inc","CAQH","Participating","CAQH Reattested","2023-10-31","13876531","","2023-10-31","10/31/2023 - Updated primary email add, DEA, board, billing address, liability and uploaded documents and re-attested - rkedare"]
["Madhavi Gadiraju, MD",1932541406,"75-2656723","TX","PE - Premier Family Care, Inc.","IMS","Participating","Enrollment Complete","2023-06-05","","","2023-07-18","7/18/2023 Per email received from IMS/OMNI June delegated roster has been processed and provider is PAR and linked to group effective 6/5/2023.  DCannon"]
["Madhavi Gadiraju, MD",1932541406,"75-2656723","TX","PE - Premier Family Care, Inc","Wellmed","Participating","Enrollment Complete","2022-01-01","","","2023-03-23","3/23/2023 Rcvd roster from UHC w/ all Wellmed participating providers.  Provider is PAR effective 1/1/2022.  DCannon"]
["Madhavi Gadiraju, MD",1932541406,"75-2656723","TX","PE - Premier Family Care, Inc","Medicare","Participating","Enrollment Complete","2019-05-01","804641","0008AH","2023-07-17","7/17/2023 Per PECOS - Medicare provider is PAR and linked to group/location.  PTAN# 804641.  DCannon"]
["Madhavi Gadiraju, MD",1932541406,"75-2656723","TX","PE - Premier Family Care, Inc","Caprock (CapStar)","Participating","Enrollment Complete","2023-06-05","","",45133,"7/26/2023 Rcvd email  confirmation from Caprock that provider is PAR and linked to group TIN/locations effective 6/5/2023.  DCannon"]
["Madhavi Gadiraju, MD",1932541406,"75-2656723","TX","PE - Premier Family Care, Inc","Scott&White (First Care)","Participating","Enrollment Complete","2019-05-01","1932541406","","2020-02-19","2/19/2020--Per payer roster received from Irma Henson, this provider is participating with this service location and TIN--tisha rader"]
["Madhavi Gadiraju, MD",1932541406,"75-2656723","TX","PE - Premier Family Care, Inc","HealthSmart PPO","Participating","Enrollment Complete","2019-06-12","1932541406","","2020-09-23","09/23/2020 - moved to completed status after reviewing follow up complete - Stacey Hudak"]
["Deborah A Frempong, APRN-FNP-BC",1811423981,"75-2656723","TX","PE - Premier Family Care, Inc","IMS","Participating","Enrollment Complete","2019-08-26","1811423981","","2020-06-22","06/22/2020- Rec'd email from the payer confirming this provider is PAR with this group/service location - Stacey Hudak"]
["Deborah A Frempong, APRN-FNP-BC",1811423981,"75-2656723","TX","PE - Premier Family Care, Inc","Galaxy Health","Participating","Enrollment Complete","2019-06-12","1811423981","","2020-07-10","07/10/2020 - updated payer line to enrollment complete status instead of \"Delegated status\" for report running purposes - Stacey Hudak"]
["Deborah A Frempong, APRN-FNP-BC",1811423981,"75-2656723","TX","PE - Premier Family Care, Inc","Boon Chapman","Participating","Enrollment Complete","2020-07-01","","","2021-08-06","8/6/2021 Boon Chapman falls under the Multiplan umbrella, received roster from Multiplan provider is listed on roster under TIN/location as PAR effective 7/1/2020.  DCannon"]
["Deborah A Frempong, APRN-FNP-BC",1811423981,"75-2656723","TX","PE - Premier Family Care, Inc","Medicaid","Participating","Enrollment Complete","","397315801","079837301","2020-01-29","01/29/2020 - found provider through payer portal. Provider is linked to these plans: FirstCare - Lubbock, TRADITIONAL MEDICAID, Amerigroup - MRSA West, FirstCare - MRSA West, Amerigroup Texas, Inc. - MRSA West - Stacey Hudak"]
["Richard E Winn, MD",1073672994,"75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","2021-11-08","","","2021-11-30","11/30/2021 Checked portal and provide is added to location. Cbankston"]
["Richard E Winn, MD",1073672994,"75-2656723","TX","PE - Premier Family Care, Inc","Superior","Participating","Enrollment Complete","2019-11-01","1073672994","","2020-07-14","07/14/2020 - Rec'd email from the payer stating this provider is EFF under PRIMED DELEGATED agreement - Stacey Hudak"]
["Richard E Winn, MD",1073672994,"75-2656723","TX","PE - Premier Family Care, Inc","Medicare","Participating","Enrollment Complete","2019-07-01","823276","","2020-08-07","8/7/2020 - moved to completed status after getting welcome letter from the clinic. No effective date was listed - Stacey Hudak"]
["Richard E Winn, MD",1073672994,"75-2656723","TX","PE - Premier Family Care, Inc","Ambetter","Participating","Enrollment Complete","2022-06-01","","","2022-06-13","6/13/2022 Per roster received from Superior provider is PAR w/ Ambetter and linked to group delegation roster effective 6/1/2022.  DCannon"]
["Megan Casselman, NP-C",1528619525,"75-2656723","TX","PE - Premier Family Care, Inc","United Health Care","Participating","Enrollment Complete","2019-10-01","1528619525","","2020-08-31","08/31/2020 - moved to completed status after reviewing follow up complete note - stacey Hudak"]
["Megan Casselman, NP-C",1528619525,"75-2656723","TX","PE - Premier Family Care, Inc","First Health Coventry","Participating","Enrollment Complete","2020-09-01","1528619525","","2020-10-01","10/01/2020 - Rec'd an email from the payer stating this enrollment has been completed  - Stacey Hudak"]
["Megan Casselman, NP-C",1528619525,"75-2656723","TX","PE - Premier Family Care, Inc","Cigna","Participating","Enrollment Complete","2019-12-30","1528619525","","2020-02-20","02/20/2020 - Rec'd verification from the payer that this provider is EFF 12-30-2019 and linked to this service location under a DIRECT CONTRACT with this payer - Stacey Hudak"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Triwest VA","In House Enrollment","Facility Enrollment","","","","2022-11-28","10/17/2022 - Received roster from Scarlett of TriWest VA; provider status: \"No Action.  TIN is CCN participating under own DCN.\""]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Triwest VA","In House Enrollment","Facility Enrollment","","","","2022-11-28","10/17/2022 - Received roster from Scarlett of TriWest VA; provider status: \"No Action.  TIN is CCN participating under own DCN.\""]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Triwest VA","In House Enrollment","Facility Enrollment","","","","2022-11-28","10/17/2022 - Received roster from Scarlett of TriWest VA; provider status: \"No Action.  TIN is CCN participating under own DCN.\""]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Triwest VA","In House Enrollment","Facility Enrollment","","","","2022-11-28","10/17/2022 - Received roster from Scarlett of TriWest VA; provider status: \"No Action.  TIN is CCN participating under own DCN.\""]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","First Health Coventry","Participating","Enrollment Complete","2022-11-15","","","2023-02-28","2/28/2023 Per First Health web portal provider is PAR and linked to group TIN/location effective 11/15/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","First Health Coventry","Participating","Enrollment Complete","2022-11-15","","","2023-02-28","2/28/2023 Per First Health web portal provider is PAR and linked to group TIN/location effective 11/15/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","First Health Coventry","Participating","Enrollment Complete","2022-11-15","","","2023-02-28","2/28/2023 Per First Health web portal provider is PAR and linked to group TIN/location effective 11/15/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","First Health Coventry","Participating","Enrollment Complete","2022-11-15","","","2023-02-28","2/28/2023 Per First Health web portal provider is PAR and linked to group TIN/location effective 11/15/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Wellcare","Participating","Enrollment Complete","2022-09-01","","","2022-09-08","9/8/2022 Per roster received from Superior August monthly delegated submission is complete and provider is PAR and linked to group TIN/locations effective  9/1/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Wellcare","Participating","Enrollment Complete","2022-09-01","","","2022-09-08","9/8/2022 Per roster received from Superior August monthly delegated submission is complete and provider is PAR and linked to group TIN/locations effective  9/1/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Wellcare","Participating","Enrollment Complete","2022-09-01","","","2022-09-08","9/8/2022 Per roster received from Superior August monthly delegated submission is complete and provider is PAR and linked to group TIN/locations effective  9/1/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Wellcare","Participating","Enrollment Complete","2022-09-01","","","2022-09-08","9/8/2022 Per roster received from Superior August monthly delegated submission is complete and provider is PAR and linked to group TIN/locations effective  9/1/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Galaxy Health","Participating","Enrollment Complete","2022-08-12","","","2022-10-15","10/15/2022 Per follow-up email from KAvalos at Galaxy August delegation roster has been completed and provider is PAR and linked to group effective 8/12/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Galaxy Health","Participating","Enrollment Complete","2022-08-12","","","2022-10-15","10/15/2022 Per follow-up email from KAvalos at Galaxy August delegation roster has been completed and provider is PAR and linked to group effective 8/12/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Galaxy Health","Participating","Enrollment Complete","2022-08-12","","","2022-10-15","10/15/2022 Per follow-up email from KAvalos at Galaxy August delegation roster has been completed and provider is PAR and linked to group effective 8/12/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Galaxy Health","Participating","Enrollment Complete","2022-08-12","","","2022-10-15","10/15/2022 Per follow-up email from KAvalos at Galaxy August delegation roster has been completed and provider is PAR and linked to group effective 8/12/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Superior","Participating","Enrollment Complete","2022-09-01","","","2022-09-08","9/8/2022 Per roster received from Superior August monthly delegated submission is complete and provider is PAR and linked to group TIN/locations effective  9/1/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Superior","Participating","Enrollment Complete","2022-09-01","","","2022-09-08","9/8/2022 Per roster received from Superior August monthly delegated submission is complete and provider is PAR and linked to group TIN/locations effective  9/1/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Superior","Participating","Enrollment Complete","2022-09-01","","","2022-09-08","9/8/2022 Per roster received from Superior August monthly delegated submission is complete and provider is PAR and linked to group TIN/locations effective  9/1/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Superior","Participating","Enrollment Complete","2022-09-01","","","2022-09-08","9/8/2022 Per roster received from Superior August monthly delegated submission is complete and provider is PAR and linked to group TIN/locations effective  9/1/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Superior","Participating","Enrollment Complete","2022-09-01","","","2022-09-08","9/8/2022 Per roster received from Superior August monthly delegated submission is complete and provider is PAR and linked to group TIN/locations effective  9/1/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Ambetter","Participating","Enrollment Complete","2022-09-01","","","2022-09-08","9/8/2022 Per roster received from Superior August monthly delegated submission is complete and provider is PAR and linked to group TIN/locations effective  9/1/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Ambetter","Participating","Enrollment Complete","2022-09-01","","","2022-09-08","9/8/2022 Per roster received from Superior August monthly delegated submission is complete and provider is PAR and linked to group TIN/locations effective  9/1/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Amerigroup","Participating","Enrollment Complete","2022-08-12","","","2022-10-28","10/28/2022 Per follow-up note from 10.21.2022 S/W Gloria of Amerigroup @ 800-454-3730. Per rep, provider is on file and participating. Link under the group and TIN effective 8/12/2022. Location is on file. Provider ID is 14387628. No recredentialing date. Dcannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Amerigroup","Participating","Enrollment Complete","2022-08-12","","","2022-10-28","10/28/2022 Per follow-up note from 10.21.2022 S/W Gloria of Amerigroup @ 800-454-3730. Per rep, provider is on file and participating. Link under the group and TIN effective 8/12/2022. Location is on file. Provider ID is 14387628. No recredentialing date. Dcannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Amerigroup","Participating","Enrollment Complete","2022-08-12","","","2022-10-28","10/28/2022 Per follow-up note from 10.21.2022 S/W Gloria of Amerigroup @ 800-454-3730. Per rep, provider is on file and participating. Link under the group and TIN effective 8/12/2022. Location is on file. Provider ID is 14387628. No recredentialing date. Dcannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Amerigroup","Participating","Enrollment Complete","2022-08-12","","","2022-10-28","10/28/2022 Per follow-up note from 10.21.2022 S/W Gloria of Amerigroup @ 800-454-3730. Per rep, provider is on file and participating. Link under the group and TIN effective 8/12/2022. Location is on file. Provider ID is 14387628. No recredentialing date. Dcannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Amerigroup","Participating","Enrollment Complete","2022-08-12","","","2022-10-28","10/28/2022 Per follow-up note from 10.21.2022 S/W Gloria of Amerigroup @ 800-454-3730. Per rep, provider is on file and participating. Link under the group and TIN effective 8/12/2022. Location is on file. Provider ID is 14387628. No recredentialing date. Dcannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Rail Road Medicare","Participating","Enrollment Complete","2022-08-28","","","2022-09-08","9/8/2022 Rcvd RR Medicare approval letter.  PTAN # Q00322530 - effective 8/28/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Rail Road Medicare","Participating","Enrollment Complete","2022-08-28","","","2022-09-08","9/8/2022 Rcvd RR Medicare approval letter.  PTAN # Q00322530 - effective 8/28/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Rail Road Medicare","Participating","Enrollment Complete","2022-08-28","","","2022-09-08","9/8/2022 Rcvd RR Medicare approval letter.  PTAN # Q00322530 - effective 8/28/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Rail Road Medicare","Participating","Enrollment Complete","2022-08-28","","","2022-09-08","9/8/2022 Rcvd RR Medicare approval letter.  PTAN # Q00322530 - effective 8/28/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","CAQH","Participating","CAQH Reattested","2023-09-27","","","2023-09-27","CAQH Reattested by DS team wthompson"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","CAQH","Participating","CAQH Reattested","2023-09-27","","","2023-09-27","CAQH Reattested by DS team wthompson"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","CAQH","Participating","CAQH Reattested","2023-09-27","","","2023-09-27","CAQH Reattested by DS team wthompson"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","CAQH","Participating","CAQH Reattested","2023-09-27","","","2023-09-27","CAQH Reattested by DS team wthompson"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","CAQH","Participating","CAQH Reattested","2023-09-27","","","2023-09-12","Added locations and COI, re-attested. Jen Videan"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","CAQH","Participating","CAQH Reattested","2023-09-27","","","2023-09-12","Added locations and COI, re-attested. Jen Videan"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","CAQH","Participating","CAQH Reattested","2023-09-27","","","2023-09-27","CAQH Reattested by DS team wthompson"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","CAQH","Participating","CAQH Reattested","2023-09-27","","","2023-09-12","Added locations and COI, re-attested. Jen Videan"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Humana","Participating","Enrollment Complete","2022-09-12","","","2022-11-15","11/15/2022 Per email rcvd from Vernita Young at Humana delegated roster provider load for August is complete.  Provider is PAR and linked to group TIN/locations effective 9/12/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Humana","Participating","Enrollment Complete","2022-09-12","","","2022-11-15","11/15/2022 Per email rcvd from Vernita Young at Humana delegated roster provider load for August is complete.  Provider is PAR and linked to group TIN/locations effective 9/12/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Humana","Participating","Enrollment Complete","2022-09-12","","","2022-11-15","11/15/2022 Per email rcvd from Vernita Young at Humana delegated roster provider load for August is complete.  Provider is PAR and linked to group TIN/locations effective 9/12/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Humana","Participating","Enrollment Complete","2022-09-12","","","2022-11-15","11/15/2022 Per email rcvd from Vernita Young at Humana delegated roster provider load for August is complete.  Provider is PAR and linked to group TIN/locations effective 9/12/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","United Health Care","Participating","Enrollment Complete","2022-09-12","","","2022-10-13","10/13/2022 Per email received from  from UHC monthly delegated roster submission has been completed and provider is PAR and in linked to group TIN effective 9/12/2022.   MPIN# 008193055.   DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","United Health Care","Participating","Enrollment Complete","2022-09-12","","","2022-10-13","10/13/2022 Per email received from  from UHC monthly delegated roster submission has been completed and provider is PAR and in linked to group TIN effective 9/12/2022.   MPIN# 008193055.   DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","United Health Care","Participating","Enrollment Complete","2022-09-12","","","2022-10-13","10/13/2022 Per email received from  from UHC monthly delegated roster submission has been completed and provider is PAR and in linked to group TIN effective 9/12/2022.   MPIN# 008193055.   DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","United Health Care","Participating","Enrollment Complete","2022-09-12","","","2022-10-13","10/13/2022 Per email received from  from UHC monthly delegated roster submission has been completed and provider is PAR and in linked to group TIN effective 9/12/2022.   MPIN# 008193055.   DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","United Health Care","Participating","Enrollment Complete","2022-09-12","","","2022-10-13","10/13/2022 Per email received from  from UHC monthly delegated roster submission has been completed and provider is PAR and in linked to group TIN effective 9/12/2022.   MPIN# 008193055.   DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Omni PPO","Participating","Enrollment Complete","2022-08-12","","","2022-10-17","10/17/2022 Per email received from German Aviles at IMS/OMNI monthly delegation roster provider load for August has been completed.  Provider is PAR and linked to group TIN effective 8/12/2022.   DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Omni PPO","Participating","Enrollment Complete","2022-08-12","","","2022-10-17","10/17/2022 Per email received from German Aviles at IMS/OMNI monthly delegation roster provider load for August has been completed.  Provider is PAR and linked to group TIN effective 8/12/2022.   DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Omni PPO","Participating","Enrollment Complete","2022-08-12","","","2022-10-17","10/17/2022 Per email received from German Aviles at IMS/OMNI monthly delegation roster provider load for August has been completed.  Provider is PAR and linked to group TIN effective 8/12/2022.   DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","HealthSmart PPO","Participating","Enrollment Complete","2022-09-12","","","2022-10-13","10/13/2022 Per Healthsmart website provider is PAR and loaded under TIN/location effective 9/12/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","HealthSmart PPO","Participating","Enrollment Complete","2022-09-12","","","2022-10-13","10/13/2022 Per Healthsmart website provider is PAR and loaded under TIN/location effective 9/12/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","HealthSmart PPO","Participating","Enrollment Complete","2022-09-12","","","2022-10-13","10/13/2022 Per Healthsmart website provider is PAR and loaded under TIN/location effective 9/12/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","Panel Closed","Panel Closed","","","","2022-09-15","9/15/2022 Per Humana Military web portal Humana Military is currently not accepting requests to join the medical surgical network. We apologize for the inconvenience, but we hope you check back soon to see if we are accepting network providers.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","Panel Closed","Panel Closed","","","","2022-09-15","9/15/2022 Per Humana Military web portal Humana Military is currently not accepting requests to join the medical surgical network. We apologize for the inconvenience, but we hope you check back soon to see if we are accepting network providers.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","Panel Closed","Panel Closed","","","","2022-09-15","9/15/2022 Per Humana Military web portal Humana Military is currently not accepting requests to join the medical surgical network. We apologize for the inconvenience, but we hope you check back soon to see if we are accepting network providers.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","Panel Closed","Panel Closed","","","","2022-09-15","9/15/2022 Per Humana Military web portal Humana Military is currently not accepting requests to join the medical surgical network. We apologize for the inconvenience, but we hope you check back soon to see if we are accepting network providers.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","Panel Closed","Panel Closed","","","","2022-09-15","9/15/2022 Per Humana Military web portal Humana Military is currently not accepting requests to join the medical surgical network. We apologize for the inconvenience, but we hope you check back soon to see if we are accepting network providers.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Boon Chapman","Participating","Enrollment Complete","2022-08-12","","","2023-09-01","9/1/2023 Per email received from Multiplan provider is PAR and linked to group TIN/locations effective 8/12/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Boon Chapman","Participating","Enrollment Complete","2022-08-12","","","2023-09-01","9/1/2023 Per email received from Multiplan provider is PAR and linked to group TIN/locations effective 8/12/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Boon Chapman","Participating","Enrollment Complete","2022-08-12","","","2023-09-01","9/1/2023 Per email received from Multiplan provider is PAR and linked to group TIN/locations effective 8/12/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Boon Chapman","Participating","Enrollment Complete","2022-08-12","","","2023-09-01","9/1/2023 Per email received from Multiplan provider is PAR and linked to group TIN/locations effective 8/12/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Cigna","Participating","Enrollment Complete","2023-03-10","8909854","","2023-03-13","3/13/2023 Rcvd email from Cigna that provider is PAR and linked to group TIN/locations effective 3/10/2023.  PID# 8909854 DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Cigna","Participating","Enrollment Complete","2023-03-10","8909854","","2023-03-13","3/13/2023 Rcvd email from Cigna that provider is PAR and linked to group TIN/locations effective 3/10/2023.  PID# 8909854 DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Cigna","Participating","Enrollment Complete","2023-03-10","8909854","","2023-03-13","3/13/2023 Rcvd email from Cigna that provider is PAR and linked to group TIN/locations effective 3/10/2023.  PID# 8909854 DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Cigna","Participating","Enrollment Complete","2023-03-10","8909854","","2023-03-13","3/13/2023 Rcvd email from Cigna that provider is PAR and linked to group TIN/locations effective 3/10/2023.  PID# 8909854 DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Medicaid","Participating","Enrollment Complete","2022-08-28","1922658319","","2022-10-24","10/24/2022 Rcvd TMHP approval letter.  Provider is PAR and linked to group effective 8/28/2022.  TPI # 1922658319.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Medicaid","Participating","Enrollment Complete","2022-08-28","1922658319","","2022-10-24","10/24/2022 Rcvd TMHP approval letter.  Provider is PAR and linked to group effective 8/28/2022.  TPI # 1922658319.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Medicaid","Participating","Enrollment Complete","2022-08-28","1922658319","","2022-10-24","10/24/2022 Rcvd TMHP approval letter.  Provider is PAR and linked to group effective 8/28/2022.  TPI # 1922658319.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Medicaid","Participating","Enrollment Complete","2022-08-28","1922658319","","2022-10-24","10/24/2022 Rcvd TMHP approval letter.  Provider is PAR and linked to group effective 8/28/2022.  TPI # 1922658319.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Scott&White (First Care)","Participating","Enrollment Complete","2022-09-12","","","2022-09-15","9/15/2022 Received approval notification from Scott & White that provider is PAR and linked to group TIN/location effective 9/12/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Scott&White (First Care)","Participating","Enrollment Complete","2022-09-12","","","2022-09-15","9/15/2022 Received approval notification from Scott & White that provider is PAR and linked to group TIN/location effective 9/12/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Scott&White (First Care)","Participating","Enrollment Complete","2022-09-12","","","2022-09-15","9/15/2022 Received approval notification from Scott & White that provider is PAR and linked to group TIN/location effective 9/12/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Scott&White (First Care)","Participating","Enrollment Complete","2022-09-12","","","2022-09-15","9/15/2022 Received approval notification from Scott & White that provider is PAR and linked to group TIN/location effective 9/12/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","IMS","Participating","Enrollment Complete","2022-08-12","","","2022-10-17","10/17/2022 Per email received from German Aviles at IMS/OMNI monthly delegation roster provider load for August has been completed.  Provider is PAR and linked to group TIN effective 8/12/2022.   DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","IMS","Participating","Enrollment Complete","2022-08-12","","","2022-10-17","10/17/2022 Per email received from German Aviles at IMS/OMNI monthly delegation roster provider load for August has been completed.  Provider is PAR and linked to group TIN effective 8/12/2022.   DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","IMS","Participating","Enrollment Complete","2022-08-12","","","2022-10-17","10/17/2022 Per email received from German Aviles at IMS/OMNI monthly delegation roster provider load for August has been completed.  Provider is PAR and linked to group TIN effective 8/12/2022.   DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","IMS","Participating","Enrollment Complete","2022-08-12","","","2022-10-17","10/17/2022 Per email received from German Aviles at IMS/OMNI monthly delegation roster provider load for August has been completed.  Provider is PAR and linked to group TIN effective 8/12/2022.   DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","IMS","Participating","Enrollment Complete","2022-08-12","","","2022-10-17","10/17/2022 Per email received from German Aviles at IMS/OMNI monthly delegation roster provider load for August has been completed.  Provider is PAR and linked to group TIN effective 8/12/2022.   DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Medicare","Participating","Enrollment Complete","2022-08-28","2G9994","0008AH","2022-08-11","8/11/2022 Rcvd Medicare approval letter.  Provider is PAR and linked to group/locations -   PTAN # 2G9994 - effective 8/28/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Medicare","Participating","Enrollment Complete","2022-08-28","2G9994","0008AH","2022-08-11","8/11/2022 Rcvd Medicare approval letter.  Provider is PAR and linked to group/locations -   PTAN # 2G9994 - effective 8/28/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Medicare","Participating","Enrollment Complete","2022-08-28","2G9994","0008AH","2022-08-11","8/11/2022 Rcvd Medicare approval letter.  Provider is PAR and linked to group/locations -   PTAN # 2G9994 - effective 8/28/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Medicare","Participating","Enrollment Complete","2022-08-28","2G9994","0008AH","2022-08-11","8/11/2022 Rcvd Medicare approval letter.  Provider is PAR and linked to group/locations -   PTAN # 2G9994 - effective 8/28/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Caprock (CapStar)","Participating","Enrollment Complete","2020-01-01","","","2022-10-12","10/12/2022 Per email from Priscilla Albertine she rcvd confirmation from Mary Rodriguez at Caprock that provider is PAR and linked to group TIN/locations effective 1/1/2020.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Caprock (CapStar)","Participating","Enrollment Complete","2020-01-01","","","2022-10-12","10/12/2022 Per email from Priscilla Albertine she rcvd confirmation from Mary Rodriguez at Caprock that provider is PAR and linked to group TIN/locations effective 1/1/2020.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Caprock (CapStar)","Participating","Enrollment Complete","2020-01-01","","","2022-10-12","10/12/2022 Per email from Priscilla Albertine she rcvd confirmation from Mary Rodriguez at Caprock that provider is PAR and linked to group TIN/locations effective 1/1/2020.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","USA PPO","Participating","Enrollment Complete","2022-09-12","","","2023-03-24","3/24/2023 In following up with USAMCO (800-872-3860) I was told that you can confirm participating via the USA MCO website  https://providersearch.usamco.com/hwprovsearch.  Provider is PAR and linked to location/TIN effective 9/12/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","USA PPO","Participating","Enrollment Complete","2022-09-12","","","2023-03-24","3/24/2023 In following up with USAMCO (800-872-3860) I was told that you can confirm participating via the USA MCO website  https://providersearch.usamco.com/hwprovsearch.  Provider is PAR and linked to location/TIN effective 9/12/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","USA PPO","Participating","Enrollment Complete","2022-09-12","","","2023-03-24","3/24/2023 In following up with USAMCO (800-872-3860) I was told that you can confirm participating via the USA MCO website  https://providersearch.usamco.com/hwprovsearch.  Provider is PAR and linked to location/TIN effective 9/12/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Aetna","Participating","Enrollment Complete","2022-11-15","","","2023-01-23","1.23.23 Rcvd confirmation from Aetna that provider is PAR at the following locations only (709 W Louisiana Ave, 3411 Caldera, 3415 N Loop 250) effective 11/15/2022 Provider ID is 6669419. Link Letter and W9 will need to be submitted by fax @859-455-8650 to Aetna (attn to network management) to link provider to other locations.  TAT is 10-15 business days. ABoles"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Aetna","Participating","Enrollment Complete","2022-11-15","","","2023-01-23","1.23.23 Rcvd confirmation from Aetna that provider is PAR at the following locations only (709 W Louisiana Ave, 3411 Caldera, 3415 N Loop 250) effective 11/15/2022 Provider ID is 6669419. Link Letter and W9 will need to be submitted by fax @859-455-8650 to Aetna (attn to network management) to link provider to other locations.  TAT is 10-15 business days. ABoles"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Aetna","Participating","Enrollment Complete","2022-11-15","","","2023-01-23","1.23.23 Rcvd confirmation from Aetna that provider is PAR at the following locations only (709 W Louisiana Ave, 3411 Caldera, 3415 N Loop 250) effective 11/15/2022 Provider ID is 6669419. Link Letter and W9 will need to be submitted by fax @859-455-8650 to Aetna (attn to network management) to link provider to other locations.  TAT is 10-15 business days. ABoles"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Aetna","Participating","Enrollment Complete","2022-11-15","","","2023-01-23","1.23.23 Rcvd confirmation from Aetna that provider is PAR at the following locations only (709 W Louisiana Ave, 3411 Caldera, 3415 N Loop 250) effective 11/15/2022 Provider ID is 6669419. Link Letter and W9 will need to be submitted by fax @859-455-8650 to Aetna (attn to network management) to link provider to other locations.  TAT is 10-15 business days. ABoles"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Wellmed","Participating","Enrollment Complete","2022-08-12","","","2023-03-23","3/23/2023 Rcvd roster from UHC w/ all Wellmed participating providers.  Provider is PAR effective 8/12/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Wellmed","Participating","Enrollment Complete","2022-08-12","","","2023-03-23","3/23/2023 Rcvd roster from UHC w/ all Wellmed participating providers.  Provider is PAR effective 8/12/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Wellmed","Participating","Enrollment Complete","2022-08-12","","","2023-03-23","3/23/2023 Rcvd roster from UHC w/ all Wellmed participating providers.  Provider is PAR effective 8/12/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Wellmed","Participating","Enrollment Complete","2022-08-12","","","2023-03-23","3/23/2023 Rcvd roster from UHC w/ all Wellmed participating providers.  Provider is PAR effective 8/12/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Wellmed","Participating","Enrollment Complete","2022-08-12","","","2023-03-23","3/23/2023 Rcvd roster from UHC w/ all Wellmed participating providers.  Provider is PAR effective 8/12/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Multiplan","Participating","Enrollment Complete","2022-08-12","","","2023-09-01","9/1/2023 Per email received from Multiplan provider is PAR and linked to group TIN/locations effective 8/12/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Multiplan","Participating","Enrollment Complete","2022-08-12","","","2023-09-01","9/1/2023 Per email received from Multiplan provider is PAR and linked to group TIN/locations effective 8/12/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Multiplan","Participating","Enrollment Complete","2022-08-12","","","2023-09-01","9/1/2023 Per email received from Multiplan provider is PAR and linked to group TIN/locations effective 8/12/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","TriCare Standard","Participating","Enrollment Complete","2023-01-05","","","2023-01-18","1/18/2023 Rcvd letter from Tricare that provider is now Tricare certified effective 1//5/2023.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","TriCare Standard","Participating","Enrollment Complete","2023-01-05","","","2023-01-18","1/18/2023 Rcvd letter from Tricare that provider is now Tricare certified effective 1//5/2023.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","TriCare Standard","Participating","Enrollment Complete","2023-01-05","","","2023-01-18","1/18/2023 Rcvd letter from Tricare that provider is now Tricare certified effective 1//5/2023.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","TriCare Standard","Participating","Enrollment Complete","2023-01-05","","","2023-01-18","1/18/2023 Rcvd letter from Tricare that provider is now Tricare certified effective 1//5/2023.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","TriCare Standard","Participating","Enrollment Complete","2023-01-05","","","2023-01-18","1/18/2023 Rcvd letter from Tricare that provider is now Tricare certified effective 1//5/2023.  DCannon"]
["Ana M Rodriguez, APRN-FNP-BC",1437790284,"75-2656723","TX","PE - Premier Family Care, Inc","Medicaid","Participating","Enrollment Complete","2020-10-01","403920802","","2021-01-20","1/20/2021 Upon review of the TMHP portal, provider has been approved and issued TPI 403920802 under Group Tax ID/TPI. KFrazier"]
["Ana M Rodriguez, APRN-FNP-BC",1437790284,"75-2656723","TX","PE - Premier Family Care, Inc","Wellmed","Participating","Enrollment Complete","2022-01-01","","","2023-03-23","3/23/2023 Rcvd roster from UHC w/ all Wellmed participating providers.  Provider is PAR effective 1/1/2022.  DCannon"]
["Ana M Rodriguez, APRN-FNP-BC",1437790284,"75-2656723","TX","PE - Premier Family Care, Inc","CAQH","Participating","CAQH Reattested","2023-09-28","14485629","","2023-07-05","6/5/2023- CAQH Reattested by Data Services - kavello"]
["James D Richardson, MD",1306827266,"75-2656723","TX","PE - Premier Family Care, Inc","Scott&White (First Care)","Provider Load","Provider Load","","","","2023-11-27",""]
["James D Richardson, MD",1306827266,"75-2656723","TX","PE - Premier Family Care, Inc","USA PPO","In Process","Add to Next Delegated Roster","","","","2023-11-27",""]
["James D Richardson, MD",1306827266,"75-2656723","TX","PE - Premier Family Care, Inc","USA PPO","Participating","Enrollment Complete","2021-01-26","1312349","","2021-03-12","3/12/2021 Per verification on payor website USAMCO.com provider is loaded as participating.  Rcvd Roster LeNetrice Myart with provider numbers and effective dates for providers.  DCannon"]
["James D Richardson, MD",1306827266,"75-2656723","TX","PE - Premier Family Care, Inc","United Health Care","In Process","Add to Next Delegated Roster","","","","2023-11-27",""]
["Kristie M Chu, MD",1780078089,"75-2656723","TX","PE - Premier Family Care, Inc","HealthSmart PPO","Participating","Enrollment Complete","2021-05-10","","","2021-06-03","6/1/2021 Per Healthsmart website provider is PAR and loaded under TIN/location effective 5/10/2021.  DCannon"]
["Kristie M Chu, MD",1780078089,"75-2656723","TX","PE - Premier Family Care, Inc","IMS","Participating","Enrollment Complete","2021-05-10","","","2021-06-15","6/15/2021 Rcvd email from German Aviles <german.aciles@imsm.net> at IMS/OMNI stating that the monthly delegated roster provider loads for March, April, May and June have been completed.  Provider is PAR and linked to location/TIN effective 5/10/2021. DCannon"]
["Kristie M Chu, MD",1780078089,"75-2656723","TX","PE - Premier Family Care, Inc","Omni PPO","Participating","Enrollment Complete","2021-05-10","","","2021-06-15","6/15/2021 Rcvd email from German Aviles <german.aciles@imsm.net> at IMS/OMNI stating that the monthly delegated roster provider loads for March, April, May and June have been completed.  Provider is PAR and linked to location/TIN effective 5/10/2021. DCannon"]
["Kristie M Chu, MD",1780078089,"75-2656723","TX","PE - Premier Family Care, Inc","Scott&White (First Care)","Participating","Enrollment Complete","2021-05-10","","","2021-08-18","8/18/2021 Rcvd complete roster from S & W list provider has PAR and loaded under TIN/location effective 5/10/2021.  DCannon"]
["Maria Montero, MD",1508218843,"75-2656723","TX","PE - North Big Spring Family Care","HealthSmart PPO","Participating","Enrollment Complete","2020-08-21","","","2021-12-03","12/3/2021 Per Healthsmart website provider is PAR and loaded under TIN/location effective 8/21/2020.  DCannon"]
["Maria Montero, MD",1508218843,"75-2656723","TX","PE - North Big Spring Family Care","Wellmed","Participating","Enrollment Complete","2022-02-01","","","2023-03-23","3/23/2023 Rcvd roster from UHC w/ all Wellmed participating providers.  Provider is PAR effective 2/1/2022.  DCannon"]
["Maria Montero, MD",1508218843,"75-2656723","TX","PE - North Big Spring Family Care","Galaxy Health","Participating","Enrollment Complete","2020-01-01","1508218843","","2020-10-05","10/5/2020 - Rec'd email back from the payer stating this enrollment has been completed - Stacey"]
["Leslie Michelle Rowland, FNP",1720111883,"75-2656723","TX","PE - Premier Family Care, Inc","Cigna","Participating","Enrollment Complete","2020-10-12","","","2021-01-18","1/18/2021 - Rcvd confirmation email from Cigna that provider has loaded and is participating under TIN and location effective 10/12/2020 CPID # 4138818.  DCannon"]
["Leslie Michelle Rowland, FNP",1720111883,"75-2656723","TX","PE - Premier Family Care, Inc","Amerigroup","Participating","Enrollment Complete","2011-05-12","","","2021-12-03","12/3/2021 Per Amerigroup roster received Joe Rodriguez provider is PAR under group TIN/location effective 5/12/2011.   DCannon"]
["Leslie Michelle Rowland, FNP",1720111883,"75-2656723","TX","PE - Premier Family Care, Inc","Superior","Participating","Enrollment Complete","2020-12-01","","","2020-12-22","12/22/2020 Rcvd email confirmation that Nov monthly roster was processed and this provider was made effective with the requested eff date of 12/1/2020.  DCannon"]
["Leslie Michelle Rowland, FNP",1720111883,"75-2656723","TX","PE - Premier Family Care, Inc","TriCare Standard","Participating","Enrollment Complete","2021-11-08","","","2021-11-30","11/30/21 Per Tricare portal, provider added to location. Cbankston"]
["Leslie Michelle Rowland, FNP",1720111883,"75-2656723","TX","PE - Premier Family Care, Inc","Ambetter","Participating","Enrollment Complete","2022-06-01","","","2022-06-13","6/13/2022 Per roster received from Superior provider is PAR and linked to group delegation roster effective 6/1/2022."]
["Leslie Michelle Rowland, FNP",1720111883,"75-2656723","TX","PE - Premier Family Care, Inc","USA PPO","Participating","Enrollment Complete","2021-01-26","1312371","","2021-03-12","3/12/2021 Per verification on payor website USAMCO.com provider is loaded as participating.  Rcvd Roster LeNetrice Myart with provider numbers and effective dates for providers.  DCannon"]
["Leslie Michelle Rowland, FNP",1720111883,"75-2656723","TX","PE - Premier Family Care, Inc","USA PPO","Participating","Enrollment Complete","2021-01-26","1312371","","2021-03-12","3/12/2021 Per verification on payor website USAMCO.com provider is loaded as participating.  Rcvd Roster LeNetrice Myart with provider numbers and effective dates for providers.  DCannon"]
["Leslie Michelle Rowland, FNP",1720111883,"75-2656723","TX","PE - Premier Family Care, Inc","Wellcare","Participating","Enrollment Complete","2021-11-01","","","2022-12-01","12/1/2022 Per roster received from Wellcare provider is PAR and linked to group TIN/location effective 11/1/2021.  DCannon"]
["Leslie Michelle Rowland, FNP",1720111883,"75-2656723","TX","PE - Premier Family Care, Inc","CAQH","Participating","CAQH Reattested","2023-10-06","","","2023-10-06","10/6/2023 CAQH reviewed and re-attested.  Update board cert and insurance.  DCannon"]
["Leslie Michelle Rowland, FNP",1720111883,"75-2656723","TX","PE - Premier Family Care, Inc","Humana","Participating","Enrollment Complete","2021-09-01","","","2021-11-18","11/18/2021 Rcvd full roster from Humana listing provider as PAR and linked to group TIN/location effective 9/1/2021.  DCannon"]
["Leslie Michelle Rowland, FNP",1720111883,"75-2656723","TX","PE - Premier Family Care, Inc","Triwest VA","Facility Enrollment","In House Enrollment","","","","2021-01-13","1/6/2021 MQA Team is working with Representatives at BCBS-TX to ensure all providers are enrolled and loaded to participate with the VACCN network in a timely manner. However, we are currently awaiting a full roster of providers currently participating and will update all records accordingly upon receipt. Kfrazier"]
["Leslie Michelle Rowland, FNP",1720111883,"75-2656723","TX","PE - Premier Family Care, Inc","Scott&White (First Care)","Participating","Enrollment Complete","2021-02-12","","","2021-01-29","1/29/2021 - Rcvd roster from Scott&White (First Care) confirming participation of provider with TIN and location effective dates.  DCannon"]
["Ni Adams, APRN-NP",1194355339,"75-2656723","TX","PE - Premier Family Care, Inc","Triwest VA","Facility Enrollment","Facility Enrollment","","","","2022-10-17","10/17/2022 - Received roster from Scarlett of TriWest VA; provider status: \"No Action.  TIN is CCN participating under own DCN.\""]
["Ni Adams, APRN-NP",1194355339,"75-2656723","TX","PE - Premier Family Care, Inc","HealthSmart PPO","Participating","Enrollment Complete","2020-10-13","","","2021-01-22","1/22/2021 - Rcvd email from Healthsmart Provider Services that provider is participating at location under TIN effective 10/13/2020.  DCannon"]
["Ni Adams, APRN-NP",1194355339,"75-2656723","TX","PE - Premier Family Care, Inc","Aetna","Participating","Enrollment Complete","2021-06-01","6615260","","2021-07-08","7/1/2021-S/W Jessie of AETNA @ 8003531232, NPI# of the provider is on file and shows link and PAR under the group and TIN# effective 6/1/2021, physical location is on file. Provider ID is 6615260.  As per Rep, Rep confirmed that once provider is credentialed w/ Aetna automatically, provider is also credentialed w/First Health and Coventry. Call ref#6028231587."]
["Ni Adams, APRN-NP",1194355339,"75-2656723","TX","PE - Premier Family Care, Inc","TriCare Standard","Participating","Enrollment Complete","2022-03-02","","","2022-03-09","3/9/2022 Per Tricare portal provider is certified and in network with location as of 3/2/2022. Cbankston"]
["Rachel Ann Murphy, RD",1124637160,"75-2656723","TX","PE - Premier Family Care, Inc","Amerigroup","Participating","Enrollment Complete","2020-12-07","","","2021-08-26","8/26/2021 Rcvd full roster from Joe Rodriguez at Amerigroup listing provider as PAR w/ group TIN and location effective 12/7/2020.  DCannon"]
["Rachel Ann Murphy, RD",1124637160,"75-2656723","TX","PE - Premier Family Care, Inc","Caprock (CapStar)","Participating","Enrollment Complete","2020-12-07","","","2021-08-01","8/1/2021 Per Mary Rodriguez w/ Caprock provider is PAR and linked to group TIN/locations effective 12/7/2020.  DCannon"]
["Premier Intensive Ca",1275522864,"75-2656723","TX","PE - Premier Intensive Cardiac Rehabilitation","Medicare","Participating","Enrollment Complete","2021-01-01","","1K9664","2021-01-12","1/12/2021 Received approval notice forwarded from Candace Wynne with assigned PTAN 1K9664 effective 1/1/2021. KFrazier"]
["Orlando Enrique Garner Cruz, MD",1417309105,"75-2656723","TX","","Scott&White (First Care)","Participating","Enrollment Complete","2021-05-10","","","2021-08-18","8/18/2021 Rcvd complete roster from S & W list provider has PAR and loaded under TIN/location effective 5/10/2021.  DCannon"]
["Orlando Enrique Garner Cruz, MD",1417309105,"75-2656723","TX","PE - Premier Family Care, Inc","USA PPO","Participating","Enrollment Complete","2021-05-10","","","2022-06-29","6/29/2022 Per email received from Priscilla Albertine at MQA from a follow-up email she received from USA PPO provider is PAR and in linked to group TIN effective 5/10/2021.  DCannon"]
["Orlando Enrique Garner Cruz, MD",1417309105,"75-2656723","TX","PE - Premier Family Care, Inc","United Health Care","Participating","Enrollment Complete","2021-05-10","","","2022-06-11","6/11/2022 Per email from Janice Edwards @ UHC delegated roster provider load has been completed and providers PAR and linked to group TIN effective 5/10/2021.  DCannon"]
["Orlando Enrique Garner Cruz, MD",1417309105,"75-2656723","TX","PE - Premier Family Care, Inc","IMS","Participating","Enrollment Complete","2021-05-10","","","2021-06-15","6/15/2021 Rcvd email from German Aviles <german.aciles@imsm.net> at IMS/OMNI stating that the monthly delegated roster provider loads for March, April, May and June have been completed.  Provider is PAR and linked to location/TIN effective 5/10/2021. DCannon"]
["Orlando Enrique Garner Cruz, MD",1417309105,"75-2656723","TX","PE - Premier Family Care, Inc","Galaxy Health","Participating","Enrollment Complete","2021-05-10","","","2021-06-03","6/3/2021 Rcvd email from Galaxy Health, Karen Avalos <kavalos@ghn.mci.com> that monthly delegation roster for May is complete and providers are loaded under TIN/locations effective 5/10/2021.  DCannon"]
["Orlando Enrique Garner Cruz, MD",1417309105,"75-2656723","TX","PE - Premier Family Care, Inc","Triwest VA","Facility Enrollment","Facility Enrollment","","","","2022-10-17","10/17/2022 - Received roster from Scarlett of TriWest VA; provider status: \"No Action.  TIN is CCN participating under own DCN.\""]
["Emily Baker, DO",1053817940,"75-2656723","TX","PE - Premier Family Care, Inc","CAQH","Participating","CAQH Reattested","2023-11-07","","","2023-11-07","11/7/2023 CAQH reviewed and re-attested.  Uploaded current malpractice COI.  DCannon"]
["Emily Baker, DO",1053817940,"75-2656723","TX","PE - Premier Family Care, Inc","Scott&White (First Care)","Participating","Enrollment Complete","2021-08-27","","","2021-10-13","10/13/21 Received email from BSWHPEXPEDITES@BSWHealth.org, provder is effective as of 08/27/2021. However, please allow 3-4 weeks before submitting claims to ensure he/she is completely configured in our system; otherwise, claims may deny. Cbankston"]
["Emily Baker, DO",1053817940,"75-2656723","TX","PE - Premier Family Care, Inc","Medicare","Participating","Enrollment Complete","2021-08-01","1R7343","0008AH","2021-07-21","7/21/2021 Received Medicare PTAN approval letter.  PTAN # 1R7343 - effective 8/1/2021 DCannon"]
["Emily Baker, DO",1053817940,"75-2656723","TX","PE - Premier Family Care, Inc","Wellcare","Participating","Enrollment Complete","2021-11-01","","","2022-11-15","11/15/2022 Per roster received from Wellcare provider is PAR and linked to group TIN/location effective 11/1/2021.  DCannon"]
["Brenda Campos-Ilesanmi, APRN-NP",1740807304,"75-2656723","TX","PE - Premier Family Care, Inc","Ambetter","Participating","Enrollment Complete","2023-07-01","","","2023-07-21","7/21/2023 Rcvd confirmation email from Superior that June delegation roster has been processed and provider has been loaded to delegation roster and PAR w/ group effective 7/1/2023.  DCannon"]
["Brenda Campos-Ilesanmi, APRN-NP",1740807304,"75-2656723","TX","PE - Premier Family Care, Inc","CAQH","Participating","CAQH Reattested","2023-11-13","","","2023-11-13","11/13/2023 CAQH Reattested WT"]
["Brenda Campos-Ilesanmi, APRN-NP",1740807304,"75-2656723","TX","PE - Premier Family Care, Inc","Superior","Participating","Enrollment Complete","2023-06-01","","","2023-07-19","7/19/2023 Rcvd email from Superior that provider is PAR and linked to new location via group delegated roster effective 6/1/2023.  DCannon"]
["Brenda Campos-Ilesanmi, APRN-NP",1740807304,"75-2656723","TX","PE - Premier Family Care, Inc","Rail Road Medicare","Participating","Enrollment Complete","2022-07-12","Q00306920","CE1588","2022-08-11","8/11/2022 Rcvd RR Medicare approval letter.  Provider is PAR and linked to group/locations -   PTAN # Q00306920 - effective 7/12/2022.  DCannon"]
["Brenda Campos-Ilesanmi, APRN-NP",1740807304,"75-2656723","TX","PE - Premier Family Care, Inc","HealthSmart PPO","In Process","Payor Follow Up","","","","2023-11-14","11/14/2023 Per Healthsmart provider portal provider is still not loaded under group TIN.  Per phone conversation with Lee Kinard at Healthsmart provider portal should be updated  by 11/27/2023.  Will allow more time, check back in 2 weeks.   DCannon"]
["Brenda Campos-Ilesanmi, APRN-NP",1740807304,"75-2656723","TX","PE - Premier Family Care, Inc","Superior","Participating","Enrollment Complete","2022-08-01","","","2023-07-17","7/17/2023 Rcvd email from Superior that provider is PAR and linked to new location via group delegated roster effective 6/1/2023.  DCannon"]
["Brenda Campos-Ilesanmi, APRN-NP",1740807304,"75-2656723","TX","PE - Premier Family Care, Inc","Multiplan","Participating","Enrollment Complete","2022-08-01","","","2022-07-24","7/24/2022 Per email from Marcie Eckhart-Havens Multiplan July delegated roster has been completed  and provider is PAR and linked to group TIN effective 8/1/2022.  DCannon"]
["Brenda Campos-Ilesanmi, APRN-NP",1740807304,"75-2656723","TX","PE - Premier Family Care, Inc","Wellmed","Participating","Enrollment Complete","2022-08-01","","","2023-03-23","3/23/2023 Rcvd roster from UHC w/ all Wellmed participating providers.  Provider is PAR effective 8/1/2022.  DCannon"]
["Brenda Campos-Ilesanmi, APRN-NP",1740807304,"75-2656723","TX","PE - Premier Family Care, Inc","TriCare Standard","In Process","Add Info Submitted","","","","2023-11-16","Currently working with the Tricare rep regarding the delay of this providers' enrollment. They have escalated the request. Ref.# 1243897205  MS"]
["Judy J Jia, MD",1588983134,"75-2656723","TX","PE - Premier Family Care, Inc","Ambetter","Participating","Enrollment Complete","2022-05-01","","","2022-06-13","6/13/2022 Per roster received from Superior provider is PAR w/ Ambetter and linked to group delegation roster effective 5/1/2022."]
["Judy J Jia, MD",1588983134,"75-2656723","TX","PE - Premier Family Care, Inc","IMS","Participating","Enrollment Complete","2022-04-11","","","2022-05-26","5/26/2022 Rcvd email from G. Aviles at IMS/OMNI stating that the monthly delegated roster provider loads for April has been completed.  Provider is PAR and linked to location/TIN effective 4/11/2022. DCannon"]
["Judy J Jia, MD",1588983134,"75-2656723","TX","PE - Premier Family Care, Inc","Multiplan","Participating","Enrollment Complete","2022-04-11","","","2022-07-24","7/24/2022 Per email from Marcie Eckhart-Havens Multiplan July delegated roster has been completed  and provider is PAR and linked to group TIN effective 4/11/2022.  DCannon"]
["Claude B Nguyen, MD",1619130929,"75-2656723","TX","PE - Premier Family Care, Inc","Caprock (CapStar)","Participating","Enrollment Complete","2022-04-11","","","2022-08-30","8/30/2022 Received a roster from Priscilla Albertine at MQA that she received from Michelle Rodriguez.  Provider is PAR and linked to group TIN/locations effective 4/11/2022.  DCannon"]
["Claude B Nguyen, MD",1619130929,"75-2656723","TX","PE - Premier Family Care, Inc","Superior","Participating","Enrollment Complete","2022-05-01","","","2022-05-03","5/3/2022 Rcvd email from Superior that April delegation roster has been completed and provider is PAR and linked to group TIN/location effective 5/1/2022.  DCannon"]
["Claude B Nguyen, MD",1619130929,"75-2656723","TX","PE - Premier Family Care, Inc","Humana","Participating","Enrollment Complete","2022-04-11","","","2022-07-14","7/14/2022 Per email received from Humana provider is PAR and linked to group TIN/location effective 4/11/2022.  DCannon"]
["John H Ownby, MD",1558343988,"75-2656723","TX","PE - Premier Family Care, Inc","Aetna","Participating","Enrollment Complete","2022-07-01","5154560","","2022-06-19","6/19/2022 Per email received from Aetna provider is PAR and linked to group TIN effective 7/1/2022.  DCannon"]
["John H Ownby, MD",1558343988,"75-2656723","TX","PE - Premier Family Care, Inc","IMS","Participating","Enrollment Complete","2022-04-11","","","2022-05-26","5/26/2022 Rcvd email from G. Aviles at IMS/OMNI stating that the monthly delegated roster provider loads for April has been completed.  Provider is PAR and linked to location/TIN effective 4/11/2022. DCannon"]
["John H Ownby, MD",1558343988,"75-2656723","TX","PE - Premier Family Care, Inc","Triwest VA","Facility Enrollment","Facility Enrollment","","","","2022-10-17","10/17/2022 - Received roster from Scarlett of TriWest VA; provider status: \"No Action.  TIN is CCN participating under own DCN.\""]
["John H Ownby, MD",1558343988,"75-2656723","TX","","CAQH","Participating","CAQH Reattested","2023-11-06","","","2023-06-05","6/5/2023- CAQH Reattested by Data Services - kavello"]
["John H Ownby, MD",1558343988,"75-2656723","TX","PE - Premier Family Care, Inc","Rail Road Medicare","Participating","Enrollment Complete","2022-02-21","Q00267339","CE1588","2022-05-26","5/26/2022 Rcvd RR Medicare approval letter. RR Medicare PTAN #  Q0267339 - effective 2/21/2022.  DCannon"]
["Kendra Cooper, APRN-FNP-BC",1780334193,"75-2656723","TX","PE - Premier Family Care, Inc","United Health Care","Participating","Enrollment Complete","2022-07-01","008051513","","2022-08-10","8/10/2022 Rcvd email from UHC that July monthly delegation roster has been completed and provider is PAR and linked to group TIN effective 7/1/2022.  MPIN # 008051513  DCannon"]
["Kendra Cooper, APRN-FNP-BC",1780334193,"75-2656723","TX","PE - Premier Family Care, Inc","USA PPO","Participating","Enrollment Complete","2022-05-09","","","2023-03-09","3/9/2023 Per email from LaNetrice Myart at USA PPO provider is PAR and linked to group/location effective 5/9/2022.  DCannon"]
["Kendra Cooper, APRN-FNP-BC",1780334193,"75-2656723","TX","PE - Premier Family Care, Inc","Scott&White (First Care)","Participating","Enrollment Complete","2022-09-13","","","2022-09-15","9/15/2022 Received approval notification from Scott & White that provider is PAR and linked to group TIN/location effective 9/13/2022.  DCannon"]
["Kendra Cooper, APRN-FNP-BC",1780334193,"75-2656723","TX","PE - Premier Family Care, Inc","Superior","Participating","Enrollment Complete","2022-08-01","","","2023-01-24","1/24/2023 Rcvd email from Priscilla Albertine at MQA of confirmation that provider is PAR in Superior Health plan under the group TIN effective 8/1/2022.   DCannon"]
["Kendra Cooper, APRN-FNP-BC",1780334193,"75-2656723","TX","PE - Premier Family Care, Inc","TriCare Standard","Participating","Enrollment Complete","2022-07-20","","","2022-09-15","9/15/2022 Per Tricare portal provider is PAR and linked to group TIN/location effective 7/20/2022.  DCannon"]
["Kendra Cooper, APRN-FNP-BC",1780334193,"75-2656723","TX","PE - Premier Family Care, Inc","CAQH","Participating","CAQH Reattested","2023-08-16","","","2023-08-16","8/16/2023 CAQH reviewed added new practice location and re-attested.  DCannon"]
["Kendra Cooper, APRN-FNP-BC",1780334193,"75-2656723","TX","PE - Premier Family Care, Inc","Caprock (CapStar)","Participating","Enrollment Complete","2020-01-01","","","2022-10-12","10/12/2022 Per email from Priscilla Albertine she rcvd confirmation from Mary Rodriguez at Caprock that provider is PAR and linked to group TIN/locations effective 1/1/2020.  DCannon"]
["Vishnu S Brahmandam, MD",1548447899,"75-2656723","TX","","Ambetter","Participating","Enrollment Complete","2022-10-01","","","2022-12-29","12/29/2022 Rcvd email from Priscilla Albertine at MQA w/ confirmation from Superior that provider is PAR and linked to group effective 10/01/2022.  DCannon"]
["Vishnu S Brahmandam, MD",1548447899,"75-2656723","TX","","Caprock (CapStar)","Participating","Enrollment Complete","2020-01-01","","","2022-10-12","10/12/2022 Per email from Priscilla Albertine she rcvd confirmation from Mary Rodriguez at Caprock that provider is PAR and linked to group TIN/locations effective 1/1/2020.  DCannon"]
["Vishnu S Brahmandam, MD",1548447899,"75-2656723","TX","PE - Premier Family Care, Inc","First Health Coventry","Participating","Enrollment Complete","2022-08-15","","","2023-02-28","2/28/2023 Per First Health web portal provider is PAR and linked to group TIN/location effective 8/15/2022.  DCannon"]
["Vishnu S Brahmandam, MD",1548447899,"75-2656723","TX","","Wellmed","Participating","Enrollment Complete","2022-12-17","","","2023-03-23","3/23/2023 Rcvd roster from UHC w/ all Wellmed participating providers.  Provider is PAR effective 12/17/2022.  DCannon"]
["Vishnu S Brahmandam, MD",1548447899,"75-2656723","TX","","United Health Care","Participating","Enrollment Complete","2022-09-12","003315195","","2022-11-01","11/1/2022 Rcvd email from UCH that provider load has been completed and provider is PAR and linked to group TIN/location effective 9/12/2022.  DCannon"]
["Vishnu S Brahmandam, MD",1548447899,"75-2656723","TX","PE - Premier Family Care, Inc","Rail Road Medicare","Participating","Enrollment Complete","2022-08-15","Q00322555","CD1588","2022-09-08","9/8/2022 Rcvd RR Medicare approval letter.  PTAN # Q00322555 - effective 8/15/2022.  DCannon"]
["Vishnu S Brahmandam, MD",1548447899,"75-2656723","TX","PE - Premier Family Care, Inc","Scott&White (First Care)","Participating","Enrollment Complete","2022-09-22","","","2023-03-08","3/8/2023 Per email received from Scott & White provider is PAR and linked to group TIN/location effective 9/23/2022.  DCannon"]
["Vishnu S Brahmandam, MD",1548447899,"75-2656723","TX","","Boon Chapman","Participating","Enrollment Complete","2022-09-12","","","2023-09-01","9/1/2023 Per email received from Multiplan provider is PAR and linked to group TIN/locations effective 9/12/2022.  DCannon"]
["Christopher A Stack, MD",1568704971,"75-2656723","TX","PE - Premier Family Care, Inc","HealthSmart PPO","Participating","Enrollment Complete","2022-06-20","","","2023-07-11","Received confirmation from Client. MS"]
["Christopher A Stack, MD",1568704971,"75-2656723","TX","PE - Premier Family Care, Inc","Humana","Participating","Enrollment Complete","2022-06-20","","","2022-08-20","8/20/2022 Per email received from Vernita Young July monthly delegated roster is complete and provider is PAR and linked to group TIN/location effective 6/20/2022.  DCannon"]
["Christopher A Stack, MD",1568704971,"75-2656723","TX","PE - Premier Family Care, Inc","TriCare Standard","Participating","Enrollment Complete","2022-09-22","","","2022-10-04","10/4/2022 Rcvd Tricare approval letter stating that provider is now a Tricare-certified provider in Texas effective 9/22/2022.  DCannon"]
["Christopher A Stack, MD",1568704971,"75-2656723","TX","PE - Premier Family Care, Inc","Multiplan","Participating","Enrollment Complete","2022-06-20","","","2022-07-24","7/24/2022 Per email from Marcie Eckhart-Havens Multiplan July delegated roster has been completed  and provider is PAR and linked to group TIN effective 6/20/2022.  DCannon"]
["Christopher A Stack, MD",1568704971,"75-2656723","TX","PE - Premier Family Care, Inc","Medicare","Participating","Enrollment Complete","2022-07-18","2G1495","0008AH","2022-07-21","7/21/2022 Rcvd Medicare approval letter.  PTAN # 2G1495 - effective 7/18/2022.  DCannon"]
["Christopher A Stack, MD",1568704971,"75-2656723","TX","PE - Premier Family Care, Inc","First Health Coventry","Participating","Enrollment Complete","","","","2023-01-18","01.18.2023: S/W Kimora of First Health @800-226-5116. Per rep, provider is participating, in network and linked under the group and TIN effective 12/01/2022. Provider ID# 3162672. Physical location is on file. Don't have payer#. Unable to obtain call ref# since the rep transferred me to a different dept. - Mary Rose Acebedo"]
["Christopher A Stack, MD",1568704971,"75-2656723","TX","","First Health Coventry","Participating","Enrollment Complete","","","","2023-01-18","01.18.2023: S/W Kimora of First Health @800-226-5116. Per rep, provider is participating, in network and linked under the group and TIN effective 12/01/2022. Provider ID# 3162672. Physical location is on file. Don't have payer#. Unable to obtain call ref# since the rep transferred me to a different dept. - Mary Rose Acebedo"]
["Annabelle Rivera, APRN-NP",1871250191,"75-2656723","TX","PE - Premier Family Care, Inc","Wellcare","Participating","Enrollment Complete","2022-11-01","","","2022-12-29","12/29/2022 Rcvd confirmation email from Superior that October delegation roster has been processed and provider has been loaded to delegation roster and PAR w/ group effective 11/1/2022.  DCannon"]
["Annabelle Rivera, APRN-NP",1871250191,"75-2656723","TX","PE - Premier Family Care, Inc","Scott&White (First Care)","Participating","Enrollment Complete","2022-10-07","","","2022-10-10","10/10/2022 Per email frmo Scott & White provider is PAR and linked to group TIN effective 10/7/2022.  DCannon"]
["Annabelle Rivera, APRN-NP",1871250191,"75-2656723","TX","PE - Premier Family Care, Inc","Boon Chapman","Participating","Enrollment Complete","2022-06-26","","","2023-09-01","9/1/2023 Per email received from Multiplan provider is PAR and linked to group TIN/locations effective 6/26/2022.  DCannon"]
["Hannah Heflin, RD",1366172579,"75-2656723","TX","PE - Premier Family Care, Inc","Wellcare","Participating","Enrollment Complete","2022-09-01","","","2022-09-08","9/8/2022 Per roster received from Superior August monthly delegated submission is complete and provider is PAR and linked to group TIN/locations effective  9/1/2022.  DCannon"]
["Hannah Heflin, RD",1366172579,"75-2656723","TX","PE - Premier Family Care, Inc","Ambetter","Participating","Enrollment Complete","2022-09-01","","","2022-09-08","9/8/2022 Per roster received from Superior August monthly delegated submission is complete and provider is PAR and linked to group TIN/locations effective  9/1/2022.  DCannon"]
["Hannah Heflin, RD",1366172579,"75-2656723","TX","PE - Premier Family Care, Inc","IMS","Participating","Enrollment Complete","2022-08-12","","","2022-10-17","10/17/2022 Per email received from German Aviles at IMS/OMNI monthly delegation roster provider load for August has been completed.  Provider is PAR and linked to group TIN effective 8/12/2022.   DCannon"]
["Hannah Heflin, RD",1366172579,"75-2656723","TX","PE - Premier Family Care, Inc","Amerigroup","Participating","Enrollment Complete","2022-08-12","","","2022-11-04","11.04.2022 S/W Chealse of Amerigroup @ 800-454-3730. Per rep, provider is showing participating with an  Effective date 08/12/2022 and link under the Group and TIN. Provider ID 14387498, Payer ID 26375 and No Recredentialing date. Service location is on file. Call ref#:I-166745338. -Danico Gabriel Melendres"]
["Christian A Richardson, APRN-FNP-BC",1184261950,"75-2656723","TX","PE - Premier Family Care, Inc","Rail Road Medicare","Participating","Enrollment Complete","2022-11-01","Q00346338","CE1588","2022-10-15","10/15/2022 Rcvd RR Medicare approval letter.  PTAN # Q00346338 - effective 11/1/2022.  DCannon"]
["Christian A Richardson, APRN-FNP-BC",1184261950,"75-2656723","TX","PE - Premier Family Care, Inc","Boon Chapman","Participating","Enrollment Complete","2022-10-10","","","2023-09-01","9/1/2023 Per email received from Multiplan provider is PAR and linked to group TIN/locations effective 10/10/2022.  DCannon"]
["Christian A Richardson, APRN-FNP-BC",1184261950,"75-2656723","TX","PE - Premier Family Care, Inc","Amerigroup","Participating","Enrollment Complete","2022-10-10","","","2023-02-01","2/1/2023 Per email response from Amerigroup Provider Relations-Texas provider is PAR and linked to group effective 10/10/2022.  PID# 14679859.  DCannon"]
["Christian A Richardson, APRN-FNP-BC",1184261950,"75-2656723","TX","PE - Premier Family Care, Inc","HealthSmart PPO","Participating","Enrollment Complete","2022-10-10","","","2022-11-28","11/28/2022 Per Healthsmart website provider is PAR and loaded under TIN/location effective 10/10/2022.  DCannon"]
["Kathryn A. Lagus, APRN-FNP-BC",1285983155,"75-2656723","TX","PE - Premier Family Care, Inc","Triwest VA","In House Enrollment","In House Enrollment","","","","2022-12-29",""]
["Kathryn A. Lagus, APRN-FNP-BC",1285983155,"75-2656723","TX","PE - Premier Family Care, Inc","Wellmed","Participating","Enrollment Complete","2023-03-07","","","2023-03-23","3/23/2023 Rcvd roster from UHC w/ all Wellmed participating providers.  Provider is PAR effective 3/7/2023.  DCannon"]
["Kathryn A. Lagus, APRN-FNP-BC",1285983155,"75-2656723","TX","PE - Premier Family Care, Inc","Rail Road Medicare","Participating","Enrollment Complete","2023-03-01","","","2023-05-24",""]
["Kathryn A. Lagus, APRN-FNP-BC",1285983155,"75-2656723","TX","PE - Premier Family Care, Inc","Amerigroup","Participating","Enrollment Complete","2022-11-28","","","2023-02-16","2.16.2023  Per follow-up note - S/W Qjuana of Amerigroup @ 800-454-3730. Provider is on file and participating. Link under the group and TIN effective 11/28/2022. Location is on file. Provider ID is 15422622.  DCannon"]
["David Powell Haynie, MD",1083672778,"75-2656723","TX","PE - Premier Family Care, Inc","Medicaid","In Process","Pending Other Enrollment","","","","2023-11-16","4214 Andrews Hwy Suite 109 Midland, TX needs to be added to the group record on TMHP before we can add provider. Jen Videan"]
["David Powell Haynie, MD",1083672778,"75-2656723","TX","PE - Premier Family Care, Inc","USA PPO","Participating","Enrollment Complete","2023-06-01","","","2023-07-24","7/24/2023 In following up with USAMCO (800-872-3860) I was told that you can confirm participating via the USA MCO website  https://providersearch.usamco.com/hwprovsearch.  Provider is PAR and linked to location/TIN effective 6/1/2023.  DCannon"]
["David Powell Haynie, MD",1083672778,"75-2656723","TX","PE - Premier Family Care, Inc","HealthSmart PPO","Participating","Enrollment Complete","2023-06-01","","","2023-11-13","11/13/2023 Per phone conversation with Lee Kinard at Healthsmart provider is PAR and linked to group TIN/location effective 6/1/2023.  DCannon"]
["David Powell Haynie, MD",1083672778,"75-2656723","TX","PE - Premier Family Care, Inc","Aetna","Participating","Enrollment Complete","2023-05-01","","","2023-05-31","05.31.2023 S/W Ria of Aetna @ 1-800-353-1232. Per rep, provider is showing participating and link under the Group and TIN with an Effective date 05/01/2023. Provider ID 4135209, Payer ID 60054 and Recredentialing date is 05/01/2026. Service location is on file. Call ref#:6149191218. - Danico Gabriel Melendres"]
["David Powell Haynie, MD",1083672778,"75-2656723","TX","PE - Premier Family Care, Inc","TriCare Standard","Participating","Enrollment Complete","2023-04-25","","","2023-05-24","Confirmed via the HM portal. MS"]
["David Powell Haynie, MD",1083672778,"75-2656723","TX","PE - Premier Family Care, Inc","Multiplan","Participating","Enrollment Complete","2023-06-01","","","2023-07-25","7/25/2023 Rcvd email confirmation from Jessica Bess at Multiplan that June roster has been processed and provider is PAR w/ group effective 6/1/2023.  DCannon"]
["David Powell Haynie, MD",1083672778,"75-2656723","TX","PE - Premier Family Care, Inc","Ambetter","Participating","Enrollment Complete","2023-07-01","","","2023-07-24","7/24/2023 Rcvd email from Superior that provider is PAR and linked group via delegated roster effective 7/1/2023.  DCannon"]
["David Powell Haynie, MD",1083672778,"75-2656723","TX","PE - Premier Family Care, Inc","Amerigroup","Participating","Enrollment Complete","2023-06-01","","","2023-10-18","10/18/2023 Per email received from Jessica Bess at  Multiplan provider is PAR with Amerigroup and linked to group TIN/locations thru Multiplan enrollment effective 6/1/2023.  DCannon"]
["David Powell Haynie, MD",1083672778,"75-2656723","TX","PE - Premier Family Care, Inc","Medicare","Participating","Enrollment Complete","2023-05-01","2W8694","","2023-11-27","Received approval letter for ICR effective 10/2/2023. MS"]
["David Powell Haynie, MD",1083672778,"75-2656723","TX","PE - Premier Family Care, Inc","CAQH","Participating","CAQH Reattested","2023-11-01","","","2001-11-10","11/01/2023  Updated board information and re-attested - rkedare"]
["David Powell Haynie, MD",1083672778,"75-2656723","TX","PE - Premier Family Care, Inc","Rail Road Medicare","Participating","Enrollment Complete","2023-05-01","","","2023-08-21","Confirmed enrollment. MS"]
["David Powell Haynie, MD",1083672778,"75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","Panel Closed","Panel Closed","","","","2023-04-25","4/25/2023 Per Humana Military web portal Humana Military is currently not accepting requests to join the medical surgical network. We apologize for the inconvenience, but we hope you check back soon to see if we are accepting network providers.  DCannon"]
["David Powell Haynie, MD",1083672778,"75-2656723","TX","PE - Premier Family Care, Inc","Omni PPO","Participating","Enrollment Complete","2023-06-01","","","2023-07-18","7/18/2023 Per email received from IMS/OMNI June delegated roster has been processed and provider is PAR and linked to group effective 6/1/2023.  DCannon"]
["David Powell Haynie, MD",1083672778,"75-2656723","TX","PE - Premier Family Care, Inc","Scott&White (First Care)","Participating","Enrollment Complete","2023-07-20","","","2023-08-08","Per response from hpdelegation@bswhealth.org, Dr. Hayne is effective 07/20/2023. Jen Videan"]
["David Powell Haynie, MD",1083672778,"75-2656723","TX","PE - Premier Family Care, Inc","Scott&White (First Care)","Participating","Enrollment Complete","2023-07-20","","","2023-08-08","Per response from hpdelegation@bswhealth.org, Dr. Hayne is effective 07/20/2023. Jen Videan"]
["David Powell Haynie, MD",1083672778,"75-2656723","TX","PE - Premier Family Care, Inc","Superior","Participating","Enrollment Complete","2023-07-01","","","2023-07-24","7/24/2023 Rcvd email from Superior that provider is PAR and linked group via delegated roster effective 7/1/2023.  DCannon"]
["Rahul P Sinha, MD",1598182412,"75-2656723","TX","PE - Premier Family Care, Inc","Multiplan","Participating","Enrollment Complete","2023-09-19","","","2023-11-09","11/9/2023 Rcvd email confirmation from Jessica Bess at Multiplan that October roster has been processed and provider is PAR w/ group effective 9/19/2023.  DCannon"]
["Rahul P Sinha, MD",1598182412,"75-2656723","TX","PE - Premier Family Care, Inc","Superior","Participating","Enrollment Complete","2023-11-01","","","2023-11-06","11/6/2023 Rcvd email from Superior that provider is PAR and linked to group TIN/location effective 11/1/2023.  DCannon"]
["Rahul P Sinha, MD",1598182412,"75-2656723","TX","","Galaxy Health","Participating","Enrollment Complete","2023-09-19","","","2023-11-07","11/7/2023 Per email received from Galaxy October delegated roster has been processed and provider is PAR and linked to group/location effective 9/19/2023.  DCannon"]
["Rahul P Sinha, MD",1598182412,"75-2656723","TX","PE - Premier Family Care, Inc","Wellmed","Thru Other Payor","Pending Other Enrollment","","","","2023-11-17","11/17/2023 Pending UHC enrollment.  DCannon"]
["Rahul P Sinha, MD",1598182412,"75-2656723","TX","PE - Premier Family Care, Inc","Aetna","In Process","Payor Follow Up","","","","2023-11-16","Application is still in process. MS"]
["Rahul P Sinha, MD",1598182412,"75-2656723","TX","PE - Premier Family Care, Inc","Wellcare","Participating","Enrollment Complete","2023-11-01","","","2023-11-06","11/6/2023 Rcvd email from Superior that provider is PAR and linked to group TIN/location effective 11/1/2023.  DCannon"]
["Rahul P Sinha, MD",1598182412,"75-2656723","TX","","Amerigroup","Participating","Enrollment Complete","2023-09-19","","","2023-11-09","11/9/2023 Per email received from Jessica Bess at  Multiplan provider is PAR with Amerigroup and linked to group TIN/locations thru Multiplan enrollment effective 9/19/2023.  DCannon"]
["Madhusmita Panda, MD",1134756364,"75-2656723","TX","PE - Premier Family Care, Inc","Wellcare","Participating","Enrollment Complete","2023-10-01","","","2023-10-16","10/16/2023 Rcvd email from Superior that provider is PAR and linked to group TIN/location effective 10/1/2023.  DCannon"]
["Madhusmita Panda, MD",1134756364,"75-2656723","TX","PE - Premier Family Care, Inc","Boon Chapman","Participating","Enrollment Complete","2024-09-08","","","2023-10-12","10/12/2023 Per email received from Jessica Bess at  Multiplan provider is PAR and linked to group TIN/locations effective 9/8/2023.  DCannon"]
["Madhusmita Panda, MD",1134756364,"75-2656723","TX","PE - Premier Family Care, Inc","Caprock (CapStar)","Participating","Enrollment Complete","2023-09-08","","","2023-09-27","9/27/2023 Rcvd email confirmation from Caprock that the September roster has been completed.  Provider is PAR and linked to group/location effective 9/8/2023.  DCannon"]
["Madhusmita Panda, MD",1134756364,"75-2656723","TX","PE - Premier Family Care, Inc","Medicare","Participating","Enrollment Complete","2023-09-24","6C1375","","2023-10-27","Received welcome letter eff 9/24/23. MS"]
["Rony Ninan, MD",1750526182,"75-2656723","TX","PE - Premier Family Care, Inc","TriCare Standard","Participating","Enrollment Complete","2023-09-06","752656723-79703-X022752656723-79703-X022","","2023-09-22","09.22.2023 S/W Brandon of TriCare Certification (Standard - Non-Network) @ 1-800-444-5445 then was trasnferred to the WPS Dept and spoke with Tyqueiasha. Per rep, provider is showing participating or certified and link under the Group and TIN with an Effective date 09/06/2023. Provider ID 752656723-79703-X022. Call ref#:Tyqueiasha09222023. - Danico Gabriel Melendres"]
["Rony Ninan, MD",1750526182,"75-2656723","TX","PE - Premier Family Care, Inc","Ambetter","Participating","Enrollment Complete","2023-11-01","","","2023-11-06","11/6/2023 Rcvd email from Superior that provider is PAR and linked to group TIN/location effective 11/1/2023.  DCannon"]
["Rony Ninan, MD",1750526182,"75-2656723","TX","PE - Premier Family Care, Inc","Humana","In Process","Payor Receipt Validated","","","","2023-10-25","10/25/2023 Rcvd confirmation email from Marcus Wester that October Delegation roster has been received and sent for processing.   Assigned the following case #'s Provider adds CO-16142269\nProvider changes CO-16142352\nProvider terms CO-16142430\nDCannon"]
["Ankit Ashwin Patel, MD",1083979322,"75-2656723","TX","PE - Premier Family Care, Inc","BCBSTX","In House Enrollment","In House Enrollment","","","","2023-10-13",""]
["Ankit Ashwin Patel, MD",1083979322,"75-2656723","TX","PE - Premier Family Care, Inc","Cigna","In Process","Payor Follow Up","","","","2023-11-07","11.07.2023 S/W Mary of Cigna @ 1-800-882-4462. Per rep, provider is out of network. Application was received on 10/17/2023 and still in process. Tracking# 13486480. Allow more time and no further document needed. TAT of 120 calendar days. Call ref#:MaryD11072023. - Danico Gabriel Melendres"]
["Ankit Ashwin Patel, MD",1083979322,"75-2656723","TX","PE - Premier Family Care, Inc","Medicaid","In Process","Application Submitted","","","","2023-11-16","11/16/2023 Application submitted online via TMHP web portal.  Request # 20369978.  DCannon"]
["Ankit Ashwin Patel, MD",1083979322,"75-2656723","TX","PE - Premier Family Care, Inc","Multiplan","In Process","Application Submitted","","","","2023-11-15","11/15/2023 Delegated roster submitted.  DCannon"]
["Ankit Ashwin Patel, MD",1083979322,"75-2656723","TX","PE - Premier Family Care, Inc","First Health Coventry","Pending Other Enrollment","Pending Other Enrollment","","","","2023-11-05","Pending Aetna approval. MS"]
["Billy S Gao, MD",1699092304,"75-2656723","TX","PE - Premier Family Care, Inc","Multiplan","In Process","Application Submitted","","","","2023-11-15","11/15/2023 Delegated roster submitted.  DCannon"]
["Billy S Gao, MD",1699092304,"75-2656723","TX","PE - Premier Family Care, Inc","United Health Care","In Process","Payor Receipt Validated","","","","2023-11-15","11/15/2023 Rcvd confirmation email that November delegated roster was received.  Reference Number: PR-7842834.  DCannon"]
["Neel N Shah, MD",1861752529,"75-2656723","TX","PE - Premier Family Care, Inc","Medicare","In Process","Confirm Par Status","","","","2023-11-20","Requested surrogacy for this provider. MS"]
["Neel N Shah, MD",1861752529,"75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","Panel Closed","Panel Closed","","","","2023-11-20","Per the Tricare portal, the enrollment panel is closed until further notice. MS"]
["Neel N Shah, MD",1861752529,"75-2656723","TX","PE - Premier Family Care, Inc","Medicaid","Pending Other Enrollment","Pending Medicare","","","","2023-11-20","Pending Medicare enrollment. Jen Videan"]
["Neel N Shah, MD",1861752529,"75-2656723","TX","PE - Premier Family Care, Inc","HealthSmart PPO","In Process","Pending PSV","","","","2023-11-21",""]
["John M McKenna, MD",1225170103,"75-2656723","TX","","CAQH","Participating","CAQH Reattested","2023-10-31","","","2023-10-30","10/31/2023 - Updated Primary Mail, Board, Cred contact  and reattested- Mkhan"]
["John M McKenna, MD",1225170103,"75-2656723","TX","","TriCare Standard","Participating","Enrollment Complete","2021-11-17","","","2022-06-21","6/21/2022 Per Tricare portal, provider is certified and linked to location eff 11/17/2021. DCannon"]
["John M McKenna, MD",1225170103,"75-2656723","TX","","Amerigroup","Participating","Enrollment Complete","2022-04-14","","","2022-09-23","9/23/2022 Per roster received from Joe Rodriguez at Amerigroup provider is PAR and linked to group TIN effective 4/14/2022.  DCannon"]
["John M McKenna, MD",1225170103,"75-2656723","TX","PE - Premier Family Care, Inc","Aetna","Participating","Enrollment Complete","2021-11-15","4361906","","2021-12-29","12/29/2021 Per F/U Notes - S/W Christine of Aetna @ 8003531232, NPI# for the provider is on file, shows linked and PAR under the group and TIN# ( Individual contract ) effective 11/15/2021, the physical location is on file, The provider ID is 4361906.   DCannon"]
["John M McKenna, MD",1225170103,"75-2656723","TX","","United Health Care","Participating","Enrollment Complete","1901-01-01","000466442","","2022-01-03","1/3/2022 Recevied email from asampat4@uhc.com, provider/group updates complete. Assigned reference number PR-6284499. Cbankston"]
["John M McKenna, MD",1225170103,"75-2656723","TX","","Omni PPO","Participating","Enrollment Complete","2021-12-06","","","2022-02-04","2/4/2022 Rcvd email from G. Aviles @ IMS/Omni that provider is PAR and linked to group TIN/location effective 12/6/2021.  DCannon"]
["John M McKenna, MD",1225170103,"75-2656723","TX","","Scott&White (First Care)","Participating","Enrollment Complete","2021-11-05","","","2022-01-11","1/11/2022 Rcvd approval letter from Scott and White.  Provider is PAR and linked to group/TIN effective 11/05/2021.  DCannon"]
["John M McKenna, MD",1225170103,"75-2656723","TX","PE - Premier Family Care, Inc","Ambetter","Participating","Enrollment Complete","2022-06-01","","","2022-06-13","6/13/2022 Per roster received from Superior provider is PAR and linked to group delegation roster effective 6/1/2022."]
["John M McKenna, MD",1225170103,"75-2656723","TX","","IMS","Participating","Enrollment Complete","2021-12-06","","","2022-02-04","2/4/2022 Rcvd email from G. Aviles @ IMS/Omni that provider is PAR and linked to group TIN/location effective 12/6/2021.  DCannon"]
["John M McKenna, MD",1225170103,"75-2656723","TX","PE - Premier Family Care, Inc","Humana","Participating","Enrollment Complete","2021-12-06","","","2022-04-21","4/21/2022 Per email received from VYoung at Humana delegated roster for December has been completed and providers loaded in Humana effective 12/6/2021.  DCannon"]
["John M McKenna, MD",1225170103,"75-2656723","TX","PE - Premier Family Care, Inc","Multiplan","Participating","Enrollment Complete","2021-12-15","","","2022-02-08","2/8/2022 Rcvd Multiplan approval letter, provider is PAR and linked to group/location effective 12/15/2022.  DCannon"]
["John M McKenna, MD",1225170103,"75-2656723","TX","PE - Premier Family Care, Inc","Triwest VA","Facility Enrollment","Facility Enrollment","","","","2022-10-17","10/17/2022 - Received roster from Scarlett of TriWest VA; provider status: \"No Action.  TIN is CCN participating under own DCN.\""]
["John M McKenna, MD",1225170103,"75-2656723","TX","","Medicaid","Participating","Enrollment Complete","2021-12-01","1225170103","","2023-11-16","11/16/2023  In checking the TMJP portal the revalidation app has been completed.  Provider is PAR effective 12/1/2021.  Revalidation date - 10/11/2028.  DCannon"]
["John M McKenna, MD",1225170103,"75-2656723","TX","PE - Premier Family Care, Inc","Cigna","Participating","Enrollment Complete","2022-01-22","8020391","","2021-11-25","11/25/21 received letter from pdmcogz@cigna.com, enrollment complete. PID 8020391 eff 1/22/2022"]
["Lawrence A Wilson, MD",1518951342,"75-2656723","TX","PE - Premier Family Care, Inc","Ambetter","Participating","Enrollment Complete","2022-04-01","","","2022-06-13","6/13/2022 Per roster received from Superior provider is PAR and linked to group delegation roster effective 4/1/2022."]
["Lawrence A Wilson, MD",1518951342,"75-2656723","TX","PE - Premier Family Care, Inc","Coventry Workers Comp","In House Enrollment","In House Enrollment","","","","2022-09-15","9/15/2022 Enrollment is now done in-house by Ventra Health for Midland Emergency Managers effective 8/1/2022.  DCannon"]
["Lawrence A Wilson, MD",1518951342,"75-2656723","TX","PE - Premier Family Care, Inc","Triwest VA","Facility Enrollment","Facility Enrollment","","","","2022-10-17","10/17/2022 - Received roster from Scarlett of TriWest VA; provider status: \"No Action.  TIN is CCN participating under own DCN.\""]
["Lawrence A Wilson, MD",1518951342,"75-2656723","TX","PE - Premier Family Care, Inc","IMS","Participating","Enrollment Complete","2021-01-07","","","2021-04-01","4/1/2021 Rcvd email from German Aviles <german.aciles@imsm.net> at IMS/OMNI stating that the monthly delegated roster provider loads for January has been completed.  Provider is PAR and linked to location/TIN effective 1/7/2021. DCannon"]
["Lawrence A Wilson, MD",1518951342,"75-2656723","TX","PE - Premier Family Care, Inc","Medicare","Participating","Enrollment Complete","2020-12-01","1L5835","00008AH","2021-01-29","1/29/2021 Received Medicare approval notice for provider's reassignment to group effective 12/1/2020 and assigned PTAN 1L5835. KFrazier"]
["Lawrence A Wilson, MD",1518951342,"75-2656723","TX","PE - Premier Family Care, Inc","United Health Care","Participating","Enrollment Complete","2021-05-18","002438204","","2021-09-01","9/1/2021 Email reponse: LAWRENCE WILSON was approved for credentialing 02/25/2021 for Texas.\nThe provider is linked and contracted to TX tin 752656723 effective 05/18/2021.\n  Additionally, if you are wanting the specific lines of business that the provider are linked to, this information is now in your LINK/My Practice Profile (https://www.uhcprovider.com/en/demographics-profiles-attestation/link-my-practice-profile.html). Please see the attached handout for more information.\n\nIf you have further questions regarding this system, please feel free to contact the LINK help desk (866-842-3278, option 1).\n\nPlease let us know if we can assist further.\n \nSincerely,\nKatherine Floyd\nUnitedHealthcare\nNetwork Management Resource Team (NMRT)\n\nCbankston"]
["Lawrence A Wilson, MD",1518951342,"75-2656723","TX","PE - Premier Intensive Cardiac Rehabilitation","Amerigroup","Participating","Enrollment Complete","2021-01-07","","","2021-12-03","12/3/2021 Per Amerigroup roster received Joe Rodriguez provider is PAR under group TIN/location effective 1/7/2021.   DCannon"]
["Lawrence A Wilson, MD",1518951342,"75-2656723","TX","PE - Premier Family Care, Inc","Humana","Participating","Enrollment Complete","2021-09-01","","","2021-11-18","11/18/2021 Rcvd full roster from Humana listing provider as PAR and linked to group TIN/location effective 9/1/2021.  DCannon"]
["Lawrence A Wilson, MD",1518951342,"75-2656723","TX","PE - Premier Family Care, Inc","Caprock (CapStar)","Participating","Enrollment Complete","2021-01-07","","","2021-04-09","4/9/2020 Rcvd roster from Mary Rodriguez <mary.rodriguez@90degreebenefits.com> at Caprock listing provider as participating under TIN.  DCannon"]
["Joseph J Shayeb, MD",1528049590,"75-2656723","TX","PE - Premier Family Care, Inc","Medicare","Participating","Enrollment Complete","2023-04-01","","","2023-06-21","Received COI application confirmation. Reference # 3231460484  MS"]
["Joseph J Shayeb, MD",1528049590,"75-2656723","TX","PE - Premier Family Care, Inc","Superior","Participating","Enrollment Complete","2023-07-01","","","2023-07-21","7/21/2023 Rcvd confirmation email from Superior that June delegation roster has been processed and provider has been loaded to delegation roster and PAR w/ group effective 7/1/2023.  DCannon"]
["Joseph J Shayeb, MD",1528049590,"75-2656723","TX","","Wellmed","Participating","Enrollment Complete","2023-06-01","","","2023-09-07","9/7/2023 Per email response from UHC June delegated roster is provider load is complete.  Provider is PAR and linked to group TIN/location effective 6/1/2023.  DCannon"]
["Joseph J Shayeb, MD",1528049590,"75-2656723","TX","","Medicaid","Participating","Enrollment Complete","2023-04-01","1528049590","","2023-10-06","Rcvd welcome ltr from TMHP. Provider is effective 04/01/2023. Jen Videan"]
["Joseph J Shayeb, MD",1528049590,"75-2656723","TX","PE - Premier Family Care, Inc","First Health Coventry","Participating","Enrollment Complete","2023-06-01","1119106","","2023-09-20","9/20/2023 Per First Health web portal provider is PAR and linked to group TIN/location effective 6/1/2023.  PID #1119106.  DCannon"]
["Joseph J Shayeb, MD",1528049590,"75-2656723","TX","","HealthSmart PPO","Participating","Enrollment Complete","2023-06-01","","","2023-11-13","11/13/2023 Per phone conversation with Lee Kinard at Healthsmart provider is PAR and linked to group TIN/location effective 6/1/2023.  DCannon"]
["Joseph J Shayeb, MD",1528049590,"75-2656723","TX","","Caprock (CapStar)","Participating","Enrollment Complete","2023-06-01","","","2023-07-26","7/26/2023 Rcvd email  confirmation from Caprock that provider is PAR and linked to group TIN/locations effective 6/1/2023.  DCannon"]
["Joseph J Shayeb, MD",1528049590,"75-2656723","TX","PE - Premier Family Care, Inc","Ambetter","Participating","Enrollment Complete","2023-07-01","","","2023-07-21","7/21/2023 Rcvd confirmation email from Superior that June delegation roster has been processed and provider has been loaded to delegation roster and PAR w/ group effective 7/1/2023.  DCannon"]
["John W Foster, Jr, MD",1679568380,"75-2656723","TX","PE - Premier Family Care, Inc","TriCare Standard","Participating","Enrollment Complete","2020-06-01","","","2020-10-30","10/30/2020 Confirmed provider is certified as non-network under Tax ID and location. Kimberly Frazier"]
["John W Foster, Jr, MD",1679568380,"75-2656723","TX","PE - Premier Family Care, Inc","Ambetter","Participating","Enrollment Complete","2022-06-01","","","2022-06-13","6/13/2022 Per roster received from Superior provider is PAR and linked to group delegation roster effective 6/1/2022."]
["John W Foster, Jr, MD",1679568380,"75-2656723","TX","PE - Premier Family Care, Inc","Cigna","Participating","Enrollment Complete","2021-08-16","1208794","","2021-08-17","8/17/2021 Received an email from discovercigna@information.cigna.com confirming provider is participating under group Tax ID effective 8/16/2021 with assigned provider identification number 1208794. KFrazier"]
["John W Foster, Jr, MD",1679568380,"75-2656723","TX","PE - Premier Family Care, Inc","Cigna","Terminated","Terminated","2020-04-01","1679568380","","2021-05-26","5/24/2021 Provider was loaded under delegation with WTPA; however, client terminated relationship and provider was termed effective 3/31/2021. Confirmed provider is not currently credentialed outside of delegation and requires full credentialing. Kfrazier"]
["Dario Beltran, MD",1912100850,"75-2656723","TX","PE - Premier Family Care, Inc","Medicaid","Enrollment Stopped","Enrollment Stopped","2020-03-15","121276305","079837301","2020-07-15","07/15/2020 - Rec'd email from the clinic stating provider is terming on 6/25/2020.  - Stacey Hudak"]
["Dario Beltran, MD",1912100850,"75-2656723","TX","PE - Premier Family Care, Inc","IMS","Participating","Enrollment Complete","2021-10-29","1922008234","","2023-08-24","8/24/2023 Per email received from IMS/Omni provider is PAR and linked to group TIN/location effective 10/29/2021.  DCannon"]
["Dario Beltran, MD",1912100850,"75-2656723","TX","PE - Premier Family Care, Inc","Wellcare","Participating","Enrollment Complete","2021-11-01","","","2022-11-15","11/15/2022 Per roster received from Wellcare provider is PAR and linked to group TIN/location effective 11/1/2021.  DCannon"]
["Jose G Delgado, MD",1578557468,"75-2656723","TX","PE - Premier Family Care, Inc","First Health Coventry","Participating","Enrollment Complete","2022-11-01","3637766","","2023-05-02","5/2/2023 Per confirm par status note -   Per rep, provider is participating with an effective date 11/01/2022 and link under the Group and TIN. Provider ID 3637766. As per Donna from there Credentialing Dept they don't have the provider's next recredentialing date then advised that their Network Team will inform the provider if the recredentialing Date is available. Service location is on file. Call ref#:610340.  DCannon"]
["Jose G Delgado, MD",1578557468,"75-2656723","TX","PE - Premier Family Care, Inc","Ambetter","Participating","Enrollment Complete","2022-11-01","","","2022-12-29","12/29/2022 Rcvd confirmation email from Superior that October delegation roster has been processed and provider has been loaded to delegation roster and PAR w/ group effective 11/1/2022.  DCannon"]
["Jose G Delgado, MD",1578557468,"75-2656723","TX","PE - Premier Family Care, Inc","United Health Care","Participating","Enrollment Complete","2022-09-12","","","2023-05-04","5/4/2023 Per email from UHC delegated roster from February has been processed.  Provider is PAR and linked to group TIN effective 9/12/2022.  DCannon"]
["Jose G Delgado, MD",1578557468,"75-2656723","TX","PE - Premier Family Care, Inc","Boon Chapman","Participating","Enrollment Complete","2022-09-12","","","2023-07-26","7/26/2023 Rcvd email from Jessica Bess at Multiplan with a full roster and provider is PAR w/ group and location effective 9/12/2022.  DCannon"]
["Jose G Delgado, MD",1578557468,"75-2656723","TX","PE - Premier Family Care, Inc","Cigna","Participating","Enrollment Complete","2022-09-12","3714369","","2022-11-08","11/8/2022 Rcvd email from Cigna that provider is PAR and linked to group TIN/location effective 9/12/2022.  PID # 3714369.  DCannon"]
["Jose G Delgado, MD",1578557468,"75-2656723","TX","PE - Premier Family Care, Inc","Superior","Participating","Enrollment Complete","2022-11-01","","","2022-12-08","12/08/2022 Rcvd confirmation email from Superior that October delegation roster has been processed and provider has been loaded to delegation roster and PAR w/ group effective 11/1/2022.  DCannon"]
["Jose G Delgado, MD",1578557468,"75-2656723","TX","PE - Premier Family Care, Inc","Wellcare","Participating","Enrollment Complete","2022-11-01","","","2022-12-29","12/29/2022 Rcvd confirmation email from Superior that October delegation roster has been processed and provider has been loaded to delegation roster and PAR w/ group effective 11/1/2022.  DCannon"]
["Jose G Delgado, MD",1578557468,"75-2656723","TX","PE - Premier Family Care, Inc","Caprock (CapStar)","Participating","Enrollment Complete","2022-09-12","","","2022-12-29","12/29/2022 Rcvd email  confirmation from Caprock that provider is PAR and linked to group TIN/locations effective 9/12/2022.  DCannon"]
["Jose G Delgado, MD",1578557468,"75-2656723","TX","PE - Premier Family Care, Inc","TriCare Standard","Participating","Enrollment Complete","2022-09-13","","","2023-05-24","Confirmed via HM portal. MS"]
["Jose G Delgado, MD",1578557468,"75-2656723","TX","PE - Premier Family Care, Inc","Scott&White (First Care)","Participating","Enrollment Complete","2022-10-07","","","2022-10-28","10/28/2022 Rcvd email from Scott & White that provider is PAR and linked to group TIN/locations effective 10/7/2022.  DCannon"]
["Jose G Delgado, MD",1578557468,"75-2656723","TX","PE - Premier Family Care, Inc","Galaxy Health","Participating","Enrollment Complete","2022-09-12","","","2022-12-31","12/31/2022 Rcvd email from Karen Avalos at Galaxy that delegated roster submission for October has been completed.  Provider is PAR and linked to group TIN effective 9/12/2022.  DCannon"]
["Jose G Delgado, MD",1578557468,"75-2656723","TX","PE - Premier Family Care, Inc","Amerigroup","Participating","Enrollment Complete","2022-10-10","","","2023-02-01","2/1/2023 Per email response from Amerigroup Provider Relations-Texas provider is PAR and linked to group effective 10/10/2022.  PID# 14614726.  DCannon"]
["Jose G Delgado, MD",1578557468,"75-2656723","TX","PE - Premier Family Care, Inc","Medicare","Participating","Enrollment Complete","2022-09-12","2I8228","0008AH","2022-09-21","9/21/2022 Rcvd Medicare approval letter from Candace Wynne.  PTAN # 2I8228 - effective 9/12/2022.  DCannon"]
["Jose G Delgado, MD",1578557468,"75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","Panel Closed","Panel Closed","","","","2022-09-13","9/13/2022 Per Humana Military web portal Tricare Prime is currently not accepting requests to join the medical/surgical network.  DCannon"]
["Jose G Delgado, MD",1578557468,"75-2656723","TX","PE - Premier Family Care, Inc","Humana","Participating","Enrollment Complete","2022-09-12","","","2023-02-17","2/17/2023 Per email received from Priscilla Albertine at MQA she received confirmation from Humana that provider is PAR and linked to group TIN/location effective 9/12/2022.  DCannon"]
["Samuel L Baumguardner, PA",1295109510,"75-2656723","TX","PE - Premier Family Care, Inc","Superior","Participating","Enrollment Complete","2017-01-01","1295109510","","2020-07-14","07/14/2020 - Rec'd spreadsheet from the delegated team stating this provider has been linked to the PriMed contract since 1-1-2017 **see the other enrollment complete line to see details about when this provider became effective with various specific products** - stacey Hudak"]
["Samuel L Baumguardner, PA",1295109510,"75-2656723","TX","PE - Premier Family Care, Inc","CAQH","Participating","Pending Info/Document","2023-03-13","13683951","","2023-11-01","11/01/2023 - Invalid ID and password - rkedare"]
["Samuel L Baumguardner, PA",1295109510,"75-2656723","TX","PE - Premier Family Care, Inc","TriCare Standard","Participating","Enrollment Complete","2018-01-11","","","2020-10-23","10/23/2020 Provider is participating with TriCare Prime; therefore, remains certified as a non-network effective 1/11/2018. Kimberly Frazier"]
["Samuel L Baumguardner, PA",1295109510,"75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","2018-01-11","","","2020-10-08","10/8/2020 Confirmed via Self-Service Portal provider is participating under Tax ID and location. Kimberly Frazier"]
["Adenike T Esho, MD",1467745240,"75-2656723","TX","PE - Premier Family Care, Inc","Amerigroup","Participating","Enrollment Complete","2019-08-30","1467745240","","2020-02-11","2/11/2020 – Received Roster from Amerigroup and provider is now PAR- Tisha Rader\n\n3/18/2020 - Also rec'd email confirmation from Multiplan/Texas True Choice confirming that this EFF information is true - Stacey Hudak"]
["Adenike T Esho, MD",1467745240,"75-2656723","TX","PE - Premier Family Care, Inc","Galaxy Health","Participating","Enrollment Complete","2019-08-26","1467745240","","2020-07-10","07/10/2020 - updated payer line to enrollment complete status instead of \"Delegated status\" for report running purposes - Stacey Hudak"]
["Adenike T Esho, MD",1467745240,"75-2656723","TX","","First Health Coventry","Participating","Enrollment Complete","2019-08-01","2739018","","2020-03-24","3/24/2020-receieved email with roster stating provider PAR 8/1/2019 PID # 2739018\ntisha rader"]
["Adenike T Esho, MD",1467745240,"75-2656723","TX","","Ambetter","Participating","Enrollment Complete","2022-06-01","","","2022-06-13","6/13/2022 Per roster received from Superior provider is PAR and linked to group delegation roster effective 6/1/2022."]
["Adenike T Esho, MD",1467745240,"75-2656723","TX","","Wellcare","Participating","Enrollment Complete","2021-11-01","","","2022-11-15","11/15/2022 Per roster received from Wellcare provider is PAR and linked to group TIN/location effective 11/1/2021.  DCannon"]
["Adenike T Esho, MD",1467745240,"75-2656723","TX","","Cigna","Participating","Enrollment Complete","2019-08-28","1467745240","","2020-02-20","02/20/2020 - Rec'd verification from the payer that this provider is EFF 2-20-2020 and linked to this service location under a DIRECT CONTRACT with this payer - Stacey Hudak"]
["Adenike T Esho, MD",1467745240,"75-2656723","TX","","CAQH","Participating","CAQH Reattested","2023-10-31","13510925","","2023-10-31","10/31/2023 CAQH reviewed and re-attested.  Updated COI.  DCannon"]
["Haritha Bellam, MD",1770883191,"75-2656723","TX","PE - Premier Family Care, Inc","Superior","Participating","Enrollment Complete","2017-01-01","1770883191","","2020-07-14","07/14/2020 - Rec'd spreadsheet from the delegated team stating this provider has been linked to the PriMed contract since 1-1-2017 **see the other enrollment complete line to see details about when this provider became effective with various specific products** - stacey Hudak"]
["Haritha Bellam, MD",1770883191,"75-2656723","TX","PE - Premier Family Care, Inc","Caprock (CapStar)","Participating","Enrollment Complete","2015-10-15","1770883191","","2020-06-02","06/02/2020 - rec'd spreadsheet back from the payer Mary Rodriguez <MRodriguez@caprockhp.com> confirming this provider/service location is EFF with this payer - Stacey Hudak"]
["Haritha Bellam, MD",1770883191,"75-2656723","TX","PE - Premier Family Care, Inc","HealthSmart PPO","Participating","Enrollment Complete","2018-08-10","1770883191","","2020-06-05","06/05/2020 - rec'd email from the payer stating provider is EFF - stacey Hudak"]
["Haritha Bellam, MD",1770883191,"75-2656723","TX","PE - Premier Family Care, Inc","Ambetter","Participating","Enrollment Complete","2022-06-01","","","2022-06-13","6/13/2022 Per roster received from Superior provider is PAR and linked to group delegation roster effective 6/1/2022."]
["Haritha Bellam, MD",1770883191,"75-2656723","TX","PE - Premier Family Care, Inc","Medicaid","Participating","Enrollment Complete","","347934701","079837301","2020-01-29","01/29/2020 - Found effective info through payer portal. Provider is PAR with the following plans; SUPERIOR - FOSTER CARE, Superior HealthPlan - Lubbock, Superior HealthPlan - Lubbock, TRADITIONAL MEDICAID, Amerigroup - MRSA West, Superior Health Plan - Lubbock, Superior Health Plan - MRSA West, Amerigroup - MRSA West, Superior HealthPlan - MRSA West, Amerigroup Texas, Inc. - MRSA West, Superior Health Plan - MRSA West - Stacey Hudak"]
["Haritha Bellam, MD",1770883191,"75-2656723","TX","PE - Premier Family Care, Inc","Aetna","Participating","Enrollment Complete","2015-07-01","1770883191","","2020-02-03","02/03/2020 - Confirmed with the payer that this provider is EFF as of 7-1-2015 under a DIRECT CONTRACT. No reval information was provided - Stacey Hudak"]
["Haritha Bellam, MD",1770883191,"75-2656723","TX","","Medicare","Participating","Enrollment Complete","2015-05-11","415412YPVD","0008AH","2020-01-29","01/29/2020 - confirmed EFF through PECOS group enrollment - Stacey Hudak"]
["Nanette R Paredes, PA",1437175163,"75-2656723","TX","PE - Premier Family Care, Inc","Cigna","Participating","Enrollment Complete","2021-07-07","3218941","","2021-07-09","7/9/2021 Received an email from discovercigna@information.cigna.com confirming provider is now participating under group Tax ID effective 7/7/2021 with assigned provider ID 3218941. KFrazier"]
["Nanette R Paredes, PA",1437175163,"75-2656723","TX","PE - Premier Family Care, Inc","Triwest VA","Facility Enrollment","Enrollment Complete","2020-12-01","","","2023-03-24","03/17/2023- Per Triwest VA  email confirmation, provider participating under practice DCN, eff. 12/01/2020. PA"]
["Nanette R Paredes, PA",1437175163,"75-2656723","TX","PE - Premier Family Care, Inc","USA PPO","Participating","Enrollment Complete","2021-01-26","959669","","2021-03-12","3/12/2021 Per verification on payor website USAMCO.com provider is loaded as participating.  Rcvd Roster LeNetrice Myart with provider numbers and effective dates for providers.  DCannon"]
["Nanette R Paredes, PA",1437175163,"75-2656723","TX","PE - Premier Family Care, Inc","Boon Chapman","Participating","Enrollment Complete","2018-10-29","","","2021-08-06","8/6/2021 Boon Chapman falls under the Multiplan umbrella, received roster from Multiplan provider is listed on roster under TIN/location as PAR effective 10/29/2018.  DCannon"]
["Johnny L Flitton, PA-C",1437356730,"75-2656723","TX","PE - Premier Family Care, Inc","IMS","Participating","Enrollment Complete","2021-11-01","","","2021-12-31","12/31/2021 Rcvd email from German Aviles <german.aciles@imsm.net> at IMS/OMNI stating that the monthly delegated roster provider loads for October and November have been completed.  Provider is PAR and linked to location/TIN effective 11/1/2021. DCannon"]
["Johnny L Flitton, PA-C",1437356730,"75-2656723","TX","PE - Premier Family Care, Inc","HealthSmart PPO","Participating","Enrollment Complete","2019-07-18","13403339","","2020-07-21","07/21/2020 - rec'd spreadsheet stating this provider/TIN/service location are EFF with PRIMED - Stacey Hudak"]
["Johnny L Flitton, PA-C",1437356730,"75-2656723","TX","PE - Premier Family Care, Inc","Medicaid","Participating","Enrollment Complete","2008-04-02","190610903","079837301","2020-03-11","03/11/2020 - Was able to confirm this rpovider is EFF through payer portal/Group TMHP enrollment. The provider is affiliated with the following plans: TRADITIONAL MEDICAID, Amerigroup - MRSA West, Amerigroup Texas, Inc. - MRSA West  - Stacey Hudak"]
["Johnny L Flitton, PA-C",1437356730,"75-2656723","TX","PE - Premier Family Care, Inc","Multiplan","Participating","Enrollment Complete","2021-11-15","","","2021-12-13","12/13/2021 Rcvd Multiplan approval letter.  Provider is PAR effective 11/15/2021.  DCannon"]
["Johnny L Flitton, PA-C",1437356730,"75-2656723","TX","PE - Premier Family Care, Inc","Humana","Participating","Enrollment Complete","2015-03-17","","","2023-02-17","2/17/2023 Per email received from Priscilla Albertine at MQA she received confirmation from Humana that provider is PAR and linked to group TIN/location effective 3/17/2015.  DCannon"]
["Johnny L Flitton, PA-C",1437356730,"75-2656723","TX","PE - Premier Family Care, Inc","Triwest VA","Facility Enrollment","Facility Enrollment","","","","2022-10-17","10/17/2022 - Received roster from Scarlett of TriWest VA; provider status: \"No Action.  TIN is CCN participating under own DCN.\""]
["Johnny L Flitton, PA-C",1437356730,"75-2656723","TX","PE - Premier Family Care, Inc","Superior","Participating","Enrollment Complete","2017-01-01","1437356730","","2020-07-14","07/14/2020 - Rec'd email from the payer stating this provider is EFF with this TIN under PRIMED DELEGATED agreement - Stacey Hudak"]
["Gerardo M Catalasan, MD",1760501720,"75-2656723","TX","","CAQH","Participating","CAQH Reattested","2023-10-04","13752595","","2023-10-04","10/04/2023 - Updated primary email, board billing address and Liability and re-attested - rkedare"]
["Gerardo M Catalasan, MD",1760501720,"75-2656723","TX","","Boon Chapman","Participating","Enrollment Complete","2020-04-03","","","2022-07-24","7/24/2022 Per email from Marcie Eckhart-Havens Multiplan July delegated roster has been completed  and provider is PAR and linked to group TIN effective 4/3/2020.   DCannon"]
["Gerardo M Catalasan, MD",1760501720,"75-2656723","TX","PE - Premier Family Care, Inc","Multiplan","Participating","Enrollment Complete","2020-04-03","","","2022-07-24","7/24/2022 Per email from Marcie Eckhart-Havens Multiplan July delegated roster has been completed  and provider is PAR and linked to group TIN effective 4/3/2020.   DCannon"]
["Gerardo M Catalasan, MD",1760501720,"75-2656723","TX","","Wellcare","Participating","Enrollment Complete","2021-11-01","","","2022-11-15","11/15/2022 Per roster received from Wellcare provider is PAR and linked to group TIN/location effective 11/1/2021.  DCannon"]
["Gerardo M Catalasan, MD",1760501720,"75-2656723","TX","","HealthSmart PPO","Participating","Enrollment Complete","2011-02-01","1760501720","","2020-06-05","06/05/2020 - rec'd email from the payer stating this provider is EFF - Stacey Hudak"]
["Gerardo M Catalasan, MD",1760501720,"75-2656723","TX","","HealthSmart PPO","Participating","Enrollment Complete","2011-02-01","1760501720","","2020-06-05","06/05/2020 - rec'd email from the payer stating this provider is EFF - Stacey Hudak"]
["Gerardo M Catalasan, MD",1760501720,"75-2656723","TX","","TriCare Standard","Participating","Enrollment Complete","2014-11-08","1760501720","","2020-09-21","09/21/2020 - Moved to completed status after reviewing follow up complete note - Stacey Hudak"]
["Gerardo M Catalasan, MD",1760501720,"75-2656723","TX","PE - Premier Family Care, Inc","Ambetter","Participating","Enrollment Complete","2022-06-01","","","2022-06-13","6/13/2022 Per roster received from Superior provider is PAR and linked to group delegation roster effective 6/1/2022."]
["Gerardo M Catalasan, MD",1760501720,"75-2656723","TX","","Wellmed","Participating","Enrollment Complete","2022-01-01","","","2023-03-23","3/23/2023 Rcvd roster from UHC w/ all Wellmed participating providers.  Provider is PAR effective 1/1/2022.  DCannon"]
["Gerardo M Catalasan, MD",1760501720,"75-2656723","TX","","USA PPO","Participating","Enrollment Complete","2009-10-23","1760501720","752656723","2020-08-26","Confirmed provider is participating with PPO, H&W and WIN networks (list of networks attached). Kimberly Frazier"]
["Jeffrey Limbacher, PA-C",1376723361,"75-2656723","TX","PE - Premier Family Care, Inc","Amerigroup","Participating","Enrollment Complete","2014-11-28","1376723361","","2020-02-11","2/11/2020 – Received Roster from Amerigroup and provider is now PAR- Tisha Rader"]
["Jeffrey Limbacher, PA-C",1376723361,"75-2656723","TX","","Medicare","Participating","Enrollment Complete","2020-09-16","1K2721","0008AH","2020-12-17","12/17/2020 Received email of approval with assigned PTAN 1K2721, effective 9/16/2020. KFrazier"]
["Jeffrey Limbacher, PA-C",1376723361,"75-2656723","TX","PE - Premier Family Care, Inc","Superior","Participating","Enrollment Complete","2017-01-01","1376723361","","2020-07-14","07/14/2020 - Rec'd spreadsheet from the delegated team stating this provider has been linked to the PriMed contract since 1-1-2017 **see the other enrollment complete line to see details about when this provider became effective with various specific products** - stacey Hudak"]
["Jeffrey Limbacher, PA-C",1376723361,"75-2656723","TX","","Scott&White (First Care)","Participating","Enrollment Complete","2018-05-11","1376723361","","2020-02-19","2/19/2020--Per payer roster received from Irma Henson, this provider is participating with this service location and TIN--tisha rader"]
["Jeffrey Limbacher, PA-C",1376723361,"75-2656723","TX","PE - WesTex Urgent Care, PLLC","CAQH","Participating","CAQH Reattested","2023-11-17","13780299","","2023-11-17","11/17/2023 Updated mailing addresses."]
["Jeffrey Limbacher, PA-C",1376723361,"75-2656723","TX","","Multiplan","Participating","Enrollment Complete","2022-01-03","","","2022-03-10","3/10/2022 Rcvd roster from Multiplan listing provider as PAR and listed under group TIN/location effective 1/3/2022.  DCannon"]
["Jeffrey Limbacher, PA-C",1376723361,"75-2656723","TX","","United Health Care","Participating","Enrollment Complete","2020-01-01","1376723361","","2020-08-31","08/31/2020 - moved to completed status after reviewing follow up completed note - Stacey Hudak"]
["Jeffrey Limbacher, PA-C",1376723361,"75-2656723","TX","","USA PPO","Participating","Enrollment Complete","2014-11-28","","","2020-09-09","Confirmed provider is participating with PPO and H&W networks (list of networks attached). Kimberly Frazier"]
["Jeffrey Limbacher, PA-C",1376723361,"75-2656723","TX","","HealthSmart PPO","Participating","Enrollment Complete","2016-07-25","13512484","","2020-07-21","07/21/2020 - rec'd spreadsheet from the payer stating this provider/TIN/service location is EFF - Stacey Hudak"]
["Jeffrey Limbacher, PA-C",1376723361,"75-2656723","TX","PE - Premier Family Care, Inc","Boon Chapman","Participating","Enrollment Complete","2022-01-03","","","","3/10/2022 Rcvd roster from Multiplan listing provider as PAR and listed under group TIN/location effective 1/3/2022.  DCannon"]
["Jeffrey Limbacher, PA-C",1376723361,"75-2656723","TX","","IMS","Participating","Enrollment Complete","2017-11-28","1376723361","","2020-06-22","06/22/2020- Rec'd email from the payer confirming this provider is PAR with this group/service location - Stacey Hudak"]
["Adriana E Nur, MD",1619982584,"75-2656723","TX","PE - Premier Family Care, Inc","Cigna","Participating","Enrollment Complete","2019-01-01","8553905","","2020-02-27","02/27/2020 - Rec'd email response from the payer stating that this provider is EFF 1-1-2019 with Premier Family under PID# 8553905 - Stacey Hudak"]
["Adriana E Nur, MD",1619982584,"75-2656723","TX","PE - Premier Family Care, Inc","Wellcare","Participating","Enrollment Complete","2021-11-01","","","2022-12-01","12/1/2022 Per roster received from Wellcare provider is PAR and linked to group TIN/location effective 11/1/2021.  DCannon"]
["Adriana E Nur, MD",1619982584,"75-2656723","TX","","Ambetter","Participating","Enrollment Complete","2022-06-01","","","2022-06-13","6/13/2022 Per roster received from Superior provider is PAR and linked to group delegation roster effective 6/1/2022."]
["Adriana E Nur, MD",1619982584,"75-2656723","TX","PE - Premier Family Care, Inc","Cigna","Participating","Enrollment Complete","2023-07-01","8553905","","2023-09-13","Received confirmation email from Cigna. MS"]
["Adriana E Nur, MD",1619982584,"75-2656723","TX","","CAQH","Participating","CAQH Reattested","2023-11-07","10740365","","2023-10-31","10/31/2023 CAQH reviewed and re-attested.  DCannon"]
["Adriana E Nur, MD",1619982584,"75-2656723","TX","","HealthSmart PPO","Participating","Enrollment Complete","2023-05-01","","","2023-11-13","11/13/2023 Per phone conversation with Lee Kinard at Healthsmart provider is PAR and linked to group TIN/location and providers specialty is listed as Hospice/Palliative Care effective 5/1/2023.  DCannon"]
["Adriana E Nur, MD",1619982584,"75-2656723","TX","PE - Premier Family Care, Inc","United Health Care","Participating","Enrollment Complete","2017-10-31","3110523","","2020-07-28","7-28-2020 - Moved to completed status after reviewing follow up complete note - Stacey Hudak"]
["Adriana E Nur, MD",1619982584,"75-2656723","TX","PE - Premier Family Care, Inc","Caprock (CapStar)","Participating","Enrollment Complete","2023-08-01","","","2023-09-12","9/12/2023 Per email received from Caprock provider is PAR and linked to group TIN/location effective 8/1/2023.  DCannon"]
["Adriana E Nur, MD",1619982584,"75-2656723","TX","PE - Premier Family Care, Inc","Galaxy Health","Participating","Enrollment Complete","2017-11-29","1619982584","","2020-07-10","07/10/2020 - updated payer line to enrollment complete status instead of \"Delegated status\" for report running purposes - Stacey Hudak"]
["Adriana E Nur, MD",1619982584,"75-2656723","TX","PE - Premier Family Care, Inc","Ambetter","Thru Other Payor","Pending Other Enrollment","","","","2023-11-17","11/17/2023 Pending Superior enrollment.  DCannon"]
["Adriana E Nur, MD",1619982584,"75-2656723","TX","PE - Premier Family Care, Inc","Humana","In Process","Payor Follow Up","","","","2023-11-17","11/17/2023 Sent follow-up email to Marcus Wester at Humana to check status of August monthly delegated roster submission.  Provider Add - CO-16128465, Provider Changes - CO-16128615,  Provider Terms - CO-16128699.  DCannon"]
["Adriana E Nur, MD",1619982584,"75-2656723","TX","","USA PPO","Participating","Enrollment Complete","2021-01-26","1082395","","2021-03-12","3/12/2021 Per verification on payor website USAMCO.com provider is loaded as participating.  Rcvd Roster LeNetrice Myart with provider numbers and effective dates for providers.  DCannon"]
["Adriana E Nur, MD",1619982584,"75-2656723","TX","","Medicare","Participating","Enrollment Complete","2017-08-01","365428YPVD","0008AH","2020-01-29","01/29/2020 - FOR PREMIER FAMILY confirmed EFF through PECOS group enrollment - Stacey Hudak"]
["Adriana E Nur, MD",1619982584,"75-2656723","TX","","HealthSmart PPO","Participating","Enrollment Complete","2019-03-27","","","2021-01-27","1/27/2021 - Rcvd confirmation email that provider is participating and linked to location and TIN effective 3/27/2019.  DCannon"]
["Adriana E Nur, MD",1619982584,"75-2656723","TX","","Medicaid","Participating","Enrollment Complete","2022-09-29","","","2023-10-11","Welcome letter rcvd from TMHP. Effective 09/29/2022 at 400 Rosalind Redfern Grover Pkwy Ste 200 Midland TX. Jen Videan"]
["Adriana E Nur, MD",1619982584,"75-2656723","TX","","First Health Coventry","Participating","Enrollment Complete","2017-12-01","1950288","","2020-03-20","03/20/2020 - Rec'd email with roster from payor stating provider PAR 12/1/2017 PID # 1950288-tisha rader"]
["Shailesh Jain, MD",1215922802,"75-2656723","TX","PE - Premier Family Care, Inc","Multiplan","In Process","Pending PSV","","","","2023-11-22",""]
["Shailesh Jain, MD",1215922802,"75-2656723","TX","PE - Premier Family Care, Inc","Ambetter","Thru Other Payor","Pending Other Enrollment","","","","2023-11-22","11/22/2023 Pending Superior enrollment.  DCannon"]
["Shailesh Jain, MD",1215922802,"75-2656723","TX","","BCBSTX","In House Enrollment","In House Enrollment","","","","2023-11-22",""]
["Shailesh Jain, MD",1215922802,"75-2656723","TX","PE - Premier Family Care, Inc","CAQH","DO NOT ENROLL","DO NOT ENROLL","2023-11-22","","","2023-11-22","11/22/2023 CAQH profile maintained by provider/practice.  DCannon"]
["Shailesh Jain, MD",1215922802,"75-2656723","TX","PE - Premier Family Care, Inc","Galaxy Health","In Process","Pending PSV","","","","2023-11-22",""]
["Shailesh Jain, MD",1215922802,"75-2656723","TX","PE - Premier Family Care, Inc","Amerigroup","In Process","Pending PSV","","","","2023-11-22",""]
["Juan C Gil, MD",1558392779,"75-2656723","TX","PE - Premier Family Care, Inc","Scott&White (First Care)","Participating","Enrollment Complete","2018-05-04","1558392779","","2020-02-19","2/19/2020--Per payer roster received from Irma Henson, this provider is participating with this service location and TIN--tisha rader"]
["Juan C Gil, MD",1558392779,"75-2656723","TX","PE - Premier Family Care, Inc","USA PPO","Participating","Enrollment Complete","2010-04-16","","","2020-09-09","Confirmed provider is participating with PPO and H&W networks (list of networks attached). Kimberly Frazier"]
["Juan C Gil, MD",1558392779,"75-2656723","TX","PE - Premier Family Care, Inc","Boon Chapman","Participating","Enrollment Complete","2016-06-01","","","2022-03-10","3/10/2022 Rcvd roster from Multiplan listing provider as PAR and listed under group TIN/location effective 6/1/2016.  DCannon"]
["Juan C Gil, MD",1558392779,"75-2656723","TX","PE - Premier Family Care, Inc","Medicare","Participating","Enrollment Complete","2010-01-04","8L22951","0008AH","2020-01-29","01/29/2020 - confirmed EFF through PECOS group enrollment - Stacey Hudak"]
["Rosanna Y Catalasan, MD",1487837712,"75-2656723","TX","PE - Premier Family Care, Inc","CAQH","Participating","CAQH Reattested","2023-10-05","12038216","","2023-10-05","10/5/2023 CAQH reviewed and re-attested.  DCannon"]
["Rosanna Y Catalasan, MD",1487837712,"75-2656723","TX","PE - Premier Family Care, Inc","TriCare Standard","Participating","Enrollment Complete","2018-11-30","1487837712","","2020-03-03","03/03/2020 - Rec'd confirmation of provider enrollment through payer portal. Provider is linked to group at this service location - Stacey Hudak"]
["Rosanna Y Catalasan, MD",1487837712,"75-2656723","TX","PE - Premier Family Care, Inc","Medicare","Participating","Enrollment Complete","2010-01-01","8L23968","0008AH","2020-01-29","01/29/2020 - confirmed EFF through PECOS group enrollment - Stacey Hudak"]
["Matthew A Sanchez, APRN-NP",1437402278,"75-2656723","TX","PE - Premier Family Care, Inc","Medicaid","Participating","Enrollment Complete","","352749103","079837301","2020-01-29","01/29/2020 - Found provider par through payer portal. Provider is active with the following plans: TRADITIONAL MEDICAID, Amerigroup - MRSA West, Amerigroup Texas, Inc. - MRSA West - Stacey Hudak"]
["Matthew A Sanchez, APRN-NP",1437402278,"75-2656723","TX","PE - Premier Family Care, Inc","Galaxy Health","Participating","Enrollment Complete","2021-11-01","","","2021-12-12","12/12/2021 Sent f/u email to Michelle Monroe at Galaxy to check status of November Delegated Roster load.  Per email response November Delegated Roster load has been completed and provider is PAR w/ group/location effective 11/1/2021.  DCannon"]
["Matthew A Sanchez, APRN-NP",1437402278,"75-2656723","TX","PE - Premier Family Care, Inc","Medicare","Participating","Enrollment Complete","2016-03-21","299111YPVD","0008AH","2020-01-29","01/29/2020 - confirmed EFF through PECOS group enrollment - Stacey Hudak"]
["Matthew A Sanchez, APRN-NP",1437402278,"75-2656723","TX","PE - Premier Family Care, Inc","Amerigroup","Participating","Enrollment Complete","2016-07-08","1437402278","","2020-02-12","2/12/2020 – Received Roster from Amerigroup and provider is now PAR- Tisha Rader\n\n3/20/2020 - Rec'd email from Multiplan/Texas True Choice confirming that this Amerigroup EFF info is true for this provider/service location - Stacey Hudak"]
["Matthew A Sanchez, APRN-NP",1437402278,"75-2656723","TX","PE - Premier Family Care, Inc","Superior","Participating","Enrollment Complete","2016-08-01","1437402278","","2020-07-14","07/14/2020 - Rec'd spreadsheet from the delegated team stating this provider has been linked to the PriMed contract since 8-1-2016 **see the other enrollment complete line to see details about when this provider became effective with various specific products** - stacey Hudak"]
["Matthew A Sanchez, APRN-NP",1437402278,"75-2656723","TX","PE - Premier Family Care, Inc","Scott&White (First Care)","Participating","Enrollment Complete","2022-04-06","","","2022-07-14","7/14/2022 Received email from HPEXPEDITES@BSWHealth.org, provider is in process and has an effective date of 4/6/2022.   DCannon"]
["Matthew A Sanchez, APRN-NP",1437402278,"75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","2016-05-07","","","2020-12-01","12/1/2020 - Per f/u report Provider is on file and Par under the group and TIN# effective 5/7/2016.  DCannon"]
["Matthew A Sanchez, APRN-NP",1437402278,"75-2656723","TX","PE - Premier Family Care, Inc","Wellmed","Participating","Enrollment Complete","2022-01-01","","","2023-03-23","3/23/2023 Rcvd roster from UHC w/ all Wellmed participating providers.  Provider is PAR effective 1/1/2022.  DCannon"]
["Matthew A Sanchez, APRN-NP",1437402278,"75-2656723","TX","PE - Premier Family Care, Inc","Wellmed","Participating","Enrollment Complete","2022-01-01","","","2023-03-23","3/23/2023 Rcvd roster from UHC w/ all Wellmed participating providers.  Provider is PAR effective 1/1/2022.  DCannon"]
["Matthew A Sanchez, APRN-NP",1437402278,"75-2656723","TX","PE - Premier Family Care, Inc","HealthSmart PPO","Participating","Enrollment Complete","2020-03-20","1437402278","","2020-06-10","06/10/2020 - Rec'd email from the payer stating this provider is EFF - Stacey Hduak"]
["Mohammed H Aljarwi, MD",1013320050,"75-2656723","TX","PE - Premier Family Care, Inc","First Health Coventry","Participating","Enrollment Complete","2022-11-01","","","2023-07-27","07.27.2023 S/W Bridgett of First Health @800-226-5116. Per rep, provider is showing participating and link under the Group and TIN with an Effective date 11/01/2022. Provider ID 2906417. Service location is on file. Call ref#:709557. - Danico Gabriel Melendres"]
["Mohammed H Aljarwi, MD",1013320050,"75-2656723","TX","","Rail Road Medicare","Participating","Enrollment Complete","2022-12-01","Q00375443","CE1588","2022-11-30","11/30/2022 Rcvd RR Medicare approval letter.  PTAN # Q00375443 - effective 12/1/2022.  DCannon"]
["Mohammed H Aljarwi, MD",1013320050,"75-2656723","TX","PE - Premier Family Care, Inc","Triwest VA","In House Enrollment","In House Enrollment","","","","2022-09-13",""]
["Mohammed H Aljarwi, MD",1013320050,"75-2656723","TX","PE - Premier Family Care, Inc","IMS","Participating","Enrollment Complete","2022-10-10","","","2022-10-17","10/17/2022 Per email received from German Aviles at IMS/OMNI monthly delegation roster provider load for October has been completed.  Provider is PAR and linked to group TIN effective 10/10/2022.   DCannon"]
["Mohammed H Aljarwi, MD",1013320050,"75-2656723","TX","","Medicare","Participating","Enrollment Complete","2022-12-01","2K0473","0008AH","2022-10-17","10/17/2022 Rcvd Medicare approval letter.  PTAN # 2K0473 - effective 12/1/2022.  DCannon"]
["Mohammed H Aljarwi, MD",1013320050,"75-2656723","TX","PE - Premier Family Care, Inc","Wellcare","Participating","Enrollment Complete","2022-11-01","","","2022-12-29","12/29/2022 Rcvd confirmation email from Superior that October delegation roster has been processed and provider has been loaded to delegation roster and PAR w/ group effective 11/1/2022.  DCannon"]
["Mohammed H Aljarwi, MD",1013320050,"75-2656723","TX","","Aetna","Participating","Enrollment Complete","2023-02-01","7016986","","2023-02-01","02.01.2023 S/W Erika of Aetna @ 800-353-1232. Per rep, provider is showing participating with an Effective date 02/01/2023 and link under the Group and TIN. Provider ID 7016986, Payer ID 60054 and Recredentialing date 02/01/2025. Service location is on file. Call ref# 6131400691. -Danico Gabriel Melendres"]
["Mohammed H Aljarwi, MD",1013320050,"75-2656723","TX","","Scott&White (First Care)","Participating","Enrollment Complete","2022-10-07","","","2022-10-28","10/28/2022 Rcvd email from Scott & White that provider is PAR and linked to group TIN/locations effective 10/7/2022.  DCannon"]
["Joan S R Petalcorin, MD",1619008141,"75-2656723","TX","PE - Premier Family Care, Inc","Cigna","Terminated","Terminated","2016-07-20","1619008141","","2021-05-25","5/24/2021 Provider was loaded under delegation with WTPA; however, client terminated relationship and provider was termed effective 3/31/2021. Confirmed provider is not currently credentialed outside of delegation and requires full credentialing. Kfrazier"]
["Joan S R Petalcorin, MD",1619008141,"75-2656723","TX","PE - Premier Family Care, Inc","Caprock (CapStar)","Participating","Enrollment Complete","2016-10-05","1619008141","","2020-06-02","06/02/2020 - rec'd spreadsheet back from the payer Mary Rodriguez <MRodriguez@caprockhp.com> confirming this provider/service location is EFF with this payer - Stacey Hudak"]
["Joan S R Petalcorin, MD",1619008141,"75-2656723","TX","PE - Premier Family Care, Inc","United Health Care","Participating","Enrollment Complete","2017-01-09","2907601","","2020-06-08","06/08/2020 - Rec'd email from the payer statign provider is EFF at this service location as of 01/09/2017 - Stacey Hudak"]
["Joan S R Petalcorin, MD",1619008141,"75-2656723","TX","PE - Premier Family Care, Inc","Humana","Participating","Enrollment Complete","2020-01-01","1619008141","","2020-07-16","7/16/2020 - Received email spreadsheet from the payor confirming that this provider is EFF at this service location and PAR with the PRIMED DELEGATED agreement - Pam Porter"]
["Tiffany D Cossey, MD",1053601344,"75-2656723","TX","PE - Premier Family Care, Inc","Superior","Participating","Enrollment Complete","2020-08-01","1053601344","","2020-08-06","8/6/2020 - Rec'd an email from the payer stating this provider was added to their database EFF: 8-1-2020 after receiving/processing the July roster - Stacey Hudak"]
["Tiffany D Cossey, MD",1053601344,"75-2656723","TX","PE - Premier Family Care, Inc","Wellmed","Participating","Enrollment Complete","2022-01-01","","","2023-03-23","3/23/2023 Rcvd roster from UHC w/ all Wellmed participating providers.  Provider is PAR effective 1/1/2022.  DCannon"]
["Tiffany D Cossey, MD",1053601344,"75-2656723","TX","PE - Premier Family Care, Inc","Caprock (CapStar)","Participating","Enrollment Complete","2019-04-04","1053601344","","2020-06-02","06/02/2020 - rec'd spreadsheet back from the payer Mary Rodriguez <MRodriguez@caprockhp.com> confirming this provider/service location is EFF with this payer - Stacey Hudak"]
["Jeffrey Hunter Atkins, MD",1760860720,"75-2656723","TX","PE - Premier Family Care, Inc","CAQH","Participating","CAQH Reattested","2023-11-01","","","2023-11-01","11/01/2023- Updated License, address, credential contact and reattested - rkedar"]
["Jeffrey Hunter Atkins, MD",1760860720,"75-2656723","TX","PE - Premier Family Care, Inc","Aetna","In Process","PreApp/LOI Sent","","","","2023-11-16","Submitted LOI and W9 via fax. MS"]
["Jeffrey Hunter Atkins, MD",1760860720,"75-2656723","TX","PE - Premier Family Care, Inc","Triwest VA","In House Enrollment","In House Enrollment","","","","2023-10-09",""]
["Jeffrey Hunter Atkins, MD",1760860720,"75-2656723","TX","PE - Premier Family Care, Inc","Cigna","Participating","Enrollment Complete","2023-11-01","8771157","","2023-10-27","Received confirmation eff 11/1/2023. MS"]
["Jeffrey Hunter Atkins, MD",1760860720,"75-2656723","TX","PE - Premier Family Care, Inc","Superior","In Process","Application Submitted","","","","2023-10-13","10/13/2023 Delegated roster submitted.  DCannon"]
["Casey Mraz, MD",1659728855,"75-2656723","TX","PE - Premier Family Care, Inc","Ambetter","Participating","Enrollment Complete","2022-06-01","","","2022-06-13","6/13/2022 Per roster received from Superior provider is PAR and linked to group delegation roster effective 6/1/2022."]
["Casey Mraz, MD",1659728855,"75-2656723","TX","PE - Premier Family Care, Inc","First Health Coventry","Participating","Enrollment Complete","2019-06-01","3278559","","2020-03-20","3/20/2020-receieved email with roster stating provider PAR  6/1/2019 PID # 3278559\ntisha rader"]
["Casey Mraz, MD",1659728855,"75-2656723","TX","PE - Premier Family Care, Inc","Omni PPO","Participating","Enrollment Complete","2019-06-14","1659728855","","2020-06-25",""]
["Saranya Rajasekar, MD",1871028365,"75-2656723","TX","","Boon Chapman","Participating","Enrollment Complete","2022-04-11","","","2022-07-24","7/24/2022 Per email from Marcie Eckhart-Havens Multiplan July delegated roster has been completed  and provider is PAR and linked to group TIN effective 4/11/2022.  DCannon"]
["Saranya Rajasekar, MD",1871028365,"75-2656723","TX","","HealthSmart PPO","Participating","Enrollment Complete","2022-04-11","","","2022-06-10","6/10/2022 Per Healthsmart website provider is PAR and loaded under TIN/location effective 4/11/2022.  DCannon"]
["Saranya Rajasekar, MD",1871028365,"75-2656723","TX","PE - Premier Family Care, Inc","Medicaid","Participating","Enrollment Complete","2022-06-01","1871028365","1275522864","2022-08-17","8/17/2022 Rcvd TX Medicaid approval letter.  TPI # 1871028365 - effective 6/1/2022 - 8/15/2027.  DCannon"]
["Saranya Rajasekar, MD",1871028365,"75-2656723","TX","","First Health Coventry","Participating","Enrollment Complete","2023-05-01","","","2022-11-04","11.04.2022: S/W Kourtney of First Health @ 800-226-5116. Provider NPI# is on file for the provider and contracted under the TIN effective 05/01/2022. Provider ID# 3556714. Physical location is on file. Payer# 73159. Ref# 458389. - Mary Rose Acebedo"]
["Saranya Rajasekar, MD",1871028365,"75-2656723","TX","","United Health Care","Participating","Enrollment Complete","2022-04-11","008166209","","2022-09-06","9/6/2022 Per email received from UHC provider is PAR and linked to group TIN/locations effective 4/11/2022.  MPIN# 008166209. \n DCannon"]
["Saranya Rajasekar, MD",1871028365,"75-2656723","TX","","Humana","Participating","Enrollment Complete","2022-04-11","","","2022-07-14","7/14/2022 Per email received from Humana provider is PAR and linked to group TIN/location effective 4/11/2022.  DCannon"]
["Saranya Rajasekar, MD",1871028365,"75-2656723","TX","","Ambetter","Participating","Enrollment Complete","2022-05-01","","","2022-06-13","6/13/2022 Per roster received from Superior provider is PAR w/ Ambetter and linked to group delegation roster effective 5/1/2022.  DCannon"]
["Saranya Rajasekar, MD",1871028365,"75-2656723","TX","PE - Premier Family Care, Inc","Rail Road Medicare","Participating","Enrollment Complete","2022-06-01","Q00267344","CE1588","2022-05-26","5/26/2022 Rcvd RR Medicare approval letter. RR Medicare PTAN #  Q00267344 - effective 6/1/2022.  DCannon"]
["Saranya Rajasekar, MD",1871028365,"75-2656723","TX","","Aetna","Participating","Enrollment Complete","2022-11-01","6655255","","2022-10-18","10/18/2022 Rcvd email from Priscilla Albertine at MQA that provider is PAR and linked to group TIN effective 11/1/2022.  PID # 6655255.  DCannon"]
["Saranya Rajasekar, MD",1871028365,"75-2656723","TX","","Scott&White (First Care)","Participating","Enrollment Complete","2022-05-10","","","2022-07-12","7/12/2022 Rcvd email from First Care Scott and White confirmation provider is PAR and linked to group TIN effective 5/10/2022.  DCannon"]
["Saranya Rajasekar, MD",1871028365,"75-2656723","TX","","Scott&White (First Care)","Participating","Enrollment Complete","2022-05-10","","","2022-07-12","7/12/2022 Rcvd email from First Care Scott and White confirmation provider is PAR and linked to group TIN effective 5/10/2022.  DCannon"]
["Tzu-Ching Wu, MD",1396930426,"75-2656723","TX","PE - Premier Family Care, Inc","United Health Care","Participating","Enrollment Complete","2019-01-01","3382000","","2020-06-08","06/8/2020 - Rec'd email from the payer stating this provider/address is EFF - Stacey Hudak"]
["Tzu-Ching Wu, MD",1396930426,"75-2656723","TX","PE - Premier Family Care, Inc","Amerigroup","Participating","Enrollment Complete","2019-05-31","1396930426","","2020-03-20","03/20/2020 - Rec'd email from the payer (multiplan/true texas choice) stating this provider/service location is EFF with amerigroup - Stacey Hudak"]
["Tzu-Ching Wu, MD",1396930426,"75-2656723","TX","PE - Premier Family Care, Inc","USA PPO","Participating","Enrollment Complete","2019-05-31","","","2020-09-09","Confirmed provider is participating with PPO and H&W networks (list of networks attached). Kimberly Frazier"]
["Staton Awtrey, MD",1376556019,"75-2656723 : P","TX","PE - Premier Family Care, Inc","Ambetter","Participating","Enrollment Complete","2022-06-01","","","2022-06-13","6/13/2022 Per roster received from Superior provider is PAR and linked to group delegation roster effective 6/1/2022."]
["Staton Awtrey, MD",1376556019,"75-2656723 : P","TX","PE - Premier Family Care, Inc","Medicaid","Participating","Enrollment Complete","2009-12-07","147713503","079837301","2020-12-15","12/15/2020 Upon review of TMHP portal and per email forwarded from Candace Wynne, provider's revalidation is complete and will be due for revalidatio 12/13/2025. KFrazier"]
["Staton Awtrey, MD",1376556019,"75-2656723 : P","TX","PE - Premier Family Care, Inc","Humana","Participating","Enrollment Complete","2020-01-01","1376556019","","2020-07-15","7/15/2020 - Received email spreadsheet from the payor confirming that this provider is EFF at this service location and PAR with the PRIMED DELEGATED agreement - Pam Porter"]
["Staton Awtrey, MD",1376556019,"75-2656723 : P","TX","PE - Premier Family Care, Inc","Boon Chapman","Participating","Enrollment Complete","2016-05-10","","","2021-08-06","8/6/2021 Boon Chapman falls under the Multiplan umbrella, received roster from Multiplan provider is listed on roster under TIN/location as PAR effective 5/10/2016.  DCannon"]
["Cindy Marriner, FNP",1922008234,"75-2656723: P","TX","PE - Premier Family Care, Inc","Scott&White (First Care)","Participating","Enrollment Complete","2018-06-15","1922008234","","2020-02-19","2/19/2020--Per payer roster received from Irma Henson, this provider is participating with this service location and TIN--tisha rader"]
["Cindy Marriner, FNP",1922008234,"75-2656723: P","TX","PE - Premier Family Care, Inc","Medicaid","Participating","Enrollment Complete","2022-09-28","154421503","079837301","2023-10-19","Welcome letter rcvd, revalidation complete. Jen Videan"]
["Cindy Marriner, FNP",1922008234,"75-2656723: P","TX","PE - Premier Family Care, Inc","Wellmed","Participating","Enrollment Complete","2022-01-01","","","2023-03-23","3/23/2023 Rcvd roster from UHC w/ all Wellmed participating providers.  Provider is PAR effective 1/1/2022.  DCannon"]
["Cindy Marriner, FNP",1922008234,"75-2656723: P","TX","PE - Premier Family Care, Inc","Galaxy Health","Participating","Enrollment Complete","2014-12-01","1922008234","","2020-07-10","07/10/2020 - updated payer line to enrollment complete status instead of \"Delegated status\" for report running purposes - Stacey Hudak"]
["Kirit N Patel, MD",1295724698,"75-2656723: P","TX","PE - Premier Family Care, Inc","Rail Road Medicare","Participating","Enrollment Complete","2011-08-25","P01058301","CE1588","2020-03-25","3/25/2020--3/25/2020-Per online check, provider is now PAR effective 08/25/2011 with provider number P01058301. Attached welcome letter to payor line.-Elonah Grace B.Gelig"]
["Kirit N Patel, MD",1295724698,"75-2656723: P","TX","PE - Premier Family Care, Inc","Humana","Participating","Enrollment Complete","2020-01-01","1295724698","","2020-07-15","7/15/2020 - Received email spreadshee from the payor confirming that this provider is EFF at this service location and PAR with the PRIMED DELEGATED agreement - Pam Porter"]
["Kirit N Patel, MD",1295724698,"75-2656723: P","TX","PE - Premier Family Care, Inc","Wellmed","Participating","Enrollment Complete","2022-01-01","","","2023-03-23","3/23/2023 Rcvd roster from UHC w/ all Wellmed participating providers.  Provider is PAR effective 1/1/2022.  DCannon"]
["Kirit N Patel, MD",1295724698,"75-2656723: P","TX","PE - Premier Family Care, Inc","Medicare","Participating","Enrollment Complete","2011-08-25","TXB134311","0008AH","2020-01-29","01/29/2020 - confirmed EFF through PECOS group enrollment - Stacey Hudak"]
["Michael J Hester, APRN-AGACNP",1275044422,"75-2656723: P","TX","PE - Premier Family Care, Inc","USA PPO","Participating","Enrollment Complete","2018-07-31","1275044422","752656723","2020-08-24","Confirmed provider is participating with PPO and H&W networks (list of networks attached). Kimberly Frazier"]
["Michael J Hester, APRN-AGACNP",1275044422,"75-2656723: P","TX","PE - Premier Family Care, Inc","IMS","Participating","Enrollment Complete","2018-07-24","1275044422","","2020-06-22","06/22/2020- Rec'd email from the payer confirming this provider is PAR with this group/service location - Stacey Hudak"]
["Michael J Hester, APRN-AGACNP",1275044422,"75-2656723: P","TX","PE - Premier Family Care, Inc","Galaxy Health","Participating","Enrollment Complete","2018-07-24","1275044422","","2020-07-17","07/17/2020 Received a spreadsheet from the payer stating this provider is effective as of 07/24/2018. – Archie Candiasan"]
["Michael J Hester, APRN-AGACNP",1275044422,"75-2656723: P","TX","PE - Premier Family Care, Inc","Wellcare","Participating","Enrollment Complete","2021-11-01","","","2022-12-01","12/1/2022 Per roster received from Wellcare provider is PAR and linked to group TIN/location effective 11/1/2021.  DCannon"]
["Michael J Hester, APRN-AGACNP",1275044422,"75-2656723: P","TX","PE - Premier Family Care, Inc","Cigna","Terminated","Terminated","2019-09-01","1275044422","","2021-05-26","5/24/2021 Provider was loaded under delegation with WTPA; however, client terminated relationship and provider was termed effective 3/31/2021. Confirmed provider is not currently credentialed outside of delegation and requires full credentialing. Kfrazier"]
["Nikolay A Azarov, MD",1093937948,"75-2656723: P","TX","PE - Premier Family Care, Inc","CAQH","Participating","CAQH Reattested","2023-10-06","13782181","","2023-10-06","10/6/2023 CAQH reviewed and re-attested.  Updated credentialing contact phone number and uploaded current COI.  DCannon"]
["Nikolay A Azarov, MD",1093937948,"75-2656723: P","TX","","Amerigroup","Participating","Enrollment Complete","2012-03-01","01448885","","2020-02-11","2/11/2020 – Received Roster from Amerigroup and provider is now PAR- additional effective dates listed on roster are:  1/1/17, 11/1/16, 8/1/12, & 1/1/2020--Tisha Rader"]
["Nikolay A Azarov, MD",1093937948,"75-2656723: P","TX","PE - Premier Family Care, Inc","Omni PPO","Participating","Enrollment Complete","2009-02-12","1093937948","","2020-06-25",""]
["Nikolay A Azarov, MD",1093937948,"75-2656723: P","TX","PE - Premier Family Care, Inc","Rail Road Medicare","Participating","Enrollment Complete","2008-11-01","P00716501","","2020-03-30","3/25/2020--3/25/2020-Per online check, provider is now PAR effective 11/01/2008 with provider number P00716501. Attached welcome letter to payor line.-Elonah Grace B.Gelig"]
["Nikolay A Azarov, MD",1093937948,"75-2656723: P","TX","PE - Premier Family Care, Inc","United Health Care","Participating","Enrollment Complete","2015-04-29","1093937948","","2020-07-30","7/30/2020 - moved to completed status after reviewing follow up complete note - Stacey Hudak"]
["Nikolay A Azarov, MD",1093937948,"75-2656723: P","TX","PE - Premier Family Care, Inc","Cigna","Participating","Enrollment Complete","2020-02-26","6493392","","2021-11-15","11/15/2021 Per f/u note S/W Steven of Cigna @ 800-882-4462. NPI# for the provider is on file  shows LINKED and  Par under the group and TIN#,  effective 2/26/2020 , the physical location is on file and the Provider ID is 6493392.   DCannon"]
["Nikolay A Azarov, MD",1093937948,"75-2656723: P","TX","PE - Premier Family Care, Inc","Ambetter","Participating","Enrollment Complete","2022-06-01","","","2022-06-13","6/13/2022 Per roster received from Superior provider is PAR and linked to group delegation roster effective 6/1/2022."]
["Nikolay A Azarov, MD",1093937948,"75-2656723: P","TX","","HealthSmart PPO","Participating","Enrollment Complete","2011-02-01","1093937948","","2020-06-05","06/05/2020 - Rec'd email from the payer stating this provider is EFF - stacey hudak"]
["Cindy Marriner, FNP",1922008234,"75-2656723: S","TX","PE - Premier Family Care, Inc","First Health Coventry","Participating","Enrollment Complete","2020-09-01","1922008234","","2020-11-02","11/2/2020 - moved to completed status after reviewing follow up complete note - Stacey Hudak"]
["Cindy Marriner, FNP",1922008234,"75-2656723: S","TX","PE - Premier Family Care, Inc","Cigna","Participating","Enrollment Complete","2019-09-01","8335090","","2020-06-17","06/17/2020 - rec'd email from the payer stating \"request completed\" - Stacey Hudak"]
["Cindy Marriner, FNP",1922008234,"75-2656723: S","TX","PE - Premier Family Care, Inc","Wellmed","Participating","Enrollment Complete","2022-01-01","","","2023-03-23","3/23/2023 Rcvd roster from UHC w/ all Wellmed participating providers.  Provider is PAR effective 1/1/2022.  DCannon"]
["Cindy Marriner, FNP",1922008234,"75-2656723: S","TX","PE - Premier Family Care, Inc","Humana","Participating","Enrollment Complete","2020-01-01","1922008234","","2020-07-16","7/16/2020 - Received email spreadsheet from the payor confirming that this provider is EFF at this service location and PAR with the PRIMED DELEGATED agreement - Pam Porter"]
["Kirit N Patel, MD",1295724698,"75-2656723: S","TX","PE - Premier Family Care, Inc","First Health Coventry","Participating","Enrollment Complete","2011-09-01","1100846","","2020-03-20","3/20/2020-receieved email with roster stating provider PAR 9/1/2011 PID # 1100846-tisha rader"]
["Kirit N Patel, MD",1295724698,"75-2656723: S","TX","PE - Premier Family Care, Inc","Cigna","Terminated","Terminated","2011-09-01","1295724698","",44342,"5/24/2021 Provider was loaded under delegation with WTPA; however, client terminated relationship and provider was termed effective 3/31/2021. Confirmed provider is not currently credentialed outside of delegation and requires full credentialing. Kfrazier"]
["Kirit N Patel, MD",1295724698,"75-2656723: S","TX","PE - Premier Family Care, Inc","Galaxy Health","Participating","Enrollment Complete","2011-09-01","1295724698","","2020-07-17","07/17/2020 Received a spreadsheet from the payer stating this provider is effective as of 09/01/2011. – Archie Candiasan"]
["Kirit N Patel, MD",1295724698,"75-2656723: S","TX","PE - Premier Family Care, Inc","Cigna","Participating","Enrollment Complete","2021-08-03","2026473","","2021-08-05","8/4/2021 Received an email from discovercigna@information.cigna.com confirming provider is now participating under group Tax ID effective 8/3/2021 with assigned provider number 2026473. KFrazier"]
["Kirit N Patel, MD",1295724698,"75-2656723: S","TX","PE - Premier Family Care, Inc","HealthSmart PPO","Participating","Enrollment Complete","2011-02-01","1295724698","","2020-06-05","06/05/2020 - Rec'd email from the payer stating this provider is EFF - Stacey Hudak"]
["Samuel L Baumguardner, PA",1295109510,"75-2656723: S","TX","PE - Premier Family Care, Inc","Galaxy Health","Participating","Enrollment Complete","2019-09-01","1295109510","","2020-08-24",""]
["Samuel L Baumguardner, PA",1295109510,"75-2656723: S","TX","PE - Premier Family Care, Inc","Boon Chapman","Participating","Enrollment Complete","2016-04-06","","","2021-08-06","8/6/2021 Boon Chapman falls under the Multiplan umbrella, received roster from Multiplan provider is listed on roster under TIN/location as PAR effective 4/6/2016.  DCannon"]
["Samuel L Baumguardner, PA",1295109510,"75-2656723: S","TX","PE - Premier Family Care, Inc","Rail Road Medicare","Participating","Enrollment Complete","2016-02-15","P01777833","CE1588","2020-05-04","05/04/2020 - Verified and updated payerline with EFF information - Stacey Hudak"]
["Samuel L Baumguardner, PA",1295109510,"75-2656723: S","TX","PE - Premier Family Care, Inc","Wellcare","Participating","Enrollment Complete","2021-11-01","","","","11/15/2022 Per roster received from Wellcare provider is PAR and linked to group TIN/location effective 11/1/2021.  DCannon"]
["Michael J Hester, APRN-AGACNP",1275044422,"75-2656723: S","TX","PE - Premier Family Care, Inc","Superior","Participating","Enrollment Complete","2018-09-01","1275044422","","2020-07-14","07/14/2020 - Rec'd email from the payer stating this provider is EFF under PRIMED DELEGATED agreement - Stacey Hudak"]
["Michael J Hester, APRN-AGACNP",1275044422,"75-2656723: S","TX","PE - Premier Family Care, Inc","Scott&White (First Care)","Participating","Enrollment Complete","2020-02-13","1275044422","","2020-10-02","10/02/2020 - moved to completed status after reviewing follow up complete note - Stacey Hudak"]
["Michael J Hester, APRN-AGACNP",1275044422,"75-2656723: S","TX","PE - Premier Family Care, Inc","Ambetter","Participating","Enrollment Complete","2022-06-01","","","2022-06-01","6/13/2022 Per roster received from Superior provider is PAR and linked to group delegation roster effective 6/1/2022."]
["Michael J Hester, APRN-AGACNP",1275044422,"75-2656723: S","TX","PE - Premier Family Care, Inc","Amerigroup","Participating","Enrollment Complete","2018-07-24","","","2021-10-21","10/21/2021  Rcvd full roster from Joe Rodriguez at Amerigroup listing provider as PAR w/ group TIN and location effective 7/24/2018.  DCannon"]
["Nikolay A Azarov, MD",1093937948,"75-2656723: S","TX","PE - Premier Family Care, Inc","Amerigroup","Participating","Enrollment Complete","2015-04-29","01448885","","2021-02-13","2/13/2021 - Rcvd complete roster from Amerigroup provider is participating and linked to TIN and location for the following plans STAR - eff 3/1/2012; Medicare - eff 8/1/2012; C-SNP - eff 1/1/2017; Other - eff 1/1/2021, Plus - eff 3/1/2012, Star_Kids - eff 11/1/2016.  DCannon"]
["Nikolay A Azarov, MD",1093937948,"75-2656723: S","TX","","Humana","Participating","Enrollment Complete","2020-01-01","1093937948","","2020-07-16","7/16/2020 - Received email spreadsheet from the payor confirming that this provider is EFF at this service location and PAR with the PRIMED DELEGATED agreement - Pam Porter"]
["Nikolay A Azarov, MD",1093937948,"75-2656723: S","TX","","Medicaid","Participating","Enrollment Complete","2009-03-24","194906703","079837301","2020-03-13","03/13/2020 - Clinic forwarded Medicaid TMHP approval letter showing where the provider was linked to the group - Stacey Hudak"]
["Nikolay A Azarov, MD",1093937948,"75-2656723: S","TX","PE - Premier Family Care, Inc","Boon Chapman","Participating","Enrollment Complete","2018-06-07","","","2021-08-06","8/6/2021 Boon Chapman falls under the Multiplan umbrella, received roster from Multiplan provider is listed on roster under TIN/location as PAR effective 6/7/2018.  DCannon"]
["Nikolay A Azarov, MD",1093937948,"75-2656723: S","TX","","Medicare","Participating","Enrollment Complete","2009-03-24","8L6420","0008AH","2020-03-13","03/13/2020 - Clinic forwarded Medicaid TMHP approval letter showing where the provider was linked to the group - Stacey Hudak"]
["Nikolay A Azarov, MD",1093937948,"75-2656723: S","TX","","IMS","Participating","Enrollment Complete","2019-09-01","1093937948","","2020-07-27","07/27/2020 - Rec'd roster response back from the payer regarding 7/15/2020 submission stating that all requested providers/service locations have been added to PriMed agreement - Stacey Hudak"]
["Staton Awtrey, MD",1376556019,"75-2656723: S","TX","PE - Premier Family Care, Inc","HealthSmart PPO","Participating","Enrollment Complete","2017-11-01","1376556019","","2020-06-10","06/10/2020 - Rec'd email from the payer stating this provider is EFF - stacey hudak"]
["Staton Awtrey, MD",1376556019,"75-2656723: S","TX","PE - Premier Family Care, Inc","Wellmed","Participating","Enrollment Complete","2022-01-01","","","2023-03-23","3/23/2023 Rcvd roster from UHC w/ all Wellmed participating providers.  Provider is PAR effective 1/1/2022.  DCannon"]
["Staton Awtrey, MD",1376556019,"75-2656723: S","TX","PE - Premier Family Care, Inc","Wellcare","Participating","Enrollment Complete","2021-11-01","","",44880,"11/15/2022 Per roster received from Wellcare provider is PAR and linked to group TIN/location effective 11/1/2021.  DCannon"]
["Staton Awtrey, MD",1376556019,"75-2656723: S","TX","PE - Premier Family Care, Inc","United Health Care","Participating","Enrollment Complete","2020-01-08","1376556019","","2020-09-08","09/08/2020 - reviewed previous note and moved to completed status - Stacey Hudak"]
["Staton Awtrey, MD",1376556019,"75-2656723: S","TX","PE - Premier Family Care, Inc","Galaxy Health","Participating","Enrollment Complete","2019-09-01","1376556019","","2020-08-21","08/21/2020 - Rec'd email confirmation that this roster was processed and this provider was made effective with the requested eff date of 9-1-2019 - Stacey Hudak"]
["KristiAnne Alexis Gore, PA-C",1558971432,"75-2781652","TX","PE - West Texas Allergy, PA","Medicare","Participating","Enrollment Complete","2023-05-24","2Y7249","","2023-09-06","Received confirmation letter. MS"]
["KristiAnne Alexis Gore, PA-C",1558971432,"75-2781652","TX","PE - West Texas Allergy, PA","United Health Care","Participating","Sent to Provider For Signature","2023-02-06","8535592","",45215,"10/16/2023 Emailed UHC contract for KristiAnne Gore to Priscilla at MQA to obtain provider signature.  DCannon"]
["KristiAnne Alexis Gore, PA-C",1558971432,"75-2781652","TX","PE - West Texas Allergy, PA","Omni PPO","Participating","Enrollment Complete","2023-02-06","1558971432","","2023-07-19","7/19/2023 Rcvd email from G.Aviles at IMS/OMNI that delegation roster provider load for February has been completed.  Provider is PAR and linked to group effective 2/6/2023.  DCannon"]
["KristiAnne Alexis Gore, PA-C",1558971432,"75-2781652","TX","PE - West Texas Allergy, PA","First Health Coventry","Participating","Enrollment Complete","2023-02-06","3649598","","2023-11-15","11.15.2023 S/W Lisa of First Health @ 1-800-353-1232. Per rep, Provider is in network with Aetna and linked to the group and TIN# effective 2/6/2023. No next recredentialing date available. PIN: 3649598. Servicing location is on file.  No Call ref#.  DCannon"]
["KristiAnne Alexis Gore, PA-C",1558971432,"75-2781652","TX","PE - West Texas Allergy, PA","Tricare Prime","Panel Closed","Panel Closed","","","","2023-05-12","Panel is currently closed."]
["KristiAnne Alexis Gore, PA-C",1558971432,"75-2781652","TX","PE - West Texas Allergy, PA","Rail Road Medicare","Participating","Enrollment Complete","2023-05-24","Q00556213","CF8499","2023-09-18","9/18/2023 Rcvd RR Medicare approval letter.  Provider PTAN - Q00556213 - effective 5/24/2023.  DCannon"]
["KristiAnne Alexis Gore, PA-C",1558971432,"75-2781652","TX","PE - West Texas Allergy, PA","CAQH","Participating","CAQH Reattested","2023-11-07","15745440","","2023-11-07","11/07/2023 CAQH Reattested WThompson"]
["Dana L Bell, APRN-FNP-BC",1073983193,"75-2781652","TX","PE - West Texas Allergy, PA","Ambetter","Participating","Enrollment Complete","2023-09-01","1073983193","","2023-09-13","9/13/2023 Rcvd email from Superior confirming that the August delegated roster provider load has been completed providers are PAR and loaded under TIN/ all locations effective 9/1/2023.  DCannon"]
["Dana L Bell, APRN-FNP-BC",1073983193,"75-2781652","TX","PE - West Texas Allergy, PA","CAQH","Participating","CAQH Reattested","2023-11-07","13954674","","2023-11-07","11/07/2023 Reattested profile"]
["Dana L Bell, APRN-FNP-BC",1073983193,"75-2781652","TX","PE - West Texas Allergy, PA","TriCare Standard","Participating","Enrollment Complete","2023-06-22","1073983193","","2023-08-23","Confirmation of provider's specialty updated. MS"]
["Dana L Bell, APRN-FNP-BC",1073983193,"75-2781652","TX","PE - West Texas Allergy, PA","Medicaid","In Process","Pending Other Enrollment","2023-05-29","1073983193","","2023-11-17","11/17/2023 19th St. location is pending for individuals until added to group record. DCannon"]
["Dana L Bell, APRN-FNP-BC",1073983193,"75-2781652","TX","PE - West Texas Allergy, PA","Aetna","Participating","Enrollment Complete","2023-05-29","4523940","","2023-08-17","8/17/2023 Per email from Priscilla Albertine at MQA she received confirmation that provider is PAR and linked to group TIN/location effective 5/29/2023.  DCannon"]
["Dana L Bell, APRN-FNP-BC",1073983193,"75-2781652","TX","PE - West Texas Allergy, PA","HealthSmart PPO","In Process","Payor Follow Up","","","","2023-11-14","11/14/2023 Per Healthsmart provider portal provider is still not loaded under group TIN.  Per phone conversation with Lee Kinard at Healthsmart provider portal should be updated  by 11/27/2023.  Will allow more time, check back in 2 weeks.   DCannon"]
["Dana L Bell, APRN-FNP-BC",1073983193,"75-2781652","TX","PE - West Texas Allergy, PA","Multiplan","Participating","Enrollment Complete","2023-08-01","1073983193","","2023-09-20","9/20/2023 Per email received from Jessica Bess at Multiplan August roster has been completed.  Provider is PAR and linked to group TIN/location effective 8/1/2023.  DCannon"]
["Dana L Bell, APRN-FNP-BC",1073983193,"75-2781652","TX","PE - West Texas Allergy, PA","Superior","Participating","Enrollment Complete","2023-09-01","1073983193","","2023-09-13","9/13/2023 Rcvd email from Superior confirming that the August delegated roster provider load has been completed providers are PAR and loaded under TIN/locations effective 9/1/2023.  DCannon"]
["Dana L Bell, APRN-FNP-BC",1073983193,"75-2781652","TX","PE - West Texas Allergy, PA","Amerigroup","In Process","Payor Follow Up","","","","2023-11-17","11/17/2023 Sent follow-up email to Cassandra Dunagon-Smith and Vanessa Christensen at Amerigroup to check status of follow-up request sent on 9/9/2023.  DCannon"]
["Dana L Bell, APRN-FNP-BC",1073983193,"75-2781652","TX","PE - West Texas Allergy, PA","Cigna","Enrollment on Hold","Pending Contracting","","","","2023-11-07","Emailed client to check on the status of the contract being signed. MS"]
["Dana L Bell, APRN-FNP-BC",1073983193,"75-2781652","TX","PE - West Texas Allergy, PA","Humana","In Process","Payor Follow Up","","","","2023-11-17","11/17/2023 Sent follow-up email to Marcus Wester at Humana requesting update.  DCannon"]
["Dana L Bell, APRN-FNP-BC",1073983193,"75-2781652","TX","PE - West Texas Allergy, PA","Wellcare","Participating","Enrollment Complete","2023-09-01","1073983193","","2023-09-13","9/13/2023 Rcvd email from Superior confirming that the August delegated roster provider load has been completed providers are PAR and loaded under TIN/ all locations effective 9/1/2023.  DCannon"]
["Dana L Bell, APRN-FNP-BC",1073983193,"75-2781652","TX","PE - West Texas Allergy, PA","Caprock (CapStar)","Participating","Enrollment Complete","2023-08-01","1073983193","","2023-09-12","9/12/2023 Per email received from Caprock provider is PAR and linked to group TIN/location effective 8/1/2023.  DCannon"]
["Dana L Bell, APRN-FNP-BC",1073983193,"75-2781652","TX","PE - West Texas Allergy, PA","Omni PPO","Participating","Enrollment Complete","2023-08-01","1073983193","","2023-09-05","9/5/2023 Per email received from IMS/OMNI May delegated roster has been processed and provider is PAR and linked to group effective 8/1/2023.  DCannon"]
["Amanda Dee Flores, APRN-FNP-BC",1083394977,"75-2781652","TX","PE - West Texas Allergy, PA","United Health Care","Participating","Enrollment Complete","2023-09-08","008866169","","2023-09-28","9/28/2023 Rcvd email confirmation from UHC that September delegated roster has been completed.  Provider is PAR and linked to group/location effective 9/8/2023.  DCannon"]
["Amanda Dee Flores, APRN-FNP-BC",1083394977,"75-2781652","TX","PE - West Texas Allergy, PA","Ambetter","Thru Other Payor","Pending Other Enrollment","","","","2023-11-17","11/17/2023 Pending Superior enrollment.  DCannon"]
["Amanda Dee Flores, APRN-FNP-BC",1083394977,"75-2781652","TX","PE - West Texas Allergy, PA","Cigna","In Process","Payor Follow Up","","","","2023-11-07","Initial Application received on 9/25/2023 and is still in process.  MS"]
["Amanda Dee Flores, APRN-FNP-BC",1083394977,"75-2781652","TX","PE - West Texas Allergy, PA","IMS","In Process","Application Submitted","","","","2023-11-15","11/15/2023 Delegated roster submitted.  DCannon"]
["Amanda Dee Flores, APRN-FNP-BC",1083394977,"75-2781652","TX","PE - West Texas Allergy, PA","Amerigroup","In Process","Payor Follow Up","","","","2023-11-17","11/17/2023 Sent follow-up email to Cassandra Dunagon-Smith and Vanessa Christensen at Amerigroup to check status of follow-up request sent on 9/9/2023.  DCannon"]
["Amanda Dee Flores, APRN-FNP-BC",1083394977,"75-2781652","TX","PE - West Texas Allergy, PA","Caprock (CapStar)","Participating","Enrollment Complete","2023-09-08","1083394977","","2023-09-27","9/27/2023 Rcvd email confirmation from Caprock that the September roster has been completed.  Provider is PAR and linked to group/location effective 9/8/2023.  DCannon"]
["Amanda Dee Flores, APRN-FNP-BC",1083394977,"75-2781652","TX","PE - West Texas Allergy, PA","Triwest VA","In House Enrollment","In House Enrollment","","","","2023-10-25",""]
["Amanda Dee Flores, APRN-FNP-BC",1083394977,"75-2781652","TX","PE - West Texas Allergy, PA","Wellmed","Thru Other Payor","Payor Follow Up","","","","2023-11-17","11/17/2023 Emailed UHC to check status WellMed enrollment.  DCannon"]
["Amanda Dee Flores, APRN-FNP-BC",1083394977,"75-2781652","TX","PE - West Texas Allergy, PA","Rail Road Medicare","Participating","Enrollment Complete","2023-08-14","Q00595265","CF8499","2023-11-07","Received enrollment approval. MS"]
["Emily D Satterfield, MSN, FNP-C",1063962355,"75-2781652","TX","PE - West Texas Allergy, PA","CAQH","Participating","CAQH Reattested","2023-11-01","14041680","","2023-11-06","11/06/2023 Corrected error and reuploaded liability. CAQH Reattested"]
["Emily D Satterfield, MSN, FNP-C",1063962355,"75-2781652","TX","PE - West Texas Allergy, PA","Humana","In Process","Payor Follow Up","","","","2023-11-17","11/17/2023 Sent follow-up email to Marcus Wester at Humana requesting update.  DCannon"]
["Emily D Satterfield, MSN, FNP-C",1063962355,"75-2781652","TX","PE - West Texas Allergy, PA","Superior","Participating","Enrollment Complete","2023-07-01","1063962355","","2023-07-21","7/21/2023 Rcvd confirmation email from Superior that June delegation roster has been processed and provider has been loaded to delegation roster and PAR w/ group effective 7/1/2023.  DCannon"]
["Emily D Satterfield, MSN, FNP-C",1063962355,"75-2781652","TX","PE - West Texas Allergy, PA","Aetna","Participating","Enrollment Complete","2023-06-01","1063962355","","2023-08-17","8/17/2023 Per email from Priscilla Albertine at MQA she received confirmation that provider is PAR and linked to group TIN/location effective 6/1/2023.  DCannon"]
["Emily D Satterfield, MSN, FNP-C",1063962355,"75-2781652","TX","PE - West Texas Allergy, PA","Travelers WC","Enrollment Stopped","Enrollment Stopped","","","","2023-07-19","Per request from MQA remove all workers comp payors for this provider. Jen Videan"]
["Emily D Satterfield, MSN, FNP-C",1063962355,"75-2781652","TX","PE - West Texas Allergy, PA","Rail Road Medicare","Participating","Enrollment Complete","2023-07-20","Q00602386","","2023-11-16","Confirmation of approval received. MS"]
["Emily D Satterfield, MSN, FNP-C",1063962355,"75-2781652","TX","PE - West Texas Allergy, PA","Gallagher","Enrollment Stopped","Enrollment Stopped","","","","2023-07-19","Per request from MQA remove all workers comp payors for this provider. Jen Videan"]
["Emily D Satterfield, MSN, FNP-C",1063962355,"75-2781652","TX","PE - West Texas Allergy, PA","Wellmed","Participating","Enrollment Complete","2023-06-01","1063962355","","2023-07-25","7/25/2023 Rcvd email from UHC that June monthly delegation roster has been completed and provider is PAR and linked to group TIN effective 6/1/2023.  MPIN # 6293261.   DCannon"]
["Emily D Satterfield, MSN, FNP-C",1063962355,"75-2781652","TX","PE - West Texas Allergy, PA","Cigna","Participating","Enrollment Complete","2023-01-02","6513263","","2023-10-20","Last name was updated in Cigna's system effective 10/10/2023. Previous name: Emily Gully. MS"]
["Emily D Satterfield, MSN, FNP-C",1063962355,"75-2781652","TX","PE - West Texas Allergy, PA","Texas Municipal League","Enrollment Stopped","Enrollment Stopped","","","","2023-07-19","7/19/2023 Per request from MQA remove all workers comp payors for this provider.  DCannon"]
["Emily D Satterfield, MSN, FNP-C",1063962355,"75-2781652","TX","PE - West Texas Allergy, PA","Medicaid","In Process","Pending Other Enrollment","","","",45246,"Per Jana Huff at West Texas Allergy, Emily has reached out to Basin Emergency Physicians regarding application they need to complete or cancel. Jen Videan 11/16/2023\n\n\nPer TMHP Emily's profile is being held up by another enrollment started by Basin Emergency Physicians to update her name from Gully to Satterfield. The admin for this group either needs to go in and complete the application or cancel the application. for us to be able to move forward with our enrollment. Emailed MQA and West Texas Allergy to assist. Jen Videan"]
["Emily D Satterfield, MSN, FNP-C",1063962355,"75-2781652","TX","PE - West Texas Allergy, PA","First Health Coventry","Participating","Enrollment Complete","2023-06-01","3015965","","2023-10-25","10/25/2023 Called First Health at 800-226-5116 spoke w/ Leandra provider is PAR and linked to group TIN and both locations effective 6/1/2023.  PID 3015965.  DCannon"]
["Emily D Satterfield, MSN, FNP-C",1063962355,"75-2781652","TX","PE - West Texas Allergy, PA","IMS","Participating","Enrollment Complete","2023-06-01","1063962355","","2023-07-18","7/18/2023 Per email received from IMS/OMNI June delegated roster has been processed and provider is PAR and linked to group effective 6/1/2023.  DCannon"]
["Emily D Satterfield, MSN, FNP-C",1063962355,"75-2781652","TX","PE - West Texas Allergy, PA","Zurich","Enrollment Stopped","Enrollment Stopped","","","","2023-07-19","Per request from MQA remove all workers comp payors for this provider. Jen Videan"]
["Emily D Satterfield, MSN, FNP-C",1063962355,"75-2781652","TX","PE - West Texas Allergy, PA","BCBSTX","In House Enrollment","In House Enrollment","","","","2023-06-07",""]
["Emily D Satterfield, MSN, FNP-C",1063962355,"75-2781652","TX","PE - West Texas Allergy, PA","Medicare","Participating","Enrollment Complete","2023-07-20","6C3922","00608K","2023-11-01","Received confirmation email of approval eff 7/20/23. MS"]
["Emily D Satterfield, MSN, FNP-C",1063962355,"75-2781652","TX","PE - West Texas Allergy, PA","Broadspire Services Inc.","Enrollment Stopped","Enrollment Stopped","","","","2023-07-19","7/19/2023 Per request from MQA remove all workers comp payors for this provider.  DCannon"]
["Emily D Satterfield, MSN, FNP-C",1063962355,"75-2781652","TX","PE - West Texas Allergy, PA","United Health Care","Participating","Enrollment Complete","2023-06-01","6293261","","2023-07-25","7/25/2023 Rcvd email from UHC that June monthly delegation roster has been completed and provider is PAR and linked to group TIN effective 6/1/2023.  MPIN # 6293261.   DCannon"]
["Emily D Satterfield, MSN, FNP-C",1063962355,"75-2781652","TX","PE - West Texas Allergy, PA","Liberty Mutual","Enrollment Stopped","Enrollment Stopped","","","","2023-07-19","Per request from MQA remove all workers comp payors for this provider. Jen Videan"]
["Emily D Satterfield, MSN, FNP-C",1063962355,"75-2781652","TX","PE - West Texas Allergy, PA","Liberty Mutual","Enrollment Stopped","Enrollment Stopped","","","","2023-07-19","Per request from MQA remove all workers comp payors for this provider. Jen Videan"]
["Emily D Satterfield, MSN, FNP-C",1063962355,"75-2781652","TX","PE - West Texas Allergy, PA","Multiplan","Participating","Enrollment Complete","2023-06-01","1063962355","","2023-07-25","7/25/2023 Rcvd email confirmation from Jessica Bess at Multiplan that June roster has been processed and provider is PAR w/ group effective 6/1/2023.  DCannon"]
["Emily D Satterfield, MSN, FNP-C",1063962355,"75-2781652","TX","PE - West Texas Allergy, PA","Boon Chapman","Participating","Enrollment Complete","2023-06-01","1063962355","","2023-07-25","7/25/2023 Rcvd email confirmation from Jessica Bess at Multiplan that June roster has been processed and provider is PAR w/ group effective 6/1/2023.  DCannon"]
["Michael P Wolbert, MD",1881711778,"75-2781652","TX","","Aetna","Participating","Enrollment Complete","2015-12-01","9826163","","2020-04-23","04/23/2020--S/W JR of Aetna @ 800-353-1232. Per rep the Provider is on file, linked & participating under the GRP & TIN effective 12/1/2015. Physical Location is on file. Provider ID #9826163. Call ref # 5234180829\ncopied note from spreadsheet-tisha rader"]
["Michael P Wolbert, MD",1881711778,"75-2781652","TX","PE - West Texas Allergy, PA","Wellmed","Terminated","Terminated","2022-01-01","1881711778","","2023-10-25","10/25/2023 Per email received from Priscilla Albertine at MQA, Dr. Wolbert's UHC contracted terminated effective 8/23/2023.  DCannon"]
["Michael P Wolbert, MD",1881711778,"75-2781652","TX","PE - West Texas Allergy, PA","First Health Coventry","Participating","Enrollment Complete","2010-08-01","1945548","","2020-03-20","3/20/2020-receieved email with roster stating provider PAR 8/1/2010 PID # 1945548-tisha rader"]
["Michael P Wolbert, MD",1881711778,"75-2781652","TX","","Caprock (CapStar)","Participating","Enrollment Complete","2021-08-02","1881711778","","2021-10-06","10/6/2021 Rcvd email from CapRock that monthly delegated roster has been loaded and the provider is PAR and linked to group TIN/location effective 8/2/2021.  DCannon"]
["Michael P Wolbert, MD",1881711778,"75-2781652","TX","","Boon Chapman","Participating","Enrollment Complete","2020-07-02","1881711778","","2021-08-06","8/6/2021 Boon Chapman falls under the Multiplan umbrella, received roster from Multiplan provider is listed on roster under TIN/location as PAR effective 7/2/2020.  DCannon"]
["Michael P Wolbert, MD",1881711778,"75-2781652","TX","","Medicaid","Participating","Enrollment Complete","2010-07-25","284181901","","2023-09-18",""]
["Michael P Wolbert, MD",1881711778,"75-2781652","TX","PE - West Texas Allergy, PA","Wellcare","Participating","Enrollment Complete","2022-09-01","1881711778","","2022-12-01","12/1/2022 Per roster received from Wellcare provider is PAR and linked to group TIN/location effective 9/1/2022.  DCannon"]
["Michael P Wolbert, MD",1881711778,"75-2781652","TX","","Multiplan","Participating","Enrollment Complete","2021-08-13","1881711778","","2021-09-15","9/15/2021 Received welcome letter from Multiplan listing provider has PAR under group TIN/location effective 8/13/2021.  DCannon"]
["Michael P Wolbert, MD",1881711778,"75-2781652","TX","PE - West Texas Allergy, PA","USA PPO","Participating","Enrollment Complete","2021-08-02","1142937","","2021-12-03","12/3/2021  In following up with USAMCO (800-872-3860) I was told that you can confirm participating via the USA MCO website  https://providersearch.usamco.com/hwprovsearch.  Provider is PAR and linked to location/TIN effective 8/2/2021.  DCannon"]
["Michael P Wolbert, MD",1881711778,"75-2781652","TX","PE - West Texas Allergy, PA","Medicare","Participating","Enrollment Complete","2010-07-25","TXB111410","00608K","2021-09-15","9/15/2021 Rcvd Medicare approval letter.   PTAN # TXB111410.  DCannon"]
["Michael P Wolbert, MD",1881711778,"75-2781652","TX","PE - West Texas Allergy, PA","Omni PPO","Participating","Enrollment Complete","2010-07-14","1881711778","","2020-06-26",""]
["Michael P Wolbert, MD",1881711778,"75-2781652","TX","PE - West Texas Allergy, PA","Humana","Participating","Enrollment Complete","2021-08-01","1881711778","","2022-08-20","8/20/2022 Per email received from Vernita Young July monthly delegated roster is complete and provider is PAR and linked to group TIN/location effective 8/1/2021.  DCannon"]
["Michael P Wolbert, MD",1881711778,"75-2781652","TX","PE - West Texas Allergy, PA","Caprock (CapStar)","Participating","Enrollment Complete","2012-03-01","1881711778","","2020-06-02","06/02/2020 - rec'd spreadsheet back from the payer Mary Rodriguez <MRodriguez@caprockhp.com> confirming this provider/service location is EFF with this payer - Stacey Hudak"]
["Michael P Wolbert, MD",1881711778,"75-2781652","TX","","Wellcare","Participating","Enrollment Complete","2022-09-01","1881711778","","2022-12-01","12/1/2022 Per roster received from Wellcare provider is PAR and linked to group TIN/location effective 9/1/2022.  DCannon"]
["Michael P Wolbert, MD",1881711778,"75-2781652","TX","","Scott&White (First Care)","Participating","Enrollment Complete","2017-09-14","1881711778","","2020-08-19","8/19/2020 - Rec'd confirmation that this provider is affiliated with the PRIMED DELEGATED ROSTER under this TIN/Service Location. This provider is networked with: \nFirstCare MyChoice PPO\nCHIP\nFirstCare Select Benefit Network\nHMO Enhanced Benefit Network\nMedicaid (FC)\nPPO Limited Benefit Network\n- Stacey Hudak"]
["Michael P Wolbert, MD",1881711778,"75-2781652","TX","PE - West Texas Allergy, PA","CAQH","In House Enrollment","CAQH Reattested","2023-11-07","11834332","","2023-11-07","11/07/2023 CAQH Reattested"]
["\"PK\" Pankaj J Patel, MD",1124009766,"75-2784378","TX","PE - Pankaj N. Patel, MD PA","Caprock (CapStar)","Participating","Enrollment Complete","2012-03-01","1124009766","","2020-09-16","09/16/2020 - Reviewed a spreadsheet rec'd from the payer stating this provider/service location has been affiliated with our PRIMED delegated roster - Stacey Hudak"]
["\"PK\" Pankaj J Patel, MD",1124009766,"75-2784378","TX","PE - Pankaj N. Patel, MD PA","TriCare Standard","Participating","Enrollment Complete","2003-04-01","1124009766","","2020-09-04","09/04/2020 - Rec'd access to TIN on payer site and confirmed this provider is certified; NON NETWORK and EFF as of 4-1-2003 at the proper service location - Stacey Hudak"]
["\"PK\" Pankaj J Patel, MD",1124009766,"75-2784378","TX","PE - Pankaj N. Patel, MD PA","Cigna","Participating","Enrollment Complete","2012-01-24","1124009766","","2020-04-22","04/22/2020--SW Sharon of Cigna @ 8008824462, Provider NPI# is on file and participating under the group and TIN# effective 1/24/2012. Location is on file. Call ref# Sharon4202020.\ncopied note from spreadsheet-tisha rader"]
["Eric J Venegas, MD",1760485502,"75-2930500","TX","PE - Eric J. Venegas, MD, PA","Wellmed","Participating","Enrollment Complete","2022-01-01","","","2023-03-23","3/23/2023 Rcvd roster from UHC w/ all Wellmed participating providers.  Provider is PAR effective 1/1/2022.  DCannon"]
["Eric J Venegas, MD",1760485502,"75-2930500","TX","PE - Eric J. Venegas, MD, PA","Ambetter","Participating","Enrollment Complete","2022-04-01","","","2022-06-13","6/13/2022 Per roster received from Superior provider is PAR and linked to group delegation roster effective 4/1/2022."]
["Eric J Venegas, MD",1760485502,"75-2930500","TX","PE - Eric J. Venegas, MD, PA","Superior","Participating","Enrollment Complete","2019-05-01","1760485502","","2020-07-14","07/14/2020 - Rec'd email from the payer stating this provider is EFF under PRIMED DELEGATED agreement - Stacey Hudak"]
["Srikanth R Deme, MD",1124103338,"75-2949900","TX","PE - Srikanth Deme MD PA","Aetna","In Process","Payor Follow Up","","","","2023-11-21","11/21/2023 Rcvd email from Brandy Smith at Aetna stating that October delegated roster is still in process and should be completed next week.  DCannon"]
["Lawrence A Wilson, MD",1518951342,"75-6000608","TX","PE - City of Midland Health Department","Amerigroup","Participating","Enrollment Complete","2021-08-01","12731150","","2022-05-19","5/19/2022 Per roster received from Amerigroup provider is PAR and linked to group TIN effective 8/1/2021.  PID #  12731150.  DCannon"]
["Lawrence A Wilson, MD",1518951342,"75-6000608","TX","PE - City of Midland Health Department","Rail Road Medicare","Participating","Enrollment Complete","2008-04-19","","P01863839","2021-06-24","6/24/2021 Pulled RR Medicare on group level and received approval of RR PTAN P01863839 effective 4/19/2008. KFrazier"]
["Lawrence A Wilson, MD",1518951342,"75-6000608","TX","PE - City of Midland Health Department","Galaxy Health","Participating","Enrollment Complete","2021-01-07","","","2021-06-04","6/4/2021 Per Karen Avalos at Galaxy Health monthly delegated submission is complete and provider is PAR and linked to group TIN/locations effective 1/7/2021.  DCannon"]
["Lawrence A Wilson, MD",1518951342,"75-6000608","TX","PE - City of Midland Health Department","First Health Coventry","Participating","Enrollment Complete","2021-01-07","","","2022-08-10","8/10/2022 Per First Health web portal provider is PAR and linked to group TIN/location effective 1/7/2021.  PID # 1103233.  DCannon"]
["Indira Donepudi, MD",1447406137,"81-1031742: P","TX","","Multiplan","Participating","Enrollment Complete","2018-09-11","1447406137","","2020-02-12","02/12/2020 - Rec'd confirmation through payer portal that this provider is enrolled EFF 9-11-2018 through an INDIVIDUAL AGREEMENT. Provider is networked with MPI - Stacey Hudak"]
["Indira Donepudi, MD",1447406137,"81-1031742: P","TX","","Superior","Participating","Enrollment Complete","2017-01-01","1447406137","","2020-07-14","07/14/2020 - Rec'd email from the payer stating this provider is EFF under PRIMED DELEGATED agreement - Stacey Hudak"]
["Indira Donepudi, MD",1447406137,"81-1031742: P","TX","PE - Permian Digestive Disease Center PA","Wellmed","Participating","Enrollment Complete","2022-01-01","","","2023-03-23","3/23/2023 Rcvd roster from UHC w/ all Wellmed participating providers.  Provider is PAR effective 1/1/2022.  DCannon"]
["Indira Donepudi, MD",1447406137,"81-1031742: P","TX","","Boon Chapman","Participating","Enrollment Complete","2018-09-11","1447406137","","2020-10-05","Enrollment thru PHCS"]
["Indira Donepudi, MD",1447406137,"81-1031742: P","TX","","TriCare Standard","Participating","Enrollment Complete","2014-06-01","1447406137","","2020-04-06","04/06/2020 - Rec'd access to this group through payer portal. Rec'd confirmation that this provider is credentialed under this TIN and service location. THIS GROUP IS NON NETWORKED, so credentialing is not required. Only certification. - STacey Hudak"]
["Indira Donepudi, MD",1447406137,"81-1031742: P","TX","PE - Permian Digestive Disease Center PA","First Health Coventry","Participating","Enrollment Complete","2016-07-01","1912442","","2020-03-20","3/20/2020-receieved email with roster stating provider PAR"]
["Indira Donepudi, MD",1447406137,"81-1031742: P","TX","PE - Permian Digestive Disease Center PA","Multiplan","Participating","Enrollment Complete","2018-09-11","1447406137","Individual contract","2020-07-06","07/06/2020 - Rec'd email from the payer stating \"Thank you for contacting our Service Department at MultiPlan. Here is the following information we have on file for Donepudi, Indira:\n\nNetwork:  MPI, PHCS, Savility, MPI WC, MPI Auto Network Participation effective: 09/11/2018 Contract Source Group contract through:  Individual contract\n\nIf any demographic information needs to be updated, please fax the information to our Registrar Department at (781) 487-8273 or email Registrar@MultiPlan.com.\" - Stacey Hudak"]
["Indira Donepudi, MD",1447406137,"81-1031742: S","TX","","HealthSmart PPO","Participating","Enrollment Complete","2014-09-23","1447406137","","2020-06-05","06/05/2020 - Rec'd email from the payer stating this provider is EFF -Stacey Hudak"]
["Indira Donepudi, MD",1447406137,"81-1031742: S","TX","PE - Permian Digestive Disease Center PA","TriCare Standard","Participating","Enrollment Complete","2020-08-06","1447406137","","2020-12-08","12/8/2020 - moved to completed status after reviewing f/u complete notw - Stacey Hudak"]
["Indira Donepudi, MD",1447406137,"81-1031742: S","TX","PE - Permian Digestive Disease Center PA","Humana","Participating","Enrollment Complete","2016-03-10","","","2021-11-18","11/18/2021 Rcvd full roster from Humana listing provider as PAR and linked to group TIN/location effective 3/10/2016.  DCannon"]
["Indira Donepudi, MD",1447406137,"81-1031742: S","TX","PE - Permian Digestive Disease Center PA","Medicare","Participating","Enrollment Complete","2016-01-09","363723ZS6M","472274","2020-05-04","05/04/2020 - confirmed provider is EFF thorugh PECOS for this provider - Stacey Hudak"]
["Indira Donepudi, MD",1447406137,"81-1031742: S","TX","PE - Permian Digestive Disease Center PA","Omni PPO","Participating","Enrollment Complete","2020-09-01","1447406137","","2020-09-04","09/04/2020 - IMS is effective, therefore this payer line is also effective - Stacey Hudak"]
["Indira Donepudi, MD",1447406137,"81-1031742: S","TX","PE - Permian Digestive Disease Center PA","IMS","Participating","Enrollment Complete","2019-09-01","1447406137","","2020-07-27","07/27/2020 - Rec'd roster response back from the payer regarding 7/15/2020 submission stating that all requested providers/service locations have been added to PriMed agreement - Stacey Hudak"]
["Asif AK Ansari, MD",1528299872,"81-3411343","TX","PE - Permian Basin Kidney Center Inc","HealthSmart PPO","Participating","Enrollment Complete","2019-10-02","10-2-2019","","2020-07-21","07/21/2020 - Rec'd email from the payer stating this provider is EFF with this TIN/service location under the WEST TEXAS PHYSICIANS ALLIANCE MDDO\ndelegation - Stacey Hudak"]
["Asif AK Ansari, MD",1528299872,"81-3411343","TX","PE - Permian Basin Kidney Center Inc","HealthSmart PPO","Participating","Enrollment Complete","2019-10-02","10-2-2019","","2020-07-21","07/21/2020 - Rec'd email from the payer stating this provider is EFF with this TIN/service location under the WEST TEXAS PHYSICIANS ALLIANCE MDDO\ndelegation - Stacey Hudak"]
["Asif AK Ansari, MD",1528299872,"81-3411343","TX","PE - Permian Basin Kidney Center Inc","Superior","Participating","Enrollment Complete","2020-04-13","","","2020-10-02","10/2/2020 - Rec'd response from the payer stating \"•\tProviders marked as \" Delegated Contract With SHP” have an active delegated contract with another entity by the same NPI & TIN through Superior Health Plan. Please note that these providers will not be accepted as part of your Delegated Opt-in. \" \nWe cannot add this provider to the PriMed delegation, as they are already with another delegated group- Stacey Hudak"]
["Asif AK Ansari, MD",1528299872,"81-3411343","TX","PE - Permian Basin Kidney Center Inc","Ambetter","In Process","Payor Follow Up","","","","2023-10-27","10/27/2023 Sent follow-up email to Superior to check status of provider in Ambetter.  DCannon"]
["Asif AK Ansari, MD",1528299872,"81-3411343","TX","PE - Permian Basin Kidney Center Inc","Triwest VA","Participating","Enrollment Complete","2021-05-15","","","2021-05-31","5/31/2021 Received forwarded email from Rebecca Pontaski with confirmation provider is participating with VACCN (TriWest) effective 5/15/2021. KFrazier"]
["Asif AK Ansari, MD",1528299872,"81-3411343","TX","PE - Permian Basin Kidney Center Inc","Scott&White (First Care)","Participating","Enrollment Complete","2020-04-03","","","2022-03-30","3/30/2022 Per email from S & W delegated roster provider load from December has been completed and provider is PAR effective 4/3/2020.  DCannon"]
["Asif AK Ansari, MD",1528299872,"81-3411343","TX","PE - Permian Basin Kidney Center Inc","IMS","Participating","Enrollment Complete","2019-09-01","1528299872","","2020-07-27","07/27/2020 - Rec'd information back from the payer stating this provider/service location was added off of the July 2020 roster - Stacey Hudak"]
["Asif AK Ansari, MD",1528299872,"81-3411343","TX","","Humana","Participating","Enrollment Complete","2019-06-04","","","2021-11-18","11/18/2021 Rcvd full roster from Humana listing provider as PAR and linked to group TIN/location effective 6/4/2019.  DCannon"]
["Asif AK Ansari, MD",1528299872,"81-3411343","TX","PE - Permian Basin Kidney Center Inc","Cigna","Participating","Enrollment Complete","2019-06-14","1528299872","","2020-04-22","04/22/2020--SW Sharon of Cigna @ 8008824462, Provider NPI# is on file and participating under the group and TIN# effective 6/14/2019. Location is on file. Call ref# Sharon4202020.\n-copied note from spreadsheet-tisha rader"]
["Asif AK Ansari, MD",1528299872,"81-3411343","TX","PE - Permian Basin Kidney Center Inc","Wellmed","Participating","Enrollment Complete","2023-03-24","","","2023-03-23","3/23/2023 Rcvd roster from UHC w/ all Wellmed participating providers.  Provider is PAR effective 3/24/2023.  DCannon"]
["Asif AK Ansari, MD",1528299872,"81-3411343","TX","","Aetna","Participating","Enrollment Complete","2019-10-15","1528299872","","2020-12-04","12/4/2020 - Rcvd completed PRIMED ROSTER back from the payer. This provider is PAR at this service location eff 9/1/2020.  DCannon"]
["Asif AK Ansari, MD",1528299872,"81-3411343","TX","PE - Permian Basin Kidney Center Inc","Ambetter","Participating","Enrollment Complete","2023-08-01","","","2023-08-15","8/15/2023 Rcvd confirmation email from Superior that July delegation roster has been processed and provider has been loaded to delegation roster and PAR w/ group/location effective 8/1/2023.  DCannon"]
["Asif AK Ansari, MD",1528299872,"81-3411343","TX","","Medicare","Participating","Enrollment Complete","2019-05-01","792562","791814","2020-04-29","04/29/2020 - Was able to confirm the providers enrollment through PECOS login - Stacey Hudak"]
["Asif AK Ansari, MD",1528299872,"81-3411343","TX","PE - Permian Basin Kidney Center Inc","Rail Road Medicare","Participating","Enrollment Complete","2019-05-01","P02323200","DZ2789","2020-05-04","05/04/2020 - verified through portal and moved to completed status - Stacey Hudak"]
["Anand C Reddy, MD",1780892760,"81-3411343: P","TX","PE - Permian Basin Kidney Center Inc","Wellcare","Participating","Enrollment Complete","2021-11-01","","","2022-12-01","12/1/2022 Per roster received from Wellcare provider is PAR and linked to group TIN/location effective 11/1/2021.  DCannon"]
["Anand C Reddy, MD",1780892760,"81-3411343: P","TX","","Scott&White (First Care)","Participating","Enrollment Complete","2020-09-28","","","2021-01-29","1/29/2021 - Rcvd roster from Scott&White (First Care) confirming participation of provider with TIN and location effective dates.  DCannon"]
["Anand C Reddy, MD",1780892760,"81-3411343: P","TX","PE - Permian Basin Kidney Center Inc","Multiplan","Participating","Enrollment Complete","2020-04-01","1780892760","Permian Basin Kidney Center Inc","2020-05-05","05/05/2020 - Rec'd email from the payer stating \"The MultiPlan / PHCS Network Application for Anand Reddy and Asif Ansari is complete. Network participation became effective as of 4/1/2020 with MultiPlan and PHCS. The provider’s network participation is through Permian Basin Kidney Center Inc.\"  - Stacey Hudak"]
["Anand C Reddy, MD",1780892760,"81-3411343: P","TX","PE - Permian Basin Kidney Center Inc","Amerigroup","Participating","Enrollment Complete","2020-04-15","07110928","","2021-02-13","2/13/2021 - Verification on payer website Amerigroup.healthsparq.com provider is participating and linked to TIN and location for the following plans CHIP, CHIP-PERINATAL, STAR, STAR-KIDS, STAR-PLUS.  DCannon"]
["Anand C Reddy, MD",1780892760,"81-3411343: P","TX","","Galaxy Health","Participating","Enrollment Complete","2019-09-01","1780892760","","2020-08-21","08/21/2020 - Rec'd email confirmation that this roster was processed and this provider was made effective with the requested eff date of 9-1-2019 - Stacey Hudak"]
["Anand C Reddy, MD",1780892760,"81-3411343: P","TX","PE - Permian Basin Kidney Center Inc","Wellmed","Participating","Enrollment Complete","2022-01-01","","","2023-03-23","3/23/2023 Rcvd roster from UHC w/ all Wellmed participating providers.  Provider is PAR effective 1/1/2022.  DCannon"]
["Anand C Reddy, MD",1780892760,"81-3411343: P","TX","","Cigna","Participating","Enrollment Complete","2019-12-16","1780892760","","2020-07-20","07/20/2020 - moved to completed status after reviewing the follow up complete note - Stacey Hudak"]
["Anand C Reddy, MD",1780892760,"81-3411343: S","TX","","IMS","Participating","Enrollment Complete","2019-05-01","1780892760","","2020-06-22","06/22/2020- Rec'd email from the payer confirming this provider is PAR with this group/service location - Stacey Hudak"]
["Anand C Reddy, MD",1780892760,"81-3411343: S","TX","","Scott&White (First Care)","Participating","Enrollment Complete","2020-09-28","","","2021-01-29","1/29/2021 - Rcvd roster from Scott&White (First Care) confirming participation of provider with TIN and location effective dates.  DCannon"]
["Glen Allen Bennion, DO",1386132876,"83-0358685","TX","PE - Midland Community Healthcare Services","Tricare Prime","Panel Closed","Panel Closed","","","","2023-11-05","Panel is closed to new providers until further notice. MS"]
["Glen Allen Bennion, DO",1386132876,"83-0358685","TX","PE - Midland Community Healthcare Services","Humana","In Process","Application Submitted","","","","2023-11-15","11/15/2023 Delegated roster submitted.  DCannon"]
["Glen Allen Bennion, DO",1386132876,"83-0358685","TX","PE - Midland Community Healthcare Services","Caprock (CapStar)","In Process","Application Submitted","","","","2023-11-15","11/15/2023 Delegated roster submitted.  DCannon"]
["Swetha Reddy Jangangari, MD",1750796009,"83-0358685","TX","PE - Midland Community Healthcare Services","USA PPO","Participating","Enrollment Complete","2018-02-28","1750796009","830358685","2020-08-19","Confirmed provider is participating with PPO and H&W networks (list of networks attached). Kimberly Frazier"]
["Swetha Reddy Jangangari, MD",1750796009,"83-0358685","TX","PE - Midland Community Healthcare Services","Superior","Participating","Enrollment Complete","2020-09-01","1750796009","","2020-09-02","09/02/2020 - Rec'd email from the payer confirming this location add has been made - Stacey Hudak"]
["Swetha Reddy Jangangari, MD",1750796009,"83-0358685","TX","PE - Midland Community Healthcare Services","Aetna","Participating","Enrollment Complete","2020-09-01","","",44174,"12/9/2020 - Rcvd confirmation from payor that provider is now active and linked to this location.  DCannon"]
["Swetha Reddy Jangangari, MD",1750796009,"83-0358685","TX","PE - Midland Community Healthcare Services","Wellcare","Participating","Enrollment Complete","2021-11-01","","","2022-12-01","12/1/2022 Per roster received from Wellcare provider is PAR and linked to group TIN/location effective 11/1/2021.  DCannon"]
["Swetha Reddy Jangangari, MD",1750796009,"83-0358685","TX","PE - Midland Community Healthcare Services","Wellcare","Participating","Enrollment Complete","2021-11-01","","","2022-12-01","12/1/2022 Per roster received from Wellcare provider is PAR and linked to group TIN/location effective 11/1/2021.  DCannon"]
["Swetha Reddy Jangangari, MD",1750796009,"83-0358685","TX","PE - Midland Community Healthcare Services","Medicaid","In House Enrollment","In House Enrollment","","","","2021-07-31","7/31/2021 This will be processed by group. KFrazier"]
["Swetha Reddy Jangangari, MD",1750796009,"83-0358685","TX","PE - Midland Community Healthcare Services","Cigna","Participating","Enrollment Complete","2020-08-28","3961479","","2020-09-01","09/01/2020 - moved to completed status after getting an email from the payer stating \"Your effective date is 08/28/2020. Your provider identification number is 3961479. \" - Stacey Hudak"]
["Swetha Reddy Jangangari, MD",1750796009,"83-0358685","TX","PE - Midland Community Healthcare Services","Wellmed","Participating","Enrollment Complete","2022-01-01","","","2023-03-23","3/23/2023 Rcvd roster from UHC w/ all Wellmed participating providers.  Provider is PAR effective 1/1/2022.  DCannon"]
["Swetha Reddy Jangangari, MD",1750796009,"83-0358685","TX","PE - Midland Community Healthcare Services","Amerigroup","Participating","Enrollment Complete","2020-03-20","","","2021-08-26","8/26/2021 Rcvd full roster from Joe Rodriguez at Amerigroup listing provider as PAR w/ group TIN and location effective 3/20/2020.  DCannon"]
["Swetha Reddy Jangangari, MD",1750796009,"83-0358685","TX","PE - Midland Community Healthcare Services","Cigna","Participating","Enrollment Complete","2021-06-01","3961479","","2021-08-27","8/27/2021 Received an email and roster from pdmcogz@cigna.com confirming practice location has been loaded to provider's record effective 6/1/2021 with assigned provider number 3961479. KFrazier"]
["Swetha Reddy Jangangari, MD",1750796009,"83-0358685","TX","PE - Midland Community Healthcare Services","IMS","Participating","Enrollment Complete","2021-06-01","","","2021-09-24","9/24/2021 Rcvd email from German Aviles at IMS/OMNI that delegation roster for July & August have been completed and updated in their system effective 6/1/2021.  DCannon"]
["Swetha Reddy Jangangari, MD",1750796009,"83-0358685","TX","PE - Midland Community Healthcare Services","Ambetter","Participating","Enrollment Complete","2022-04-01","","","2022-06-13","6/13/2022 Per roster received from Superior provider is PAR and linked to group delegation roster effective 4/1/2022."]
["Swetha Reddy Jangangari, MD",1750796009,"83-0358685","TX","PE - Midland Community Healthcare Services","United Health Care","Participating","Enrollment Complete","2020-09-01","","","2020-11-10","11/10/2020 - Ref # 5554765 Rcvd email from UHC demo update completed MPIN # 006790663."]
["Swetha Reddy Jangangari, MD",1750796009,"83-0358685","TX","PE - Midland Community Healthcare Services","Caprock (CapStar)","Participating","Enrollment Complete","2020-03-20","","","2021-04-09","4/9/2020 Rcvd roster from Mary Rodriguez <mary.rodriguez@90degreebenefits.com> at Caprock listing provider as participating under TIN.  DCannon"]
["Swetha Reddy Jangangari, MD",1750796009,"83-0358685","TX","PE - Midland Community Healthcare Services","Superior","Participating","Enrollment Complete","2021-08-01","","","2021-08-05","8/5/2021 Rcvd email from Superior that monthly delegation roster for May is complete and providers are loaded under TIN/locations effective 8/1/2021.  DCannon"]
["Trinidad Marquez, FNP",1447701602,"83-0358685","TX","PE - Midland Community Healthcare Services","First Health Coventry","Participating","Enrollment Complete","2017-04-01","3016142","","2020-03-20","3/20/2020-receieved email with roster stating provider PAR 4/1/2017 PID # 3016142\ntisha rader"]
["Trinidad Marquez, FNP",1447701602,"83-0358685","TX","PE - Midland Community Healthcare Services","CAQH","In House Enrollment","In House Enrollment","2020-06-11","13952422","","2020-06-11","06/11/2020 - Provider did not supply CAQH login. Provider will maintain this info in-house - Stacey Hudak"]
["Trinidad Marquez, FNP",1447701602,"83-0358685","TX","PE - Midland Community Healthcare Services","First Health Coventry","Participating","Enrollment Complete","2017-04-01","1447701602","","2020-09-24","09/24/2020 - moved to enrollment complete status - Stacey Hudak"]
["Trinidad Marquez, FNP",1447701602,"83-0358685","TX","PE - Midland Community Healthcare Services","Superior","Participating","Enrollment Complete","2017-03-01","1447701602","","2020-07-14","07/14/2020 - Rec'd email from the payer stating this provider is EFF under PRIMED DELEGATED agreement - Stacey Hudak"]
["Trinidad Marquez, FNP",1447701602,"83-0358685","TX","PE - Midland Community Healthcare Services","HealthSmart PPO","Participating","Enrollment Complete","2017-01-31","1447701602","","2020-06-04","06/24/2020 - Rec'd email from the payer stating this provider is EFF - Stacey Hudak"]
["Trinidad Marquez, FNP",1447701602,"83-0358685","TX","PE - Midland Community Healthcare Services","Amerigroup","Participating","Enrollment Complete","2020-04-07","","","2021-10-21","10/21/2021  Rcvd full roster from Joe Rodriguez at Amerigroup listing provider as PAR w/ group TIN and location effective 4/7/2020.  DCannon"]
["Trinidad Marquez, FNP",1447701602,"83-0358685","TX","PE - Midland Community Healthcare Services","First Health Coventry","Participating","Enrollment Complete","2017-04-01","3016142","","2020-03-20","3/20/2020-receieved email with roster stating provider PAR 4/1/2017 PID # 3016142\ntisha rader"]
["Trinidad Marquez, FNP",1447701602,"83-0358685","TX","PE - Midland Community Healthcare Services","Wellmed","Participating","Enrollment Complete","2022-01-01","","","2023-03-23","3/23/2023 Rcvd roster from UHC w/ all Wellmed participating providers.  Provider is PAR effective 1/1/2022.  DCannon"]
["Trinidad Marquez, FNP",1447701602,"83-0358685","TX","PE - Midland Community Healthcare Services","Ambetter","Participating","Enrollment Complete","2022-06-01","","","2022-06-20","6/20/2022 Per roster received from Superior provider is PAR and linked to group delegation roster effective 6/1/2022."]
["Trinidad Marquez, FNP",1447701602,"83-0358685","TX","PE - Midland Community Healthcare Services","Scott&White (First Care)","Participating","Enrollment Complete","2021-06-01","","","2021-10-06","10/6/2021 Rcvd confirmaton email from S & W that July delegated roster has been complete and provider is PAR w/ TIN and location effective 6/1/2021.  DCannon"]
["Trinidad Marquez, FNP",1447701602,"83-0358685","TX","PE - Midland Community Healthcare Services","HealthSmart PPO","Participating","Enrollment Complete","2017-01-31","1447701602","","2020-06-04","06/24/2020 - Rec'd email from the payer stating this provider is EFF - Stacey Hudak"]
["Chabacana Maxwell, FNP",1154767234,"83-0358685","TX","PE - Midland Community Healthcare Services","United Health Care","Participating","Enrollment Complete","2017-09-12","","","2021-08-31","Received email from networkhelp@uhc.com stating the provider is linked to the Tax ID effective 9/12/2017, both locations are loaded. Cbankston"]
["Chabacana Maxwell, FNP",1154767234,"83-0358685","TX","PE - Midland Community Healthcare Services","Ambetter","Participating","Enrollment Complete","2022-04-01","","","2022-06-13","6/13/2022 Per roster received from Superior provider is PAR and linked to group delegation roster effective 4/1/2022."]
["Chabacana Maxwell, FNP",1154767234,"83-0358685","TX","PE - Midland Community Healthcare Services","IMS","Participating","Enrollment Complete","2021-06-01","","","2021-09-24","9/24/2021 Rcvd email from German Aviles at IMS/OMNI that delegation roster for July & August have been completed and updated in their system effective 6/1/2021.  DCannon"]
["Tonya Murphy, FNP",1891931341,"83-0358685","TX","PE - Midland Community Healthcare Services","HealthSmart PPO","Participating","Enrollment Complete","2019-02-20","","","2021-01-27","1/27/2021 - Rcvd email from payer showing provider as participating at location and linked to TIN effective 2/20/2019.  DCannon"]
["Tonya Murphy, FNP",1891931341,"83-0358685","TX","PE - Midland Community Healthcare Services","Humana","Participating","Enrollment Complete","2019-02-20","","","2021-11-18","11/18/2021 Rcvd full roster from Humana listing provider as PAR and linked to group TIN/location effective 2/20/2019.  DCannon"]
["Tonya Murphy, FNP",1891931341,"83-0358685","TX","PE - Midland Community Healthcare Services","TriCare Standard","Participating","Enrollment Complete","2021-12-09","","","2022-03-09","3/9/2022 Per Tricare portal, provider is certified and linked to location as of 12/9/2021. Cbankston"]
["Tonya Murphy, FNP",1891931341,"83-0358685","TX","PE - Midland Community Healthcare Services","TriCare Standard","Participating","Enrollment Complete","2020-08-25","1891931341","","2020-09-09","09/09/2020 - moved to completed status after reviewing the last note - Stacey Hudak"]
["Tonya Murphy, FNP",1891931341,"83-0358685","TX","PE - Midland Community Healthcare Services","Omni PPO","Participating","Enrollment Complete","2020-08-01","","","2022-04-13","4/13/2022 Per roster from IMS/Omni provider is PAR and linked to group TIN/location effective 8/1/2020.  DCannon"]
["Tonya Murphy, FNP",1891931341,"83-0358685","TX","PE - Midland Community Healthcare Services","Ambetter","Participating","Enrollment Complete","2022-04-01","","","2022-06-13","6/13/2022 Per roster received from Superior provider is PAR and linked to group delegation roster effective 4/1/2022."]
["Tonya Murphy, FNP",1891931341,"83-0358685","TX","PE - Midland Community Healthcare Services","HealthSmart PPO","Participating","Enrollment Complete","2021-06-01","","","2021-08-05","8/5/2021 Per Healthsmart website provider is PAR and loaded under TIN/location effective 6/12021.  DCannon"]
["Tonya Murphy, FNP",1891931341,"83-0358685","TX","PE - Midland Community Healthcare Services","Scott&White (First Care)","Participating","Enrollment Complete","2021-06-01","","","2021-10-06","10/6/2021 Rcvd confirmaton email from S & W that July delegated roster has been complete and provider is PAR w/ TIN and location effective 6/1/2021.  DCannon"]
["Tonya Murphy, FNP",1891931341,"83-0358685","TX","PE - Midland Community Healthcare Services","TriCare Standard","Participating","Enrollment Complete","2020-08-25","1891931341","","2020-09-09","09/09/2020 - moved to completed status after reviewing the last note - Stacey Hudak"]
["Tonya Murphy, FNP",1891931341,"83-0358685","TX","PE - Midland Community Healthcare Services","CAQH","In House Enrollment","In House Enrollment","2020-06-11","11927807","","2020-06-11","06/11/2020 - Provider did not supply CAQH login. Provider will maintain this info in-house - Stacey Hudak"]
["Tonya Murphy, FNP",1891931341,"83-0358685","TX","PE - Midland Community Healthcare Services","Wellmed","Participating","Enrollment Complete","2022-01-01","","","2023-03-23","3/23/2023 Rcvd roster from UHC w/ all Wellmed participating providers.  Provider is PAR effective 1/1/2022.  DCannon"]
["Tonya Murphy, FNP",1891931341,"83-0358685","TX","PE - Midland Community Healthcare Services","United Health Care","Participating","Enrollment Complete","2019-12-01","2990326","","2020-11-30","11/30/2020 - Rcvd confirmation email from payer stating that provider has been linked and added to tax ID and location effective 12/1/2019.  DCannon"]
["Tonya Murphy, FNP",1891931341,"83-0358685","TX","PE - Midland Community Healthcare Services","Wellcare","Participating","Enrollment Complete","2021-11-01","","","2022-12-01","12/1/2022 Per roster received from Wellcare provider is PAR and linked to group TIN/location effective 11/1/2021.  DCannon"]
["Tonya Murphy, FNP",1891931341,"83-0358685","TX","PE - Midland Community Healthcare Services","Wellcare","Participating","Enrollment Complete","2021-11-01","","","2022-12-01","12/1/2022 Per roster received from Wellcare provider is PAR and linked to group TIN/location effective 11/1/2021.  DCannon"]
["Tonya Murphy, FNP",1891931341,"83-0358685","TX","PE - Midland Community Healthcare Services","First Health Coventry","Participating","Enrollment Complete","2020-09-01","1891931341","","2020-09-23","09/30/2020 - moved to completed status after reviewing follow up complete - Stacey Hudak"]
["Michael Okoye, DO",1205299922,"83-0358685","TX","PE - Midland Community Healthcare Services","Medicare","In House Enrollment","In House Enrollment","","","","2021-08-03","8/3/2021 Medicare enrollment is done in-house by MCHS.  DCannon"]
["Michael Okoye, DO",1205299922,"83-0358685","TX","PE - Midland Community Healthcare Services","CAQH","In House Enrollment","In House Enrollment","2020-06-11","14529394","","2020-06-11","06/11/2020 - Provider did not supply CAQH login. Provider will maintain this info in-house - Stacey Hudak"]
["Michael Okoye, DO",1205299922,"83-0358685","TX","PE - Midland Community Healthcare Services","HealthSmart PPO","Participating","Enrollment Complete","2019-10-21","","","2021-01-27","1/27/2021 - Rcvd email from payer showing provider as participating at location and linked to TIN effective 10/21/2019.  DCannon"]
["Michael Okoye, DO",1205299922,"83-0358685","TX","PE - Midland Community Healthcare Services","Scott&White (First Care)","Participating","Enrollment Complete","2021-06-01","","","2021-10-06","10/6/2021 Rcvd confirmaton email from S & W that July delegated roster has been complete and provider is PAR w/ TIN and location effective 6/1/2021.  DCannon"]
["Michael Okoye, DO",1205299922,"83-0358685","TX","PE - Midland Community Healthcare Services","Molina","Participating","Enrollment Complete","2020-01-15","","","2022-10-20","10/20/2022 Rcvd email from Priscilla Albertine at MQA with roster from Marcie Eckhart-Havens at Multiplan with confirmation that provider is PAR w/ Molina under group TIN/location effective 1/15/2020.  DCannon"]
["Michael Okoye, DO",1205299922,"83-0358685","TX","PE - Midland Community Healthcare Services","TriCare Standard","Participating","Enrollment Complete","2021-12-09","","","2022-02-10","2/10/2022 Per Tricare portal, provider is linked to location as of 12.9.2021. Cbankston"]
["Michael Okoye, DO",1205299922,"83-0358685","TX","PE - Midland Community Healthcare Services","Medicaid","Participating","In House Enrollment","2019-09-09","405063501","165581301","2020-10-02","10/2/2020 - Rec'd an email from the clinic with the medicaid approval letter. This enrollment is maintained in house. Symplr is storing this information in Cactus for use with other enrollments/payers - Stacey Hudak"]
["Michael Okoye, DO",1205299922,"83-0358685","TX","PE - Midland Community Healthcare Services","Medicare","Participating","In House Enrollment","2019-09-09","868716","00304W","2020-02-07","02/07/2020 - The payer list has indicated \"We credential our own Medicare\" - Stacey Hudak"]
["Michael Okoye, DO",1205299922,"83-0358685","TX","PE - Midland Community Healthcare Services","Wellmed","Participating","Enrollment Complete","2022-01-01","","","2023-03-23","3/23/2023 Rcvd roster from UHC w/ all Wellmed participating providers.  Provider is PAR effective 1/1/2022.  DCannon"]
["Michael Okoye, DO",1205299922,"83-0358685","TX","","Triwest VA","DO NOT ENROLL","DO NOT ENROLL","","","","","Provider did not select inclusion with this payor."]
["Michael Okoye, DO",1205299922,"83-0358685","TX","PE - Midland Community Healthcare Services","Ambetter","Participating","Enrollment Complete","2022-04-01","","","2022-06-13","6/13/2022 Per roster received from Superior provider is PAR and linked to group delegation roster effective 4/1/2022."]
["Michael Okoye, DO",1205299922,"83-0358685","TX","PE - Midland Community Healthcare Services","Ambetter","Participating","Enrollment Complete","2022-06-01","","","2022-06-20","6/20/2022 Per roster received from Superior provider is PAR and linked to group delegation roster effective 6/1/2022."]
["Michael Okoye, DO",1205299922,"83-0358685","TX","PE - Midland Community Healthcare Services","TriCare Standard","Participating","Enrollment Complete","2020-01-01","","","2020-12-04","12/4/2020 Confirmed provider is certified as non-network provider under group. KFrazier"]
["Michael Okoye, DO",1205299922,"83-0358685","TX","PE - Midland Community Healthcare Services","Galaxy Health","Participating","Enrollment Complete","2020-03-20","","","2022-04-09","4/9/2022 Per roster received from Galaxy provider is listed as PAR and linked to group TIN/location effective 3/20/2020.  DCannon"]
["Jose Saucedo, FNP",1184265050,"83-0358685","TX","PE - Midland Community Healthcare Services","Aetna","Participating","Enrollment Complete","2020-08-01","6838699","","2020-07-20","07/20/2020 - Rec'd email from the payer stating \"Welcome to the provider network effective 8/1/2020. Your Provider Identification Number (PIN) is: 6838699\" - Stacey Hudak"]
["Jose Saucedo, FNP",1184265050,"83-0358685","TX","PE - Midland Community Healthcare Services","Galaxy Health","Participating","Enrollment Complete","2021-06-01","","","2021-08-05","8/5/2021 Per Karen Avalos at Galaxy Health monthly delegated submission is complete and provider is PAR and linked to group TIN/locations effective  6/1/2021.  DCannon"]
["Jose Saucedo, FNP",1184265050,"83-0358685","TX","PE - Midland Community Healthcare Services","Multiplan","Participating","Enrollment Complete","2019-11-14","1184265050","9904220","2020-02-12","02/12/2020 - This group, Midland Community Healthcare Services has a direct group contract (contract #9904220) and this provider is linked EFF 11-14-2019. This provider is par under network MPI - Stacey Hudak"]
["Jose Saucedo, FNP",1184265050,"83-0358685","TX","PE - Midland Community Healthcare Services","First Health Coventry","Participating","Enrollment Complete","2020-09-01","1184265050","","2020-09-24","09/24/2020 - moved to completed status after reviewing follow up complete note - Stacey Hudak"]
["Jose Saucedo, FNP",1184265050,"83-0358685","TX","PE - Midland Community Healthcare Services","Ambetter","Participating","Enrollment Complete","2022-04-01","","","2022-06-13","6/13/2022 Per roster received from Superior provider is PAR and linked to group delegation roster effective 4/1/2022."]
["Jose Saucedo, FNP",1184265050,"83-0358685","TX","PE - Midland Community Healthcare Services","Ambetter","Participating","Enrollment Complete","2022-04-01","","","2022-06-13","6/13/2022 Per roster received from Superior provider is PAR and linked to group delegation roster effective 4/1/2022."]
["Jose Saucedo, FNP",1184265050,"83-0358685","TX","PE - Midland Community Healthcare Services","Boon Chapman","Participating","Enrollment Complete","2020-03-20","","","2022-07-24","7/24/2022 Per email from Marcie Eckhart-Havens Multiplan July delegated roster has been completed  and provider is PAR and linked to group TIN effective 3/20/2020.   DCannon"]
["Jose Saucedo, FNP",1184265050,"83-0358685","TX","PE - Midland Community Healthcare Services","First Health Coventry","Participating","Enrollment Complete","2020-09-01","1184265050","","2020-09-24","09/24/2020 - moved to completed status after reviewing follow up complete note - Stacey Hudak"]
["Jose Saucedo, FNP",1184265050,"83-0358685","TX","PE - Midland Community Healthcare Services","TriCare Standard","Participating","Enrollment Complete","2019-09-13","","","2020-11-07","11/6/2020 Received email confirmation from COVID19.Certification.Requests@wpsic.com provider is certified as a non-network provider under Group Tax ID effective 9/13/2019. Kimberly Frazier"]
["Jose Saucedo, FNP",1184265050,"83-0358685","TX","PE - Midland Community Healthcare Services","Wellcare","Participating","Enrollment Complete","2021-11-01","","","2022-12-01","12/1/2022 Per roster received from Wellcare provider is PAR and linked to group TIN/location effective 11/1/2021.  DCannon"]
["Jose Saucedo, FNP",1184265050,"83-0358685","TX","PE - Midland Community Healthcare Services","Ambetter","Participating","Enrollment Complete","2022-06-01","","","2022-06-20","6/20/2022 Per roster received from Superior provider is PAR and linked to group delegation roster effective 6/1/2022."]
["Jose Saucedo, FNP",1184265050,"83-0358685","TX","PE - Midland Community Healthcare Services","Scott&White (First Care)","Participating","Enrollment Complete","2021-06-01","","",44475,"10/6/2021 Rcvd confirmaton email from S & W that July delegated roster has been complete and provider is PAR w/ TIN and location effective 6/1/2021.  DCannon"]
["Jose Saucedo, FNP",1184265050,"83-0358685","TX","PE - Midland Community Healthcare Services","Amerigroup","Participating","Enrollment Complete","2020-01-15","1184265050","","2020-03-20","03/20/2020 - Rec'd email from the payer (Multiplan/Texas True Choice)  stating this provider is EFF at this service location with Amerigroup - Stacey Hudak"]
["Jose Saucedo, FNP",1184265050,"83-0358685","TX","PE - Midland Community Healthcare Services","Wellmed","Participating","Enrollment Complete","2022-01-01","","","2023-03-23","3/23/2023 Rcvd roster from UHC w/ all Wellmed participating providers.  Provider is PAR effective 1/1/2022.  DCannon"]
["Jose Saucedo, FNP",1184265050,"83-0358685","TX","PE - Midland Community Healthcare Services","Wellmed","Participating","Enrollment Complete","2022-01-01","","","2023-03-23","3/23/2023 Rcvd roster from UHC w/ all Wellmed participating providers.  Provider is PAR effective 1/1/2022.  DCannon"]
["Lisa A. Hernandez, NP",1942766092,"83-0358685","TX","PE - Midland Community Healthcare Services","Humana","Participating","Enrollment Complete","2021-09-01","","","2021-11-18","11/18/2021 Rcvd full roster from Humana listing provider as PAR and linked to group TIN/location effective 9/1/2021.  DCannon"]
["Lisa A. Hernandez, NP",1942766092,"83-0358685","TX","PE - Midland Community Healthcare Services","Scott&White (First Care)","Participating","Enrollment Complete","2021-06-01","","","2021-10-06","10/6/2021 Rcvd confirmaton email from S & W that provider is PAR w/ TIN and location effective 5/20/2021.  DCannon"]
["Lisa A. Hernandez, NP",1942766092,"83-0358685","TX","PE - Midland Community Healthcare Services","HealthSmart PPO","Participating","Enrollment Complete","2021-06-01","","","2021-12-03","12/3/2021 Per Healthsmart website provider is PAR and loaded under TIN/location effective 6/1/2021.  DCannon"]
["Lisa A. Hernandez, NP",1942766092,"83-0358685","TX","PE - Midland Community Healthcare Services","Caprock (CapStar)","Participating","Enrollment Complete","2021-05-20","","","2021-08-05","8/5/2021 Rcvd email from Caprock Provider Services provider_services_shared.t8@90degreebenefits.com  that providers from April, May and June delegated rosters have been loaded into their systems under requested TINS effective 5/20/2021.  DCannon"]
["Lisa A. Hernandez, NP",1942766092,"83-0358685","TX","PE - Midland Community Healthcare Services","Medicare","In House Enrollment","In House Enrollment","","1L7420","","2021-04-15","4/15/2021 Practice completes own provider enrollments. KFrazier"]
["Lisa A. Hernandez, NP",1942766092,"83-0358685","TX","PE - Midland Community Healthcare Services","Omni PPO","Participating","Enrollment Complete","2021-06-01","","","2021-09-24","9/24/2021 Rcvd email from German Aviles at IMS/OMNI that delegation roster for July & August have been completed and updated in their system effective 6/1/2021.  DCannon"]
["Lisa A. Hernandez, NP",1942766092,"83-0358685","TX","PE - Midland Community Healthcare Services","Cigna","Participating","Enrollment Complete","2021-05-28","5155848","","2021-07-01","7/1/2021- S/W Ana of Cigna @  8008824462, NPI# is on file for the provider,shows link and Par  under the group and TIN# effective 5/28/2021 the physical location is on file.  Provider ID is 5155848, No call ref#- Herminia Gilongos"]
["Lisa A. Hernandez, NP",1942766092,"83-0358685","TX","PE - Midland Community Healthcare Services","Multiplan","Participating","Enrollment Complete","2021-04-20","","","2021-07-02","7/1/2021 Received roster from Multiplan confirming participation of providers with TIN /locations effective 4/20/2021.  DCannon"]
["Lisa A. Hernandez, NP",1942766092,"83-0358685","TX","PE - Midland Community Healthcare Services","Ambetter","Participating","Enrollment Complete","2022-04-01","","","2022-06-13","6/13/2022 Per roster received from Superior provider is PAR and linked to group delegation roster effective 4/1/2022."]
["Lisa A. Hernandez, NP",1942766092,"83-0358685","TX","PE - Midland Community Healthcare Services","Scott&White (First Care)","Participating","Enrollment Complete","2021-05-20","","","2021-08-18","8/18/2021 Rcvd complete roster from S & W list provider has PAR and loaded under TIN/location effective 5/20/2021.  DCannon"]
["Lisa A. Hernandez, NP",1942766092,"83-0358685","TX","PE - Midland Community Healthcare Services","Multiplan","Participating","Enrollment Complete","2021-05-20","","","2022-07-24","7/24/2022 Per email from Marcie Eckhart-Havens Multiplan July delegated roster has been completed  and provider is PAR and linked to group TIN effective 5/20/2021.  DCannon"]
["Innocentia Ifunanya Onyemetu, NP",1790457075,"83-0358685","TX","PE - Midland Community Healthcare Services","USA PPO","Participating","Enrollment Complete","2022-05-09","","","2022-08-10","8/10/2022 In following up with USAMCO (800-872-3860) I was told that you can confirm participating via the USA MCO website  https://providersearch.usamco.com/hwprovsearch.  Provider is PAR and linked to location/TIN effective 5/9/2022.  DCannon"]
["Innocentia Ifunanya Onyemetu, NP",1790457075,"83-0358685","TX","PE - Midland Community Healthcare Services","USA PPO","Participating","Enrollment Complete","2022-05-09","","","2022-08-10","8/10/2022 In following up with USAMCO (800-872-3860) I was told that you can confirm participating via the USA MCO website  https://providersearch.usamco.com/hwprovsearch.  Provider is PAR and linked to location/TIN effective 5/9/2022.  DCannon"]
["Innocentia Ifunanya Onyemetu, NP",1790457075,"83-0358685","TX","PE - Midland Community Healthcare Services","First Health Coventry","Participating","Enrollment Complete","2022-05-09","3558012","","2022-08-10","8/10/2022 Per First Health web portal provider is PAR and linked to group TIN/location effective 5/9/2022.  PID# 3558012  DCannon"]
["Innocentia Ifunanya Onyemetu, NP",1790457075,"83-0358685","TX","PE - Midland Community Healthcare Services","United Health Care","Participating","Enrollment Complete","2022-05-09","007929415","","2022-06-29","6/29/2022 Per email received from  from UHC monthly delegated roster submission has been completed and provider is PAR and in linked to group TIN effective 5/9/2022.   MPIN# 007929415.   DCannon"]
["Innocentia Ifunanya Onyemetu, NP",1790457075,"83-0358685","TX","PE - Midland Community Healthcare Services","Humana","Participating","Enrollment Complete","2022-05-09","","","2022-08-20","8/20/2022 Per email received from Vernita Young July monthly delegated roster is complete and provider is PAR and linked to group TIN/location effective 5/9/2022.  DCannon"]
["Innocentia Ifunanya Onyemetu, NP",1790457075,"83-0358685","TX","PE - Midland Community Healthcare Services","Wellcare","Participating","Enrollment Complete","2022-06-01","","","2022-07-01","7/1/2022 Received June Monthly Validation roster from Superior and provider is PAR and linked effective 6/1/2022.  DCannon"]
["Innocentia Ifunanya Onyemetu, NP",1790457075,"83-0358685","TX","PE - Midland Community Healthcare Services","Tricare Prime","Panel Closed","Panel Closed","","","","2022-10-28","10/28/2022 Per Tricare/Humana Military is currently not accepting requests to join the medical surgical network. Will check back soon to see if we are accepting network providers.  DCannon"]
["Innocentia Ifunanya Onyemetu, NP",1790457075,"83-0358685","TX","PE - Midland Community Healthcare Services","Tricare Prime","Panel Closed","Panel Closed","","","","2022-10-28","10/28/2022 Per Tricare/Humana Military is currently not accepting requests to join the medical surgical network. Will check back soon to see if we are accepting network providers.  DCannon"]
["Innocentia Ifunanya Onyemetu, NP",1790457075,"83-0358685","TX","PE - Midland Community Healthcare Services","Boon Chapman","Participating","Enrollment Complete","2022-05-09","","","2022-07-24","7/24/2022 Per email from Marcie Eckhart-Havens Multiplan July delegated roster has been completed  and provider is PAR and linked to group TIN effective 5/9/2022.  DCannon"]
["Innocentia Ifunanya Onyemetu, NP",1790457075,"83-0358685","TX","PE - Midland Community Healthcare Services","Wellmed","Participating","Enrollment Complete","2022-07-24","","","2023-03-23","3/23/2023 Rcvd roster from UHC w/ all Wellmed participating providers.  Provider is PAR effective 7/24/2022.  DCannon"]
["Innocentia Ifunanya Onyemetu, NP",1790457075,"83-0358685","TX","PE - Midland Community Healthcare Services","Triwest VA","In House Enrollment","In House Enrollment","","","","2022-04-26",""]
["Innocentia Ifunanya Onyemetu, NP",1790457075,"83-0358685","TX","PE - Midland Community Healthcare Services","Scott&White (First Care)","Participating","Enrollment Complete","2022-05-09","","","2022-08-11","8/11/2022 Rcvd email from Scott & White that monthly delegated roster for June has been completed and providers are loaded to group delegation roster effective 5/9/2022.  DCannon"]
["Innocentia Ifunanya Onyemetu, NP",1790457075,"83-0358685","TX","PE - Midland Community Healthcare Services","Amerigroup","Participating","Enrollment Complete","2022-05-09","","","2022-09-23","9/23/2022 Per roster received from Joe Rodriguez at Amerigroup provider is PAR and linked to group TIN effective 5/9/2022.  DCannon"]
["Innocentia Ifunanya Onyemetu, NP",1790457075,"83-0358685","TX","PE - Midland Community Healthcare Services","Amerigroup","Participating","Enrollment Complete","2022-05-09","","","2022-09-23","9/23/2022 Per roster received from Joe Rodriguez at Amerigroup provider is PAR and linked to group TIN effective 5/9/2022.  DCannon"]
["Innocentia Ifunanya Onyemetu, NP",1790457075,"83-0358685","TX","PE - Midland Community Healthcare Services","Galaxy Health","Participating","Enrollment Complete","2022-05-09","","","2022-08-17","8/17/2022 Per email from Karen Avalos at Galaxy delegated roster for May is complete and provider is loaded effective 5/9/2022.  DCannon"]
["Innocentia Ifunanya Onyemetu, NP",1790457075,"83-0358685","TX","PE - Midland Community Healthcare Services","Multiplan","Participating","Enrollment Complete","2022-05-09","","","2022-07-24","7/24/2022 Per email from Marcie Eckhart-Havens Multiplan July delegated roster has been completed  and provider is PAR and linked to group TIN effective 5/9/2022.  DCannon"]
["Innocentia Ifunanya Onyemetu, NP",1790457075,"83-0358685","TX","PE - Midland Community Healthcare Services","TriCare Standard","Participating","Enrollment Complete","2022-06-29","","","2022-07-14","7/14/2022 Per Humana Military provider portal provider is PAR and linked to group TIN/location effective 6/29/2022.  DCannon"]
["Innocentia Ifunanya Onyemetu, NP",1790457075,"83-0358685","TX","PE - Midland Community Healthcare Services","Omni PPO","Participating","Enrollment Complete","2022-05-09","","","2022-07-05","7/5/2022 Rcvd email from G.Aviles at IMS/OMNI that delegation roster provider load for June has been completed.  Provider is PAR and linked to group effective 5/9/2022.  DCannon"]
["Innocentia Ifunanya Onyemetu, NP",1790457075,"83-0358685","TX","PE - Midland Community Healthcare Services","Superior","Participating","Enrollment Complete","2022-06-01","","","2022-06-01","6/1/2022 Per roster received from Superior May monthly delegated submission is complete and provider is PAR and linked to group TIN/locations effective  6/1/2022.  DCannon"]
["Innocentia Ifunanya Onyemetu, NP",1790457075,"83-0358685","TX","PE - Midland Community Healthcare Services","Superior","Participating","Enrollment Complete","2022-06-01","","","2022-06-01","6/1/2022 Per roster received from Superior May monthly delegated submission is complete and provider is PAR and linked to group TIN/locations effective  6/1/2022.  DCannon"]
["Innocentia Ifunanya Onyemetu, NP",1790457075,"83-0358685","TX","PE - Midland Community Healthcare Services","IMS","Participating","Enrollment Complete","2022-05-09","","","2022-07-05","7/5/2022 Rcvd email from G.Aviles at IMS/OMNI that delegation roster provider load for June has been completed.  Provider is PAR and linked to group effective 5/9/2022.  DCannon"]
["Innocentia Ifunanya Onyemetu, NP",1790457075,"83-0358685","TX","PE - Midland Community Healthcare Services","Ambetter","Participating","Enrollment Complete","2022-06-01","","","2022-06-20","6/20/2022 Per roster received from Superior provider is PAR and linked to group delegation roster effective 6/1/2022."]
["Innocentia Ifunanya Onyemetu, NP",1790457075,"83-0358685","TX","PE - Midland Community Healthcare Services","Aetna","Participating","Enrollment Complete","2022-05-09","6689991","","2022-06-21","6/21/2022 Per follow-up note - S/w Joan of Aetna @ 800-353-1232. Provider NPI# is on file for the provider and is participating effective 05/09/2022  under the group and TIN#. PIN: 6689991. Physical location is on file. Call ref# 6094998732. - DCannon"]
["Innocentia Ifunanya Onyemetu, NP",1790457075,"83-0358685","TX","PE - Midland Community Healthcare Services","HealthSmart PPO","Participating","Enrollment Complete","2022-05-09","","","2022-07-14","7/14/2022 Per Healthsmart website provider is PAR and loaded under TIN/location effective 5/9/2022.  DCannon"]
["Innocentia Ifunanya Onyemetu, NP",1790457075,"83-0358685","TX","PE - Midland Community Healthcare Services","Caprock (CapStar)","Participating","Enrollment Complete","2022-05-09","","","2022-08-30","8/30/2022 Received a roster from Priscilla Albertine at MQA that she received from Michelle Rodriguez.  Provider is PAR and linked to group TIN/locations effective 5/9/2022.  DCannon"]
["Innocentia Ifunanya Onyemetu, NP",1790457075,"83-0358685","TX","PE - Midland Community Healthcare Services","Cigna","Participating","Enrollment Complete","2022-04-05","6841061","","2022-06-21","6/21/2022 Per follow-up note - NPI# for the provider is on file shows link and Par under the group and TIN# effective 4/5/2022, the physical location is on file and the Provider ID is 6841061.  Call ref # Angel6142022. - DCannon"]
["Innocentia Ifunanya Onyemetu, NP",1790457075,"83-0358685","TX","PE - Midland Community Healthcare Services","Cigna","Participating","Enrollment Complete","2022-04-05","6841061","","2022-06-21","6/21/2022 Per follow-up note - NPI# for the provider is on file shows link and Par under the group and TIN# effective 4/5/2022, the physical location is on file and the Provider ID is 6841061.  Call ref # Angel6142022. - DCannon"]
["Mark Stevens Clee, MD",1972946648,"83-0358685","TX","PE - Midland Community Healthcare Services","Amerigroup","Participating","Enrollment Complete","2022-08-29","","","2022-11-04","11.04.2022 Per follow-up note - S/W Chealse of Amerigroup @ 800-454-3730. Per rep, provider is showing participating with an  Effective date 08/29/2022 and link under the Group and TIN. Provider ID 14501240, Payer ID 26375 and No Recredentialing date. Service location is on file. Call ref#:I-166745338.  DCannon"]
["Mark Stevens Clee, MD",1972946648,"83-0358685","TX","PE - Midland Community Healthcare Services","Medicaid","Participating","Enrollment Complete","2022-08-31","1972946648","","2022-09-14","9/14/2022 Per email from Denisse Villa at MCHS provider is PAR in TX Medicaid effective 8/31/2022.  TPI # 1972946648.  DCannon"]
["Mark Stevens Clee, MD",1972946648,"83-0358685","TX","PE - Midland Community Healthcare Services","Triwest VA","DO NOT ENROLL","DO NOT ENROLL","","","","2022-11-18","Provider Type Not Applicable"]
["Mark Stevens Clee, MD",1972946648,"83-0358685","TX","PE - Midland Community Healthcare Services","First Health Coventry","Participating","Enrollment Complete","2022-11-01","","","2023-02-15","02.15.2023 S/W Shannon of First Health @800-226-5116. Per rep, provider is in network and linked under the TIN effective 11/01/2022. Don't have next recredentialing date. Provider ID# 1972946648. Physical location is on file. Don't have payer#. Unable to obtain call ref# since rep transferred me to a different department. - Mary Rose Acebedo"]
["Mark Stevens Clee, MD",1972946648,"83-0358685","TX","PE - Midland Community Healthcare Services","Aetna","Participating","Enrollment Complete","2022-08-29","8664296","","2022-10-18","10/18/2022 Per email from Priscilla Albertine at MQA provider is PAR and linked to group TIN effective 8/29/2022.  PID # 8664296.  DCannon"]
["Mark Stevens Clee, MD",1972946648,"83-0358685","TX","PE - Midland Community Healthcare Services","Multiplan","Participating","Enrollment Complete","2022-08-29","","","2023-03-10","3/10/2023 Per email from Priscilla Albertine at MQA, she received confirmation from Multiplan that provider is PAR and linked to group TIN/locations effective 8/29/2022.  DCannon"]
["Mark Stevens Clee, MD",1972946648,"83-0358685","TX","PE - Midland Community Healthcare Services","Multiplan","Participating","Enrollment Complete","2022-08-29","","","2023-03-10","3/10/2023 Per email from Priscilla Albertine at MQA, she received confirmation from Multiplan that provider is PAR and linked to group TIN/locations effective 8/29/2022.  DCannon"]
["Mark Stevens Clee, MD",1972946648,"83-0358685","TX","PE - Midland Community Healthcare Services","Omni PPO","Participating","Enrollment Complete","2022-08-29","","","2022-10-17","10/17/2022 Per email received from German Aviles at IMS/OMNI monthly delegation roster provider load for September has been completed.  Provider is PAR and linked to group TIN effective 8/29/2022.   DCannon"]
["Mark Stevens Clee, MD",1972946648,"83-0358685","TX","PE - Midland Community Healthcare Services","Omni PPO","Participating","Enrollment Complete","2022-08-29","","","2022-10-17","10/17/2022 Per email received from German Aviles at IMS/OMNI monthly delegation roster provider load for September has been completed.  Provider is PAR and linked to group TIN effective 8/29/2022.   DCannon"]
["Mark Stevens Clee, MD",1972946648,"83-0358685","TX","PE - Midland Community Healthcare Services","IMS","Participating","Enrollment Complete","2022-08-29","","","2022-10-17","10/17/2022 Per email received from German Aviles at IMS/OMNI monthly delegation roster provider load for September has been completed.  Provider is PAR and linked to group TIN effective 8/29/2022.   DCannon"]
["Mark Stevens Clee, MD",1972946648,"83-0358685","TX","PE - Midland Community Healthcare Services","Superior","Participating","Enrollment Complete","2022-10-01","","","2022-12-19","12/19/2022 Rcvd email from Priscilla Albertine at MQA w/ confirmation from Superior that provider is PAR and linked to group effective 10/01/2022.  DCannon"]
["Mark Stevens Clee, MD",1972946648,"83-0358685","TX","PE - Midland Community Healthcare Services","Superior","Participating","Enrollment Complete","2022-10-01","","","2022-12-19","12/19/2022 Rcvd email from Priscilla Albertine at MQA w/ confirmation from Superior that provider is PAR and linked to group effective 10/01/2022.  DCannon"]
["Mark Stevens Clee, MD",1972946648,"83-0358685","TX","PE - Midland Community Healthcare Services","Wellcare","Participating","Enrollment Complete","2022-10-01","","","2022-12-29","12/29/2022 Rcvd email from Priscilla Albertine at MQA w/ confirmation from Superior that provider is PAR and linked to group effective 10/01/2022.  DCannon"]
["Mark Stevens Clee, MD",1972946648,"83-0358685","TX","PE - Midland Community Healthcare Services","Wellmed","Participating","Enrollment Complete","2022-08-29","","","2023-03-23","3/23/2023 Rcvd roster from UHC w/ all Wellmed participating providers.  Provider is PAR effective 8/29/2022.  DCannon"]
["Mark Stevens Clee, MD",1972946648,"83-0358685","TX","PE - Midland Community Healthcare Services","Wellmed","Participating","Enrollment Complete","2022-08-29","","","2023-03-23","3/23/2023 Rcvd roster from UHC w/ all Wellmed participating providers.  Provider is PAR effective 8/29/2022.  DCannon"]
["Mark Stevens Clee, MD",1972946648,"83-0358685","TX","PE - Midland Community Healthcare Services","Galaxy Health","Participating","Enrollment Complete","2022-08-29","","","2022-09-27","9/27/2022 Rcvd email from Karen Avalos at Galaxy that delegated roster submission for September has been completed.  Provider is PAR and linked to group TIN effective 8/29/2022.  DCannon"]
["Mark Stevens Clee, MD",1972946648,"83-0358685","TX","PE - Midland Community Healthcare Services","HealthSmart PPO","Participating","Enrollment Complete","2022-08-29","","","2022-11-01","11/1/2022 Per Healthsmart website provider is PAR and loaded under TIN/location effective 8/29/2022.  DCannon"]
["Mark Stevens Clee, MD",1972946648,"83-0358685","TX","PE - Midland Community Healthcare Services","Scott&White (First Care)","Participating","Enrollment Complete","2022-10-15","","","2022-10-10","10/10/2022 Per roster received from Scott & White provider is PAR and linked to TIN effective 10/15/2022.  DCannon"]
["Mark Stevens Clee, MD",1972946648,"83-0358685","TX","PE - Midland Community Healthcare Services","Cigna","Participating","Enrollment Complete","2022-07-18","9246114","","2022-10-26","10/26/2022 Rcvd email from CIGNA that provider is PAR and linked to group TIN/locations effective 7/18/2022.  PID # 9246114.  DCannon"]
["Mark Stevens Clee, MD",1972946648,"83-0358685","TX","PE - Midland Community Healthcare Services","Cigna","Participating","Enrollment Complete","2022-07-18","9246114","","2022-10-26","10/26/2022 Rcvd email from CIGNA that provider is PAR and linked to group TIN/locations effective 7/18/2022.  PID # 9246114.  DCannon"]
["Mark Stevens Clee, MD",1972946648,"83-0358685","TX","PE - Midland Community Healthcare Services","TriCare Standard","Participating","Enrollment Complete","2022-09-08","","","2022-09-15","9/15/2022 Per Tricare portal provider is PAR and linked to group TIN/location effective 9/8/2022.  DCannon"]
["Mark Stevens Clee, MD",1972946648,"83-0358685","TX","PE - Midland Community Healthcare Services","Boon Chapman","Participating","Enrollment Complete","2022-08-29","","","2023-03-10","3/10/2023 Per email from Priscilla Albertine at MQA, she received confirmation from Multiplan that provider is PAR and linked to group TIN/locations effective 8/29/2022.  DCannon"]
["Mark Stevens Clee, MD",1972946648,"83-0358685","TX","PE - Midland Community Healthcare Services","Tricare Prime","Panel Closed","Panel Closed","","","","2022-09-15","9/15/2022 Per Humana Military web portal Humana Military is currently not accepting requests to join the medical surgical network. We apologize for the inconvenience, but we hope you check back soon to see if we are accepting network providers.  DCannon"]
["Mark Stevens Clee, MD",1972946648,"83-0358685","TX","PE - Midland Community Healthcare Services","Ambetter","Participating","Enrollment Complete","2022-10-01","","","2022-12-29","12/29/2022 Rcvd email from Priscilla Albertine at MQA w/ confirmation from Superior that provider is PAR and linked to group effective 10/01/2022.  DCannon"]
["Mark Stevens Clee, MD",1972946648,"83-0358685","TX","PE - Midland Community Healthcare Services","Caprock (CapStar)","Participating","Enrollment Complete","2020-01-01","","","2022-10-12","10/12/2022 Per email from Priscilla Albertine she rcvd confirmation from Mary Rodriguez at Caprock that provider is PAR and linked to group TIN/locations effective 1/1/2020.  DCannon"]
["Marisela Sample, LPC",1396470357,"83-0358685","TX","PE - Midland Community Healthcare Services","Scott&White (First Care)","Participating","Enrollment Complete","2022-10-31","","","2023-08-17","8/17/2023 Received email from Scott & White HPDELEGATION@BSWHealth.org that provider load from November has been completed and provider is PAR effective 10/31/2022.  DCannon"]
["Marisela Sample, LPC",1396470357,"83-0358685","TX","PE - Midland Community Healthcare Services","Wellcare","Participating","Enrollment Complete","2022-12-01","","","2022-12-29","12/29/2022 Rcvd confirmation email from Superior that November delegation roster has been processed and provider has been loaded to delegation roster and PAR w/ group effective 12/1/2022.  DCannon"]
["Marisela Sample, LPC",1396470357,"83-0358685","TX","PE - Midland Community Healthcare Services","Amerigroup","Participating","Enrollment Complete","2022-10-31","","","2023-02-01","2/1/2023 Per email response from Amerigroup Provider Relations-Texas provider is PAR and linked to group effective 10/31/2022.  PID# 14835000.  DCannon"]
["Marisela Sample, LPC",1396470357,"83-0358685","TX","PE - Midland Community Healthcare Services","Ambetter","Participating","Enrollment Complete","2022-12-01","","",44924,"12/29/2022 Rcvd confirmation email from Superior that November delegation roster has been processed and provider has been loaded to delegation roster and PAR w/ group effective 12/1/2022.  DCannon"]
["Marisela Sample, LPC",1396470357,"83-0358685","TX","PE - Midland Community Healthcare Services","HealthSmart PPO","Participating","Enrollment Complete","2022-10-31","","","2022-12-29","12/29/2022 Per Healthsmart website provider is PAR and loaded under TIN/location effective 10/31/2022.  DCannon"]
["Marisela Sample, LPC",1396470357,"83-0358685","TX","PE - Midland Community Healthcare Services","Galaxy Health","Participating","Enrollment Complete","2022-10-31","","","2022-12-31","12/31/2022 Rcvd email from Karen Avalos at Galaxy that delegated roster submission for November has been completed.  Provider is PAR and linked to group TIN effective 10/31/2022.  DCannon"]
["Marisela Sample, LPC",1396470357,"83-0358685","TX","PE - Midland Community Healthcare Services","Superior","Participating","Enrollment Complete","2022-12-01","","","2022-12-08","12/08/2022 Rcvd confirmation email from Superior that November delegation roster has been processed and provider has been loaded to delegation roster and PAR w/ group effective 12/1/2022.  DCannon"]
["Marisela Sample, LPC",1396470357,"83-0358685","TX","PE - Midland Community Healthcare Services","Caprock (CapStar)","Participating","Enrollment Complete","2022-10-31","","","2022-11-21","11/21/2022 Rcvd email from Caprock that November Delegation roster provider load has been completed.  Provider is PAR and linked to group effective 10/31/2022.  DCannon"]
["Marisela Sample, LPC",1396470357,"83-0358685","TX","PE - Midland Community Healthcare Services","IMS","Participating","Enrollment Complete","2022-10-31","","","2023-01-05","1/5/2023 Per email received from German Aviles at IMS/OMNI monthly delegation roster provider load for November has been completed.  Provider is PAR and linked to group TIN effective 10/31/2022.   DCannon"]
["Marisela Sample, LPC",1396470357,"83-0358685","TX","PE - Midland Community Healthcare Services","Aetna","Participating","Enrollment Complete","2022-10-31","","","2022-12-15","12.15.22 Called Aetna @800.353.1232 and spoke with rep. Gelo who confirmed provider is participating effective 10/31/2022 at service locations and Tax ID. No recred date given per rep. Provider # 8624593. Call ref# 6124264748. ABoles"]
["Marisela Sample, LPC",1396470357,"83-0358685","TX","PE - Midland Community Healthcare Services","First Health Coventry","Participating","Enrollment Complete","2022-10-31","","","2023-02-28","2/28/2023 Per First Health web portal provider is PAR and linked to group TIN/location effective 10/31/2022.  DCannon"]
["Marisela Sample, LPC",1396470357,"83-0358685","TX","PE - Midland Community Healthcare Services","Medicaid","In House Enrollment","In House Enrollment","","","","2022-10-04",""]
["Esther Ebele Ihediwa, APRN-FNP-BC",1215633011,"83-0358685","TX","PE - Midland Community Healthcare Services","Tricare Prime","Panel Closed","Panel Closed","","","","2023-08-17","Unfortunately, at this time the network is closed. Humana Military thanks you for your interest in joining the TRICARE East Region network to provide care for our beneficiaries. At this time, we are not currently expanding our network based on your specialty and location within the East Region. Please understand that every market is different based on the beneficiary population and the types of services needed in a particular location. Thank you again for your inquiry.   You can monitor the link below for network opening status.    Join the TRICARE East network (humanamilitary.com)   Humana Military is currently not accepting requests to join the medical surgical network. We apologize for the inconvenience, but we hope you check back soon to see if we are accepting network providers."]
["Esther Ebele Ihediwa, APRN-FNP-BC",1215633011,"83-0358685","TX","PE - Midland Community Healthcare Services","United Health Care","Participating","Enrollment Complete","2023-08-22","008866025","","2023-09-28","9/28/2023 Rcvd email confirmation from UHC that September delegated roster has been completed.  Provider is PAR and linked to group/location effective 8/22/2023.  DCannon"]
["Esther Ebele Ihediwa, APRN-FNP-BC",1215633011,"83-0358685","TX","PE - Midland Community Healthcare Services","Cigna","Participating","Enrollment Complete","2023-10-06","","","2023-10-09","Received confirmation email. Attached. MS"]
["Esther Ebele Ihediwa, APRN-FNP-BC",1215633011,"83-0358685","TX","PE - Midland Community Healthcare Services","CAQH","In House Enrollment","In House Enrollment","","","","2023-06-28","6/28/2023- per notification form, provider will maintain own CAQH - kavello"]
["Esther Ebele Ihediwa, APRN-FNP-BC",1215633011,"83-0358685","TX","PE - Midland Community Healthcare Services","Scott&White (First Care)","Participating","Enrollment Complete","2023-10-15","","","2023-10-12","10/12/2023 Per email received from Scott & White provider is PAR and linked to group TIN/locations effective 10/15/2023.  DCannon"]
["Esther Ebele Ihediwa, APRN-FNP-BC",1215633011,"83-0358685","TX","PE - Midland Community Healthcare Services","Wellcare","Participating","Enrollment Complete","2023-10-01","","","2023-10-16","10/16/2023 Rcvd email from Superior that provider is PAR and linked to group TIN/location effective 10/1/2023.  DCannon"]
["Esther Ebele Ihediwa, APRN-FNP-BC",1215633011,"83-0358685","TX","PE - Midland Community Healthcare Services","HealthSmart PPO","In Process","Payor Follow Up","","","","2023-11-14","11/14/2023 Per Healthsmart provider portal provider is still not loaded under group TIN.  Per phone conversation with Lee Kinard at Healthsmart provider portal should be updated  by 11/27/2023.  Will allow more time, check back in 2 weeks.   DCannon"]
["Esther Ebele Ihediwa, APRN-FNP-BC",1215633011,"83-0358685","TX","PE - Midland Community Healthcare Services","Boon Chapman","Participating","Enrollment Complete","2023-08-22","","","2023-10-12","10/12/2023 Per email received from Jessica Bess at  Multiplan provider is PAR and linked to group TIN/locations effective 8/22/2023.  DCannon"]
["Esther Ebele Ihediwa, APRN-FNP-BC",1215633011,"83-0358685","TX","PE - Midland Community Healthcare Services","TriCare Standard","Participating","Enrollment Complete","2023-09-14","","","2023-09-26","Provider has been loaded to the Andrews Hwy location effective 9/14/23. MS"]
["Esther Ebele Ihediwa, APRN-FNP-BC",1215633011,"83-0358685","TX","PE - Midland Community Healthcare Services","TriCare Standard","Participating","Enrollment Complete","2023-09-14","","","2023-09-26","Provider has been loaded to the Andrews Hwy location effective 9/14/23. MS"]
["Esther Ebele Ihediwa, APRN-FNP-BC",1215633011,"83-0358685","TX","PE - Midland Community Healthcare Services","TriCare Standard","Participating","Enrollment Complete","2023-09-14","","","2023-09-26","Provider has been loaded to the Andrews Hwy location effective 9/14/23. MS"]
["Esther Ebele Ihediwa, APRN-FNP-BC",1215633011,"83-0358685","TX","PE - Midland Community Healthcare Services","Humana","In Process","Payor Follow Up","","","","2023-11-17","11/17/2023 Sent follow-up email to Marcus Wester at Humana to check status of September monthly delegated roster submission.  Provider Add - CO16127988, Provider Changes - CO-16128096,  Provider Terms - CO-16128221.  DCannon"]
["Esther Ebele Ihediwa, APRN-FNP-BC",1215633011,"83-0358685","TX","PE - Midland Community Healthcare Services","Humana","In Process","Payor Follow Up","","","","2023-11-17","11/17/2023 Sent follow-up email to Marcus Wester at Humana to check status of September monthly delegated roster submission.  Provider Add - CO16127988, Provider Changes - CO-16128096,  Provider Terms - CO-16128221.  DCannon"]
["Esther Ebele Ihediwa, APRN-FNP-BC",1215633011,"83-0358685","TX","PE - Midland Community Healthcare Services","Multiplan","Participating","Enrollment Complete","2023-08-22","","","2023-10-12","10/12/2023 Per email received from Jessica Bess at  Multiplan provider is PAR and linked to group TIN/locations effective 8/22/2023.  DCannon"]
["Esther Ebele Ihediwa, APRN-FNP-BC",1215633011,"83-0358685","TX","PE - Midland Community Healthcare Services","Superior","Participating","Enrollment Complete","2023-10-01","","","2023-10-16","10/16/2023 Rcvd email from Superior that provider is PAR and linked to group TIN/location effective 10/1/2023.  DCannon"]
["Esther Ebele Ihediwa, APRN-FNP-BC",1215633011,"83-0358685","TX","PE - Midland Community Healthcare Services","Superior","Participating","Enrollment Complete","2023-10-01","","","2023-10-16","10/16/2023 Rcvd email from Superior that provider is PAR and linked to group TIN/location effective 10/1/2023.  DCannon"]
["Briana Janene Smith, APRN-FNP-BC",1215488754,"83-0358685","TX","PE - Midland Community Healthcare Services","TriCare Standard","Participating","Enrollment Complete","2023-09-25","","","2023-09-28","Provider is enrolled with the Florida location effective 9/25. MS"]
["Briana Janene Smith, APRN-FNP-BC",1215488754,"83-0358685","TX","PE - Midland Community Healthcare Services","CAQH","In House Enrollment","In House Enrollment","","","","2023-09-18","9/18/13-Per notification form - provider will maintain - kavello"]
["Briana Janene Smith, APRN-FNP-BC",1215488754,"83-0358685","TX","PE - Midland Community Healthcare Services","CAQH","In House Enrollment","In House Enrollment","","","","2023-09-18","9/18/13-Per notification form - provider will maintain - kavello"]
["Briana Janene Smith, APRN-FNP-BC",1215488754,"83-0358685","TX","PE - Midland Community Healthcare Services","Aetna","In Process","Application Submitted","","","","2023-11-15","11/15/2023 Delegated roster submitted.  DCannon"]
["Briana Janene Smith, APRN-FNP-BC",1215488754,"83-0358685","TX","PE - Midland Community Healthcare Services","United Health Care","In Process","Payor Receipt Validated","","","","2023-11-15","11/15/2023 Rcvd confirmation email that November delegated roster was received.  Reference Number: PR-7842834.  DCannon"]
["Briana Janene Smith, APRN-FNP-BC",1215488754,"83-0358685","TX","PE - Midland Community Healthcare Services","United Health Care","In Process","Payor Receipt Validated","","","","2023-11-15","11/15/2023 Rcvd confirmation email that November delegated roster was received.  Reference Number: PR-7842834.  DCannon"]
["Briana Janene Smith, APRN-FNP-BC",1215488754,"83-0358685","TX","PE - Midland Community Healthcare Services","Cigna","In Process","Payor Receipt Validated","","","","2023-11-15","Received receipt of application Ref 13467964  MS"]
["Briana Janene Smith, APRN-FNP-BC",1215488754,"83-0358685","TX","PE - Midland Community Healthcare Services","Superior","In Process","Application Submitted","","","","2023-11-15","11/15/2023 Delegated roster submitted.  DCannon"]
["Briana Janene Smith, APRN-FNP-BC",1215488754,"83-0358685","TX","PE - Midland Community Healthcare Services","Superior","In Process","Application Submitted","","","","2023-11-15","11/15/2023 Delegated roster submitted.  DCannon"]
["Briana Janene Smith, APRN-FNP-BC",1215488754,"83-0358685","TX","PE - Midland Community Healthcare Services","Wellmed","Thru Other Payor","Pending Other Enrollment","","","","2023-11-09","11/9/2023 Pending UHC enrollment.  DCannon"]
["Briana Janene Smith, APRN-FNP-BC",1215488754,"83-0358685","TX","PE - Midland Community Healthcare Services","Multiplan","In Process","Application Submitted","","","","2023-11-15","11/15/2023 Delegated roster submitted.  DCannon"]
["Briana Janene Smith, APRN-FNP-BC",1215488754,"83-0358685","TX","PE - Midland Community Healthcare Services","HealthSmart PPO","In Process","Application Submitted","","","","2023-11-15","11/15/2023 Delegated roster submitted.  DCannon"]
["Briana Janene Smith, APRN-FNP-BC",1215488754,"83-0358685","TX","PE - Midland Community Healthcare Services","Caprock (CapStar)","In Process","Application Submitted","","","","2023-11-15","11/15/2023 Delegated roster submitted.  DCannon"]
["Briana Janene Smith, APRN-FNP-BC",1215488754,"83-0358685","TX","PE - Midland Community Healthcare Services","Scott&White (First Care)","In Process","Application Submitted","","","","2023-11-15","11/15/2023 Delegated roster submitted.  DCannon"]
["Briana Janene Smith, APRN-FNP-BC",1215488754,"83-0358685","TX","PE - Midland Community Healthcare Services","Amerigroup","In Process","Application Submitted","","","","2023-11-15","11/15/2023 Delegated roster submitted.  DCannon"]
["Briana Janene Smith, APRN-FNP-BC",1215488754,"83-0358685","TX","PE - Midland Community Healthcare Services","IMS","In Process","Application Submitted","","","","2023-11-15","11/15/2023 Delegated roster submitted.  DCannon"]
["Chandan Mazumder, MD",1093928913,"83-0358685","TX","PE - Midland Community Healthcare Services","Amerigroup","Participating","Enrollment Complete","2020-02-12","","","2021-12-02","12/2/2021 Per Amerigroup roster received Joe Rodriguez for MCHS TIN 83-0358685 provider is PAR under group TIN/location effective 2/12/2020.   DCannon"]
["Chandan Mazumder, MD",1093928913,"83-0358685","TX","PE - Midland Community Healthcare Services","Wellcare","Participating","Enrollment Complete","2021-11-01","","","2022-12-01","12/1/2022 Per roster received from Wellcare provider is PAR and linked to group TIN/location effective 11/1/2021.  DCannon"]
["Chandan Mazumder, MD",1093928913,"83-0358685","TX","PE - Midland Community Healthcare Services","Wellmed","Participating","Enrollment Complete","2022-01-01","","","2023-03-23","3/23/2023 Rcvd roster from UHC w/ all Wellmed participating providers.  Provider is PAR effective 1/1/2022.  DCannon"]
["Chandan Mazumder, MD",1093928913,"83-0358685","TX","PE - Midland Community Healthcare Services","Wellmed","Participating","Enrollment Complete","2022-01-01","","","2023-03-23","3/23/2023 Rcvd roster from UHC w/ all Wellmed participating providers.  Provider is PAR effective 1/1/2022.  DCannon"]
["Chandan Mazumder, MD",1093928913,"83-0358685","TX","PE - Midland Community Healthcare Services","Cigna","Participating","Enrollment Complete","2021-06-01","4341928","","2021-08-27","8/27/2021 Received an email and roster from pdmcogz@cigna.com confirming practice location has been loaded to provider's record effective 6/1/2021 with assigned provider number 4341928. KFrazier"]
["Chandan Mazumder, MD",1093928913,"83-0358685","TX","PE - Midland Community Healthcare Services","USA PPO","Participating","Enrollment Complete","2021-06-01","","","2021-08-05","8/5/2021  In following up with USAMCO (800-872-3860) I was told that you can confirm participating via the USA MCO website  https://providersearch.usamco.com/hwprovsearch.  Provider is PAR and linked to location/TIN effective 6/1/2021.  DCannon"]
["Chandan Mazumder, MD",1093928913,"83-0358685","TX","PE - Midland Community Healthcare Services","Cigna","Participating","Enrollment Complete","2021-06-01","4341928","","2021-08-27","8/27/2021 Received an email and roster from pdmcogz@cigna.com confirming practice location has been loaded to provider's record effective 6/1/2021 with assigned provider number 4341928. KFrazier"]
["Chandan Mazumder, MD",1093928913,"83-0358685","TX","PE - Midland Community Healthcare Services","Scott&White (First Care)","Participating","Enrollment Complete","2020-09-28","","","2021-01-29","1/29/2021 - Rcvd roster from Scott&White (First Care) confirming participation of provider with TIN and location effective dates.  DCannon"]
["Chandan Mazumder, MD",1093928913,"83-0358685","TX","PE - Midland Community Healthcare Services","United Health Care","Participating","Enrollment Complete","2020-07-29","1093928913","","2020-08-06","8/6/2020 - Rec'd email from the payer stating \"Good news! We’ve completed the provider/group updates you requested on Jul 29, 2020 9:56:56 AM. Your request was assigned reference number PR-5410028 .\" - Stacey Hudak"]
["Chandan Mazumder, MD",1093928913,"83-0358685","TX","PE - Midland Community Healthcare Services","Omni PPO","Participating","Enrollment Complete","2020-08-01","","","2020-08-25","Confirmed provider is participating at this location as of 8/1/2020. Kimberly Frazier"]
["Chandan Mazumder, MD",1093928913,"83-0358685","TX","PE - Midland Community Healthcare Services","Omni PPO","Participating","Enrollment Complete","2021-06-01","","","2021-09-24","9/24/2021 Rcvd email from German Aviles at IMS/OMNI that delegation roster for July & August have been completed and updated in their system effective 6/1/2021.  DCannon"]
["Chandan Mazumder, MD",1093928913,"83-0358685","TX","PE - Midland Community Healthcare Services","HealthSmart PPO","Participating","Enrollment Complete","2021-06-01","","","2021-08-05","8/5/2021 Per Healthsmart website provider is PAR and loaded under TIN/location effective 6/1/2021.  DCannon"]
["Chandan Mazumder, MD",1093928913,"83-0358685","TX","PE - Midland Community Healthcare Services","Aetna","Participating","Enrollment Complete","2021-06-01","9672268","","2021-09-09","9/9/2021 Rcvd full roster from Jamie Roberts at Aetna on 9/8/2021 confirming that provider is PAR and linked to group TIN/locations effective 6/1/2021.  PID # 9672268  DCannon"]
["Chandan Mazumder, MD",1093928913,"83-0358685","TX","PE - Midland Community Healthcare Services","Molina","Participating","Enrollment Complete","2020-06-30","","","2022-10-20","10/20/2022 Rcvd email from Priscilla Albertine at MQA with roster from Marcie Eckhart-Havens at Multiplan with confirmation that provider is PAR w/ Molina under group TIN/location effective 6/30/2020.  DCannon"]
["Khadijah A. Abdurrazaq, MD",1336304120,"83-0358685","TX","PE - Midland Community Healthcare Services","Multiplan","Participating","Enrollment Complete","2020-09-17","","","2022-07-24","7/24/2022 Per email from Marcie Eckhart-Havens Multiplan July delegated roster has been completed  and provider is PAR and linked to group TIN effective 9/17/2020.  DCannon"]
["Khadijah A. Abdurrazaq, MD",1336304120,"83-0358685","TX","PE - Midland Community Healthcare Services","Superior","Participating","Enrollment Complete","2021-08-01","","","2021-08-05","8/5/2021 Rcvd email from Superior that monthly delegation roster for May is complete and providers are loaded under TIN/locations effective 8/1/2021.  DCannon"]
["Khadijah A. Abdurrazaq, MD",1336304120,"83-0358685","TX","PE - Midland Community Healthcare Services","TriCare Standard","Participating","Enrollment Complete","2013-07-01","","","2020-10-23","10/23/2020 Confirmed via provider self-service portal provider is certified as non-network under the Group Tax ID and location effective 7/1/2013. Kimberly Frazier"]
["Khadijah A. Abdurrazaq, MD",1336304120,"83-0358685","TX","PE - Midland Community Healthcare Services","United Health Care","Participating","Enrollment Complete","2019-12-01","1336304120","","2020-08-31","08/31/2020 - moved to completed status after reviewing follow up complete note - Stacey Hduak"]
["Khadijah A. Abdurrazaq, MD",1336304120,"83-0358685","TX","PE - Midland Community Healthcare Services","Ambetter","Participating","Enrollment Complete","2022-04-01","","","2022-06-13","6/13/2022 Per roster received from Superior provider is PAR and linked to group delegation roster effective 4/1/2022."]
["Khadijah A. Abdurrazaq, MD",1336304120,"83-0358685","TX","PE - Midland Community Healthcare Services","Omni PPO","Participating","Enrollment Complete","2021-06-01","","","2021-09-24","9/24/2021 Rcvd email from German Aviles at IMS/OMNI that delegation roster for July & August have been completed and updated in their system effective 6/1/2021.  DCannon"]
["Khadijah A. Abdurrazaq, MD",1336304120,"83-0358685","TX","PE - Midland Community Healthcare Services","Aetna","Participating","Enrollment Complete","2019-03-15","1336304120","","2020-04-23","04/23/2020--S/W Bella of Aetna @ 8003531232, provider NPI is on file for the provider and participating effective 03/15/19 under the group and TIN. Delegated with Midland Community Healthcare Services. Physical location is on file. Provider ID# 9132703. Call ref# 5235911662.\ncopied note from spreadsheet-tisha rader"]
["Khadijah A. Abdurrazaq, MD",1336304120,"83-0358685","TX","PE - Midland Community Healthcare Services","Superior","Participating","Enrollment Complete","2017-01-01","1336304120","","2020-07-14","07/14/2020 - Rec'd email from the payer stating this provider is EFF under PRIMED DELEGATED agreement - Stacey Hudak"]
["Khadijah A. Abdurrazaq, MD",1336304120,"83-0358685","TX","PE - Midland Community Healthcare Services","Wellcare","Participating","Enrollment Complete","2021-11-01","","","2022-11-15","11/15/2022 Per roster received from Wellcare provider is PAR and linked to group TIN/location effective 11/1/2021.  DCannon"]
["Khadijah A. Abdurrazaq, MD",1336304120,"83-0358685","TX","PE - Midland Community Healthcare Services","HealthSmart PPO","Participating","Enrollment Complete","2013-08-22","1336304120","","2020-06-05","06/05/2020 - Rec'd spreadsheet from the payer stating provider is EFF - Stacey Hudak"]
["Khadijah A. Abdurrazaq, MD",1336304120,"83-0358685","TX","PE - Midland Community Healthcare Services","Amerigroup","Participating","Enrollment Complete","2020-09-17","","","2021-12-02","12/2/2021 Per Amerigroup roster received Joe Rodriguez for MCHS TIN 83-0358685 provider is PAR under group TIN/location effective 9/17/2020.   DCannon"]
["Khadijah A. Abdurrazaq, MD",1336304120,"83-0358685","TX","PE - Midland Community Healthcare Services","Scott&White (First Care)","Participating","Enrollment Complete","2021-06-01","","","2021-10-06","10/6/2021 Rcvd confirmaton email from S & W that July delegated roster has been complete and provider is PAR w/ TIN and location effective 6/1/2021.  DCannon"]
["Eliseo Rivera, MD",1013990761,"83-0358685","TX","PE - Midland Community Healthcare Services","Aetna","Participating","Enrollment Complete","2005-07-01","","","2020-12-04","12/4/2020 - Rcvd completed PRIMED ROSTER back from the payer. This provider is PAR at this service location eff 9/1/2020.  DCannon"]
["Eliseo Rivera, MD",1013990761,"83-0358685","TX","PE - Midland Community Healthcare Services","IMS","Participating","Enrollment Complete","2021-06-01","","","2021-09-24","9/24/2021 Rcvd email from German Aviles at IMS/OMNI that delegation roster for July & August have been completed and updated in their system effective 6/1/2021.  DCannon"]
["Eliseo Rivera, MD",1013990761,"83-0358685","TX","PE - Midland Community Healthcare Services","Ambetter","Participating","Enrollment Complete","2022-04-01","","","2022-06-13","6/13/2022 Per roster received from Superior provider is PAR and linked to group delegation roster effective 4/1/2022."]
["Eliseo Rivera, MD",1013990761,"83-0358685","TX","PE - Midland Community Healthcare Services","Wellmed","Participating","Enrollment Complete","2022-01-01","","","2023-03-23","3/23/2023 Rcvd roster from UHC w/ all Wellmed participating providers.  Provider is PAR effective 1/1/2022.  DCannon"]
["Eliseo Rivera, MD",1013990761,"83-0358685","TX","PE - Midland Community Healthcare Services","Wellmed","Participating","Enrollment Complete","2022-01-01","","","2023-03-23","3/23/2023 Rcvd roster from UHC w/ all Wellmed participating providers.  Provider is PAR effective 1/1/2022.  DCannon"]
["Eliseo Rivera, MD",1013990761,"83-0358685","TX","PE - Midland Community Healthcare Services","TriCare Standard","Participating","Enrollment Complete","2015-07-11","1013990761","","2020-09-24","09/24/2020 - moved to completed status after reviewing follow up complete - stacey Hudak"]
["Eliseo Rivera, MD",1013990761,"83-0358685","TX","PE - Midland Community Healthcare Services","Amerigroup","Participating","Enrollment Complete","2020-04-03","1013990761","","2020-03-20","03/20/2020 - Rec'd email from the payer (Multiplan/Texas True Choice)  stating this provider is EFF at this service location with Amerigroup - Stacey Hudak"]
["Eliseo Rivera, MD",1013990761,"83-0358685","TX","PE - Midland Community Healthcare Services","First Health Coventry","Participating","Enrollment Complete","2021-08-28","1099473","","2022-02-04","2/4/2022 Per roster received from First Health provider is PAR and linked to group TIN/location effective 8/28/2021.  DCannon"]
["Eliseo Rivera, MD",1013990761,"83-0358685","TX","PE - Midland Community Healthcare Services","Humana","Participating","Enrollment Complete","2015-12-08","","","2021-11-18","11/18/2021 Rcvd full roster from Humana listing provider as PAR and linked to group TIN/location effective 12/8/2015.  DCannon"]
["Eliseo Rivera, MD",1013990761,"83-0358685","TX","PE - Midland Community Healthcare Services","Cigna","Participating","Enrollment Complete","2020-07-22","6653474","","2020-07-24","7/24/2020 - Rec'd email from the payer stating \"Your effective date is 07/22/2020. Your provider identification number is 6653474\" - Stacey Hudak"]
["Eliseo Rivera, MD",1013990761,"83-0358685","TX","PE - Midland Community Healthcare Services","Amerigroup","Participating","Enrollment Complete","2020-04-03","","","2021-08-26","8/26/2021 Rcvd full roster from Joe Rodriguez at Amerigroup listing provider as PAR w/ group TIN and location effective 4/3/2020.  DCannon"]
["Eliseo Rivera, MD",1013990761,"83-0358685","TX","PE - Midland Community Healthcare Services","Wellcare","Participating","Enrollment Complete","2021-11-01","","","2022-12-01","12/1/2022 Per roster received from Wellcare provider is PAR and linked to group TIN/location effective 11/1/2021.  DCannon"]
["Eliseo Rivera, MD",1013990761,"83-0358685","TX","PE - Midland Community Healthcare Services","HealthSmart PPO","Participating","Enrollment Complete","2021-06-01","","","2021-08-05","8/5/2021 Per Healthsmart website provider is PAR and loaded under TIN/location effective 6/1/2021.  DCannon"]
["Eliseo Rivera, MD",1013990761,"83-0358685","TX","PE - Midland Community Healthcare Services","Boon Chapman","Participating","Enrollment Complete","2017-10-03","","","2022-02-24","2/24/2022 Per follow-up note on 2/18/2022 - Provider NPI# is on file for the provider and participating effective 10/03/2017 under the group and TIN#. Provider ID#  12418437. Physical location is on file. Call ref# 7919804 -DCannon"]
["Elisa L Brown, MD",1811086986,"83-0358685","TX","PE - Midland Community Healthcare Services","Wellcare","Participating","Enrollment Complete","2021-11-01","","","2022-11-15","11/15/2022 Per roster received from Wellcare provider is PAR and linked to group TIN/location effective 11/1/2021.  DCannon"]
["Elisa L Brown, MD",1811086986,"83-0358685","TX","PE - Midland Community Healthcare Services","HealthSmart PPO","Participating","Enrollment Complete","2019-09-26","1811086986","","2020-06-05","06/05/2020 - Rec'd email from the payer stating this provider is EFF - Stacey Hudak"]
["Elisa L Brown, MD",1811086986,"83-0358685","TX","PE - Midland Community Healthcare Services","Molina","Participating","Enrollment Complete","2022-10-06","","","2023-02-28","2/28/2023 Per email received from Priscilla Albertine at MQA provider is PAR with Molina and linked to group effective 10/6/2022.  DCannon"]
["Elisa L Brown, MD",1811086986,"83-0358685","TX","PE - Midland Community Healthcare Services","Amerigroup","Participating","Enrollment Complete","2017-07-03","","","2021-12-02","12/2/2021 Per Amerigroup roster received Joe Rodriguez for MCHS TIN 83-0358685 provider is PAR under group TIN/location effective 7/3/2017.   DCannon"]
["Elisa L Brown, MD",1811086986,"83-0358685","TX","PE - Midland Community Healthcare Services","Ambetter","Participating","Enrollment Complete","2022-06-01","","","2022-06-20","6/20/2022 Per roster received from Superior provider is PAR and linked to group delegation roster effective 6/1/2022."]
["Elisa L Brown, MD",1811086986,"83-0358685","TX","PE - Midland Community Healthcare Services","USA PPO","Participating","Enrollment Complete","2021-06-01","","","2021-08-05","8/5/2021  In following up with USAMCO (800-872-3860) I was told that you can confirm participating via the USA MCO website  https://providersearch.usamco.com/hwprovsearch.  Provider is PAR and linked to location/TIN effective 6/1/2021.  DCannon"]
["Elisa L Brown, MD",1811086986,"83-0358685","TX","PE - Midland Community Healthcare Services","Caprock (CapStar)","Participating","Enrollment Complete","2019-08-26","","","2020-09-14",""]
["Elisa L Brown, MD",1811086986,"83-0358685","TX","PE - Midland Community Healthcare Services","Amerigroup","Participating","Enrollment Complete","2020-01-16","1811086986","","2020-03-18","03/18/2020 - Rec'd confirmation from the payer via spreadsheet stating this provider is EFF with Amerigroup through Texas True Care - Stacey Hudak"]
["Elisa L Brown, MD",1811086986,"83-0358685","TX","PE - Midland Community Healthcare Services","Wellmed","Participating","Enrollment Complete","2022-01-01","","","2023-03-23","3/23/2023 Rcvd roster from UHC w/ all Wellmed participating providers.  Provider is PAR effective 1/1/2022.  DCannon"]
["Elisa L Brown, MD",1811086986,"83-0358685","TX","PE - Midland Community Healthcare Services","Wellmed","Participating","Enrollment Complete","2022-01-01","","","2023-03-23","3/23/2023 Rcvd roster from UHC w/ all Wellmed participating providers.  Provider is PAR effective 1/1/2022.  DCannon"]
["Elisa L Brown, MD",1811086986,"83-0358685","TX","PE - Midland Community Healthcare Services","Wellcare","Participating","Enrollment Complete","2021-11-01","","","2022-11-15","11/15/2022 Per roster received from Wellcare provider is PAR and linked to group TIN/location effective 11/1/2021.  DCannon"]
["Elisa L Brown, MD",1811086986,"83-0358685","TX","PE - Midland Community Healthcare Services","HealthSmart PPO","Participating","Enrollment Complete","2019-09-26","","","2021-01-27","1/27/2021 - Rcvd email from payer showing provider as participating at location and linked to TIN effective 9/26/2019.  DCannon"]
["Irina Remsburg, MD",1639439185,"83-0358685","TX","PE - Midland Community Healthcare Services","Wellmed","Participating","Enrollment Complete","2022-01-01","","","2023-03-23","3/23/2023 Rcvd roster from UHC w/ all Wellmed participating providers.  Provider is PAR effective 1/1/2022.  DCannon"]
["Irina Remsburg, MD",1639439185,"83-0358685","TX","PE - Midland Community Healthcare Services","Wellmed","Participating","Enrollment Complete","2022-01-01","","","2023-03-23","3/23/2023 Rcvd roster from UHC w/ all Wellmed participating providers.  Provider is PAR effective 1/1/2022.  DCannon"]
["Irina Remsburg, MD",1639439185,"83-0358685","TX","PE - Midland Community Healthcare Services","HealthSmart PPO","Participating","Enrollment Complete","2019-07-18","","","2021-04-11","4/11/2021 Rcvd email from HealthSmart <mdipsupport@healthsmart.com> confirming participation of provider under TIN and location effective 07/18/2019.  DCannon"]
["Irina Remsburg, MD",1639439185,"83-0358685","TX","PE - Midland Community Healthcare Services","Amerigroup","Participating","Enrollment Complete","2020-01-13","","","2021-12-02","12/2/2021 Per Amerigroup roster received Joe Rodriguez for MCHS TIN 83-0358685 provider is PAR under group TIN/location effective 1/13/2020.   DCannon"]
["Irina Remsburg, MD",1639439185,"83-0358685","TX","PE - Midland Community Healthcare Services","IMS","Participating","Enrollment Complete","2021-06-01","","","2021-09-24","9/24/2021 Rcvd email from German Aviles at IMS/OMNI that delegation roster for July & August have been completed and updated in their system effective 6/1/2021.  DCannon"]
["Irina Remsburg, MD",1639439185,"83-0358685","TX","PE - Midland Community Healthcare Services","Multiplan","Participating","Enrollment Complete","2020-06-30","1348074","","2022-02-24","2/24/2022 Per follow-up note on 2/17/2022 - Provider NPI# is on file for the provider and is participating effective 6/30/2020 under the group and TIN#. Provider ID 13484074. Physical location is on file. Call ref# 7917950.  - DCannon"]
["Irina Remsburg, MD",1639439185,"83-0358685","TX","PE - Midland Community Healthcare Services","TriCare Standard","Participating","Enrollment Complete","2021-12-14","","","2022-02-11","2/11/2022 Per Tricare portal, provider is linked to location as of 12.14.2021. Cbankston"]
["Irina Remsburg, MD",1639439185,"83-0358685","TX","PE - Midland Community Healthcare Services","United Health Care","Participating","Enrollment Complete","2021-02-13","5733523","","2021-07-09","7/9/2021 Received roster from networkhelp@uhc.com confirming provider is participating under group Tax ID and location with an effective date of 2/13/2021 and assigned provider ID 5733523. KFrazier"]
["Irina Remsburg, MD",1639439185,"83-0358685","TX","PE - Midland Community Healthcare Services","Ambetter","Participating","Enrollment Complete","2022-04-01","","","2022-06-13","6/13/2022 Per roster received from Superior provider is PAR and linked to group delegation roster effective 4/1/2022."]
["Irina Remsburg, MD",1639439185,"83-0358685","TX","PE - Midland Community Healthcare Services","Aetna","Participating","Enrollment Complete","2021-06-01","5435845","","2021-09-09","9/9/2021 Rcvd full roster from Jamie Roberts at Aetna on 9/8/2021 confirming that provider is PAR and linked to group TIN/locations effective 6/1/2021.  PID # 5435845  DCannon"]
["Irina Remsburg, MD",1639439185,"83-0358685","TX","PE - Midland Community Healthcare Services","Wellcare","Participating","Enrollment Complete","2021-11-01","","","2022-12-01","12/1/2022 Per roster received from Wellcare provider is PAR and linked to group TIN/location effective 11/1/2021.  DCannon"]
["Irina Remsburg, MD",1639439185,"83-0358685","TX","PE - Midland Community Healthcare Services","Triwest VA","Enrollment Stopped","Enrollment Stopped","","","","2022-10-17","10/17/2022 - Received roster from Scarlett of TriWest VA; provider status: \"No Action.  Pediatrics specialty.\""]
["Irina Remsburg, MD",1639439185,"83-0358685","TX","PE - Midland Community Healthcare Services","Amerigroup","Participating","Enrollment Complete","2016-09-16","03421665","","2021-02-13","2/13/2021 - Rcvd complete roster from Amerigroup provider is participating and linked to TIN and location for the following plans STAR - eff 9/16/2016;  PLUS - eff 9/16/2016, Star_Kids - eff 10/22/2015.  DCannon"]
["Irina Remsburg, MD",1639439185,"83-0358685","TX","PE - Midland Community Healthcare Services","Medicaid","In House Enrollment","In House Enrollment","","","","2021-08-04","8/4/2021 Medicaid enrollment completed in-house by MCHS.  DCannon"]
["Chabacana Maxwell, FNP",1154767234,"83-0358685: P","TX","PE - Midland Community Healthcare Services","Amerigroup","Participating","Enrollment Complete","2018-08-03","1154767234","","2020-03-19","03/19/2020 - Rec'd email from the payer (Multiplan/Texas True Choice) has sent confirmation that this provider is EFF with Amerigroup - Stacey Hudak"]
["Chabacana Maxwell, FNP",1154767234,"83-0358685: P","TX","PE - Midland Community Healthcare Services","IMS","Participating","Enrollment Complete","2015-08-29","1154767234","","2020-06-22","06/22/2020- Rec'd email from the payer confirming this provider is PAR with this group/service location - Stacey Hudak"]
["Chabacana Maxwell, FNP",1154767234,"83-0358685: P","TX","PE - Midland Community Healthcare Services","Wellcare","Participating","Enrollment Complete","2021-11-01","","","2022-12-01","12/1/2022 Per roster received from Wellcare provider is PAR and linked to group TIN/location effective 11/1/2021.  DCannon"]
["Chabacana Maxwell, FNP",1154767234,"83-0358685: S","TX","PE - Midland Community Healthcare Services","Boon Chapman","Participating","Enrollment Complete","2016-07-26","","","2022-07-01","7/1/2022 Provider is PAR and linked to group TIN/location effective 7/26/2016.  DCannon"]
["Chabacana Maxwell, FNP",1154767234,"83-0358685: S","TX","PE - Midland Community Healthcare Services","Superior","Participating","Enrollment Complete","2017-01-01","1154767234","","2020-07-14","07/14/2020 - Rec'd email from the payer stating this provider is EFF under PRIMED DELEGATED agreement - Stacey Hudak"]
["Chabacana Maxwell, FNP",1154767234,"83-0358685: S","TX","PE - Midland Community Healthcare Services","Wellcare","Participating","Enrollment Complete","2021-11-01","","","2022-12-01","12/1/2022 Per roster received from Wellcare provider is PAR and linked to group TIN/location effective 11/1/2021.  DCannon"]
["Chabacana Maxwell, FNP",1154767234,"83-0358685: S","TX","PE - Midland Community Healthcare Services","Medicare","Participating","In House Enrollment","2015-05-26","418117YM2M","00304W","2020-07-15","07/15/2020 - entered payer line to store Medicare EFF information, but this is maitained at the clinic - not by Symplr - Stacey Hudak"]
["Chabacana Maxwell, FNP",1154767234,"83-0358685: T","TX","PE - Midland Community Healthcare Services","Superior","Participating","Enrollment Complete","2020-09-01","1154767234","","2020-09-02","09/02/2020 - rec'd email from the payer stating this updated has been completed - Stacey Hudak"]
["Chabacana Maxwell, FNP",1154767234,"83-0358685: T","TX","PE - Midland Community Healthcare Services","Ambetter","Participating","Enrollment Complete","2022-04-01","","","2022-06-13","6/13/2022 Per roster received from Superior provider is PAR and linked to group delegation roster effective 4/1/2022."]
["Chabacana Maxwell, FNP",1154767234,"83-0358685: T","TX","PE - Midland Community Healthcare Services","TriCare Standard","Participating","Enrollment Complete","2021-12-09","","","2022-02-10","2/10/2022 Per Tricare portal, provider added to location eff 12.9.2021. Cbankston"]
["Justin D Shanks, APRN-FNP-BC",1205477874,"84-2617748","TX","PE - Midland Medicine PA","Multiplan","Participating","Enrollment Complete","2022-06-01","","","2022-07-24","7/24/2022 Per email from Marcie Eckhart-Havens Multiplan July delegated roster has been completed  and provider is PAR and linked to group TIN effective 6/1/2022.  DCannon"]
["Justin D Shanks, APRN-FNP-BC",1205477874,"84-2617748","TX","PE - Midland Medicine PA","IMS","Participating","Enrollment Complete","2022-06-01","","","2022-07-05","7/5/2022 Rcvd email from G.Aviles at IMS/OMNI that delegation roster provider load for June has been completed.  Provider is PAR and linked to group effective 6/1/2022.  DCannon"]
["Justin D Shanks, APRN-FNP-BC",1205477874,"84-2617748","ME","PE - Midland Medicine PA","Liberty Mutual","In House Enrollment","In House Enrollment","","","","2022-09-15","9/15/2022 Enrollment is now done in-house by Ventra Health for Midland Emergency Managers effective 8/1/2022.  DCannon"]
["Justin D Shanks, APRN-FNP-BC",1205477874,"84-2617748","ME","PE - Midland Medicine PA","HealthSmart PPO","Participating","Enrollment Complete","2021-08-09","","","2021-10-06","10/6/2021 Per Healthsmart website provider is PAR and loaded under TIN/location effective 8/9/2021.  DCannon"]
["Justin D Shanks, APRN-FNP-BC",1205477874,"84-2617748","TX","PE - Midland Medicine PA","Rail Road Medicare","Participating","Enrollment Complete","2021-04-01","Q00110014","","2022-05-13","5/13/2022 RR Medicare PTAN # Q00110014 effective 4/1/2021.  DCannon"]
["Justin D Shanks, APRN-FNP-BC",1205477874,"84-2617748","TX","PE - Midland Medicine PA","Aetna","Participating","Enrollment Complete","2022-06-01","","","2022-06-02","6/2/2022 Per Aetna provider directory provider is PAR and linked to group TIN/location effective 6/1/2022.   DCannon"]
["Amanda J Wilson, FNP-BC",1609484419,"84-2617748","TX","PE - Midland Medicine PA","Superior","Participating","Enrollment Complete","2022-06-01","","","2022-06-01","6/1/2022 Rcvd roster from Superior Health Plan confirming provider is PAR and linked to group TIN/location effective 6/1/2022.  DCannon"]
["Amanda J Wilson, FNP-BC",1609484419,"84-2617748","TX","PE - Midland Medicine PA","Superior","Participating","Enrollment Complete","2022-06-01","","","2022-06-01","6/1/2022 Rcvd roster from Superior Health Plan confirming provider is PAR and linked to group TIN/location effective 6/1/2022.  DCannon"]
["Amanda J Wilson, FNP-BC",1609484419,"84-2617748","TX","PE - Midland Medicine PA","Scott&White (First Care)","Participating","Enrollment Complete","2022-05-09","","","2022-08-11","8/11/2022 Rcvd email from Scott & White that monthly delegated roster for June has been completed and providers are loaded to group delegation roster effective 5/9/2022.  DCannon"]
["Amanda J Wilson, FNP-BC",1609484419,"84-2617748","TX","PE - Midland Medicine PA","First Health Coventry","Participating","Enrollment Complete","2022-05-09"," 3558017","","2022-07-28","7/28/2022 Per First Health web portal provider is PAR and linked to group TIN/location effective 5/9/2022.  DCannon"]
["Amanda J Wilson, FNP-BC",1609484419,"84-2617748","TX","PE - Midland Medicine PA","Multiplan","Participating","Enrollment Complete","2022-05-09","","","2022-07-24","7/24/2022 Per email from Marcie Eckhart-Havens Multiplan July delegated roster has been completed  and provider is PAR and linked to group TIN effective 5/9/2022.  DCannon"]
["Amanda J Wilson, FNP-BC",1609484419,"84-2617748","TX","PE - Midland Medicine PA","Tricare Prime","Panel Closed","Panel Closed","","","","2022-09-15","9/15/2022 Per Humana Military web portal Humana Military is currently not accepting requests to join the medical surgical network. We apologize for the inconvenience, but we hope you check back soon to see if we are accepting network providers.  DCannon"]
["Laura Sonnenburg, PA",1003214511,"84-2617748","TX","","BCBSTX","In House Enrollment","In House Enrollment","","","","2023-07-25",""]
["Laura Sonnenburg, PA",1003214511,"84-2617748","TX","PE - Midland Medicine PA","Gallagher","Panel Closed","Panel Closed","","","","2023-07-10","Thru Coventry Health. MS"]
["Laura Sonnenburg, PA",1003214511,"84-2617748","TX","","Ambetter","Participating","Enrollment Complete","2023-09-01","","","2023-10-16","10/16/2023 Rcvd email from Superior that provider is PAR and linked to group TIN/location effective 9/1/2023.  DCannon"]
["Laura Sonnenburg, PA",1003214511,"84-2617748","TX","","Boon Chapman","Participating","Enrollment Complete","2023-08-01","","","2023-09-20","9/20/2023 Per email received from Jessica Bess at Multiplan August roster has been completed.  Provider is PAR and linked to group TIN/location effective 8/1/2023.  DCannon"]
["Laura Sonnenburg, PA",1003214511,"84-2617748","TX","PE - Midland Medicine PA","USA PPO","Participating","Enrollment Complete","2023-08-01","","","2023-11-20","11/20/2023  In following up with USAMCO (800-872-3860) I was told that you can confirm participating via the USA MCO website  https://providersearch.usamco.com/hwprovsearch.  Provider is PAR and linked to locations/TIN effective 8/1/2023.  DCannon"]
["Laura Sonnenburg, PA",1003214511,"84-2617748","TX","PE - Midland Medicine PA","Liberty Mutual","Panel Closed","Panel Closed","","","","2023-07-10","Thru Coventry Health. MS"]
["Laura Sonnenburg, PA",1003214511,"84-2617748","TX","PE - Midland Medicine PA","Galaxy Health","Participating","Enrollment Complete","2023-08-01","","","2023-09-19","9/19/2023 Per email received from Galaxy August delegated roster has been processed and provider is PAR and linked to group/location effective 8/1/2023.  DCannon"]
["Laura Sonnenburg, PA",1003214511,"84-2617748","TX","","Galaxy Health","Participating","Enrollment Complete","2023-08-01","","","2023-09-19","9/19/2023 Per email received from Galaxy August delegated roster has been processed and provider is PAR and linked to group/location effective 8/1/2023.  DCannon"]
["Laura Sonnenburg, PA",1003214511,"84-2617748","TX","PE - Midland Medicine PA","TriCare Standard","In Process","Payor Follow Up","","","","2023-11-01","Emailed Tricare rep to get access so I can update this providers last name and add her to my TIN. She is listed in the system as Laura Quinn. MS"]
["Laura Sonnenburg, PA",1003214511,"84-2617748","TX","","TriCare Standard","In Process","Payor Follow Up","","","","2023-11-01","Emailed Tricare rep to get access so I can update this providers last name and add her to my TIN. She is listed in the system as Laura Quinn. MS"]
["Laura Sonnenburg, PA",1003214511,"84-2617748","TX","PE - Midland Medicine PA","Rail Road Medicare","Participating","Enrollment Complete","2023-06-01","Q00537215","","2023-08-21","Confirmed enrollment. MS"]
["Laura Sonnenburg, PA",1003214511,"84-2617748","TX","","Rail Road Medicare","Participating","Enrollment Complete","2023-06-01","Q00537215","","2023-08-21","Confirmed enrollment. MS"]
["Laura Sonnenburg, PA",1003214511,"84-2617748","TX","PE - Midland Medicine PA","Caprock (CapStar)","Participating","Enrollment Complete","2023-08-01","","","2023-09-12","9/12/2023 Per email received from Caprock provider is PAR and linked to group TIN/location effective 8/1/2023.  DCannon"]
["Laura Sonnenburg, PA",1003214511,"84-2617748","TX","","Caprock (CapStar)","Participating","Enrollment Complete","2023-08-01","","","2023-09-12","9/12/2023 Per email received from Caprock provider is PAR and linked to group TIN/location effective 8/1/2023.  DCannon"]
["Laura Sonnenburg, PA",1003214511,"84-2617748","TX","PE - Midland Medicine PA","Alliance WC","Enrollment Stopped","Action Needed","","","","2023-12-01","Per the above note, new enrollment app can be submitted in December. MS"]
["Laura Sonnenburg, PA",1003214511,"84-2617748","TX","","Alliance WC","Enrollment Stopped","Action Needed","","","","2023-12-01","Per the above note, new enrollment app can be submitted in December. MS"]
["Laura Sonnenburg, PA",1003214511,"84-2617748","TX","PE - Midland Medicine PA","Humana","In Process","Payor Follow Up","","","","2023-11-17","11/17/2023 Sent follow-up email to Marcus Wester at Humana to check status of August monthly delegated roster submission.  Provider Add - CO-16128465, Provider Changes - CO-16128615,  Provider Terms - CO-16128699.  DCannon"]
["Laura Sonnenburg, PA",1003214511,"84-2617748","TX","","Humana","In Process","Payor Follow Up","","","","2023-11-17","11/17/2023 Sent follow-up email to Marcus Wester at Humana to check status of August monthly delegated roster submission.  Provider Add - CO-16128465, Provider Changes - CO-16128615,  Provider Terms - CO-16128699.  DCannon"]
["Laura Sonnenburg, PA",1003214511,"84-2617748","TX","PE - Midland Medicine PA","Wellmed","Participating","Enrollment Complete","2023-08-01","","",45212,"10/13/2023 Provider is PAR and linked to group TIN effective 8/1/2023.  DCannon"]
["Laura Sonnenburg, PA",1003214511,"84-2617748","TX","","Wellmed","Participating","Enrollment Complete","2023-08-01","","",45212,"10/13/2023 Provider is PAR and linked to group TIN effective 8/1/2023.  DCannon"]
["Laura Sonnenburg, PA",1003214511,"84-2617748","TX","PE - Midland Medicine PA","Medicare","Participating","Enrollment Complete","2023-06-01","2W9073","","2023-08-02","Received email confirmation of approval. MS"]
["Laura Sonnenburg, PA",1003214511,"84-2617748","TX","","Medicare","Participating","Enrollment Complete","2023-06-01","2W9073","","2023-08-02","Received email confirmation of approval. MS"]
["Laura Sonnenburg, PA",1003214511,"84-2617748","TX","PE - Midland Medicine PA","Medicare","Participating","Application Submitted","2023-06-01","2W9073","","2023-11-15","Application submitted to update providers last name in the record. T111520230002455  MS"]
["Laura Sonnenburg, PA",1003214511,"84-2617748","TX","","Medicare","Participating","Application Submitted","2023-06-01","2W9073","","2023-11-15","Application submitted to update providers last name in the record. T111520230002455  MS"]
["Laura Sonnenburg, PA",1003214511,"84-2617748","TX","PE - Midland Medicine PA","Superior","Participating","Enrollment Complete","2023-09-01","","","2023-09-13","9/13/2023 Rcvd email from Superior confirming that the August delegated roster provider load has been completed providers are PAR and loaded under TIN/locations effective 9/1/2023.  DCannon"]
["Laura Sonnenburg, PA",1003214511,"84-2617748","TX","","Superior","Participating","Enrollment Complete","2023-09-01","","","2023-09-13","9/13/2023 Rcvd email from Superior confirming that the August delegated roster provider load has been completed providers are PAR and loaded under TIN/locations effective 9/1/2023.  DCannon"]
["Laura Sonnenburg, PA",1003214511,"84-2617748","TX","PE - Midland Medicine PA","Coventry Workers Comp","Panel Closed","Panel Closed","","","","2023-07-10",""]
["Laura Sonnenburg, PA",1003214511,"84-2617748","TX","","Coventry Workers Comp","Panel Closed","Panel Closed","","","","2023-07-10",""]
["Laura Sonnenburg, PA",1003214511,"84-2617748","TX","PE - Midland Medicine PA","Multiplan","Participating","Enrollment Complete","2023-08-01","","","2023-09-20","9/20/2023 Per email received from Jessica Bess at Multiplan August roster has been completed.  Provider is PAR and linked to group TIN/location effective 8/1/2023.  DCannon"]
["Laura Sonnenburg, PA",1003214511,"84-2617748","TX","","Multiplan","Participating","Enrollment Complete","2023-08-01","","","2023-09-20","9/20/2023 Per email received from Jessica Bess at Multiplan August roster has been completed.  Provider is PAR and linked to group TIN/location effective 8/1/2023.  DCannon"]
["Laura Sonnenburg, PA",1003214511,"84-2617748","TX","PE - Midland Medicine PA","Aetna","Participating","Enrollment Complete","2023-08-01","4929401","","2023-09-19","09.19.2023 S/W IceB of Aetna @ 1-800-353-1232. Per rep, provider is in network with Aetna for the state of TX and participating under the group and TIN# effective 08/01/2023. PIN: 4929401. Physical location is on file. No next recredentialing date available. Payer# 60054. Call ref# 6163752278. - Willie Ravas"]
["Laura Sonnenburg, PA",1003214511,"84-2617748","TX","","Aetna","Participating","Enrollment Complete","2023-08-01","4929401","","2023-09-19","09.19.2023 S/W IceB of Aetna @ 1-800-353-1232. Per rep, provider is in network with Aetna for the state of TX and participating under the group and TIN# effective 08/01/2023. PIN: 4929401. Physical location is on file. No next recredentialing date available. Payer# 60054. Call ref# 6163752278. - Willie Ravas"]
["Laura Sonnenburg, PA",1003214511,"84-2617748","TX","PE - Midland Medicine PA","Broadspire Services Inc.","In Process","Pending Info/Document","","","","2023-11-20","Midland Medicine PA is not in contract with Broadspire. Emailed MQA to see is they want to pursue group contract. Jen Videan"]
["Laura Sonnenburg, PA",1003214511,"84-2617748","TX","","Broadspire Services Inc.","In Process","Pending Info/Document","","","","2023-11-20","Midland Medicine PA is not in contract with Broadspire. Emailed MQA to see is they want to pursue group contract. Jen Videan"]
["Laura Sonnenburg, PA",1003214511,"84-2617748","TX","PE - Midland Medicine PA","United Health Care","Participating","Enrollment Complete","2023-08-01","00005273773","","2023-10-13","10/13/2023 Per email received from  from UHC monthly delegated roster submission has been completed and provider is PAR and in linked to group TIN effective 8/1/2023.   MPIN# 00005273773.   DCannon"]
["Laura Sonnenburg, PA",1003214511,"84-2617748","TX","","United Health Care","Participating","Enrollment Complete","2023-08-01","00005273773","","2023-10-13","10/13/2023 Per email received from  from UHC monthly delegated roster submission has been completed and provider is PAR and in linked to group TIN effective 8/1/2023.   MPIN# 00005273773.   DCannon"]
["Laura Sonnenburg, PA",1003214511,"84-2617748","TX","PE - Midland Medicine PA","Scott&White (First Care)","Participating","Enrollment Complete","2023-09-14","","","2023-09-29","9/29/2023 Rcvd confirmation from Scott & White that provider has been loaded at all locations effective 9/14/2023.  DCannon"]
["Laura Sonnenburg, PA",1003214511,"84-2617748","TX","","Scott&White (First Care)","Participating","Enrollment Complete","2023-09-14","","","2023-09-29","9/29/2023 Rcvd confirmation from Scott & White that provider has been loaded at all locations effective 9/14/2023.  DCannon"]
["Laura Sonnenburg, PA",1003214511,"84-2617748","TX","PE - Midland Medicine PA","Cigna","Participating","Enrollment Complete","2023-10-11","","","2023-10-12","Received enrollment confirmation email. MS"]
["Laura Sonnenburg, PA",1003214511,"84-2617748","TX","","Cigna","Participating","Enrollment Complete","2023-10-11","","","2023-10-12","Received enrollment confirmation email. MS"]
["Laura Sonnenburg, PA",1003214511,"84-2617748","TX","PE - Midland Medicine PA","Texas Municipal League","Enrollment Stopped","Thru Other Payor","","","","2023-11-20","Pleased see noted under the Alliance payor line. New enrollment app should be submitted in December. MS"]
["Laura Sonnenburg, PA",1003214511,"84-2617748","TX","","Texas Municipal League","Enrollment Stopped","Thru Other Payor","","","","2023-11-20","Pleased see noted under the Alliance payor line. New enrollment app should be submitted in December. MS"]
["Laura Sonnenburg, PA",1003214511,"84-2617748","TX","PE - Midland Medicine PA","Medicaid","In Process","Action Needed","","","","2023-11-22","Please provide a follow up status. MS"]
["Laura Sonnenburg, PA",1003214511,"84-2617748","TX","","Medicaid","In Process","Action Needed","","","","2023-11-22","Please provide a follow up status. MS"]
["Jeffrey Hunter Atkins, MD",1760860720,"84-2617748","TX","PE - Midland Medicine PA","Superior","Participating","Enrollment Complete","2022-06-01","","","2022-06-01","6/1/2022 Rcvd roster from Superior Health Plan confirming provider is PAR and linked to group TIN/location effective 6/1/2022.  DCannon"]
["Jeffrey Hunter Atkins, MD",1760860720,"84-2617748","TX","PE - Midland Medicine PA","CAQH","Participating","CAQH Reattested","2023-11-01","","","2023-11-01","11/01/2023- Updated License, address, credential contact and reattested - rkedar"]
["Jeffrey Hunter Atkins, MD",1760860720,"84-2617748","TX","PE - Midland Medicine PA","CAQH","Participating","CAQH Reattested","2023-11-01","","","2023-11-01","11/01/2023- Updated License, address, credential contact and reattested - rkedar"]
["Jeffrey Hunter Atkins, MD",1760860720,"84-2617748","TX","PE - Premier Family Care, Inc","CAQH","Participating","CAQH Reattested","2023-11-01","","","2023-11-01","11/01/2023- Updated License, address, credential contact and reattested - rkedar"]
["Jeffrey Hunter Atkins, MD",1760860720,"84-2617748","TX","PE - Midland Medicine PA","Galaxy Health","Participating","Enrollment Complete","2022-06-01","","","2022-08-17","8/17/2022 Per email from Karen Avalos at Galaxy delegated roster for May is complete and provider is loaded effective 6/1/2022.  DCannon"]
["Jeffrey Hunter Atkins, MD",1760860720,"84-2617748","TX","PE - Midland Medicine PA","Omni PPO","Participating","Enrollment Complete","2022-06-01","","","2022-07-05","7/5/2022 Rcvd email from G.Aviles at IMS/OMNI that delegation roster provider load for June has been completed.  Provider is PAR and linked to group effective 6/1/2022.  DCannon"]
["Jeffrey Hunter Atkins, MD",1760860720,"84-2617748","TX","PE - Midland Medicine PA","IMS","Participating","Enrollment Complete","2022-06-01","","","2022-07-05","7/5/2022 Rcvd email from G.Aviles at IMS/OMNI that delegation roster provider load for June has been completed.  Provider is PAR and linked to group effective 6/1/2022.  DCannon"]
["Jeffrey Hunter Atkins, MD",1760860720,"84-2617748","TX","PE - Premier Family Care, Inc","IMS","Participating","Enrollment Complete","2022-06-01","","","2022-07-05","7/5/2022 Rcvd email from G.Aviles at IMS/OMNI that delegation roster provider load for June has been completed.  Provider is PAR and linked to group effective 6/1/2022.  DCannon"]
["Jeffrey Hunter Atkins, MD",1760860720,"84-2617748","TX","PE - Midland Medicine PA","Aetna","Participating","Enrollment Complete","2022-06-01","6107649","","2022-06-02","6/2/2022 Per Aetna provider directory provider is PAR and linked to group TIN/location effective 6/1/2022.   DCannon"]
["Jeffrey Hunter Atkins, MD",1760860720,"84-2617748","TX","PE - Midland Medicine PA","Scott&White (First Care)","Participating","Enrollment Complete","2022-06-01","","","2022-08-11","8/11/2022 Rcvd email from Scott & White that monthly delegated roster for June has been completed and providers are loaded to group delegation roster effective 6/1/2022.  DCannon"]
["Jeffrey Hunter Atkins, MD",1760860720,"84-2617748","TX","PE - Midland Medicine PA","Caprock (CapStar)","Participating","Enrollment Complete","2020-01-01","","","2022-10-12","10/12/2022 Per email from Priscilla Albertine she rcvd confirmation from Mary Rodriguez at Caprock that provider is PAR and linked to group TIN/locations effective 1/1/2020.  DCannon"]
["Jeffrey Hunter Atkins, MD",1760860720,"84-2617748","TX","PE - Midland Medicine PA","Medicare","Participating","Enrollment Complete","2022-06-01","IN5324","IN5325","2022-06-08","6/8/2022 Per PECOS location has been added to group PTAN # and provider is now linked to location effective 6/1/2022, PTAN # IN5324.  DCannon"]
["Jeffrey Hunter Atkins, MD",1760860720,"84-2617748","TX","PE - Midland Medicine PA","United Health Care","Participating","Enrollment Complete","2022-06-01","006780333","","2022-06-29","6/29/2022 Per email received from  from UHC monthly delegated roster submission has been completed and provider is PAR and in linked to group TIN effective 6/1/2022.   MPIN# 006780333.   DCannon"]
["Jeffrey Hunter Atkins, MD",1760860720,"84-2617748","TX","PE - Midland Medicine PA","Humana","Participating","Enrollment Complete","2022-06-01","","","2022-07-14","7/14/2022 Per email received from Humana provider is PAR and linked to group TIN/location effective 6/1/2022.  DCannon"]
["Jeffrey Hunter Atkins, MD",1760860720,"84-2617748","TX","PE - Midland Medicine PA","Ambetter","Participating","Enrollment Complete","2022-06-01","","","2022-06-13","6/13/2022 Per roster received from Superior provider is PAR and linked to group delegation roster effective 6/1/2022."]
["Jeffrey Hunter Atkins, MD",1760860720,"84-2617748","TX","PE - Midland Medicine PA","First Health Coventry","Participating","Enrollment Complete","2022-06-01","3165776","","2022-08-10","8/10/2022 Per First Health web portal provider is PAR and linked to group TIN/location effective 6/1/2022.  PID# 3165776 DCannon"]
["Jeffrey Hunter Atkins, MD",1760860720,"84-2617748","TX","PE - Midland Medicine PA","Multiplan","Participating","Enrollment Complete","2022-06-01","","","2022-07-24","7/24/2022 Per email from Marcie Eckhart-Havens Multiplan July delegated roster has been completed  and provider is PAR and linked to group TIN effective 6/1/2022.  DCannon"]
["Jeffrey Hunter Atkins, MD",1760860720,"84-2617748","TX","PE - Midland Medicine PA","Boon Chapman","Participating","Enrollment Complete","2022-06-01","","","2022-07-24","7/24/2022 Per email from Marcie Eckhart-Havens Multiplan July delegated roster has been completed  and provider is PAR and linked to group TIN effective 6/1/2022.  DCannon"]
["Jeffrey Hunter Atkins, MD",1760860720,"84-2617748","TX","PE - Midland Medicine PA","HealthSmart PPO","Participating","Enrollment Complete","2022-06-01","","","2022-07-14","7/14/2022 Per Healthsmart website provider is PAR and loaded under TIN/location effective 6/1/2022.  DCannon"]
["Jeffrey Hunter Atkins, MD",1760860720,"84-2617748","TX","PE - Midland Medicine PA","TriCare Standard","Participating","Enrollment Complete","2022-07-14","","","2022-07-21","7/21/2022 Per Tricare portal provider is PAR and linked to group TIN/ new location effective 7/14/2022.  DCannon"]
["Jeffrey Hunter Atkins, MD",1760860720,"84-2617748","TX","PE - Midland Medicine PA","Wellcare","Participating","Enrollment Complete","2022-06-01","","","2022-07-01","7/1/2022 Received June Monthly Validation roster from Superior and provider is PAR and linked effective 6/1/2022.  DCannon"]
["Jeffrey Hunter Atkins, MD",1760860720,"84-2617748","TX","PE - Midland Medicine PA","Wellmed","Participating","Enrollment Complete","2022-01-01","","","2023-03-23","3/23/2023 Rcvd roster from UHC w/ all Wellmed participating providers.  Provider is PAR effective 1/1/2022.  DCannon"]
["Jeffrey Hunter Atkins, MD",1760860720,"84-2617748","TX","PE - Midland Medicine PA","Rail Road Medicare","Participating","Enrollment Complete","2021-04-01","P02614743","EA8735","2023-10-20","10/20/2023  RR PTAN P02614743, and group RR PTAN EA8735, effective 4/1/2021. DCannon"]
["Jeffrey Hunter Atkins, MD",1760860720,"84-2617748","TX","PE - Midland Medicine PA","Cigna","Participating","Enrollment Complete","2022-06-01","8771157","","2022-05-26","5/26/2022 Rcvd email from Cigna that providers new location has been added and linked to group TIN effective 6/1/2022.  PID # 8771157.  DCannon"]
["Jeffrey Hunter Atkins, MD",1760860720,"84-2617748","TX","PE - Midland Medicine PA","Amerigroup","Participating","Enrollment Complete","2022-06-01","","","2022-09-23","9/23/2022 Per roster received from Joe Rodriguez at Amerigroup provider is PAR and linked to group TIN effective 6/1/2022.  DCannon"]
["Jeffrey Hunter Atkins, MD",1760860720,"84-2617748","TX","PE - Midland Medicine PA","Medicaid","In Process","Pending Other Enrollment","","","","2023-11-01","Unable to complete individual enrollment until 1407 W Illinois and 5212 Sinclair get added to the group enrollment. Follow up email sent to Priscilla and Neeraja. Jen Videan"]
["Abiodun A Okin-Ayileka, MD",1922328079,"84-4724927","ME","PE - ADA Adult and Children Family Clinic LLC","United Health Care","Participating","Enrollment Complete","2021-04-13","1922328079","","2021-03-30","3/30/2021 Received email from Rep Kelly Johnson at kelly_l_johnson@uhc.com confirming group and provider are now participating effective 4/13/2021. KFrazier"]
["Abiodun A Okin-Ayileka, MD",1922328079,"84-4724927","TX","PE - ADA Adult and Children Family Clinic LLC","Amerigroup","Participating","Enrollment Complete","2023-07-15","","","2023-10-18","10/18/2023 Per email received from Jessica Bess at  Multiplan provider is PAR with Amerigroup and linked to group TIN/locations thru Multiplan enrollment effective 7/15/2023.  DCannon"]
["Abiodun A Okin-Ayileka, MD",1922328079,"84-4724927","ME","PE - ADA Adult and Children Family Clinic LLC","Ambetter","Participating","Enrollment Complete","2022-04-01","","","2022-06-13","6/13/2022 Per roster received from Superior provider is PAR and linked to group delegation roster effective 4/1/2022."]
["Abiodun A Okin-Ayileka, MD",1922328079,"84-4724927","TX","PE - ADA Adult and Children Family Clinic LLC","Cigna","Participating","Enrollment Complete","2019-09-01","","","2023-08-14","08.14.2023 S/W Sam of Cigna @ 1-800-882-4462, Provider is showing participating and link under the Group and TIN with an Effective date 09/01/2019. Provider ID 9763901. Service address is on file. Call ref#:SamB08142023.-Danico Gabriel Melendres"]
["Abiodun A Okin-Ayileka, MD",1922328079,"84-4724927","ME","PE - ADA Adult and Children Family Clinic LLC","Omni PPO","Participating","Enrollment Complete","2019-09-01","1922328079","","2020-07-27","IMS complete"]
["Abiodun A Okin-Ayileka, MD",1922328079,"84-4724927","TX","PE - ADA Adult and Children Family Clinic LLC","Galaxy Health","Participating","Enrollment Complete","2023-07-15","","","2023-07-25","7/25/2023 Per email received from Galaxy June delegated roster has been processed and provider is PAR and linked to group effective 7/15/2023.  DCannon"]
["Abiodun A Okin-Ayileka, MD",1922328079,"84-4724927","ME","PE - ADA Adult and Children Family Clinic LLC","Caprock (CapStar)","Participating","Enrollment Complete","2020-06-01","","","2020-06-01",""]
["Abiodun A Okin-Ayileka, MD",1922328079,"84-4724927","TX","PE - ADA Adult and Children Family Clinic LLC","Wellmed","Participating","Enrollment Complete","2023-07-15","","","2023-10-02","10/2/2023 Per email response from UHC June delegated roster is provider load is complete.  Provider is PAR and linked to group TIN/location effective 7/15/2023.  DCannon"]
["Abiodun A Okin-Ayileka, MD",1922328079,"84-4724927","TX","PE - ADA Adult and Children Family Clinic LLC","Sedgwick","Enrollment Stopped","Enrollment Stopped","","","","2023-11-27","Per MQA, I’ve now received word from ADA Adult and Children Family Clinic, LLC they are not seeking Worker’s Comp enrollments, per attached.\nPlease discontinue WC enrollments for this TIN at this time. Jen Videan"]
["Abiodun A Okin-Ayileka, MD",1922328079,"84-4724927","TX","PE - ADA Adult and Children Family Clinic LLC","Multiplan","Participating","Enrollment Complete","2023-07-15","","","2023-07-25","7/25/2023 Rcvd email confirmation from Jessica Bess at Multiplan that June roster has been processed and provider is PAR w/ group effective 7/15/2023.  DCannon"]
["Abiodun A Okin-Ayileka, MD",1922328079,"84-4724927","ME","PE - ADA Adult and Children Family Clinic LLC","Omni PPO","Participating","Enrollment Complete","2023-07-15","","","2023-07-18","7/18/2023 Per email received from IMS/OMNI June delegated roster has been processed and provider is PAR and linked to group effective 7/15/2023.  DCannon"]
["Abiodun A Okin-Ayileka, MD",1922328079,"84-4724927","ME","PE - ADA Adult and Children Family Clinic LLC","IMS","Participating","Enrollment Complete","2023-07-15","","","2023-07-18","7/18/2023 Per email received from IMS/OMNI June delegated roster has been processed and provider is PAR and linked to group effective 7/15/2023.  DCannon"]
["Abiodun A Okin-Ayileka, MD",1922328079,"84-4724927","ME","PE - ADA Adult and Children Family Clinic LLC","Cigna","Participating","Enrollment Complete","2019-09-01","9763901","","2020-06-22","06/22/2020 - Rec'd effective email from the payer - Stacey Hudak"]
["Abiodun A Okin-Ayileka, MD",1922328079,"84-4724927","TX","PE - ADA Adult and Children Family Clinic LLC","Boon Chapman","Participating","Enrollment Complete","2023-07-15","","","2023-07-25","7/25/2023 Rcvd email confirmation from Jessica Bess at Multiplan that June roster has been processed and provider is PAR w/ group effective 7/15/2023.  DCannon"]
["Abiodun A Okin-Ayileka, MD",1922328079,"84-4724927","ME","PE - ADA Adult and Children Family Clinic LLC","Scott&White (First Care)","Participating","Enrollment Complete","2020-09-28","","","2021-01-29","1/29/2021 - Rcvd roster from Scott&White (First Care) confirming participation of provider with TIN and location effective dates.  DCannon"]
["Abiodun A Okin-Ayileka, MD",1922328079,"84-4724927","TX","PE - ADA Adult and Children Family Clinic LLC","Aetna","Participating","Enrollment Complete","2020-08-01","","","2023-08-17","8/17/2023 Per email from Priscilla Albertine at MQA she received a roster confirming that provider is PAR and linked to group TIN/location effective 8/1/2020.  DCannon"]
["Abiodun A Okin-Ayileka, MD",1922328079,"84-4724927","TX","PE - ADA Adult and Children Family Clinic LLC","Medicare","Participating","Enrollment Complete","","","","2023-10-12","Confirmed the new location has been added to the group enrollment. MS"]
["Abiodun A Okin-Ayileka, MD",1922328079,"84-4724927","TX","ADA Adult and Children Family Clinic LLC","Aetna","Participating","Enrollment Complete","2020-08-01","1922328079","",44096,"9/22/2020 Provider is PAR and linked to group effective 8/1/2020."]
["Abiodun A Okin-Ayileka, MD",1922328079,"84-4724927","TX","PE - ADA Adult and Children Family Clinic LLC","HealthSmart PPO","Participating","Enrollment Complete","2023-05-01","","","2023-11-13","11/13/2023 Per phone conversation with Lee Kinard at Healthsmart provider is PAR and linked to group TIN/location effective 5/1/2023.  DCannon"]
["Abiodun A Okin-Ayileka, MD",1922328079,"84-4724927","ME","PE - ADA Adult and Children Family Clinic LLC","Superior","Participating","Enrollment Complete","2020-08-01","1922328079","","2020-09-02","09/02/2020 - Rec'd emailed confirmation from the payer stating this provider has been added to the PriMed delegation - Stacey Hudak"]
["Abiodun A Okin-Ayileka, MD",1922328079,"84-4724927","ME","PE - ADA Adult and Children Family Clinic LLC","Rail Road Medicare","Participating","Enrollment Complete","2020-03-30","Q00252376","EB5513","2022-04-28","4/28/2022 Rcvd RR Medicare approval letter.   PTAN # Q00252376 - effective 3/30/2020.  DCannon"]
["Abiodun A Okin-Ayileka, MD",1922328079,"84-4724927","ME","PE - ADA Adult and Children Family Clinic LLC","Galaxy Health","Participating","Enrollment Complete","2019-09-01","1922328079","","2020-08-21","08/21/2020 - Rec'd email confirmation that this roster was processed and this provider was made effective with the requested eff date of 9-1-2019 - Stacey Hudak"]
["Abiodun A Okin-Ayileka, MD",1922328079,"84-4724927","TX","PE - ADA Adult and Children Family Clinic LLC","USA PPO","Participating","Enrollment Complete","2023-07-01","","","2023-08-23","8/23/2023 In following up with USAMCO (800-872-3860) I was told that you can confirm participating via the USA MCO website  https://providersearch.usamco.com/hwprovsearch.  Provider is PAR and linked to location/TIN effective 7/1/2023.  DCannon"]
["Abiodun A Okin-Ayileka, MD",1922328079,"84-4724927","ME","PE - ADA Adult and Children Family Clinic LLC","First Health Coventry","Participating","Enrollment Complete","2020-06-12","","","2023-07-21","7/21/2023 Per email received from Priscilla Albertine provider is PAR and linked to group/TIN effective 7/15/2023.  DCannon"]
["Abiodun A Okin-Ayileka, MD",1922328079,"84-4724927","ME","","First Health Coventry","Participating","Enrollment Complete","2020-06-12","","","2023-07-21","7/21/2023 Per email received from Priscilla Albertine provider is PAR and linked to group/TIN effective 7/15/2023.  DCannon"]
["Abiodun A Okin-Ayileka, MD",1922328079,"84-4724927","ME","PE - ADA Adult and Children Family Clinic LLC","First Health Coventry","Participating","Enrollment Complete","2020-06-12","","","2023-10-09","10/9/2023 Rcvd email confirmation from Priscilla at MQA that provider effective date has been back dated to 6/12/2020 and the new location has been added.  DCannon"]
["Abiodun A Okin-Ayileka, MD",1922328079,"84-4724927","ME","","First Health Coventry","Participating","Enrollment Complete","2020-06-12","","","2023-10-09","10/9/2023 Rcvd email confirmation from Priscilla at MQA that provider effective date has been back dated to 6/12/2020 and the new location has been added.  DCannon"]
["Abiodun A Okin-Ayileka, MD",1922328079,"84-4724927","TX","PE - ADA Adult and Children Family Clinic LLC","Wellcare","Participating","Enrollment Complete","2023-07-01","","","2023-07-21","7/21/2023 Rcvd confirmation email from Superior that June delegation roster has been processed and provider has been loaded to delegation roster and PAR w/ group effective 7/1/2023.  DCannon"]
["Abiodun A Okin-Ayileka, MD",1922328079,"84-4724927","ME","PE - ADA Adult and Children Family Clinic LLC","CAQH","Participating","CAQH Reattested","2023-11-13","12577050","","2023-11-13","11/13/2023 CAQH Reattested WT"]
["Abiodun A Okin-Ayileka, MD",1922328079,"84-4724927","ME","ADA Adult and Children Family Clinic LLC","CAQH","Participating","CAQH Reattested","2023-11-13","12577050","","2023-11-13","11/13/2023 CAQH Reattested WT"]
["Abiodun A Okin-Ayileka, MD",1922328079,"84-4724927","TX","ADA Adult and Children Family Clinic LLC","CAQH","Participating","CAQH Reattested","2023-11-13","12577050","","2023-11-13","11/13/2023 CAQH Reattested WT"]
["Abiodun A Okin-Ayileka, MD",1922328079,"84-4724927","TX","ADA Adult and Children Family Clinic LLC","CAQH","Participating","CAQH Reattested","2023-11-13","12577050","","2023-11-13","11/13/2023 CAQH Reattested WT"]
["Abiodun A Okin-Ayileka, MD",1922328079,"84-4724927","ME","PE - ADA Adult and Children Family Clinic LLC","Triwest VA","Facility Enrollment","Facility Enrollment","","","","2022-11-23","10/17/2022 - Received roster from Scarlett of TriWest VA; provider status: \"No Action.  TIN is CCN participating under own DCN.\""]
["Abiodun A Okin-Ayileka, MD",1922328079,"84-4724927","TX","PE - ADA Adult and Children Family Clinic LLC","Superior","Participating","Enrollment Complete","2023-07-01","","","2023-07-21","7/21/2023 Rcvd confirmation email from Superior that June delegation roster has been processed and provider has been loaded to delegation roster and PAR w/ group effective 7/1/2023.  DCannon"]
["Abiodun A Okin-Ayileka, MD",1922328079,"84-4724927","TX","PE - ADA Adult and Children Family Clinic LLC","United Health Care","Participating","Enrollment Complete","2023-07-15","","","2023-09-07","9/7/2023 Per email response from UHC June delegated roster is provider load is complete.  Provider is PAR and linked to group TIN/location effective 7/15/2023.  DCannon"]
["Abiodun A Okin-Ayileka, MD",1922328079,"84-4724927","TX","PE - ADA Adult and Children Family Clinic LLC","First Health Coventry","Participating","Enrollment Complete","2020-06-12","","","2023-10-09","10/9/2023 Rcvd email confirmation from Priscilla at MQA that provider effective date has been back dated to 6/12/2020 and the new location has been added.  DCannon"]
["Abiodun A Okin-Ayileka, MD",1922328079,"84-4724927","TX","ADA Adult and Children Family Clinic LLC","TriCare Standard","Participating","Enrollment Complete","2020-10-28","","","2020-11-17","11/17/2020 - Checked the Humana-Military website provider credentialing is completed effective 10/28/20.  DCannon"]
["Abiodun A Okin-Ayileka, MD",1922328079,"84-4724927","ME","PE - ADA Adult and Children Family Clinic LLC","IMS","Participating","Enrollment Complete","2019-09-01","1922328079","","2020-07-27","07/27/2020 - Rec'd roster response back from the payer regarding 7/15/2020 submission stating that all requested providers/service locations have been added to PriMed agreement - Stacey Hudak"]
["Abiodun A Okin-Ayileka, MD",1922328079,"84-4724927","TX","PE - ADA Adult and Children Family Clinic LLC","Scott&White (First Care)","Participating","Enrollment Complete","2023-07-15","","","2023-08-17","8/17/2023 Received email from Scott & White HPDELEGATION@BSWHealth.org that provider load from June has been completed and provider is PAR effective 7/15/2023.  DCannon"]
["Abiodun A Okin-Ayileka, MD",1922328079,"84-4724927","ME","PE - ADA Adult and Children Family Clinic LLC","USA PPO","Participating","Enrollment Complete","2021-01-26","1238258","","2021-03-12","3/12/2021 Per verification on payor website USAMCO.com provider is loaded as participating.  Rcvd Roster LeNetrice Myart with provider numbers and effective dates for providers.  DCannon"]
["Abiodun A Okin-Ayileka, MD",1922328079,"84-4724927","ME","PE - ADA Adult and Children Family Clinic LLC","HealthSmart PPO","Participating","Enrollment Complete","2020-05-15","","","2021-12-03","12/3/2021 Per Healthsmart website provider is PAR and loaded under TIN/location effective 5/15/2020.  DCannon"]
["Abiodun A Okin-Ayileka, MD",1922328079,"84-4724927","ME","PE - ADA Adult and Children Family Clinic LLC","Multiplan","Participating","Enrollment Complete","2021-05-28","","","2021-09-15","9/15/2021 Received roster from Multiplan listing provider as PAR under group TIN/location effective 5/28/2021.  DCannon"]
["Abiodun A Okin-Ayileka, MD",1922328079,"84-4724927","ME","PE - ADA Adult and Children Family Clinic LLC","Wellmed","Participating","Enrollment Complete","2022-01-01","","","2023-03-23","3/23/2023 Rcvd roster from UHC w/ all Wellmed participating providers.  Provider is PAR effective 1/1/2022.  DCannon"]
["Abiodun A Okin-Ayileka, MD",1922328079,"84-4724927","TX","PE - ADA Adult and Children Family Clinic LLC","Caprock (CapStar)","Participating","Enrollment Complete","2023-07-15","","","2023-07-26","7/26/2023 Rcvd email  confirmation from Caprock that provider is PAR and linked to group TIN/locations effective 7/15/2023.  DCannon"]
["Abiodun A Okin-Ayileka, MD",1922328079,"84-4724927","ME","PE - ADA Adult and Children Family Clinic LLC","Liberty Mutual","Enrollment Stopped","Enrollment Stopped","","","","2021-08-05","8/4/2021 Provider does not see WC patients; therefore, enrollment has stopped. KFrazier"]
["Abiodun A Okin-Ayileka, MD",1922328079,"84-4724927","TX","PE - ADA Adult and Children Family Clinic LLC","Triwest VA","In House Enrollment","In House Enrollment","","","","2023-06-14",""]
["Abiodun A Okin-Ayileka, MD",1922328079,"84-4724927","TX","PE - ADA Adult and Children Family Clinic LLC","Ambetter","Participating","Enrollment Complete","2023-07-01","","","2023-07-21","7/21/2023 Rcvd confirmation email from Superior that June delegation roster has been processed and provider has been loaded to delegation roster and PAR w/ group effective 7/1/2023.  DCannon"]
["Abiodun A Okin-Ayileka, MD",1922328079,"84-4724927","ME","PE - ADA Adult and Children Family Clinic LLC","Amerigroup","Participating","Enrollment Complete","2019-09-18","","","2021-08-26","8/26/2021 Rcvd full roster from Joe Rodriguez at Amerigroup listing provider as PAR w/ group TIN and location effective 9/18/2019.  DCannon"]
["Abiodun A Okin-Ayileka, MD",1922328079,"84-4724927","ME","ADA Adult and Children Family Clinic LLC","Amerigroup","Participating","Enrollment Complete","2019-09-18","","","2021-08-26","8/26/2021 Rcvd full roster from Joe Rodriguez at Amerigroup listing provider as PAR w/ group TIN and location effective 9/18/2019.  DCannon"]
["Abiodun A Okin-Ayileka, MD",1922328079,"84-4724927","TX","ADA Adult and Children Family Clinic LLC","Amerigroup","Participating","Enrollment Complete","2019-09-18","","","2021-08-26","8/26/2021 Rcvd full roster from Joe Rodriguez at Amerigroup listing provider as PAR w/ group TIN and location effective 9/18/2019.  DCannon"]
["Abiodun A Okin-Ayileka, MD",1922328079,"84-4724927","TX","ADA Adult and Children Family Clinic LLC","Amerigroup","Participating","Enrollment Complete","2019-09-18","","","2021-08-26","8/26/2021 Rcvd full roster from Joe Rodriguez at Amerigroup listing provider as PAR w/ group TIN and location effective 9/18/2019.  DCannon"]
["Abiodun A Okin-Ayileka, MD",1922328079,"84-4724927","ME","PE - ADA Adult and Children Family Clinic LLC","Boon Chapman","Participating","Enrollment Complete","2021-05-28","","","2021-09-15","9/15/2021 Received roster from Multiplan listing provider as PAR under group TIN/location effective 5/28/2021.  DCannon"]
["Abiodun A Okin-Ayileka, MD",1922328079,"84-4724927","ME","PE - ADA Adult and Children Family Clinic LLC","Medicare","Participating","Enrollment Complete","2020-03-30","1B0151","1B0142","2020-06-23","06/23/2020 - Rec'd PECOS login and was able to verify providers EFF info with group - Stacey Hudak"]
["Abiodun A Okin-Ayileka, MD",1922328079,"84-4724927","TX","PE - ADA Adult and Children Family Clinic LLC","Humana","Participating","Enrollment Complete","2023-07-15","","","2023-10-27","10/27/2023 Per email received from Humana provider is PAR and linked to group TIN/locations effective 7/15/2023.  DCannon"]
["Abiodun A Okin-Ayileka, MD",1922328079,"84-4724927","ME","PE - ADA Adult and Children Family Clinic LLC","Sedgwick","Participating","Enrollment Complete","2021-01-26","","","2021-05-06","5/6/2021  In following up with USAMCO (800-872-3860) I was told that you can confirm participating via the USA MCO website  https://providersearch.usamco.com/hwprovsearch.  Provider is PAR and linked to location/TIN effective 1/26/2021.  DCannon"]
["Abiodun A Okin-Ayileka, MD",1922328079,"84-4724927","TX","PE - ADA Adult and Children Family Clinic LLC","Medicaid","In Process","Pending Info/Document","","","","2023-11-27","Per TMHP, Dr. Okin currently has a request in progress preventing me from making any updates. There is a draft started by McCamey County Hospital District that either needs to be completed or cancelled. I submitted an escalation request to have this cancelled by TMHP, however, it takes up to 30 days. Please let me know if McCamey County Hospital District is a current employer that needs to complete this request or if they can go in and cancel prior to 30 days. Emailed MQA for assistance. Jen Videan"]
["Basin Dermatology",1063003754,"85-3162122","TX","PE - Basin Dermatology","United Health Care","Participating","Enrollment Complete","2021-09-03","","","2021-08-20","8/19/2021 Received group executed group agreement confirming participation for Dr. Caglia, which is effective 9/3/2021, which was forwarded to Rebecca Pontaski for distribution to the appropriate staff.  KFrazier"]
["Basin Dermatology",1063003754,"85-3162122","TX","PE - Basin Dermatology","Medicare","Participating","Enrollment Complete","2021-04-28","","1T8900","2021-09-15","9/9/2021 Received approval from Medicare that provider and group have been approved.  Group PTAN # 1T8900 and Individual Provider PTAN # 1T8899 - effective 4/28/2021.  DCannon"]
["Basin Dermatology",1063003754,"85-3162122","TX","PE - Basin Dermatology","Tricare Prime","Panel Closed","Panel Closed","","","","2023-10-20",""]
["Adrienne C Do, PA",1003372418,"85-3162122","TX","PE - Basin Dermatology","United Health Care","Participating","Enrollment Complete","2021-09-03","","","2021-10-20","10/20/21 Received email from debra_keck@uhc.com, provider completem par as of 9/03/21. Cbankston"]
["Adrienne C Do, PA",1003372418,"85-3162122","TX","PE - Basin Dermatology","Boon Chapman","Participating","Enrollment Complete","2021-09-15","13774270","","2022-02-24","2/24/2022 Per follow-up note from 2/22/2022 - NPI# for the provider is on file, shows Linked and Par under the TIN#, effective 9/15/2021, the physical location is on file and the Provider ID is 13774270. Case ref#7923274. - DCannon"]
["Adrienne C Do, PA",1003372418,"85-3162122","TX","PE - Basin Dermatology","Aetna","Participating","Enrollment Complete","2021-09-15","","","2021-10-29","10/29/2021 Per email from Mary Hanna at Aetna provider is PAR and linked to group TIN and location effective 9/15/2021.  DCannon"]
["Adrienne C Do, PA",1003372418,"85-3162122","TX","PE - Basin Dermatology","Medicare","Participating","Enrollment Complete","2021-09-01","1U3424","1T8900","2021-09-25","9/25/2021 Per PECOS provider is PAR and linked to group/locations.  PTAN # 1U3424 - effective 9/1/2021.  DCannon"]
["Adrienne C Do, PA",1003372418,"85-3162122","TX","PE - Basin Dermatology","First Health Coventry","In Process","Application Submitted","","","","2023-10-26","10/26/2023 Delegated roster submitted 9/15/2023 still in process.   DCannon"]
["Adrienne C Do, PA",1003372418,"85-3162122","TX","PE - Basin Dermatology","HealthSmart PPO","Participating","Enrollment Complete","2021-08-26","","","2021-12-03","12/3/2021 Per Healthsmart website provider is PAR and loaded under TIN/location effective 8/26/2021.  DCannon"]
["Adrienne C Do, PA",1003372418,"85-3162122","TX","PE - Basin Dermatology","Triwest VA","Participating","Enrollment Complete","2022-11-14","","","2022-11-14","11/14/22 Per Scarlett Abigail, provider effective 8/1/22"]
["Adrienne C Do, PA",1003372418,"85-3162122","TX","PE - Basin Dermatology","CAQH","Participating","CAQH Reattested","2023-10-03","","","2023-10-03","10/03/2023 - Updated License, DEA, Liability and re-attested - rkedare"]
["Adrienne C Do, PA",1003372418,"85-3162122","TX","PE - Basin Dermatology","IMS","Participating","Enrollment Complete","2021-08-26","","","2021-10-22","10/22/2021 Rcvd email from German Aviles at IMS/OMNI that delegation roster for September has been completed and updated in their system effective 8/26/2021.  DCannon"]
["Adrienne C Do, PA",1003372418,"85-3162122","TX","PE - Basin Dermatology","TriCare Standard","Participating","Enrollment Complete","2021-12-15","","","2022-02-10","2/10/2022 Per tricare portal, provider is linked to location as of 12/15/2021. Cbankston"]
["Adrienne C Do, PA",1003372418,"85-3162122","TX","PE - Basin Dermatology","Galaxy Health","Participating","Enrollment Complete","2021-08-26","","","2021-09-16","9/16/2021 Rcvd email from Galaxy that delegated roster for September has been processed and provider is PAR and linked to group TIN/locations effective 8/26/2021.  DCannon"]
["Adrienne C Do, PA",1003372418,"85-3162122","TX","PE - Basin Dermatology","Cigna","Participating","Enrollment Complete","2021-11-01","9076378","","2021-11-03","11.3.21 Received email DiscoverCigna@information.cigna.com. Application to participate in the Cigna network has been approved. Effective date is 11/01/2021. Provider identification number is 9076378. Cbankston"]
["Adrienne C Do, PA",1003372418,"85-3162122","TX","PE - Basin Dermatology","Omni PPO","Participating","Enrollment Complete","2021-08-26","","","2021-10-22","10/22/2021 Rcvd email from German Aviles at IMS/OMNI that delegation roster for September has been completed and updated in their system effective 8/26/2021.  DCannon"]
["Adrienne C Do, PA",1003372418,"85-3162122","TX","PE - Basin Dermatology","Wellmed","Participating","Enrollment Complete","2021-09-03","","","2023-03-23","3/23/2023 Rcvd roster from UHC w/ all Wellmed participating providers.  Provider is PAR effective 9/3/2021.  DCannon"]
["Adrienne C Do, PA",1003372418,"85-3162122","TX","PE - Basin Dermatology","Humana","Participating","Enrollment Complete","2021-09-01","","","2021-11-18","11/18/2021 Rcvd full roster from Humana listing provider as PAR and linked to group TIN/location effective 9/1/2021.  DCannon"]
["Adrienne C Do, PA",1003372418,"85-3162122","TX","PE - Basin Dermatology","Caprock (CapStar)","Participating","Enrollment Complete","2021-08-26","","","2021-09-17","9/17/2021 Rcvd email from CapRock that monthly delegated roster has been loaded and the provider is PAR and linked to group TIN/location effective 8/26/2021.  DCannon"]
["Adrienne C Do, PA",1003372418,"85-3162122","TX","PE - Basin Dermatology","Multiplan","Participating","Enrollment Complete","2021-09-15","","","2022-03-10","3/10/2022 Rcvd roster from Multiplan listing provider as PAR and listed under group TIN/location effective 9/15/2021.  DCannon"]
["Adrienne C Do, PA",1003372418,"85-3162122","TX","PE - Basin Dermatology","Rail Road Medicare","Participating","Enrollment Complete","2021-09-01","Q00166601","EB1950","2021-11-18","Rcvd RR Medicare PTAN via online RR Medicare portal.  PTAN # Q00166601 - effective 9/1/2021.  DCannon"]
["Michael T Caglia, MD",1568789550,"85-3162122","TX","PE - Basin Dermatology","HealthSmart PPO","Participating","Enrollment Complete","2019-07-18","","","2022-04-23","4/23/2022 Per follow-up note - Providers NPI # is on file and participating effective 7/18/2019 under the group and TIN.  Unable to give the Provider ID#.  Physical location is on file.  DCannon"]
["Michael T Caglia, MD",1568789550,"85-3162122","TX","PE - Basin Dermatology","USA PPO","Participating","Enrollment Complete","2021-06-01","","","2021-08-04","8/4/2021  In following up with USAMCO (800-872-3860) I was told that you can confirm participating via the USA MCO website  https://providersearch.usamco.com/hwprovsearch.  Provider is PAR and linked to location/TIN effective 6/12021.  DCannon"]
["Michael T Caglia, MD",1568789550,"85-3162122","TX","PE - Basin Dermatology","Triwest VA","Participating","Enrollment Complete","2022-08-01","","","2022-11-14","11/14/22 Per Scarlett Abigail, provider effective from 8/1/22"]
["Michael T Caglia, MD",1568789550,"85-3162122","TX","PE - Basin Dermatology","Boon Chapman","Participating","Enrollment Complete","2017-03-13","13568107","","2022-02-24","2/24/2022 Per follow-up note from 2/22/2022 -  NPI# for the provider is on file, shows Linked and Par under the TIN#, effective 3/13/2017, the physical location is on file and the Provider ID is  13568107. Case ref#7923274.  - DCannon"]
["Michael T Caglia, MD",1568789550,"85-3162122","TX","PE - Basin Dermatology","Medicare","Participating","Enrollment Complete","2021-04-28","1T8899","1T8900","2021-09-15","9/9/2021 Received approval from Medicare that provider and group have been approved.  Group PTAN # 1T8900 and Individual Provider PTAN # 1T8899 - effective 4/28/2021.  DCannon"]
["Michael T Caglia, MD",1568789550,"85-3162122","TX","PE - Basin Dermatology","TriCare Standard","Participating","Enrollment Complete","2021-03-25"," 853162122 79703 A002"," 853162122 79703 A001","","4/5/2021 Received an email from Latisha Green at Latisha.Green@wpsic.com confirming group and providers are Certified as non-network providers effective 3/25/2021 with assigned ID's as follows:\n\nGROUP                 853162122 79703 A001\nM. CAGLIA          853162122 79703 A002\nM. SIMS               853162122 79703 A003\n\nKFrazier"]
["Michael T Caglia, MD",1568789550,"85-3162122","TX","PE - Basin Dermatology","Caprock (CapStar)","Participating","Enrollment Complete","2021-06-01","","","2021-08-04","8/4/2021 Rcvd email from Caprock Provider Services provider_services_shared.t8@90degreebenefits.com  that providers from April, May and June delegated rosters have been loaded into their systems under requested TINS effective 6/1/2021.  DCannon"]
["Michael T Caglia, MD",1568789550,"85-3162122","TX","PE - Basin Dermatology","First Health Coventry","Participating","Enrollment Complete","2021-06-01","","","2021-10-22","10/22/2021 Per First Health online provider directory provider is PAR and linked to group/locations  effective 6/1/2021  DCannon"]
["Michael T Caglia, MD",1568789550,"85-3162122","TX","PE - Basin Dermatology","Omni PPO","Participating","Enrollment Complete","2021-06-01","","","2021-06-15","6/15/2021 Rcvd email from German Aviles <german.aciles@imsm.net> at IMS/OMNI stating that the monthly delegated roster provider loads for March, April, May and June have been completed.  Provider is PAR and linked to location/TIN effective 6/1/2021. DCannon"]
["Michael T Caglia, MD",1568789550,"85-3162122","TX","PE - Basin Dermatology","Wellmed","Participating","Enrollment Complete","2021-09-03","","","2023-03-23","3/23/2023 Rcvd roster from UHC w/ all Wellmed participating providers.  Provider is PAR effective 9/3/2021.  DCannon"]
["Michael T Caglia, MD",1568789550,"85-3162122","TX","PE - Basin Dermatology","Cigna","Participating","Enrollment Complete","2021-05-01","6008373","","2021-09-08","9/8/2021 Received an email from 9psscent@cigna.com confirming provider is now participating under group Tax ID effective 5/1/2021 with basic lines of business OAP, PPO and HMO with assigned provider ID 6008373, which was communicated to Rebecca Pontaski via email. KFrazier"]
["Michael T Caglia, MD",1568789550,"85-3162122","TX","PE - Basin Dermatology","Scott&White (First Care)","Participating","Enrollment Complete","2021-06-01","","","2021-08-04","8/4/2021 Rccvd email from Scott & White swhpdelegation@bswhealth.org that provider is PAR and linked to TIN/locations effective 6/1/2021.  DCannon"]
["Michael T Caglia, MD",1568789550,"85-3162122","TX","PE - Basin Dermatology","United Health Care","Participating","Enrollment Complete","2021-09-03","","","2021-08-20","8/19/2021 Received group executed group agreement confirming participation for Dr. Caglia, which is effective 9/3/2021, which was forwarded to Rebecca Pontaski for distribution to the appropriate staff.  KFrazier"]
["Michael T Caglia, MD",1568789550,"85-3162122","TX","PE - Basin Dermatology","Humana","Participating","Enrollment Complete","2021-09-01","","","2021-11-18","11/18/2021 Rcvd full roster from Humana listing provider as PAR and linked to group TIN/location effective 9/1/2021.  DCannon"]
["Michael T Caglia, MD",1568789550,"85-3162122","TX","PE - Basin Dermatology","Wellcare","Participating","Enrollment Complete","2021-11-01","","","2022-11-15","11/15/2022 Per roster received from Wellcare provider is PAR and linked to group TIN/location effective 11/1/2021.  DCannon"]
["Michael T Caglia, MD",1568789550,"85-3162122","TX","PE - Basin Dermatology","Rail Road Medicare","Participating","Enrollment Complete","2021-04-28","P02630882","EB1950","2021-11-18","11/18/2021 Rcvd RR Medicare PTAN # P02630882 - eff 4/28/2021.  DCannon"]
["Michael T Caglia, MD",1568789550,"85-3162122","TX","PE - Basin Dermatology","Multiplan","Participating","Enrollment Complete","2017-03-13","","","2022-03-10","3/10/2022 Rcvd roster from Multiplan listing provider as PAR and listed under group TIN/location effective 3/13/2017.  DCannon"]
["Michael T Caglia, MD",1568789550,"85-3162122","TX","PE - Basin Dermatology","IMS","Participating","Enrollment Complete","2021-06-01","","","2021-06-15","6/15/2021 Rcvd email from German Aviles <german.aciles@imsm.net> at IMS/OMNI stating that the monthly delegated roster provider loads for March, April, May and June have been completed.  Provider is PAR and linked to location/TIN effective 6/1/2021. DCannon"]
["Michael T Caglia, MD",1568789550,"85-3162122","TX","PE - Basin Dermatology","Aetna","Participating","Enrollment Complete","2021-06-01","4177272","","2021-07-01","7/1/2021 Per Aetna roster received from Jamie Roberts provider is PAR and linked to TIN/locations effective 6/1/2021.  DCannon"]
["Michael T Caglia, MD",1568789550,"85-3162122","TX","PE - Basin Dermatology","Galaxy Health","Participating","Enrollment Complete","2021-06-01","","","2021-06-04","6/4/2021 Per Karen Avalos at Galaxy Health monthly delegated submission is complete and provider is PAR and linked to group TIN/locations effective 6/1/2021.  DCannon"]
["Michael T Caglia, MD",1568789550,"85-3162122","TX","PE - Basin Dermatology","Ambetter","Participating","Enrollment Complete","2022-04-01","","","2022-06-13","6/13/2022 Received April Monthly Validation roster from Superior and provider is PAR and linked effective 4/1/2022.  DCannon"]
["Michael T Caglia, MD",1568789550,"85-3162122","TX","PE - Basin Dermatology","Amerigroup","Enrollment Stopped","Enrollment Stopped","","","","2021-08-05","8/5/2021 Provider will not be accepting Medicaid therefore, Amerigroup enrollment will not be persued.  DCannon"]
["Leela S Pillarisetty, MD",1235484114,"86-3825791","TX","PE - West Texas Ob/Gyn","Wellmed","Participating","Enrollment Complete","2022-05-13","","","2023-03-23","3/23/2023 Rcvd roster from UHC w/ all Wellmed participating providers.  Provider is PAR effective 5/13/2022.  DCannon"]
["Leela S Pillarisetty, MD",1235484114,"86-3825791","TX","PE - West Texas Ob/Gyn","Wellmed","Participating","Enrollment Complete","2022-05-13","","","2023-03-23","3/23/2023 Rcvd roster from UHC w/ all Wellmed participating providers.  Provider is PAR effective 5/13/2022.  DCannon"]
["Leela S Pillarisetty, MD",1235484114,"86-3825791","TX","PE - West Texas Ob/Gyn","Wellmed","Participating","Enrollment Complete","2022-05-13","","","2023-03-23","3/23/2023 Rcvd roster from UHC w/ all Wellmed participating providers.  Provider is PAR effective 5/13/2022.  DCannon"]
["Leela S Pillarisetty, MD",1235484114,"86-3825791","TX","PE - West Texas Ob/Gyn","Wellmed","Participating","Enrollment Complete","2022-05-13","","","2023-03-23","3/23/2023 Rcvd roster from UHC w/ all Wellmed participating providers.  Provider is PAR effective 5/13/2022.  DCannon"]
["Leela S Pillarisetty, MD",1235484114,"86-3825791","TX","PE - West Texas Ob/Gyn","Omni PPO","Participating","Enrollment Complete","2022-01-10","","","2022-02-04","2/4/2022 Rcvd email from G. Aviles @ IMS/Omni that provider is PAR and linked to group TIN/location effective 1/10/2022.  DCannon"]
["Leela S Pillarisetty, MD",1235484114,"86-3825791","TX","PE - West Texas Ob/Gyn","Omni PPO","Participating","Enrollment Complete","2022-01-10","","","2022-02-04","2/4/2022 Rcvd email from G. Aviles @ IMS/Omni that provider is PAR and linked to group TIN/location effective 1/10/2022.  DCannon"]
["Leela S Pillarisetty, MD",1235484114,"86-3825791","TX","PE - West Texas Ob/Gyn","Omni PPO","Participating","Enrollment Complete","2022-01-10","","","2022-02-04","2/4/2022 Rcvd email from G. Aviles @ IMS/Omni that provider is PAR and linked to group TIN/location effective 1/10/2022.  DCannon"]
["Leela S Pillarisetty, MD",1235484114,"86-3825791","TX","PE - West Texas Ob/Gyn","Omni PPO","Participating","Enrollment Complete","2022-01-10","","","2022-02-04","2/4/2022 Rcvd email from G. Aviles @ IMS/Omni that provider is PAR and linked to group TIN/location effective 1/10/2022.  DCannon"]
["Leela S Pillarisetty, MD",1235484114,"86-3825791","TX","PE - West Texas Ob/Gyn","Triwest VA","In House Enrollment","In House Enrollment","","","","2022-02-23",""]
["Leela S Pillarisetty, MD",1235484114,"86-3825791","TX","PE - West Texas Ob/Gyn","Triwest VA","In House Enrollment","In House Enrollment","","","","2022-02-23",""]
["Leela S Pillarisetty, MD",1235484114,"86-3825791","TX","PE - West Texas Ob/Gyn","Triwest VA","In House Enrollment","In House Enrollment","","","","2022-02-23",""]
["Leela S Pillarisetty, MD",1235484114,"86-3825791","TX","PE - West Texas Ob/Gyn","Triwest VA","In House Enrollment","In House Enrollment","","","","2022-02-23",""]
["Leela S Pillarisetty, MD",1235484114,"86-3825791","TX","PE - West Texas Ob/Gyn","CAQH","Participating","CAQH Reattested","2023-10-04","","","2023-10-04","10/04/2023 - Updated cred contact, Billing address Liability and re-attested - rkedare"]
["Leela S Pillarisetty, MD",1235484114,"86-3825791","TX","PE - West Texas Ob/Gyn","CAQH","Participating","CAQH Reattested","2023-10-04","","","2023-10-04","10/04/2023 - Updated cred contact, Billing address Liability and re-attested - rkedare"]
["Leela S Pillarisetty, MD",1235484114,"86-3825791","TX","PE - West Texas Ob/Gyn","CAQH","Participating","CAQH Reattested","2023-10-04","","","2023-10-04","10/04/2023 - Updated cred contact, Billing address Liability and re-attested - rkedare"]
["Leela S Pillarisetty, MD",1235484114,"86-3825791","TX","PE - West Texas Ob/Gyn","CAQH","Participating","CAQH Reattested","2023-10-04","","","2023-10-04","10/04/2023 - Updated cred contact, Billing address Liability and re-attested - rkedare"]
["Leela S Pillarisetty, MD",1235484114,"86-3825791","TX","PE - West Texas Ob/Gyn","TriCare Standard","Participating","Enrollment Complete","2021-12-31","","","2022-02-25","2/25/2022 Per Tricare portal, provider is linked to location eff 12/31/2021. Cbankston"]
["Leela S Pillarisetty, MD",1235484114,"86-3825791","TX","PE - West Texas Ob/Gyn","TriCare Standard","Participating","Enrollment Complete","2021-12-31","","","2022-02-25","2/25/2022 Per Tricare portal, provider is linked to location eff 12/31/2021. Cbankston"]
["Leela S Pillarisetty, MD",1235484114,"86-3825791","TX","PE - West Texas Ob/Gyn","TriCare Standard","Participating","Enrollment Complete","2021-12-31","","","2022-02-25","2/25/2022 Per Tricare portal, provider is linked to location eff 12/31/2021. Cbankston"]
["Leela S Pillarisetty, MD",1235484114,"86-3825791","TX","PE - West Texas Ob/Gyn","TriCare Standard","Participating","Enrollment Complete","2021-12-31","","","2022-02-25","2/25/2022 Per Tricare portal, provider is linked to location eff 12/31/2021. Cbankston"]
["Leela S Pillarisetty, MD",1235484114,"86-3825791","TX","PE - West Texas Ob/Gyn","Scott&White (First Care)","Participating","Enrollment Complete","2022-02-15","","","2022-05-05","5/5/2022 Rcvd email from Scott & White confirming that the February delegation roster has been completed and the provider are now loaded and PAR w/ group TIN/locations effective 2/15/2022.  DCannon"]
["Leela S Pillarisetty, MD",1235484114,"86-3825791","TX","PE - West Texas Ob/Gyn","Scott&White (First Care)","Participating","Enrollment Complete","2022-02-15","","","2022-05-05","5/5/2022 Rcvd email from Scott & White confirming that the February delegation roster has been completed and the provider are now loaded and PAR w/ group TIN/locations effective 2/15/2022.  DCannon"]
["Leela S Pillarisetty, MD",1235484114,"86-3825791","TX","PE - West Texas Ob/Gyn","Scott&White (First Care)","Participating","Enrollment Complete","2022-02-15","","","2022-05-05","5/5/2022 Rcvd email from Scott & White confirming that the February delegation roster has been completed and the provider are now loaded and PAR w/ group TIN/locations effective 2/15/2022.  DCannon"]
["Leela S Pillarisetty, MD",1235484114,"86-3825791","TX","PE - West Texas Ob/Gyn","Scott&White (First Care)","Participating","Enrollment Complete","2022-02-15","","","2022-05-05","5/5/2022 Rcvd email from Scott & White confirming that the February delegation roster has been completed and the provider are now loaded and PAR w/ group TIN/locations effective 2/15/2022.  DCannon"]
["Leela S Pillarisetty, MD",1235484114,"86-3825791","TX","PE - West Texas Ob/Gyn","Medicare","Participating","Enrollment Complete","2021-04-17","1S4718","1S4719","2022-05-03","5/3/2022 Rcvd email from Candace with confirmation of group and provider's individual Medicare PTANS.  Group PTAN # 1S4719 and Individual PTAN # 1S4718 - effective 4/17/2021. \nDCannon"]
["Leela S Pillarisetty, MD",1235484114,"86-3825791","TX","PE - West Texas Ob/Gyn","Medicare","Participating","Enrollment Complete","2021-04-17","1S4718","1S4719","2022-05-03","5/3/2022 Rcvd email from Candace with confirmation of group and provider's individual Medicare PTANS.  Group PTAN # 1S4719 and Individual PTAN # 1S4718 - effective 4/17/2021. \nDCannon"]
["Leela S Pillarisetty, MD",1235484114,"86-3825791","TX","PE - West Texas Ob/Gyn","Medicare","Participating","Enrollment Complete","2021-04-17","1S4718","1S4719","2022-05-03","5/3/2022 Rcvd email from Candace with confirmation of group and provider's individual Medicare PTANS.  Group PTAN # 1S4719 and Individual PTAN # 1S4718 - effective 4/17/2021. \nDCannon"]
["Leela S Pillarisetty, MD",1235484114,"86-3825791","TX","PE - West Texas Ob/Gyn","Medicare","Participating","Enrollment Complete","2021-04-17","1S4718","1S4719","2022-05-03","5/3/2022 Rcvd email from Candace with confirmation of group and provider's individual Medicare PTANS.  Group PTAN # 1S4719 and Individual PTAN # 1S4718 - effective 4/17/2021. \nDCannon"]
["Leela S Pillarisetty, MD",1235484114,"86-3825791","TX","PE - West Texas Ob/Gyn","IMS","Participating","Enrollment Complete","2022-01-10","","","2022-02-04","2/4/2022 Rcvd email from G. Aviles @ IMS/Omni that provider is PAR and linked to group TIN/location effective 1/10/2022.  DCannon"]
["Leela S Pillarisetty, MD",1235484114,"86-3825791","TX","PE - West Texas Ob/Gyn","IMS","Participating","Enrollment Complete","2022-01-10","","","2022-02-04","2/4/2022 Rcvd email from G. Aviles @ IMS/Omni that provider is PAR and linked to group TIN/location effective 1/10/2022.  DCannon"]
["Leela S Pillarisetty, MD",1235484114,"86-3825791","TX","PE - West Texas Ob/Gyn","IMS","Participating","Enrollment Complete","2022-01-10","","","2022-02-04","2/4/2022 Rcvd email from G. Aviles @ IMS/Omni that provider is PAR and linked to group TIN/location effective 1/10/2022.  DCannon"]
["Leela S Pillarisetty, MD",1235484114,"86-3825791","TX","PE - West Texas Ob/Gyn","IMS","Participating","Enrollment Complete","2022-01-10","","","2022-02-04","2/4/2022 Rcvd email from G. Aviles @ IMS/Omni that provider is PAR and linked to group TIN/location effective 1/10/2022.  DCannon"]
["Leela S Pillarisetty, MD",1235484114,"86-3825791","TX","PE - West Texas Ob/Gyn","HealthSmart PPO","Participating","Enrollment Complete","2022-01-10","","","2022-04-05","4/5/2022 Per Healthsmart website provider is PAR and loaded under TIN/location effective 1/10/2022.  DCannon"]
["Leela S Pillarisetty, MD",1235484114,"86-3825791","TX","PE - West Texas Ob/Gyn","HealthSmart PPO","Participating","Enrollment Complete","2022-01-10","","","2022-04-05","4/5/2022 Per Healthsmart website provider is PAR and loaded under TIN/location effective 1/10/2022.  DCannon"]
["Leela S Pillarisetty, MD",1235484114,"86-3825791","TX","PE - West Texas Ob/Gyn","HealthSmart PPO","Participating","Enrollment Complete","2022-01-10","","","2022-04-05","4/5/2022 Per Healthsmart website provider is PAR and loaded under TIN/location effective 1/10/2022.  DCannon"]
["Leela S Pillarisetty, MD",1235484114,"86-3825791","TX","PE - West Texas Ob/Gyn","HealthSmart PPO","Participating","Enrollment Complete","2022-01-10","","","2022-04-05","4/5/2022 Per Healthsmart website provider is PAR and loaded under TIN/location effective 1/10/2022.  DCannon"]
["Leela S Pillarisetty, MD",1235484114,"86-3825791","TX","PE - West Texas Ob/Gyn","Aetna","Participating","Enrollment Complete","2022-01-10","","","2022-02-08","2/8/2022 Per email from Jamie Roberts @ Aetna provider is PAR and linked to group TIN/location effective 1/10/2022.  DCannon"]
["Leela S Pillarisetty, MD",1235484114,"86-3825791","TX","PE - West Texas Ob/Gyn","Aetna","Participating","Enrollment Complete","2022-01-10","","","2022-02-08","2/8/2022 Per email from Jamie Roberts @ Aetna provider is PAR and linked to group TIN/location effective 1/10/2022.  DCannon"]
["Leela S Pillarisetty, MD",1235484114,"86-3825791","TX","PE - West Texas Ob/Gyn","Aetna","Participating","Enrollment Complete","2022-01-10","","","2022-02-08","2/8/2022 Per email from Jamie Roberts @ Aetna provider is PAR and linked to group TIN/location effective 1/10/2022.  DCannon"]
["Leela S Pillarisetty, MD",1235484114,"86-3825791","TX","PE - West Texas Ob/Gyn","Aetna","Participating","Enrollment Complete","2022-01-10","","","2022-02-08","2/8/2022 Per email from Jamie Roberts @ Aetna provider is PAR and linked to group TIN/location effective 1/10/2022.  DCannon"]
["Leela S Pillarisetty, MD",1235484114,"86-3825791","TX","PE - West Texas Ob/Gyn","Multiplan","Participating","Enrollment Complete","2017-09-01","","","2022-03-10","3/10/2022 Rcvd roster from Multiplan listing provider as PAR and listed under group TIN/location effective 9/1/2017.  DCannon"]
["Leela S Pillarisetty, MD",1235484114,"86-3825791","TX","PE - West Texas Ob/Gyn","Multiplan","Participating","Enrollment Complete","2017-09-01","","","2022-03-10","3/10/2022 Rcvd roster from Multiplan listing provider as PAR and listed under group TIN/location effective 9/1/2017.  DCannon"]
["Leela S Pillarisetty, MD",1235484114,"86-3825791","TX","PE - West Texas Ob/Gyn","Multiplan","Participating","Enrollment Complete","2017-09-01","","","2022-03-10","3/10/2022 Rcvd roster from Multiplan listing provider as PAR and listed under group TIN/location effective 9/1/2017.  DCannon"]
["Leela S Pillarisetty, MD",1235484114,"86-3825791","TX","PE - West Texas Ob/Gyn","Multiplan","Participating","Enrollment Complete","2017-09-01","","","2022-03-10","3/10/2022 Rcvd roster from Multiplan listing provider as PAR and listed under group TIN/location effective 9/1/2017.  DCannon"]
["Leela S Pillarisetty, MD",1235484114,"86-3825791","TX","PE - West Texas Ob/Gyn","USA PPO","Participating","Enrollment Complete","2022-01-10","","","2022-03-29","3/29/2022  In following up with USAMCO (800-872-3860) I was told that you can confirm participating via the USA MCO website  https://providersearch.usamco.com/hwprovsearch.  Provider is PAR and linked to location/TIN effective 1/10/2022.  DCannon"]
["Leela S Pillarisetty, MD",1235484114,"86-3825791","TX","PE - West Texas Ob/Gyn","USA PPO","Participating","Enrollment Complete","2022-01-10","","","2022-03-29","3/29/2022  In following up with USAMCO (800-872-3860) I was told that you can confirm participating via the USA MCO website  https://providersearch.usamco.com/hwprovsearch.  Provider is PAR and linked to location/TIN effective 1/10/2022.  DCannon"]
["Leela S Pillarisetty, MD",1235484114,"86-3825791","TX","PE - West Texas Ob/Gyn","USA PPO","Participating","Enrollment Complete","2022-01-10","","","2022-03-29","3/29/2022  In following up with USAMCO (800-872-3860) I was told that you can confirm participating via the USA MCO website  https://providersearch.usamco.com/hwprovsearch.  Provider is PAR and linked to location/TIN effective 1/10/2022.  DCannon"]
["Leela S Pillarisetty, MD",1235484114,"86-3825791","TX","PE - West Texas Ob/Gyn","USA PPO","Participating","Enrollment Complete","2022-01-10","","","2022-03-29","3/29/2022  In following up with USAMCO (800-872-3860) I was told that you can confirm participating via the USA MCO website  https://providersearch.usamco.com/hwprovsearch.  Provider is PAR and linked to location/TIN effective 1/10/2022.  DCannon"]
["Leela S Pillarisetty, MD",1235484114,"86-3825791","TX","PE - West Texas Ob/Gyn","Amerigroup","Participating","Enrollment Complete","2022-01-10","12802966","","2022-05-19","5/19/2022 Per roster received from Amerigroup provider is PAR and linked to group TIN effective 1/10/2022.  PID #  12802966.  DCannon"]
["Leela S Pillarisetty, MD",1235484114,"86-3825791","TX","PE - West Texas Ob/Gyn","Amerigroup","Participating","Enrollment Complete","2022-01-10","12802966","","2022-05-19","5/19/2022 Per roster received from Amerigroup provider is PAR and linked to group TIN effective 1/10/2022.  PID #  12802966.  DCannon"]
["Leela S Pillarisetty, MD",1235484114,"86-3825791","TX","PE - West Texas Ob/Gyn","Amerigroup","Participating","Enrollment Complete","2022-01-10","12802966","","2022-05-19","5/19/2022 Per roster received from Amerigroup provider is PAR and linked to group TIN effective 1/10/2022.  PID #  12802966.  DCannon"]
["Leela S Pillarisetty, MD",1235484114,"86-3825791","TX","PE - West Texas Ob/Gyn","Amerigroup","Participating","Enrollment Complete","2022-01-10","12802966","","2022-05-19","5/19/2022 Per roster received from Amerigroup provider is PAR and linked to group TIN effective 1/10/2022.  PID #  12802966.  DCannon"]
["Leela S Pillarisetty, MD",1235484114,"86-3825791","TX","PE - West Texas Ob/Gyn","Medicaid","Enrollment on Hold","Pending Info/Document","","","","2023-11-27","Emailed MQA for assistance with TMHP password. Jen Videan"]
["Leela S Pillarisetty, MD",1235484114,"86-3825791","TX","PE - West Texas Ob/Gyn","Medicaid","Enrollment on Hold","Pending Info/Document","","","","2023-11-27","Emailed MQA for assistance with TMHP password. Jen Videan"]
["Leela S Pillarisetty, MD",1235484114,"86-3825791","TX","PE - West Texas Ob/Gyn","Medicaid","Enrollment on Hold","Pending Info/Document","","","","2023-11-27","Emailed MQA for assistance with TMHP password. Jen Videan"]
["Leela S Pillarisetty, MD",1235484114,"86-3825791","TX","PE - West Texas Ob/Gyn","Medicaid","Enrollment on Hold","Pending Info/Document","","","","2023-11-27","Emailed MQA for assistance with TMHP password. Jen Videan"]
["Leela S Pillarisetty, MD",1235484114,"86-3825791","TX","PE - West Texas Ob/Gyn","Wellcare","Participating","Enrollment Complete","2021-11-01","","","2022-12-01","12/1/2022 Per roster received from Wellcare provider is PAR and linked to group TIN/location effective 11/1/2021.  DCannon"]
["Leela S Pillarisetty, MD",1235484114,"86-3825791","TX","PE - West Texas Ob/Gyn","Wellcare","Participating","Enrollment Complete","2021-11-01","","","2022-12-01","12/1/2022 Per roster received from Wellcare provider is PAR and linked to group TIN/location effective 11/1/2021.  DCannon"]
["Leela S Pillarisetty, MD",1235484114,"86-3825791","TX","PE - West Texas Ob/Gyn","Wellcare","Participating","Enrollment Complete","2021-11-01","","","2022-12-01","12/1/2022 Per roster received from Wellcare provider is PAR and linked to group TIN/location effective 11/1/2021.  DCannon"]
["Leela S Pillarisetty, MD",1235484114,"86-3825791","TX","PE - West Texas Ob/Gyn","Wellcare","Participating","Enrollment Complete","2021-11-01","","","2022-12-01","12/1/2022 Per roster received from Wellcare provider is PAR and linked to group TIN/location effective 11/1/2021.  DCannon"]
["Leela S Pillarisetty, MD",1235484114,"86-3825791","TX","PE - West Texas Ob/Gyn","Humana","Participating","Enrollment Complete","2022-01-10","","","2022-06-19","6/19/2022 Per email received from V. Thomas at Humana provider is PAR and linked to group TIN effective 1/10/2022.  DCannon"]
["Leela S Pillarisetty, MD",1235484114,"86-3825791","TX","PE - West Texas Ob/Gyn","Humana","Participating","Enrollment Complete","2022-01-10","","","2022-06-19","6/19/2022 Per email received from V. Thomas at Humana provider is PAR and linked to group TIN effective 1/10/2022.  DCannon"]
["Leela S Pillarisetty, MD",1235484114,"86-3825791","TX","PE - West Texas Ob/Gyn","Humana","Participating","Enrollment Complete","2022-01-10","","","2022-06-19","6/19/2022 Per email received from V. Thomas at Humana provider is PAR and linked to group TIN effective 1/10/2022.  DCannon"]
["Leela S Pillarisetty, MD",1235484114,"86-3825791","TX","PE - West Texas Ob/Gyn","Humana","Participating","Enrollment Complete","2022-01-10","","","2022-06-19","6/19/2022 Per email received from V. Thomas at Humana provider is PAR and linked to group TIN effective 1/10/2022.  DCannon"]
["Leela S Pillarisetty, MD",1235484114,"86-3825791","TX","PE - West Texas Ob/Gyn","Superior","Participating","Enrollment Complete","2022-02-01","","","2022-02-01","2/7/2022 Rcvd email from Superior that provider is PAR and linked to group TIN/location effective 2/1/2022.  DCannon"]
["Leela S Pillarisetty, MD",1235484114,"86-3825791","TX","PE - West Texas Ob/Gyn","Superior","Participating","Enrollment Complete","2022-02-01","","","2022-02-01","2/7/2022 Rcvd email from Superior that provider is PAR and linked to group TIN/location effective 2/1/2022.  DCannon"]
["Leela S Pillarisetty, MD",1235484114,"86-3825791","TX","PE - West Texas Ob/Gyn","Superior","Participating","Enrollment Complete","2022-02-01","","","2022-02-01","2/7/2022 Rcvd email from Superior that provider is PAR and linked to group TIN/location effective 2/1/2022.  DCannon"]
["Leela S Pillarisetty, MD",1235484114,"86-3825791","TX","PE - West Texas Ob/Gyn","Superior","Participating","Enrollment Complete","2022-02-01","","","2022-02-01","2/7/2022 Rcvd email from Superior that provider is PAR and linked to group TIN/location effective 2/1/2022.  DCannon"]
["Leela S Pillarisetty, MD",1235484114,"86-3825791","TX","PE - West Texas Ob/Gyn","Galaxy Health","Participating","Enrollment Complete","2022-01-10","","","2022-03-10","3/10/2022 Rcvd email from K. Avalos @ Galaxy that provider is PAR and linked to group TIN/location effective 1/10/2022.  DCannon"]
["Leela S Pillarisetty, MD",1235484114,"86-3825791","TX","PE - West Texas Ob/Gyn","Galaxy Health","Participating","Enrollment Complete","2022-01-10","","","2022-03-10","3/10/2022 Rcvd email from K. Avalos @ Galaxy that provider is PAR and linked to group TIN/location effective 1/10/2022.  DCannon"]
["Leela S Pillarisetty, MD",1235484114,"86-3825791","TX","PE - West Texas Ob/Gyn","Galaxy Health","Participating","Enrollment Complete","2022-01-10","","","2022-03-10","3/10/2022 Rcvd email from K. Avalos @ Galaxy that provider is PAR and linked to group TIN/location effective 1/10/2022.  DCannon"]
["Leela S Pillarisetty, MD",1235484114,"86-3825791","TX","PE - West Texas Ob/Gyn","Galaxy Health","Participating","Enrollment Complete","2022-01-10","","","2022-03-10","3/10/2022 Rcvd email from K. Avalos @ Galaxy that provider is PAR and linked to group TIN/location effective 1/10/2022.  DCannon"]
["Leela S Pillarisetty, MD",1235484114,"86-3825791","TX","PE - West Texas Ob/Gyn","United Health Care","Participating","Enrollment Complete","2022-01-10","","","2022-06-11","6/11/2022 Per email from Janice Edwards @ UHC delegated roster provider load has been completed and providers PAR and linked to group TIN effective 1/10/2022.  DCannon"]
["Leela S Pillarisetty, MD",1235484114,"86-3825791","TX","PE - West Texas Ob/Gyn","United Health Care","Participating","Enrollment Complete","2022-01-10","","","2022-06-11","6/11/2022 Per email from Janice Edwards @ UHC delegated roster provider load has been completed and providers PAR and linked to group TIN effective 1/10/2022.  DCannon"]
["Leela S Pillarisetty, MD",1235484114,"86-3825791","TX","PE - West Texas Ob/Gyn","United Health Care","Participating","Enrollment Complete","2022-01-10","","","2022-06-11","6/11/2022 Per email from Janice Edwards @ UHC delegated roster provider load has been completed and providers PAR and linked to group TIN effective 1/10/2022.  DCannon"]
["Leela S Pillarisetty, MD",1235484114,"86-3825791","TX","PE - West Texas Ob/Gyn","United Health Care","Participating","Enrollment Complete","2022-01-10","","","2022-06-11","6/11/2022 Per email from Janice Edwards @ UHC delegated roster provider load has been completed and providers PAR and linked to group TIN effective 1/10/2022.  DCannon"]
["Leela S Pillarisetty, MD",1235484114,"86-3825791","TX","PE - West Texas Ob/Gyn","Boon Chapman","Participating","Enrollment Complete","2017-09-01","","","2022-03-10","3/10/2022 Rcvd roster from Multiplan listing provider as PAR and listed under group TIN/location effective 9/1/2017.  DCannon"]
["Leela S Pillarisetty, MD",1235484114,"86-3825791","TX","PE - West Texas Ob/Gyn","Boon Chapman","Participating","Enrollment Complete","2017-09-01","","","2022-03-10","3/10/2022 Rcvd roster from Multiplan listing provider as PAR and listed under group TIN/location effective 9/1/2017.  DCannon"]
["Leela S Pillarisetty, MD",1235484114,"86-3825791","TX","PE - West Texas Ob/Gyn","Boon Chapman","Participating","Enrollment Complete","2017-09-01","","","2022-03-10","3/10/2022 Rcvd roster from Multiplan listing provider as PAR and listed under group TIN/location effective 9/1/2017.  DCannon"]
["Leela S Pillarisetty, MD",1235484114,"86-3825791","TX","PE - West Texas Ob/Gyn","Boon Chapman","Participating","Enrollment Complete","2017-09-01","","","2022-03-10","3/10/2022 Rcvd roster from Multiplan listing provider as PAR and listed under group TIN/location effective 9/1/2017.  DCannon"]
["Deepika Devalla, MD",1265872592,"86-3825791","TX","PE - West Texas Ob/Gyn","Galaxy Health","Participating","Enrollment Complete","2022-01-01","","","2022-06-01","6/1/2022 Per Karen Avalos at Galaxy Health April monthly delegated submission is complete and provider is PAR and linked to group TIN/locations effective  1/1/2022.  DCannon"]
["Deepika Devalla, MD",1265872592,"86-3825791","TX","PE - West Texas Ob/Gyn","Galaxy Health","Participating","Enrollment Complete","2022-01-01","","","2022-06-01","6/1/2022 Per Karen Avalos at Galaxy Health April monthly delegated submission is complete and provider is PAR and linked to group TIN/locations effective  1/1/2022.  DCannon"]
["Deepika Devalla, MD",1265872592,"86-3825791","TX","PE - West Texas Ob/Gyn","Galaxy Health","Participating","Enrollment Complete","2022-01-01","","","2022-06-01","6/1/2022 Per Karen Avalos at Galaxy Health April monthly delegated submission is complete and provider is PAR and linked to group TIN/locations effective  1/1/2022.  DCannon"]
["Deepika Devalla, MD",1265872592,"86-3825791","TX","PE - West Texas Ob/Gyn","Galaxy Health","Participating","Enrollment Complete","2022-01-01","","","2022-06-01","6/1/2022 Per Karen Avalos at Galaxy Health April monthly delegated submission is complete and provider is PAR and linked to group TIN/locations effective  1/1/2022.  DCannon"]
["Deepika Devalla, MD",1265872592,"86-3825791","TX","PE - West Texas Ob/Gyn","Medicare","In Process","Pending Info/Document","","","","2023-11-16","Requested surrogacy from client for both the provider and the group. The inital submission was done through Dana's account, but was denied due to the provider not signing the application. I will need the provider and the group to approve surrogacy for me to complete this enrollment. MS"]
["Deepika Devalla, MD",1265872592,"86-3825791","TX","PE - West Texas Ob/Gyn","Medicare","In Process","Pending Info/Document","","","","2023-11-16","Requested surrogacy from client for both the provider and the group. The inital submission was done through Dana's account, but was denied due to the provider not signing the application. I will need the provider and the group to approve surrogacy for me to complete this enrollment. MS"]
["Deepika Devalla, MD",1265872592,"86-3825791","TX","PE - West Texas Ob/Gyn","Medicare","In Process","Pending Info/Document","","","","2023-11-16","Requested surrogacy from client for both the provider and the group. The inital submission was done through Dana's account, but was denied due to the provider not signing the application. I will need the provider and the group to approve surrogacy for me to complete this enrollment. MS"]
["Deepika Devalla, MD",1265872592,"86-3825791","TX","PE - West Texas Ob/Gyn","Medicare","In Process","Pending Info/Document","","","","2023-11-16","Requested surrogacy from client for both the provider and the group. The inital submission was done through Dana's account, but was denied due to the provider not signing the application. I will need the provider and the group to approve surrogacy for me to complete this enrollment. MS"]
["Deepika Devalla, MD",1265872592,"86-3825791","TX","PE - West Texas Ob/Gyn","Caprock (CapStar)","Participating","Enrollment Complete","2020-01-01","","","2022-10-12","10/12/2022 Per email from Priscilla Albertine she rcvd confirmation from Mary Rodriguez at Caprock that provider is PAR and linked to group TIN/locations effective 1/1/2020.  DCannon"]
["Deepika Devalla, MD",1265872592,"86-3825791","TX","PE - West Texas Ob/Gyn","Caprock (CapStar)","Participating","Enrollment Complete","2020-01-01","","","2022-10-12","10/12/2022 Per email from Priscilla Albertine she rcvd confirmation from Mary Rodriguez at Caprock that provider is PAR and linked to group TIN/locations effective 1/1/2020.  DCannon"]
["Deepika Devalla, MD",1265872592,"86-3825791","TX","PE - West Texas Ob/Gyn","Caprock (CapStar)","Participating","Enrollment Complete","2020-01-01","","","2022-10-12","10/12/2022 Per email from Priscilla Albertine she rcvd confirmation from Mary Rodriguez at Caprock that provider is PAR and linked to group TIN/locations effective 1/1/2020.  DCannon"]
["Deepika Devalla, MD",1265872592,"86-3825791","TX","PE - West Texas Ob/Gyn","Caprock (CapStar)","Participating","Enrollment Complete","2020-01-01","","","2022-10-12","10/12/2022 Per email from Priscilla Albertine she rcvd confirmation from Mary Rodriguez at Caprock that provider is PAR and linked to group TIN/locations effective 1/1/2020.  DCannon"]
["Deepika Devalla, MD",1265872592,"86-3825791","TX","PE - West Texas Ob/Gyn","United Health Care","Participating","Enrollment Complete","2022-05-13","","","2022-07-20","7/20/2022 Per email received from  from UHC monthly delegated roster submission has been completed and provider is PAR and in linked to group TIN effective 5/13/2022.   MPIN# 006290221.   DCannon"]
["Deepika Devalla, MD",1265872592,"86-3825791","TX","PE - West Texas Ob/Gyn","United Health Care","Participating","Enrollment Complete","2022-05-13","","","2022-07-20","7/20/2022 Per email received from  from UHC monthly delegated roster submission has been completed and provider is PAR and in linked to group TIN effective 5/13/2022.   MPIN# 006290221.   DCannon"]
["Deepika Devalla, MD",1265872592,"86-3825791","TX","PE - West Texas Ob/Gyn","United Health Care","Participating","Enrollment Complete","2022-05-13","","","2022-07-20","7/20/2022 Per email received from  from UHC monthly delegated roster submission has been completed and provider is PAR and in linked to group TIN effective 5/13/2022.   MPIN# 006290221.   DCannon"]
["Deepika Devalla, MD",1265872592,"86-3825791","TX","PE - West Texas Ob/Gyn","United Health Care","Participating","Enrollment Complete","2022-05-13","","","2022-07-20","7/20/2022 Per email received from  from UHC monthly delegated roster submission has been completed and provider is PAR and in linked to group TIN effective 5/13/2022.   MPIN# 006290221.   DCannon"]
["Deepika Devalla, MD",1265872592,"86-3825791","TX","PE - West Texas Ob/Gyn","Boon Chapman","Participating","Enrollment Complete","2022-01-01","","","2004-07-24","7/24/2022 Per email from Marcie Eckhart-Havens Multiplan July delegated roster has been completed  and provider is PAR and linked to group TIN effective 1/1/2022.  DCannon"]
["Deepika Devalla, MD",1265872592,"86-3825791","TX","PE - West Texas Ob/Gyn","Boon Chapman","Participating","Enrollment Complete","2022-01-01","","","2004-07-24","7/24/2022 Per email from Marcie Eckhart-Havens Multiplan July delegated roster has been completed  and provider is PAR and linked to group TIN effective 1/1/2022.  DCannon"]
["Deepika Devalla, MD",1265872592,"86-3825791","TX","PE - West Texas Ob/Gyn","Boon Chapman","Participating","Enrollment Complete","2022-01-01","","","2004-07-24","7/24/2022 Per email from Marcie Eckhart-Havens Multiplan July delegated roster has been completed  and provider is PAR and linked to group TIN effective 1/1/2022.  DCannon"]
["Deepika Devalla, MD",1265872592,"86-3825791","TX","PE - West Texas Ob/Gyn","Boon Chapman","Participating","Enrollment Complete","2022-01-01","","","2004-07-24","7/24/2022 Per email from Marcie Eckhart-Havens Multiplan July delegated roster has been completed  and provider is PAR and linked to group TIN effective 1/1/2022.  DCannon"]
["Deepika Devalla, MD",1265872592,"86-3825791","TX","PE - West Texas Ob/Gyn","TriCare Standard","Participating","Enrollment Complete","2022-04-18","","","2022-05-06","5/6/2022 Per Tricare portal provider is PAR and linked to group TIN/location effective 4/18/2022.  DCannon"]
["Deepika Devalla, MD",1265872592,"86-3825791","TX","PE - West Texas Ob/Gyn","TriCare Standard","Participating","Enrollment Complete","2022-04-18","","","2022-05-06","5/6/2022 Per Tricare portal provider is PAR and linked to group TIN/location effective 4/18/2022.  DCannon"]
["Deepika Devalla, MD",1265872592,"86-3825791","TX","PE - West Texas Ob/Gyn","TriCare Standard","Participating","Enrollment Complete","2022-04-18","","","2022-05-06","5/6/2022 Per Tricare portal provider is PAR and linked to group TIN/location effective 4/18/2022.  DCannon"]
["Deepika Devalla, MD",1265872592,"86-3825791","TX","PE - West Texas Ob/Gyn","TriCare Standard","Participating","Enrollment Complete","2022-04-18","","","2022-05-06","5/6/2022 Per Tricare portal provider is PAR and linked to group TIN/location effective 4/18/2022.  DCannon"]
["Deepika Devalla, MD",1265872592,"86-3825791","TX","PE - West Texas Ob/Gyn","Ambetter","Participating","Enrollment Complete","2022-05-01","","","2022-06-13","6/13/2022 Per roster received from Superior provider is PAR w/ Ambetter and linked to group delegation roster effective 5/1/2022.  DCannon"]
["Deepika Devalla, MD",1265872592,"86-3825791","TX","PE - West Texas Ob/Gyn","Triwest VA","In House Enrollment","In House Enrollment","","","","2022-04-13",""]
["Deepika Devalla, MD",1265872592,"86-3825791","TX","PE - West Texas Ob/Gyn","Triwest VA","In House Enrollment","In House Enrollment","","","","2022-04-13",""]
["Deepika Devalla, MD",1265872592,"86-3825791","TX","PE - West Texas Ob/Gyn","Triwest VA","In House Enrollment","In House Enrollment","","","","2022-04-13",""]
["Deepika Devalla, MD",1265872592,"86-3825791","TX","PE - West Texas Ob/Gyn","Triwest VA","In House Enrollment","In House Enrollment","","","","2022-04-13",""]
["Deepika Devalla, MD",1265872592,"86-3825791","TX","PE - West Texas Ob/Gyn","HealthSmart PPO","Participating","Enrollment Complete","2022-01-01","","","2022-06-10","6/10/2022 Per Healthsmart website provider is PAR and loaded under TIN/location effective 1/1/2022.  DCannon"]
["Deepika Devalla, MD",1265872592,"86-3825791","TX","PE - West Texas Ob/Gyn","HealthSmart PPO","Participating","Enrollment Complete","2022-01-01","","","2022-06-10","6/10/2022 Per Healthsmart website provider is PAR and loaded under TIN/location effective 1/1/2022.  DCannon"]
["Deepika Devalla, MD",1265872592,"86-3825791","TX","PE - West Texas Ob/Gyn","HealthSmart PPO","Participating","Enrollment Complete","2022-01-01","","","2022-06-10","6/10/2022 Per Healthsmart website provider is PAR and loaded under TIN/location effective 1/1/2022.  DCannon"]
["Deepika Devalla, MD",1265872592,"86-3825791","TX","PE - West Texas Ob/Gyn","HealthSmart PPO","Participating","Enrollment Complete","2022-01-01","","","2022-06-10","6/10/2022 Per Healthsmart website provider is PAR and loaded under TIN/location effective 1/1/2022.  DCannon"]
["Deepika Devalla, MD",1265872592,"86-3825791","TX","PE - West Texas Ob/Gyn","Omni PPO","Participating","Enrollment Complete","2022-01-01","","","2022-05-26","5/26/2022 Rcvd email from G. Aviles at IMS/OMNI stating that the monthly delegated roster provider loads for April has been completed.  Provider is PAR and linked to location/TIN effective 1/1/2022. DCannon"]
["Deepika Devalla, MD",1265872592,"86-3825791","TX","PE - West Texas Ob/Gyn","Omni PPO","Participating","Enrollment Complete","2022-01-01","","","2022-05-26","5/26/2022 Rcvd email from G. Aviles at IMS/OMNI stating that the monthly delegated roster provider loads for April has been completed.  Provider is PAR and linked to location/TIN effective 1/1/2022. DCannon"]
["Deepika Devalla, MD",1265872592,"86-3825791","TX","PE - West Texas Ob/Gyn","Omni PPO","Participating","Enrollment Complete","2022-01-01","","","2022-05-26","5/26/2022 Rcvd email from G. Aviles at IMS/OMNI stating that the monthly delegated roster provider loads for April has been completed.  Provider is PAR and linked to location/TIN effective 1/1/2022. DCannon"]
["Deepika Devalla, MD",1265872592,"86-3825791","TX","PE - West Texas Ob/Gyn","Omni PPO","Participating","Enrollment Complete","2022-01-01","","","2022-05-26","5/26/2022 Rcvd email from G. Aviles at IMS/OMNI stating that the monthly delegated roster provider loads for April has been completed.  Provider is PAR and linked to location/TIN effective 1/1/2022. DCannon"]
["Deepika Devalla, MD",1265872592,"86-3825791","TX","PE - West Texas Ob/Gyn","Humana","Participating","Enrollment Complete","2022-01-01","","","2022-07-14","7/14/2022 Per email received from Humana provider is PAR and linked to group TIN/location effective 1/1/2022.  DCannon"]
["Deepika Devalla, MD",1265872592,"86-3825791","TX","PE - West Texas Ob/Gyn","Humana","Participating","Enrollment Complete","2022-01-01","","","2022-07-14","7/14/2022 Per email received from Humana provider is PAR and linked to group TIN/location effective 1/1/2022.  DCannon"]
["Deepika Devalla, MD",1265872592,"86-3825791","TX","PE - West Texas Ob/Gyn","Humana","Participating","Enrollment Complete","2022-01-01","","","2022-07-14","7/14/2022 Per email received from Humana provider is PAR and linked to group TIN/location effective 1/1/2022.  DCannon"]
["Deepika Devalla, MD",1265872592,"86-3825791","TX","PE - West Texas Ob/Gyn","Humana","Participating","Enrollment Complete","2022-01-01","","","2022-07-14","7/14/2022 Per email received from Humana provider is PAR and linked to group TIN/location effective 1/1/2022.  DCannon"]
["Deepika Devalla, MD",1265872592,"86-3825791","TX","PE - West Texas Ob/Gyn","First Health Coventry","In Process","Application Resubmitted","","","","2023-10-20","10/20/2023 Per action needed note 2nd app resubmitted online via Aetna web portal.  DCannon"]
["Deepika Devalla, MD",1265872592,"86-3825791","TX","PE - West Texas Ob/Gyn","First Health Coventry","In Process","Application Resubmitted","","","","2023-10-20","10/20/2023 Per action needed note 2nd app resubmitted online via Aetna web portal.  DCannon"]
["Deepika Devalla, MD",1265872592,"86-3825791","TX","PE - West Texas Ob/Gyn","First Health Coventry","In Process","Application Resubmitted","","","","2023-10-20","10/20/2023 Per action needed note 2nd app resubmitted online via Aetna web portal.  DCannon"]
["Deepika Devalla, MD",1265872592,"86-3825791","TX","PE - West Texas Ob/Gyn","First Health Coventry","In Process","Application Resubmitted","","","","2023-10-20","10/20/2023 Per action needed note 2nd app resubmitted online via Aetna web portal.  DCannon"]
["Deepika Devalla, MD",1265872592,"86-3825791","TX","PE - West Texas Ob/Gyn","Cigna","Participating","Enrollment Complete","2022-01-01","6345618","","2022-04-27","4/27/2022 Rcvd email from Cigna that provider is PAR and linked to group TIN/location effective 1/1/2022.  PID # 6345618.  DCannon"]
["Deepika Devalla, MD",1265872592,"86-3825791","TX","PE - West Texas Ob/Gyn","Cigna","Participating","Enrollment Complete","2022-01-01","6345618","","2022-04-27","4/27/2022 Rcvd email from Cigna that provider is PAR and linked to group TIN/location effective 1/1/2022.  PID # 6345618.  DCannon"]
["Deepika Devalla, MD",1265872592,"86-3825791","TX","PE - West Texas Ob/Gyn","Cigna","Participating","Enrollment Complete","2022-01-01","6345618","","2022-04-27","4/27/2022 Rcvd email from Cigna that provider is PAR and linked to group TIN/location effective 1/1/2022.  PID # 6345618.  DCannon"]
["Deepika Devalla, MD",1265872592,"86-3825791","TX","PE - West Texas Ob/Gyn","Cigna","Participating","Enrollment Complete","2022-01-01","6345618","","2022-04-27","4/27/2022 Rcvd email from Cigna that provider is PAR and linked to group TIN/location effective 1/1/2022.  PID # 6345618.  DCannon"]
["Deepika Devalla, MD",1265872592,"86-3825791","TX","PE - West Texas Ob/Gyn","Rail Road Medicare","Pending Other Enrollment","Pending Medicare","","","","2023-11-18","Still pending MCR. MS"]
["Deepika Devalla, MD",1265872592,"86-3825791","TX","PE - West Texas Ob/Gyn","Rail Road Medicare","Pending Other Enrollment","Pending Medicare","","","","2023-11-18","Still pending MCR. MS"]
["Deepika Devalla, MD",1265872592,"86-3825791","TX","PE - West Texas Ob/Gyn","Rail Road Medicare","Pending Other Enrollment","Pending Medicare","","","","2023-11-18","Still pending MCR. MS"]
["Deepika Devalla, MD",1265872592,"86-3825791","TX","PE - West Texas Ob/Gyn","Rail Road Medicare","Pending Other Enrollment","Pending Medicare","","","","2023-11-18","Still pending MCR. MS"]
["Deepika Devalla, MD",1265872592,"86-3825791","TX","PE - West Texas Ob/Gyn","Amerigroup","Participating","Enrollment Complete","2022-01-10","","","2022-09-23","9/23/2022 Per roster received from Joe Rodriguez at Amerigroup provider is PAR and linked to group TIN effective 1/10/2022.  DCannon"]
["Deepika Devalla, MD",1265872592,"86-3825791","TX","PE - West Texas Ob/Gyn","Amerigroup","Participating","Enrollment Complete","2022-01-10","","","2022-09-23","9/23/2022 Per roster received from Joe Rodriguez at Amerigroup provider is PAR and linked to group TIN effective 1/10/2022.  DCannon"]
["Deepika Devalla, MD",1265872592,"86-3825791","TX","PE - West Texas Ob/Gyn","Amerigroup","Participating","Enrollment Complete","2022-01-10","","","2022-09-23","9/23/2022 Per roster received from Joe Rodriguez at Amerigroup provider is PAR and linked to group TIN effective 1/10/2022.  DCannon"]
["Deepika Devalla, MD",1265872592,"86-3825791","TX","PE - West Texas Ob/Gyn","Amerigroup","Participating","Enrollment Complete","2022-01-10","","","2022-09-23","9/23/2022 Per roster received from Joe Rodriguez at Amerigroup provider is PAR and linked to group TIN effective 1/10/2022.  DCannon"]
["Deepika Devalla, MD",1265872592,"86-3825791","TX","PE - West Texas Ob/Gyn","Multiplan","Participating","Enrollment Complete","2022-01-01","","","2022-07-24","7/24/2022 Per email from Marcie Eckhart-Havens Multiplan July delegated roster has been completed  and provider is PAR and linked to group TIN effective 1/1/2022.  DCannon"]
["Deepika Devalla, MD",1265872592,"86-3825791","TX","PE - West Texas Ob/Gyn","Multiplan","Participating","Enrollment Complete","2022-01-01","","","2022-07-24","7/24/2022 Per email from Marcie Eckhart-Havens Multiplan July delegated roster has been completed  and provider is PAR and linked to group TIN effective 1/1/2022.  DCannon"]
["Deepika Devalla, MD",1265872592,"86-3825791","TX","PE - West Texas Ob/Gyn","Multiplan","Participating","Enrollment Complete","2022-01-01","","","2022-07-24","7/24/2022 Per email from Marcie Eckhart-Havens Multiplan July delegated roster has been completed  and provider is PAR and linked to group TIN effective 1/1/2022.  DCannon"]
["Deepika Devalla, MD",1265872592,"86-3825791","TX","PE - West Texas Ob/Gyn","Multiplan","Participating","Enrollment Complete","2022-01-01","","","2022-07-24","7/24/2022 Per email from Marcie Eckhart-Havens Multiplan July delegated roster has been completed  and provider is PAR and linked to group TIN effective 1/1/2022.  DCannon"]
["Deepika Devalla, MD",1265872592,"86-3825791","TX","PE - West Texas Ob/Gyn","Aetna","Participating","Enrollment Complete","2022-01-01","5484622","","2022-06-21","6/21/2022 Per follow-up note - 06/13/2022 - S/w Chris of Aetna @ 800-353-1232. Provider NPI# is on file for the provider and is participating effective 01/01/2022 under the group and TIN#. PIN: 5484822. Physical location is on file. Call ref# 6095008958. - DCannon"]
["Deepika Devalla, MD",1265872592,"86-3825791","TX","PE - West Texas Ob/Gyn","Aetna","Participating","Enrollment Complete","2022-01-01","5484622","","2022-06-21","6/21/2022 Per follow-up note - 06/13/2022 - S/w Chris of Aetna @ 800-353-1232. Provider NPI# is on file for the provider and is participating effective 01/01/2022 under the group and TIN#. PIN: 5484822. Physical location is on file. Call ref# 6095008958. - DCannon"]
["Deepika Devalla, MD",1265872592,"86-3825791","TX","PE - West Texas Ob/Gyn","Aetna","Participating","Enrollment Complete","2022-01-01","5484622","","2022-06-21","6/21/2022 Per follow-up note - 06/13/2022 - S/w Chris of Aetna @ 800-353-1232. Provider NPI# is on file for the provider and is participating effective 01/01/2022 under the group and TIN#. PIN: 5484822. Physical location is on file. Call ref# 6095008958. - DCannon"]
["Deepika Devalla, MD",1265872592,"86-3825791","TX","PE - West Texas Ob/Gyn","Aetna","Participating","Enrollment Complete","2022-01-01","5484622","","2022-06-21","6/21/2022 Per follow-up note - 06/13/2022 - S/w Chris of Aetna @ 800-353-1232. Provider NPI# is on file for the provider and is participating effective 01/01/2022 under the group and TIN#. PIN: 5484822. Physical location is on file. Call ref# 6095008958. - DCannon"]
["Deepika Devalla, MD",1265872592,"86-3825791","TX","PE - West Texas Ob/Gyn","Wellmed","Participating","Enrollment Complete","2022-05-13","","","2023-03-23","3/23/2023 Rcvd roster from UHC w/ all Wellmed participating providers.  Provider is PAR effective 5/13/2022.  DCannon"]
["Deepika Devalla, MD",1265872592,"86-3825791","TX","PE - West Texas Ob/Gyn","Wellmed","Participating","Enrollment Complete","2022-05-13","","","2023-03-23","3/23/2023 Rcvd roster from UHC w/ all Wellmed participating providers.  Provider is PAR effective 5/13/2022.  DCannon"]
["Deepika Devalla, MD",1265872592,"86-3825791","TX","PE - West Texas Ob/Gyn","Wellmed","Participating","Enrollment Complete","2022-05-13","","","2023-03-23","3/23/2023 Rcvd roster from UHC w/ all Wellmed participating providers.  Provider is PAR effective 5/13/2022.  DCannon"]
["Deepika Devalla, MD",1265872592,"86-3825791","TX","PE - West Texas Ob/Gyn","Wellmed","Participating","Enrollment Complete","2022-05-13","","","2023-03-23","3/23/2023 Rcvd roster from UHC w/ all Wellmed participating providers.  Provider is PAR effective 5/13/2022.  DCannon"]
["Deepika Devalla, MD",1265872592,"86-3825791","TX","PE - West Texas Ob/Gyn","Wellcare","Participating","Enrollment Complete","2022-05-01","","","2022-07-01","7/1/2022 Received May Monthly Validation roster from Superior and provider is PAR and linked effective 5/1/2022.  DCannon"]
["Deepika Devalla, MD",1265872592,"86-3825791","TX","PE - West Texas Ob/Gyn","Superior","Participating","Enrollment Complete","2022-05-01","","","2022-05-03","5/3/2022 Rcvd email from Superior that April delegation roster has been completed and provider is PAR and linked to group TIN/location effective 5/1/2022.  DCannon"]
["Deepika Devalla, MD",1265872592,"86-3825791","TX","PE - West Texas Ob/Gyn","Superior","Participating","Enrollment Complete","2022-05-01","","","2022-05-03","5/3/2022 Rcvd email from Superior that April delegation roster has been completed and provider is PAR and linked to group TIN/location effective 5/1/2022.  DCannon"]
["Deepika Devalla, MD",1265872592,"86-3825791","TX","PE - West Texas Ob/Gyn","Superior","Participating","Enrollment Complete","2022-05-01","","","2022-05-03","5/3/2022 Rcvd email from Superior that April delegation roster has been completed and provider is PAR and linked to group TIN/location effective 5/1/2022.  DCannon"]
["Deepika Devalla, MD",1265872592,"86-3825791","TX","PE - West Texas Ob/Gyn","Superior","Participating","Enrollment Complete","2022-05-01","","","2022-05-03","5/3/2022 Rcvd email from Superior that April delegation roster has been completed and provider is PAR and linked to group TIN/location effective 5/1/2022.  DCannon"]
["Deepika Devalla, MD",1265872592,"86-3825791","TX","PE - West Texas Ob/Gyn","USA PPO","In Process","Payor Follow Up","","","","2023-11-27","11/27/2023 Per USA PPO provider portal provider is still not loaded under new locations.  Will allow more time, check back in 2 weeks.  \nDCannon"]
["Deepika Devalla, MD",1265872592,"86-3825791","TX","PE - West Texas Ob/Gyn","USA PPO","In Process","Payor Follow Up","","","","2023-11-27","11/27/2023 Per USA PPO provider portal provider is still not loaded under new locations.  Will allow more time, check back in 2 weeks.  \nDCannon"]
["Deepika Devalla, MD",1265872592,"86-3825791","TX","PE - West Texas Ob/Gyn","USA PPO","In Process","Payor Follow Up","","","","2023-11-27","11/27/2023 Per USA PPO provider portal provider is still not loaded under new locations.  Will allow more time, check back in 2 weeks.  \nDCannon"]
["Deepika Devalla, MD",1265872592,"86-3825791","TX","PE - West Texas Ob/Gyn","USA PPO","In Process","Payor Follow Up","","","","2023-11-27","11/27/2023 Per USA PPO provider portal provider is still not loaded under new locations.  Will allow more time, check back in 2 weeks.  \nDCannon"]
["Deepika Devalla, MD",1265872592,"86-3825791","TX","PE - West Texas Ob/Gyn","IMS","Participating","Enrollment Complete","2022-01-01","","","2022-05-26","5/26/2022 Rcvd email from G. Aviles at IMS/OMNI stating that the monthly delegated roster provider loads for April has been completed.  Provider is PAR and linked to location/TIN effective 1/1/2022. DCannon"]
["Deepika Devalla, MD",1265872592,"86-3825791","TX","PE - West Texas Ob/Gyn","IMS","Participating","Enrollment Complete","2022-01-01","","","2022-05-26","5/26/2022 Rcvd email from G. Aviles at IMS/OMNI stating that the monthly delegated roster provider loads for April has been completed.  Provider is PAR and linked to location/TIN effective 1/1/2022. DCannon"]
["Deepika Devalla, MD",1265872592,"86-3825791","TX","PE - West Texas Ob/Gyn","IMS","Participating","Enrollment Complete","2022-01-01","","","2022-05-26","5/26/2022 Rcvd email from G. Aviles at IMS/OMNI stating that the monthly delegated roster provider loads for April has been completed.  Provider is PAR and linked to location/TIN effective 1/1/2022. DCannon"]
["Deepika Devalla, MD",1265872592,"86-3825791","TX","PE - West Texas Ob/Gyn","IMS","Participating","Enrollment Complete","2022-01-01","","","2022-05-26","5/26/2022 Rcvd email from G. Aviles at IMS/OMNI stating that the monthly delegated roster provider loads for April has been completed.  Provider is PAR and linked to location/TIN effective 1/1/2022. DCannon"]
["Deepika Devalla, MD",1265872592,"86-3825791","TX","PE - West Texas Ob/Gyn","Scott&White (First Care)","Participating","Enrollment Complete","2023-09-18","","","2023-10-02","10/2/2023 Rcvd email confirmation from Scott & White that provider is PAR and linked to group/locations effective 9/18/2023.  DCannon"]
["Deepika Devalla, MD",1265872592,"86-3825791","TX","PE - West Texas Ob/Gyn","Scott&White (First Care)","Participating","Enrollment Complete","2023-09-18","","","2023-10-02","10/2/2023 Rcvd email confirmation from Scott & White that provider is PAR and linked to group/locations effective 9/18/2023.  DCannon"]
["Deepika Devalla, MD",1265872592,"86-3825791","TX","PE - West Texas Ob/Gyn","Scott&White (First Care)","Participating","Enrollment Complete","2023-09-18","","","2023-10-02","10/2/2023 Rcvd email confirmation from Scott & White that provider is PAR and linked to group/locations effective 9/18/2023.  DCannon"]
["Deepika Devalla, MD",1265872592,"86-3825791","TX","PE - West Texas Ob/Gyn","Scott&White (First Care)","Participating","Enrollment Complete","2023-09-18","","","2023-10-02","10/2/2023 Rcvd email confirmation from Scott & White that provider is PAR and linked to group/locations effective 9/18/2023.  DCannon"]
["Sridhar R Allam, MD",1700061819,"88-1668292","TX","PE - Premier Texas Kidney Care, PLLC","IMS","Participating","Enrollment Complete","2022-06-20","","","2022-10-17","10/17/2022 Per email received from German Aviles at IMS/OMNI monthly delegation roster provider load for July has been completed.  Provider is PAR and linked to group TIN effective 6/20/2022.   DCannon"]
["Sridhar R Allam, MD",1700061819,"88-1668292","TX","","IMS","Participating","Enrollment Complete","2022-06-20","","","2022-10-17","10/17/2022 Per email received from German Aviles at IMS/OMNI monthly delegation roster provider load for July has been completed.  Provider is PAR and linked to group TIN effective 6/20/2022.   DCannon"]
["Sridhar R Allam, MD",1700061819,"88-1668292","TX","PE - Premier Texas Kidney Care, PLLC","Superior","Participating","Enrollment Complete","2022-08-01","","","2022-08-10","8/10/2022 Per roster received from Superior July monthly delegated submission is complete and provider is PAR and linked to group TIN/locations effective  8/1/2022.  DCannon"]
["Sridhar R Allam, MD",1700061819,"88-1668292","TX","","Superior","Participating","Enrollment Complete","2022-08-01","","","2022-08-10","8/10/2022 Per roster received from Superior July monthly delegated submission is complete and provider is PAR and linked to group TIN/locations effective  8/1/2022.  DCannon"]
["Sridhar R Allam, MD",1700061819,"88-1668292","TX","PE - Premier Texas Kidney Care, PLLC","CAQH","Participating","CAQH Reattested","2023-11-01","","","2023-11-01","11/01/2023 - CAQH Re-attested, updated and uploaded, license and board - dkonar"]
["Sridhar R Allam, MD",1700061819,"88-1668292","TX","","CAQH","Participating","CAQH Reattested","2023-11-01","","","2023-11-01","11/01/2023 - CAQH Re-attested, updated and uploaded, license and board - dkonar"]
["Sridhar R Allam, MD",1700061819,"88-1668292","TX","PE - Premier Texas Kidney Care, PLLC","Scott&White (First Care)","Participating","Enrollment Complete","2022-08-15","","","2022-10-10","10/10/2022 Per roster received from Scott & White provider is PAR and linked to TIN effective 8/15/2022.  DCannon"]
["Sridhar R Allam, MD",1700061819,"88-1668292","TX","","Scott&White (First Care)","Participating","Enrollment Complete","2022-08-15","","","2022-10-10","10/10/2022 Per roster received from Scott & White provider is PAR and linked to TIN effective 8/15/2022.  DCannon"]
["Sridhar R Allam, MD",1700061819,"88-1668292","TX","PE - Premier Texas Kidney Care, PLLC","Omni PPO","Participating","Enrollment Complete","2022-06-20","","","2022-10-17","10/17/2022 Per email received from German Aviles at IMS/OMNI monthly delegation roster provider load for July has been completed.  Provider is PAR and linked to group TIN effective 6/20/2022.   DCannon"]
["Sridhar R Allam, MD",1700061819,"88-1668292","TX","","Omni PPO","Participating","Enrollment Complete","2022-06-20","","","2022-10-17","10/17/2022 Per email received from German Aviles at IMS/OMNI monthly delegation roster provider load for July has been completed.  Provider is PAR and linked to group TIN effective 6/20/2022.   DCannon"]
["Sridhar R Allam, MD",1700061819,"88-1668292","TX","PE - Premier Texas Kidney Care, PLLC","Boon Chapman","Participating","Enrollment Complete","2022-06-20","","","2022-07-24","7/24/2022 Per email from Marcie Eckhart-Havens Multiplan July delegated roster has been completed  and provider is PAR and linked to group TIN effective 6/20/2022.  DCannon"]
["Sridhar R Allam, MD",1700061819,"88-1668292","TX","","Boon Chapman","Participating","Enrollment Complete","2022-06-20","","","2022-07-24","7/24/2022 Per email from Marcie Eckhart-Havens Multiplan July delegated roster has been completed  and provider is PAR and linked to group TIN effective 6/20/2022.  DCannon"]
["Sridhar R Allam, MD",1700061819,"88-1668292","TX","PE - Premier Texas Kidney Care, PLLC","Humana","Participating","Enrollment Complete","2022-06-20","","","2022-08-20","8/20/2022 Per email received from Vernita Young July monthly delegated roster is complete and provider is PAR and linked to group TIN/location effective 6/20/2022.  DCannon"]
["Sridhar R Allam, MD",1700061819,"88-1668292","TX","","Humana","Participating","Enrollment Complete","2022-06-20","","","2022-08-20","8/20/2022 Per email received from Vernita Young July monthly delegated roster is complete and provider is PAR and linked to group TIN/location effective 6/20/2022.  DCannon"]
["Sridhar R Allam, MD",1700061819,"88-1668292","TX","PE - Premier Texas Kidney Care, PLLC","Medicare","Participating","Enrollment Complete","2022-05-01","2F0275","2F0276","2022-07-20","06/28/2022 Provider is PAR in Texas Medicare, and linked to group.  PTAN # 2F0275 - effective 5/1/2022.  DCannon"]
["Sridhar R Allam, MD",1700061819,"88-1668292","TX","","Medicare","Participating","Enrollment Complete","2022-05-01","2F0275","2F0276","2022-07-20","06/28/2022 Provider is PAR in Texas Medicare, and linked to group.  PTAN # 2F0275 - effective 5/1/2022.  DCannon"]
["Sridhar R Allam, MD",1700061819,"88-1668292","TX","PE - Premier Texas Kidney Care, PLLC","Multiplan","Participating","Enrollment Complete","2022-06-20","","","2022-07-24","7/24/2022 Per email from Marcie Eckhart-Havens Multiplan July delegated roster has been completed  and provider is PAR and linked to group TIN effective 6/20/2022.  DCannon"]
["Sridhar R Allam, MD",1700061819,"88-1668292","TX","","Multiplan","Participating","Enrollment Complete","2022-06-20","","","2022-07-24","7/24/2022 Per email from Marcie Eckhart-Havens Multiplan July delegated roster has been completed  and provider is PAR and linked to group TIN effective 6/20/2022.  DCannon"]
["Sridhar R Allam, MD",1700061819,"88-1668292","TX","PE - Premier Texas Kidney Care, PLLC","USA PPO","Participating","Enrollment Complete","2022-06-20","","","2023-10-23","10/23/2023 Per roster received from USA PPO provider is PAR and linked to group TIN effective 6/20/2022.  DCannon"]
["Sridhar R Allam, MD",1700061819,"88-1668292","TX","","USA PPO","Participating","Enrollment Complete","2022-06-20","","","2023-10-23","10/23/2023 Per roster received from USA PPO provider is PAR and linked to group TIN effective 6/20/2022.  DCannon"]
["Sridhar R Allam, MD",1700061819,"88-1668292","TX","PE - Premier Texas Kidney Care, PLLC","Rail Road Medicare","Participating","Enrollment Complete","2022-05-01","P02660539","EB8061","2022-09-16","9/16/2022 Rcvd RR Medicare approval letter.  PTAN # P02660539 - effective 5/1/2022.  DCannon"]
["Sridhar R Allam, MD",1700061819,"88-1668292","TX","","Rail Road Medicare","Participating","Enrollment Complete","2022-05-01","P02660539","EB8061","2022-09-16","9/16/2022 Rcvd RR Medicare approval letter.  PTAN # P02660539 - effective 5/1/2022.  DCannon"]
["Sridhar R Allam, MD",1700061819,"88-1668292","TX","PE - Premier Texas Kidney Care, PLLC","HealthSmart PPO","Participating","Enrollment Complete","2022-06-20","","","2023-07-11","Received confirmation from Client. MS"]
["Sridhar R Allam, MD",1700061819,"88-1668292","TX","","HealthSmart PPO","Participating","Enrollment Complete","2022-06-20","","","2023-07-11","Received confirmation from Client. MS"]
["Sridhar R Allam, MD",1700061819,"88-1668292","TX","PE - Premier Texas Kidney Care, PLLC","TriCare Standard","Participating","Enrollment Complete","2022-07-22","","","2023-09-01","Confirmed via Tricare web portal. MS"]
["Sridhar R Allam, MD",1700061819,"88-1668292","TX","","TriCare Standard","Participating","Enrollment Complete","2022-07-22","","","2023-09-01","Confirmed via Tricare web portal. MS"]
["Sridhar R Allam, MD",1700061819,"88-1668292","TX","PE - Premier Texas Kidney Care, PLLC","Tricare Prime","Panel Closed","Panel Closed","","","","2022-10-28","10/28/2022 Per Tricare/Humana Military is currently not accepting requests to join the medical surgical network. Will check back soon to see if we are accepting network providers.  DCannon"]
["Sridhar R Allam, MD",1700061819,"88-1668292","TX","","Tricare Prime","Panel Closed","Panel Closed","","","","2022-10-28","10/28/2022 Per Tricare/Humana Military is currently not accepting requests to join the medical surgical network. Will check back soon to see if we are accepting network providers.  DCannon"]
["Sridhar R Allam, MD",1700061819,"88-1668292","TX","PE - Premier Texas Kidney Care, PLLC","First Health Coventry","Enrollment on Hold","Enrollment on Hold","","","","2023-11-22","11/22/2023 Per previous note - provider is part of a delegated group and the provider would need to contact that delegated group to make any updates/changes.   Will reach out to MQA for assistance. DCannon"]
["Sridhar R Allam, MD",1700061819,"88-1668292","TX","","First Health Coventry","Enrollment on Hold","Enrollment on Hold","","","","2023-11-22","11/22/2023 Per previous note - provider is part of a delegated group and the provider would need to contact that delegated group to make any updates/changes.   Will reach out to MQA for assistance. DCannon"]
["Sridhar R Allam, MD",1700061819,"88-1668292","TX","PE - Premier Texas Kidney Care, PLLC","Medicaid","In Process","Pending Info/Document","","","","2023-11-21","Application is ready to be signed by Dr. Allam. Emailed MQA to assist. Jen Videan"]
["Sridhar R Allam, MD",1700061819,"88-1668292","TX","","Medicaid","In Process","Pending Info/Document","","","","2023-11-21","Application is ready to be signed by Dr. Allam. Emailed MQA to assist. Jen Videan"]
["Sridhar R Allam, MD",1700061819,"88-1668292","TX","PE - Premier Texas Kidney Care, PLLC","Caprock (CapStar)","Participating","Enrollment Complete","2020-01-01","","","2022-10-12","10/12/2022 Per email from Priscilla Albertine she rcvd confirmation from Mary Rodriguez at Caprock that provider is PAR and linked to group TIN/locations effective 1/1/2020.  DCannon"]
["Sridhar R Allam, MD",1700061819,"88-1668292","TX","","Caprock (CapStar)","Participating","Enrollment Complete","2020-01-01","","","2022-10-12","10/12/2022 Per email from Priscilla Albertine she rcvd confirmation from Mary Rodriguez at Caprock that provider is PAR and linked to group TIN/locations effective 1/1/2020.  DCannon"]
["Sridhar R Allam, MD",1700061819,"88-1668292","TX","PE - Premier Texas Kidney Care, PLLC","Wellcare","Participating","Enrollment Complete","2022-08-01","","","2022-08-10","8/10/2022 Per roster received from Superior May monthly delegated submission is complete and provider is PAR and linked to group TIN/locations effective  8/1/2022.  DCannon"]
["Sridhar R Allam, MD",1700061819,"88-1668292","TX","","Wellcare","Participating","Enrollment Complete","2022-08-01","","","2022-08-10","8/10/2022 Per roster received from Superior May monthly delegated submission is complete and provider is PAR and linked to group TIN/locations effective  8/1/2022.  DCannon"]
["Sridhar R Allam, MD",1700061819,"88-1668292","TX","PE - Premier Texas Kidney Care, PLLC","Cigna","Participating","Enrollment Complete","2022-05-01","0461877","","2022-07-15","7/15/2022 Per confirm par status note on 6/3/2022 - S/W Frank at Cigna, who confirmed provider is credentialed in TX through a delegation and is linked to tax ID as of 5/1/2022. Provider ID is 0461877. Ref # is frank 6/3/2022. HSmith"]
["Sridhar R Allam, MD",1700061819,"88-1668292","TX","","Cigna","Participating","Enrollment Complete","2022-05-01","0461877","","2022-07-15","7/15/2022 Per confirm par status note on 6/3/2022 - S/W Frank at Cigna, who confirmed provider is credentialed in TX through a delegation and is linked to tax ID as of 5/1/2022. Provider ID is 0461877. Ref # is frank 6/3/2022. HSmith"]
["Sridhar R Allam, MD",1700061819,"88-1668292","TX","PE - Premier Texas Kidney Care, PLLC","United Health Care","Participating","Enrollment Complete","2022-06-20","","","2022-08-10","8/10/2022 Per email received from  from UHC monthly delegated roster submission has been completed and provider is PAR and in linked to group TIN effective 6/20/2022.    DCannon"]
["Sridhar R Allam, MD",1700061819,"88-1668292","TX","","United Health Care","Participating","Enrollment Complete","2022-06-20","","","2022-08-10","8/10/2022 Per email received from  from UHC monthly delegated roster submission has been completed and provider is PAR and in linked to group TIN effective 6/20/2022.    DCannon"]
["Sridhar R Allam, MD",1700061819,"88-1668292","TX","PE - Premier Texas Kidney Care, PLLC","Aetna","Participating","Enrollment Complete","2022-06-20","","","2023-04-11","4/11/2023 Rcvd email from Priscilla Albertine at MQA provider is PAR and linked to group TIN/location effective 6/20/2022.  DCannon"]
["Sridhar R Allam, MD",1700061819,"88-1668292","TX","","Aetna","Participating","Enrollment Complete","2022-06-20","","","2023-04-11","4/11/2023 Rcvd email from Priscilla Albertine at MQA provider is PAR and linked to group TIN/location effective 6/20/2022.  DCannon"]
["Sridhar R Allam, MD",1700061819,"88-1668292","TX","PE - Premier Texas Kidney Care, PLLC","Galaxy Health","Participating","Enrollment Complete","2022-06-20","","","2022-08-17","8/17/2022 Per email from Karen Avalos at Galaxy delegated roster for July is complete and provider is loaded effective 6/20/2022.  DCannon"]
["Sridhar R Allam, MD",1700061819,"88-1668292","TX","","Galaxy Health","Participating","Enrollment Complete","2022-06-20","","","2022-08-17","8/17/2022 Per email from Karen Avalos at Galaxy delegated roster for July is complete and provider is loaded effective 6/20/2022.  DCannon"]
["Joyce O. Alase, MD",1295168318,"88-2797281","TX","PE - Healing Hands Medical Clinic","Medicaid","Enrollment on Hold","Pending Other Enrollment","","","","2023-10-13","Joyce Alase, MD is now par with Medicare. However, in order to proceed with her individual Medicaid enrollment, the group Healing Hands Medical Clinic needs to be enrolled with Medicaid. Jen Videan"]
["Joyce O. Alase, MD",1295168318,"88-2797281","TX","PE - Healing Hands Medical Clinic","Scott&White (First Care)","Participating","Enrollment Complete","2022-10-15","","","2022-10-10","10/10/2022 Per roster received from Scott & White provider is PAR and linked to TIN effective 10/15/2022.  DCannon"]
["Joyce O. Alase, MD",1295168318,"88-2797281","TX","PE - Healing Hands Medical Clinic","First Health Coventry","Participating","Enrollment Complete","2022-11-01","3284256","","2023-07-25","7/25/2023 Per email response from First Health provider is PAR and linked to group effective 11/1/2022.   Billing and mailing address on file are correct.  PID # 3284256 DCannon"]
["Joyce O. Alase, MD",1295168318,"88-2797281","TX","PE - Healing Hands Medical Clinic","Multiplan","Participating","Enrollment Complete","2022-08-29","","","2023-07-25","7/25/2023 Rcvd email from Jessica Bess at Multiplan with a full roster and provider is PAR w/ group and location effective 8/29/2022.  DCannon"]
["Joyce O. Alase, MD",1295168318,"88-2797281","TX","PE - Healing Hands Medical Clinic","Tricare Prime","Panel Closed","Panel Closed","","","","2022-10-28","10/28/2022 Per Tricare/Humana Military is currently not accepting requests to join the medical surgical network. Will check back soon to see if we are accepting network providers.  DCannon"]
["Joyce O. Alase, MD",1295168318,"88-2797281","TX","PE - Healing Hands Medical Clinic","HealthSmart PPO","Participating","Enrollment Complete","2022-08-29","","","2022-11-01","11/1/2022 Per Healthsmart website provider is PAR and loaded under TIN/location effective 8/29/2022.  DCannon"]
["Joyce O. Alase, MD",1295168318,"88-2797281","TX","PE - Healing Hands Medical Clinic","USA PPO","In Process","Payor Follow Up","","","","2023-11-27","11/27/2023 Per USA PPO provider portal provider is still not loaded under new locations.  Will allow more time, check back in 2 weeks.  \nDCannon"]
["Joyce O. Alase, MD",1295168318,"88-2797281","TX","PE - Healing Hands Medical Clinic","IMS","Participating","Enrollment Complete","2022-08-29","","","2022-10-17","10/17/2022 Per email received from German Aviles at IMS/OMNI monthly delegation roster provider load for September has been completed.  Provider is PAR and linked to group TIN effective 8/29/2022.   DCannon"]
["Joyce O. Alase, MD",1295168318,"88-2797281","TX","PE - Healing Hands Medical Clinic","TriCare Standard","Participating","Enrollment Complete","2022-09-23","","","2023-01-05","1/5/2023 Per Humana Military/Tricare portal provider is now a PAR Tricare Certified provider effective 9/23/2022.  DCannon"]
["Joyce O. Alase, MD",1295168318,"88-2797281","TX","PE - Healing Hands Medical Clinic","Wellmed","Participating","Enrollment Complete","2022-10-04","","","2023-03-23","3/23/2023 Rcvd roster from UHC w/ all Wellmed participating providers.  Provider is PAR effective 10/04/2022.  DCannon"]
["Joyce O. Alase, MD",1295168318,"88-2797281","TX","PE - Healing Hands Medical Clinic","Rail Road Medicare","Participating","Enrollment Complete","2023-01-25","P02703383","","2023-08-21","Confirmed enrollment. MS"]
["Joyce O. Alase, MD",1295168318,"88-2797281","TX","PE - Healing Hands Medical Clinic","Aetna","Participating","Enrollment Complete","2022-11-01","","","2023-05-19","Rep confirmed provider is participating under the TIN effective 11/1/2022. MS"]
["Joyce O. Alase, MD",1295168318,"88-2797281","TX","PE - Healing Hands Medical Clinic","Medicare","Participating","Enrollment Complete","2023-01-25","2U7317","2U7269","2023-06-15","Confirmed provider is participating. MS"]
["Joyce O. Alase, MD",1295168318,"88-2797281","TX","PE - Healing Hands Medical Clinic","Amerigroup","Participating","Enrollment Complete","2022-08-09","","","2022-11-04","11.04.2022 Per follow-up note -  S/W Chealse of Amerigroup @ 800-454-3730. Per rep, provider is showing participating with an  Effective date 08/09/2022 and link under the Group and TIN. Provider ID 14467387, Payer ID 26375 and No Recredentialing date. Service location is on file. Call ref#:I-166745338. -DCannon"]
["Joyce O. Alase, MD",1295168318,"88-2797281","TX","PE - Healing Hands Medical Clinic","Caprock (CapStar)","Participating","Enrollment Complete","2020-01-01","","","2022-10-12","10/12/2022 Per email from Priscilla Albertine she rcvd confirmation from Mary Rodriguez at Caprock that provider is PAR and linked to group TIN/locations effective 1/1/2020.  DCannon"]
["Joyce O. Alase, MD",1295168318,"88-2797281","TX","PE - Healing Hands Medical Clinic","Triwest VA","Participating","Enrollment Complete","2022-10-15","","","2022-10-05","10/05/2022 - Received email from Linda Navejar (Linda_Navejar@bcbstx.com) informing provider is participating within TriWest VA's network, effective 10/15/2022."]
["Joyce O. Alase, MD",1295168318,"88-2797281","TX","PE - Healing Hands Medical Clinic","Cigna","Participating","Enrollment Complete","2022-10-13","","","2022-11-29","11/29/2022 Rcvd email from Cigna at intake_pdm@cigna.com that provider is PAR and linked to group TIN/location effective 10/13/2022.  DCannon"]
["Joyce O. Alase, MD",1295168318,"88-2797281","TX","PE - Healing Hands Medical Clinic","Boon Chapman","Participating","Enrollment Complete","2022-08-29","","","2023-07-25","7/25/2023 Rcvd email from Jessica Bess at Multiplan with a full roster and provider is PAR w/ group and location effective 8/29/2022.  DCannon"]
["Joyce O. Alase, MD",1295168318,"88-2797281","TX","PE - Healing Hands Medical Clinic","Humana","Participating","Enrollment Complete","2022-08-29","","","2022-11-15","11/15/2022 Per email rcvd from Vernita Young at Humana delegated roster provider load for September is complete.  Provider is PAR and linked to group TIN/locations effective 8/29/2022.  DCannon"]
["Joyce O. Alase, MD",1295168318,"88-2797281","TX","PE - Healing Hands Medical Clinic","Galaxy Health","Participating","Enrollment Complete","2022-08-29","","","2022-09-27","9/27/2022 Rcvd email from Karen Avalos at Galaxy that delegated roster submission for September has been completed.  Provider is PAR and linked to group TIN effective 8/29/2022.  DCannon"]
["Joyce O. Alase, MD",1295168318,"88-2797281","TX","PE - Healing Hands Medical Clinic","CAQH","Participating","Pending Info/Document","2022-10-31","","","2023-06-05","6/5/2023-Invalid Login - kavello"]
["Joyce O. Alase, MD",1295168318,"88-2797281","TX","PE - Healing Hands Medical Clinic","Omni PPO","Participating","Enrollment Complete","2022-08-29","","","2022-10-17","10/17/2022 Per email received from German Aviles at IMS/OMNI monthly delegation roster provider load for September has been completed.  Provider is PAR and linked to group TIN effective 8/29/2022.   DCannon"]
["Joyce O. Alase, MD",1295168318,"88-2797281","TX","PE - Healing Hands Medical Clinic","United Health Care","Participating","Enrollment Complete","2022-08-29","006795726","","2022-10-27","10/27/2022 Rcvd email from UCH that provider load has been completed and provider is PAR and linked to group TIN/location effective 8/29/2022.  MPIN # 006795726.   DCannon"]
["Premila L S Johnson, MD",1184727562,"90-0858471","TX","PE - Premila Johnson, MD, LP","Omni PPO","Participating","Enrollment Complete","2012-09-01","1184727562","","2020-06-29","06/29/2020 - IMS is PAR, therefore this payer is also effective  - Stacey Hudak"]
["Premila L S Johnson, MD",1184727562,"90-0858471","TX","","Omni PPO","Participating","Enrollment Complete","2012-09-01","1184727562","","2020-06-29","06/29/2020 - IMS is PAR, therefore this payer is also effective  - Stacey Hudak"]
["Premila L S Johnson, MD",1184727562,"90-0858471","TX","PE - Premila Johnson, MD, LP","Wellmed","Participating","Enrollment Complete","2022-01-01","","","2023-03-23","3/23/2023 Rcvd roster from UHC w/ all Wellmed participating providers.  Provider is PAR effective 1/1/2022.  DCannon"]
["Premila L S Johnson, MD",1184727562,"90-0858471","TX","","Wellmed","Participating","Enrollment Complete","2022-01-01","","","2023-03-23","3/23/2023 Rcvd roster from UHC w/ all Wellmed participating providers.  Provider is PAR effective 1/1/2022.  DCannon"]
["Premila L S Johnson, MD",1184727562,"90-0858471","TX","PE - Premila Johnson, MD, LP","United Health Care","Participating","Enrollment Complete","2015-10-26","1184727562","","2020-07-30","7/30/2020 - moved to completed status after reviewing follow up complete note - Stacey Hudak"]
["Premila L S Johnson, MD",1184727562,"90-0858471","TX","","United Health Care","Participating","Enrollment Complete","2015-10-26","1184727562","","2020-07-30","7/30/2020 - moved to completed status after reviewing follow up complete note - Stacey Hudak"]
["Premila L S Johnson, MD",1184727562,"90-0858471","TX","PE - Premila Johnson, MD, LP","Scott&White (First Care)","Participating","Enrollment Complete","2018-01-01","1184727562","","2020-04-16","04/16/2020 - Rec'd confirmation from the payer stating this provider is EFF under the DELEGATED PRIMED agreement with PPO only products with this TIN/Service Location- Stacey Hudak"]
["Premila L S Johnson, MD",1184727562,"90-0858471","TX","","Scott&White (First Care)","Participating","Enrollment Complete","2018-01-01","1184727562","","2020-04-16","04/16/2020 - Rec'd confirmation from the payer stating this provider is EFF under the DELEGATED PRIMED agreement with PPO only products with this TIN/Service Location- Stacey Hudak"]
["Premila L S Johnson, MD",1184727562,"90-0858471","TX","PE - Premila Johnson, MD, LP","Boon Chapman","Participating","Enrollment Complete","2014-06-04","","","2021-08-06","8/6/2021 Boon Chapman falls under the Multiplan umbrella, received roster from Multiplan provider is listed on roster under TIN/location as PAR effective 6/4/2014.  DCannon"]
["Premila L S Johnson, MD",1184727562,"90-0858471","TX","","Boon Chapman","Participating","Enrollment Complete","2014-06-04","","","2021-08-06","8/6/2021 Boon Chapman falls under the Multiplan umbrella, received roster from Multiplan provider is listed on roster under TIN/location as PAR effective 6/4/2014.  DCannon"]
["Premila L S Johnson, MD",1184727562,"90-0858471","TX","PE - Premila Johnson, MD, LP","USA PPO","Participating","Enrollment Complete","2020-03-20","","","2021-05-04","5/4/2021  In following up with USAMCO (800-872-3860) I was told that you can confirm participating via the USA MCO website  https://providersearch.usamco.com/hwprovsearch.  Provider is PAR and linked to location/TIN effective 3/20/2020.  DCannon"]
["Premila L S Johnson, MD",1184727562,"90-0858471","TX","","USA PPO","Participating","Enrollment Complete","2020-03-20","","","2021-05-04","5/4/2021  In following up with USAMCO (800-872-3860) I was told that you can confirm participating via the USA MCO website  https://providersearch.usamco.com/hwprovsearch.  Provider is PAR and linked to location/TIN effective 3/20/2020.  DCannon"]
["Premila L S Johnson, MD",1184727562,"90-0858471","TX","PE - Premila Johnson, MD, LP","Humana","Participating","Enrollment Complete","2017-05-01","1184727562","","2020-08-31","08/31/2020 - moved to completed status after reviewing follow up complete note - Stacey Hudak"]
["Premila L S Johnson, MD",1184727562,"90-0858471","TX","","Humana","Participating","Enrollment Complete","2017-05-01","1184727562","","2020-08-31","08/31/2020 - moved to completed status after reviewing follow up complete note - Stacey Hudak"]
["Premila L S Johnson, MD",1184727562,"90-0858471","TX","PE - Premila Johnson, MD, LP","Wellcare","Participating","Enrollment Complete","2021-11-01","","","2022-12-01","12/1/2022 Per roster received from Wellcare provider is PAR and linked to group TIN/location effective 11/1/2021.  DCannon"]
["Premila L S Johnson, MD",1184727562,"90-0858471","TX","","Wellcare","Participating","Enrollment Complete","2021-11-01","","","2022-12-01","12/1/2022 Per roster received from Wellcare provider is PAR and linked to group TIN/location effective 11/1/2021.  DCannon"]
["Premila L S Johnson, MD",1184727562,"90-0858471","TX","PE - Premila Johnson, MD, LP","Caprock (CapStar)","Participating","Enrollment Complete","2012-09-01","1184727562","","2020-06-02","06/02/2020 - rec'd spreadsheet back from the payer Mary Rodriguez <MRodriguez@caprockhp.com> confirming this provider/service location is EFF with this payer - Stacey Hudak"]
["Premila L S Johnson, MD",1184727562,"90-0858471","TX","","Caprock (CapStar)","Participating","Enrollment Complete","2012-09-01","1184727562","","2020-06-02","06/02/2020 - rec'd spreadsheet back from the payer Mary Rodriguez <MRodriguez@caprockhp.com> confirming this provider/service location is EFF with this payer - Stacey Hudak"]
["Premila L S Johnson, MD",1184727562,"90-0858471","TX","PE - Premila Johnson, MD, LP","Ambetter","Participating","Enrollment Complete","2022-04-01","","","2022-06-13","6/13/2022 Received April Monthly Validation roster from Superior and provider is PAR and linked effective 4/1/2022.  DCannon"]
["Premila L S Johnson, MD",1184727562,"90-0858471","TX","","Ambetter","Participating","Enrollment Complete","2022-04-01","","","2022-06-13","6/13/2022 Received April Monthly Validation roster from Superior and provider is PAR and linked effective 4/1/2022.  DCannon"]
["Premila L S Johnson, MD",1184727562,"90-0858471","TX","PE - Premila Johnson, MD, LP","IMS","Participating","Enrollment Complete","2012-09-01","1184727562","","2020-06-22","06/22/2020- Rec'd email from the payer confirming this provider is PAR with this group/service location - Stacey Hudak"]
["Premila L S Johnson, MD",1184727562,"90-0858471","TX","","IMS","Participating","Enrollment Complete","2012-09-01","1184727562","","2020-06-22","06/22/2020- Rec'd email from the payer confirming this provider is PAR with this group/service location - Stacey Hudak"]
["Premila L S Johnson, MD",1184727562,"90-0858471","TX","PE - Premila Johnson, MD, LP","Multiplan","Participating","Enrollment Complete","2014-06-04","1184727562","West Texas Physicians Alliance","2020-07-06","07/06/2020 - Rec'd email from the payer stating: \n\"Thank you for contacting our Service Department at Multiplan and Beech Street. Here is the following information we have on file for Johnson, Premila:\n\nNetwork:  MPI\nNetwork Participation effective: 09/01/2012 Contract Source Group contract through: West Texas Physicians Alliance\n\nNetwork:  Beech Street\nNetwork Participation effective: 06/04/2014 Contract Source Group contract through: West Texas Physicians Alliance\n\nIf any demographic information needs to be updated, please fax the information to our Registrar Department at (781) 487-8273 or email Registrar@MultiPlan.com.\" - Stacey Hudak"]
["Premila L S Johnson, MD",1184727562,"90-0858471","TX","","Multiplan","Participating","Enrollment Complete","2014-06-04","1184727562","West Texas Physicians Alliance","2020-07-06","07/06/2020 - Rec'd email from the payer stating: \n\"Thank you for contacting our Service Department at Multiplan and Beech Street. Here is the following information we have on file for Johnson, Premila:\n\nNetwork:  MPI\nNetwork Participation effective: 09/01/2012 Contract Source Group contract through: West Texas Physicians Alliance\n\nNetwork:  Beech Street\nNetwork Participation effective: 06/04/2014 Contract Source Group contract through: West Texas Physicians Alliance\n\nIf any demographic information needs to be updated, please fax the information to our Registrar Department at (781) 487-8273 or email Registrar@MultiPlan.com.\" - Stacey Hudak"]
["Premila L S Johnson, MD",1184727562,"90-0858471","TX","PE - Premila Johnson, MD, LP","CAQH","In House Enrollment","In House Enrollment","","","","2021-06-01","6/1/2021 Received email from Diane Faulkner the group/providers have confirmed they will process all quarterly maintence will be handled In-House. Therefore, requested they remove the PES contact information so we will no longer receive notices and pending clarification. KFrazier"]
["Premila L S Johnson, MD",1184727562,"90-0858471","TX","","CAQH","In House Enrollment","In House Enrollment","","","","2021-06-01","6/1/2021 Received email from Diane Faulkner the group/providers have confirmed they will process all quarterly maintence will be handled In-House. Therefore, requested they remove the PES contact information so we will no longer receive notices and pending clarification. KFrazier"]
["Premila L S Johnson, MD",1184727562,"90-0858471","TX","PE - Premila Johnson, MD, LP","Aetna","Participating","Enrollment Complete","2007-01-01","1184727562","","2020-03-26","3/26/2020--SW Sandra of Aetna @ 800-353-1232. NPI is on file for the provider and is participating effective 1/1/2007 under group and TIN. DIRECT CONTRAC with Aetna. Physical location is on file. Call ref# 5195894813.\ntisha rader"]
["Premila L S Johnson, MD",1184727562,"90-0858471","TX","","Aetna","Participating","Enrollment Complete","2007-01-01","1184727562","","2020-03-26","3/26/2020--SW Sandra of Aetna @ 800-353-1232. NPI is on file for the provider and is participating effective 1/1/2007 under group and TIN. DIRECT CONTRAC with Aetna. Physical location is on file. Call ref# 5195894813.\ntisha rader"]
["Premila L S Johnson, MD",1184727562,"90-0858471","TX","PE - Premila Johnson, MD, LP","Superior","Participating","Enrollment Complete","2017-01-01","1184727562","","2020-07-14","07/14/2020 - Rec'd email from the payer stating this provider is EFF under PRIMED DELEGATED agreement - Stacey Hudak"]
["Premila L S Johnson, MD",1184727562,"90-0858471","TX","","Superior","Participating","Enrollment Complete","2017-01-01","1184727562","","2020-07-14","07/14/2020 - Rec'd email from the payer stating this provider is EFF under PRIMED DELEGATED agreement - Stacey Hudak"]
["Tareq Hulali, MD",1194813709,"90-0956632","TX","PE - Tareq Hulali, MD LLLP","USA PPO","Participating","Enrollment Complete","2019-01-31","","","2020-09-09","Confirmed provider is participating with PPO and H&W networks (list of networks attached). Kimberly Frazier"]
["Tareq Hulali, MD",1194813709,"90-0956632","TX","PE - Tareq Hulali, MD LLLP","Wellcare","Participating","Enrollment Complete","2021-11-01","","","2022-12-01","12/1/2022 Per roster received from Wellcare provider is PAR and linked to group TIN/location effective 11/1/2021.  DCannon"]
["Tareq Hulali, MD",1194813709,"90-0956632","TX","PE - Tareq Hulali, MD LLLP","IMS","Participating","Enrollment Complete","2019-01-21","1194813709","","2020-06-22","06/22/2020- Rec'd email from the payer confirming this provider is PAR with this group/service location - Stacey Hudak"]
["Tareq Hulali, MD",1194813709,"90-0956632","TX","PE - Tareq Hulali, MD LLLP","Galaxy Health","Participating","Enrollment Complete","2018-12-21","1194813709","","2020-07-17","7/17/2020 - Received a spreadsheet from the payer stating this provider is effective as of 12/21/2018 - Jesriel Segovia"]
["Tareq Hulali, MD",1194813709,"90-0956632","TX","PE - Tareq Hulali, MD LLLP","Superior","Participating","Enrollment Complete","2019-03-01","1194813709","","2020-07-14","07/14/2020 - Rec'd email from the payer stating this provider is EFF under PRIMED DELEGATED agreement - Stacey Hudak"]
["Tareq Hulali, MD",1194813709,"90-0956632","TX","PE - Tareq Hulali, MD LLLP","Multiplan","Participating","Enrollment Complete","2014-08-10","1194813709","Kids Kare Pediatrics Group Contract","2020-02-13","02/13/2020 - Rec'd notification through payer portal that this provider is effective under a direct group contract as of 8-10-2014 through Kids Kare Pediatrics. \nThis provider is in network with Multiplan - Stacey Hudak"]
["Tareq Hulali, MD",1194813709,"90-0956632","TX","PE - Tareq Hulali, MD LLLP","Humana","Participating","Enrollment Complete","2013-08-29","1194813709","","2020-06-30","6/30/2020 - Rec'd email spreasheet from payor confirming that this provider is EFF at this service location and PAR with the PRIMED DELEGATED agreement - Pam Porter"]
["Tareq Hulali, MD",1194813709,"90-0956632","TX","PE - Tareq Hulali, MD LLLP","Aetna","Participating","Enrollment Complete","2010-01-15","1194813709","","2020-03-26","3/26/2020--SW Sheldon of Aetna @ 800-353-1232. NPI is on file for the provider 1/15/2010 under group and TIN. Physical location is on file. Per rep provider is delagated to Premier family care. Call ref# 519608545\ntisha rader"]
["Tareq Hulali, MD",1194813709,"90-0956632","TX","PE - Tareq Hulali, MD LLLP","Scott&White (First Care)","Participating","Enrollment Complete","2019-01-21","","","2021-01-29","1/29/2021 - Rcvd roster from Scott&White (First Care) confirming participation of provider with TIN and location effective dates.  DCannon"]
["Tareq Hulali, MD",1194813709,"90-0956632","TX","PE - Tareq Hulali, MD LLLP","Ambetter","Participating","Enrollment Complete","2022-04-01","","","2022-06-13","6/13/2022 Received April Monthly Validation roster from Superior and provider is PAR and linked effective 4/1/2022.  DCannon"]
["Tareq Hulali, MD",1194813709,"90-0956632","TX","PE - Tareq Hulali, MD LLLP","HealthSmart PPO","Participating","Enrollment Complete","2011-02-01","1194813709","","2020-06-10","06/10/2020 - Rec'd email from the payer stating this provider is EFF - Stacey Hudak"]
["Tareq Hulali, MD",1194813709,"90-0956632","TX","PE - Tareq Hulali, MD LLLP","CAQH","Participating","CAQH Reattested","2023-10-02","12064910","","2023-10-02","10/02/2023 - Updated License, DEA, Board - rkedar"]
["Tareq Hulali, MD",1194813709,"90-0956632","TX","PE - Tareq Hulali, MD LLLP","Omni PPO","Participating","Enrollment Complete","2019-01-21","1194813709","","2020-06-25",""]
["Vincent P Rascon, DPM",1346236924,"91-1559006: P","TX","PE - Vincent P. Rascon","Rail Road Medicare","Participating","Enrollment Complete","1997-10-01","480027409","N/A - no group link/PTAN","2020-03-10","03/10/2020 - Found EFF info through payer portal - Stacey Hudak"]
["Vincent P Rascon, DPM",1346236924,"91-1559006: P","TX","PE - Vincent P. Rascon","Multiplan","Participating","Enrollment Complete","2003-07-01","1346236924","Permian Basin Healthcare Ntwrk","2020-07-06","07/06/2020 - Rec'd email from the payer stating \"Network:  MPI/PHCS/Beech\nNetwork Participation effective:07/01/2003\n\nContract Source Group contract through: Permian Basin Healthcare Ntwrk\" - Stacey Hudak"]
["Vincent P Rascon, DPM",1346236924,"91-1559006: P","TX","PE - Vincent P. Rascon","USA PPO","Participating","Enrollment Complete","2009-10-23","1346236924","911559006","2020-08-19","Confirmed provider is participating with PPO and H&W networks (list of networks attached). Kimberly Frazier"]
["Vincent P Rascon, DPM",1346236924,"91-1559006: P","TX","PE - Vincent P. Rascon","Cigna","Participating","Enrollment Complete","2010-08-01","1346236924","","2020-04-22","04/22/2020--S/W Rica of Cigna @ 8008824462, provider NPI# is on file for the provider and is participating effective 8/1/2010 under the group and TIN#. Physical location is on file. Call ref# Rica04202020.\ncopied note from spreadsheet-tisha rader"]
["Vincent P Rascon, DPM",1346236924,"91-1559006: P","TX","PE - Vincent P. Rascon","Medicaid","Participating","Enrollment Complete","1997-06-01","018575301","","2021-01-27","1/27/2021 - Per follow up notes providers NPI # is on file and is participating at location and TIN.  TPI 018575301 effective 6/1/1997.  DCannon"]
["Vincent P Rascon, DPM",1346236924,"91-1559006: P","TX","PE - Vincent P. Rascon","Amerigroup","Participating","Enrollment Complete","2015-12-09","","","2022-10-11","10/11/2022 Per email from Priscilla Albertine at MQA she received an updated from Joe Rodriguez at Amerigroup regarding additional location added for provider.  Provider is PAR and linked to group TIN/location.  DCannon"]
["Vincent P Rascon, DPM",1346236924,"91-1559006: P","TX","PE - Vincent P. Rascon","Omni PPO","Participating","Enrollment Complete","2012-01-01","1346236924","","2020-06-26",""]
["Vincent P Rascon, DPM",1346236924,"91-1559006: P","TX","PE - Vincent P. Rascon","Humana","Participating","Enrollment Complete","2010-10-15","","","2023-02-17","2/17/2023 Per email received from Priscilla Albertine at MQA she received confirmation from Humana that provider is PAR and linked to group TIN/location effective 10/15/2010.  DCannon"]
["Vincent P Rascon, DPM",1346236924,"91-1559006: P","TX","PE - Vincent P. Rascon","HealthSmart PPO","Participating","Enrollment Complete","2011-02-01","1346236924","","2020-06-10","06/10/2020 - Rec'd email from the payer stating this provider is EFF - Stacey Hudak"]
["Vincent P Rascon, DPM",1346236924,"91-1559006: P","TX","PE - Vincent P. Rascon","Boon Chapman","Participating","Enrollment Complete","2003-07-01","1346236924","","2020-10-05","enrolled thru PHCS"]
["Vincent P Rascon, DPM",1346236924,"91-1559006: P","TX","PE - Vincent P. Rascon","Caprock (CapStar)","Participating","Enrollment Complete","2012-01-01","1346236924","","2020-06-02","06/02/2020 - rec'd spreadsheet back from the payer Mary Rodriguez <MRodriguez@caprockhp.com> confirming this provider/service location is EFF with this payer - Stacey Hudak"]
["Vincent P Rascon, DPM",1346236924,"91-1559006: P","TX","PE - Vincent P. Rascon","TriCare Standard","Participating","Enrollment Complete","2020-11-01","","","2021-08-06","8/6/2021 Upon review of prior notes, provider is certified as non-network effective 11/1/2020. KFrazier"]
["Vincent P Rascon, DPM",1346236924,"91-1559006: P","TX","PE - Vincent P. Rascon","Galaxy Health","Participating","Enrollment Complete","2019-09-01","1346236924","","2020-08-24","08/21/2020 - Rec'd email confirmation that this roster was processed and this provider was made effective with the requested eff date of 9-1-2019 - Stacey Hudak"]
["Vincent P Rascon, DPM",1346236924,"91-1559006: P","TX","PE - Vincent P. Rascon","IMS","Participating","Enrollment Complete","2012-01-01","1346236924","","2020-06-22","06/22/2020- Rec'd email from the payer confirming this provider is PAR with this group/service location - Stacey Hudak"]
["Vincent P Rascon, DPM",1346236924,"91-1559006: P","TX","PE - Vincent P. Rascon","Medicare","Participating","Enrollment Complete","2008-07-15","00147E","","2020-10-27","10/27/2020 - I cant get access to this providers PECOS account (requested from clinic many times) to verify this service location is on file. Moved to effective par status to bring current. If there is a claims payment issue, we can address this at that time - Stacey Hudak"]
["Vincent P Rascon, DPM",1346236924,"91-1559006: P","TX","PE - Vincent P. Rascon","Triwest VA","Participating","Enrollment Complete","2022-08-01","","","2022-11-14","11/14/22 Per Scarlett Abigail, provider is effective 8/1/22"]
["Vincent P Rascon, DPM",1346236924,"91-1559006: P","TX","PE - Vincent P. Rascon","United Health Care","Participating","Enrollment Complete","2006-12-15","1017086","","2020-06-08",""]
["Vincent P Rascon, DPM",1346236924,"91-1559006: P","TX","PE - Vincent P. Rascon","First Health Coventry","Participating","Enrollment Complete","2008-09-01","1121891","","2020-03-20","3/20/2020-receieved email with roster stating provider PAR 9/1/2008 PID # 1121891\ntisha rader"]
["Vincent P Rascon, DPM",1346236924,"91-1559006: P","TX","PE - Vincent P. Rascon","Aetna","Participating","Enrollment Complete","2019-10-01","1346236924","","2020-03-24","3/24/2020--S/W Erickof Aetna @ 18003531232, provider NPI# is on file for the provider and is participating effective 10/01/2019 under the group and TIN#. Physical location is on file. DELEGATED CONTRACT THRU PRIMED HEALTH NETWORK--Call ref# 5192739438.\ntisha rader"]
["Vincent P Rascon, DPM",1346236924,"91-1559006: P","TX","PE - Vincent P. Rascon","Scott&White (First Care)","Participating","Enrollment Complete","2016-02-01","","","2021-01-29","1/29/2021 - Rcvd roster from Scott&White (First Care) confirming participation of provider with TIN and location effective dates.  DCannon"]
["Vincent P Rascon, DPM",1346236924,"91-1559006: S","TX","PE - Vincent P. Rascon","IMS","Participating","Enrollment Complete","2012-01-01","","","2020-06-22","06/22/2020- Rec'd email from the payer confirming this provider is PAR with this group/service location - Stacey Hudak"]
["Vincent P Rascon, DPM",1346236924,"91-1559006: S","TX","PE - Vincent P. Rascon","USA PPO","Participating","Enrollment Complete","2009-10-23","","","2020-09-09","Confirmed provider is participating with PPO and H&W networks (list of networks attached). Kimberly Frazier"]
["Vincent P Rascon, DPM",1346236924,"91-1559006: S","TX","PE - Vincent P. Rascon","Scott&White (First Care)","Participating","Enrollment Complete","2016-02-01","","","2021-01-29","1/29/2021 - Rcvd roster from Scott&White (First Care) confirming participation of provider with TIN and location effective dates.  DCannon"]
["Vincent P Rascon, DPM",1346236924,"91-1559006: S","TX","PE - Vincent P. Rascon","Omni PPO","Participating","Enrollment Complete","2012-01-01","1346236924","","2020-06-25",""]
["Vincent P Rascon, DPM",1346236924,"91-1559006: S","TX","PE - Vincent P. Rascon","CAQH","Participating","CAQH Reattested","2023-10-05","10777222","","2023-10-05","10/05/2023 -  Updated DEA ,  affiliation, Insurance, and reattested - rkedar"]
["Vincent P Rascon, DPM",1346236924,"91-1559006: S","TX","PE - Vincent P. Rascon","TriCare Standard","Participating","Enrollment Complete","2020-11-01","","","2021-12-14","12/14/2021 Per note on 7/2/2021. Provider is certified as of 11/1/2020. Cbankston"]
["Vincent P Rascon, DPM",1346236924,"91-1559006: S","TX","PE - Vincent P. Rascon","Amerigroup","Participating","Enrollment Complete","2015-12-09","1346236924","","2020-03-20","03/20/2020 - Rec'd email from the payer (Multiplan/Texas True Choice) stating this provider is EFF at this service location with Amerigroup - Stacey Hudak"]
["Vincent P Rascon, DPM",1346236924,"91-1559006: S","TX","PE - Vincent P. Rascon","Triwest VA","Participating","Enrollment Complete","2022-08-01","","","2022-11-14","11/14/22 Per Scarlett Abigail, provider is effective 8/1/22"]
["Vincent P Rascon, DPM",1346236924,"91-1559006: S","TX","PE - Vincent P. Rascon","Multiplan","Participating","Enrollment Complete","2003-07-01","1346236924","","2020-02-12","02/12/2020 - Per payer portal, this provider is EFF 7-1-2003 under an INDIVIDUAL CONTRACT. This provider is networked with Multiplan and PHCS - Stacey Hudak"]
["Vincent P Rascon, DPM",1346236924,"91-1559006: S","TX","PE - Vincent P. Rascon","Humana","Participating","Enrollment Complete","2011-01-01","1346236924","","2020-08-31","08/31/2020 - moved to completed status after reviewing follow up complete note - Stacey Hudak"]
["Vincent P Rascon, DPM",1346236924,"91-1559006: S","TX","PE - Vincent P. Rascon","Medicare","Participating","Enrollment Complete","1998-06-01","00147E","N/A - no group enrollment/PTAN","2020-03-10","03/10/2020 - Logged onto provider account through PECOS and found that this provider only has an individual enrollment. Is not reassigned to group - Stacey Hudak"]
["Vincent P Rascon, DPM",1346236924,"91-1559006: S","TX","PE - Vincent P. Rascon","Aetna","Participating","Enrollment Complete","2005-07-01","1346236924","","2020-04-15","04/15/2020 - the follow up team states \"S/W Anna of Aetna @ 8003531232, provider NPI is on file for the provider and participating effective 07/01/2005 under thre group and TIN with Direct contract. Physical location is on file. Call ref# 5225879870. \" - Stacey Hudak"]
["Vincent P Rascon, DPM",1346236924,"91-1559006: S","TX","PE - Vincent P. Rascon","Galaxy Health","Participating","Enrollment Complete","1999-04-28","1346236924","","2020-07-17","7/17/2020 - Received a spreadsheet from the payer stating this provider is effective as of 4/28/1999. - Jesriel Segovia"]
["Vincent P Rascon, DPM",1346236924,"91-1559006: S","TX","PE - Vincent P. Rascon","United Health Care","Participating","Enrollment Complete","2006-12-15","1017086","","2020-06-08","06/08/2020 - Rec'd email stating this provider/service location are EFF 12/15/2006 - under provider ID# 1017086 - Stacey Hudak"]
["Vincent P Rascon, DPM",1346236924,"91-1559006: S","TX","PE - Vincent P. Rascon","Medicaid","Participating","Enrollment Complete","2020-12-16","018575301","","2020-12-18","12/18/2020 Recevied TMHP revalidation completion successful which is valid until 12/16/2025. KFrazier"]
["Vincent P Rascon, DPM",1346236924,"91-1559006: S","TX","PE - Vincent P. Rascon","Boon Chapman","Participating","Enrollment Complete","2003-07-01","1346236924","","2020-10-05","Enrolled thru PHCS"]
["Vincent P Rascon, DPM",1346236924,"91-1559006: S","TX","PE - Vincent P. Rascon","HealthSmart PPO","Participating","Enrollment Complete","2011-02-01","1346236924","","2020-06-10","06/10/2020 - Rec'd email from the payer stating this provider is EFF - Stacey Hudak"]
["Vincent P Rascon, DPM",1346236924,"91-1559006: S","TX","PE - Vincent P. Rascon","Cigna","Participating","Enrollment Complete","2010-08-01","1346236924","","2020-04-22","04/22/2020--S/W Rica of Cigna @ 8008824462, provider NPI# is on file for the provider and is participating effective 8/1/2010 under the group and TIN#. Physical location is on file. Call ref# Rica04202020.\ncopied note from spreadsheet-tisha rader"]
["Vincent P Rascon, DPM",1346236924,"91-1559006: S","TX","PE - Vincent P. Rascon","First Health Coventry","Participating","Enrollment Complete","2008-09-01","1121891","","2020-03-20","3/20/2020-receieved email with roster stating provider PAR 9/1/2008 PID # 1121891\ntisha rader"]
["Vincent P Rascon, DPM",1346236924,"91-1559006: S","TX","PE - Vincent P. Rascon","Caprock (CapStar)","Participating","Enrollment Complete","2012-01-01","1346236924","","2020-06-02","06/02/2020 - rec'd spreadsheet back from the payer Mary Rodriguez <MRodriguez@caprockhp.com> confirming this provider/service location is EFF with this payer - Stacey Hudak"]
["Vincent P Rascon, DPM",1346236924,"91-1559006: S","TX","PE - Vincent P. Rascon","Rail Road Medicare","Participating","Enrollment Complete",35704,"480027409","N/A - no group link/PTAN","2020-03-10","03/10/2020 - Found EFF info through payer portal - Stacey Hudak"]
["Sandra Maerzacker, MD",1396190823,"92-1786827","TX","Sandra Maerzacker, MD, PLLC","Omni PPO","Participating","Enrollment Complete","2023-01-03","","","2023-05-17","5/17//2023 Rcvd email from German Aviles at IMS/OMNI that delegation roster for July & August have been completed and updated in their system effective 1/3/2023.  DCannon"]
["Sandra Maerzacker, MD",1396190823,"92-1786827","TX","Sandra Maerzacker, MD, PLLC","Caprock (CapStar)","Participating","Enrollment Complete","2023-01-03","","","2023-03-20","3/20/2023 Rcvd email from Caprock that March delegation roster load has been completed.  Provider is PAR and linked to group TIN/location effective 1/3/2023.  DCannon"]
["Sandra Maerzacker, MD",1396190823,"92-1786827","TX","Sandra Maerzacker, MD, PLLC","United Health Care","Participating","Enrollment Complete","2023-09-06","007274702","","2023-09-07","9/7/2023 Per email received from Priscilla Albertine at MQA provider is PAR and linked to group TIN/location effective 9/6/2023.  DCannon"]
["Sandra Maerzacker, MD",1396190823,"92-1786827","TX","Sandra Maerzacker, MD, PLLC","Multiplan","Participating","Enrollment Complete","2021-08-13","","","2023-06-21","Rcvd effective date of 08/13/2021 from jessica.bess@MultiPlan.com.\nJen Videan"]
["Sandra Maerzacker, MD",1396190823,"92-1786827","TX","Sandra Maerzacker, MD, PLLC","Ambetter","Participating","Enrollment Complete","2023-04-01","","","2023-07-17","7/17/2023 Rcvd email from Superior that provider is PAR and linked to new group TIN via group delegated roster effective 4/1/2023.  DCannon"]
["Sandra Maerzacker, MD",1396190823,"92-1786827","TX","Sandra Maerzacker, MD, PLLC","USA PPO","Participating","Enrollment Complete","2023-03-15","","","2023-10-18","10/18/2023 Per USA MCO roster received correct effective date is 3/15/2023.  DCannon"]
["Sandra Maerzacker, MD",1396190823,"92-1786827","TX","Sandra Maerzacker, MD, PLLC","Galaxy Health","Participating","Enrollment Complete","2023-01-03","","","2023-04-25","4/25/2023 Per email from Karen Avalos at Galaxy March delegated roster has been completed.  Provider is PAR and linked to group TIN/location effective 1/3/2023.  DCannon"]
["Sandra Maerzacker, MD",1396190823,"92-1786827","TX","Sandra Maerzacker, MD, PLLC","Scott&White (First Care)","In Process","Payor Follow Up","","","","2023-10-13","10/13/2023 Sent email to Scott & White to check provider status.  DCannon"]
["Sandra Maerzacker, MD",1396190823,"92-1786827","TX","Sandra Maerzacker, MD, PLLC","Boon Chapman","Participating","Enrollment Complete","2021-08-13","","","2023-08-21","8/21/2023 Provider PAR w/ Multiplan effective 8/13/2021.  DCannon"]
["Sandra Maerzacker, MD",1396190823,"92-1786827","TX","Sandra Maerzacker, MD, PLLC","BCBSTX","Participating","Enrollment Complete","2023-06-08","","","","06/08/2023 - effective date. Participating with the following products: Blue Advantage HMO, BlueChoice PPO, Health Select, Blue Essentials, Medicare Advantage HMO, Medicare Advantage PPO, Dual Eligible Special Needs Plan, Wellmed MA HMO\n-PA"]
["Sandra Maerzacker, MD",1396190823,"92-1786827","TX","Sandra Maerzacker, MD, PLLC","IMS","Participating","Enrollment Complete","2023-01-03","","","2023-05-17","5/17//2023 Rcvd email from German Aviles at IMS/OMNI that delegation roster for July & August have been completed and updated in their system effective 1/3/2023.  DCannon"]
["Sandra Maerzacker, MD",1396190823,"92-1786827","TX","Sandra Maerzacker, MD, PLLC","Wellcare","Participating","Enrollment Complete","2023-04-01","","","2023-07-17","7/17/2023 Rcvd email from Superior that provider is PAR and linked to new group TIN via group delegated roster effective 4/1/2023.  DCannon"]
["Sandra Maerzacker, MD",1396190823,"92-1786827","TX","Sandra Maerzacker, MD, PLLC","Superior","Participating","Enrollment Complete","2023-04-01","","","2023-07-17","7/17/2023 Rcvd email from Superior that provider is PAR and linked to new group TIN via group delegated roster effective 4/1/2023.  DCannon"]
["Sandra Maerzacker, MD",1396190823,"92-1786827","TX","Sandra Maerzacker, MD, PLLC","First Health Coventry","Participating","Enrollment Complete","2023-11-01","","","2023-10-31","10/31/2023 Rcvd copy of signed and executed contract from First Health.  Provider and group are PAR effective 11/1/2023.  DCannon"]
["Sandra Maerzacker, MD",1396190823,"92-1786827","TX","Sandra Maerzacker, MD, PLLC","Cigna","Participating","Enrollment Complete","2023-01-03","","","2023-08-14","08.14.2023 S/W Tom of Cigna @ 1-800-882-4462, Provider is showing participating and link under the Group and TIN with an Effective date 01/03/2023. Provider ID 9669133. Service address is on file. Call ref#:TomF08142023.-Danico Gabriel Melendres"]
["Sandra Maerzacker, MD",1396190823,"92-1786827","TX","Sandra Maerzacker, MD, PLLC","Aetna","Participating","Enrollment Complete","2023-01-03","","","2023-08-21","8/21/2023 Rcvd email from Priscilla Albertine at MQA with correct effective date for provider should be 1/3/2023.  DCannon"]
["Sandra Maerzacker, MD",1396190823,"92-1786827","TX","Sandra Maerzacker, MD, PLLC","Triwest VA","In House Enrollment","In House Enrollment","","","","2023-03-24",""]
["Sandra Maerzacker, MD",1396190823,"92-1786827","TX","Sandra Maerzacker, MD, PLLC","HealthSmart PPO","Participating","Enrollment Complete","2023-01-03","","","2023-11-13","11/13/2023 Per phone conversation w/ Lee Kinard at Healthsmart provider is PAR and linked to group TIN effective 1/3/2023.  DCannon"]
["Sandra Maerzacker, MD",1396190823,"92-1786827","TX","Sandra Maerzacker, MD, PLLC","Medicaid","In Process","Action Needed","","","","2023-11-22","Please provide a status update. MS"]
["Sandra Maerzacker, MD",1396190823,"92-1786827","TX","Sandra Maerzacker, MD, PLLC","Amerigroup","Participating","Enrollment Complete",44421,"","","2023-10-18","10/18/2023 Per email received from Jessica Bess at  Multiplan provider is PAR with Amerigroup and linked to group TIN/locations thru Multiplan enrollment effective 8/13/2021.  DCannon"]

{"sheet":"TaxIDSearch","index":2,"n_rows":21,"n_cols":11,"rows_kept":21,"cut":false,"hidden":true,"merged":[]}
["Provider Name","Practice Name","Payor Name","Enrollment Status","Current Status","Effective Date","Indiv ID #","Group ID#","Note Date","Notes","Symplr Rep"]
["Sandra Maerzacker, MD","Sandra Maerzacker, MD, PLLC","Omni PPO","Participating","Enrollment Complete","2023-01-03",null,null,"2023-05-17","5/17//2023 Rcvd email from German Aviles at IMS/OMNI that delegation roster for July & August have been completed and updated in their system effective 1/3/2023.  DCannon"]
["Sandra Maerzacker, MD","Sandra Maerzacker, MD, PLLC","Caprock (CapStar)","Participating","Enrollment Complete","2023-01-03",null,null,"2023-03-20","3/20/2023 Rcvd email from Caprock that March delegation roster load has been completed.  Provider is PAR and linked to group TIN/location effective 1/3/2023.  DCannon"]
["Sandra Maerzacker, MD","Sandra Maerzacker, MD, PLLC","United Health Care","Participating","Enrollment Complete","2023-09-06",7274702,null,"2023-09-07","9/7/2023 Per email received from Priscilla Albertine at MQA provider is PAR and linked to group TIN/location effective 9/6/2023.  DCannon"]
["Sandra Maerzacker, MD","Sandra Maerzacker, MD, PLLC","Multiplan","Participating","Enrollment Complete","2021-08-13",null,null,"2023-06-21","Rcvd effective date of 08/13/2021 from jessica.bess@MultiPlan.com.\nJen Videan"]
["Sandra Maerzacker, MD","Sandra Maerzacker, MD, PLLC","Ambetter","Participating","Enrollment Complete","2023-04-01",null,null,"2023-07-17","7/17/2023 Rcvd email from Superior that provider is PAR and linked to new group TIN via group delegated roster effective 4/1/2023.  DCannon"]
["Sandra Maerzacker, MD","Sandra Maerzacker, MD, PLLC","USA PPO","Participating","Enrollment Complete","2023-03-15",null,null,"2023-10-18","10/18/2023 Per USA MCO roster received correct effective date is 3/15/2023.  DCannon"]
["Sandra Maerzacker, MD","Sandra Maerzacker, MD, PLLC","Galaxy Health","Participating","Enrollment Complete","2023-01-03",null,null,"2023-04-25","4/25/2023 Per email from Karen Avalos at Galaxy March delegated roster has been completed.  Provider is PAR and linked to group TIN/location effective 1/3/2023.  DCannon"]
["Sandra Maerzacker, MD","Sandra Maerzacker, MD, PLLC","Scott&White (First Care)","In Process","Payor Follow Up",null,null,null,"2023-10-13","10/13/2023 Sent email to Scott & White to check provider status.  DCannon"]
["Sandra Maerzacker, MD","Sandra Maerzacker, MD, PLLC","Boon Chapman","Participating","Enrollment Complete","2021-08-13",null,null,"2023-08-21","8/21/2023 Provider PAR w/ Multiplan effective 8/13/2021.  DCannon"]
["Sandra Maerzacker, MD","Sandra Maerzacker, MD, PLLC","BCBSTX","Participating","Enrollment Complete","2023-06-08",null,null,null,"06/08/2023 - effective date. Participating with the following products: Blue Advantage HMO, BlueChoice PPO, Health Select, Blue Essentials, Medicare Advantage HMO, Medicare Advantage PPO, Dual Eligible Special Needs Plan, Wellmed MA HMO\n-PA"]
["Sandra Maerzacker, MD","Sandra Maerzacker, MD, PLLC","IMS","Participating","Enrollment Complete","2023-01-03",null,null,"2023-05-17","5/17//2023 Rcvd email from German Aviles at IMS/OMNI that delegation roster for July & August have been completed and updated in their system effective 1/3/2023.  DCannon"]
["Sandra Maerzacker, MD","Sandra Maerzacker, MD, PLLC","Wellcare","Participating","Enrollment Complete","2023-04-01",null,null,"2023-07-17","7/17/2023 Rcvd email from Superior that provider is PAR and linked to new group TIN via group delegated roster effective 4/1/2023.  DCannon"]
["Sandra Maerzacker, MD","Sandra Maerzacker, MD, PLLC","Superior","Participating","Enrollment Complete","2023-04-01",null,null,"2023-07-17","7/17/2023 Rcvd email from Superior that provider is PAR and linked to new group TIN via group delegated roster effective 4/1/2023.  DCannon"]
["Sandra Maerzacker, MD","Sandra Maerzacker, MD, PLLC","First Health Coventry","Participating","Enrollment Complete","2023-11-01",null,null,"2023-10-31","10/31/2023 Rcvd copy of signed and executed contract from First Health.  Provider and group are PAR effective 11/1/2023.  DCannon"]
["Sandra Maerzacker, MD","Sandra Maerzacker, MD, PLLC","Cigna","Participating","Enrollment Complete","2023-01-03",null,null,"2023-08-14","08.14.2023 S/W Tom of Cigna @ 1-800-882-4462, Provider is showing participating and link under the Group and TIN with an Effective date 01/03/2023. Provider ID 9669133. Service address is on file. Call ref#:TomF08142023.-Danico Gabriel Melendres"]
["Sandra Maerzacker, MD","Sandra Maerzacker, MD, PLLC","Aetna","Participating","Enrollment Complete","2023-01-03",null,null,"2023-08-21","8/21/2023 Rcvd email from Priscilla Albertine at MQA with correct effective date for provider should be 1/3/2023.  DCannon"]
["Sandra Maerzacker, MD","Sandra Maerzacker, MD, PLLC","Triwest VA","In House Enrollment","In House Enrollment",null,null,null,"2023-03-24"]
["Sandra Maerzacker, MD","Sandra Maerzacker, MD, PLLC","HealthSmart PPO","Participating","Enrollment Complete","2023-01-03",null,null,"2023-11-13","11/13/2023 Per phone conversation w/ Lee Kinard at Healthsmart provider is PAR and linked to group TIN effective 1/3/2023.  DCannon"]
["Sandra Maerzacker, MD","Sandra Maerzacker, MD, PLLC","Medicaid","In Process","Action Needed",null,null,null,"2023-11-22","Please provide a status update. MS"]
["Sandra Maerzacker, MD","Sandra Maerzacker, MD, PLLC","Amerigroup","Participating","Enrollment Complete","2021-08-13",null,null,"2023-10-18","10/18/2023 Per email received from Jessica Bess at  Multiplan provider is PAR with Amerigroup and linked to group TIN/locations thru Multiplan enrollment effective 8/13/2021.  DCannon"]

{"sheet":"NPISearch","index":3,"n_rows":43,"n_cols":11,"rows_kept":43,"cut":false,"hidden":true,"merged":[]}
["Provider Name","Practice Name","Payor Name","Enrollment Status","Current Status","Effective Date","Indiv ID #","Group ID#","Note Date","Notes","Symplr Rep"]
["Sandra Maerzacker, MD","PE - Sari Nabulsi, MD, LTD, LLP","Caprock (CapStar)","Participating","Enrollment Complete","2021-08-13",null,null,"2021-10-06","10/6/2021 Rcvd email from CapRock that monthly delegated roster has been loaded and the provider is PAR and linked to group TIN/location effective 8/13/2021.  DCannon"]
["Sandra Maerzacker, MD","PE - Sari Nabulsi, MD, LTD, LLP","Multiplan","Participating","Enrollment Complete","2021-08-13",null,null,"2021-09-15","9/15/2021 Received welcome letter from Multiplan listing provider has PAR under group TIN/location effective 8/13/2021.  DCannon"]
["Sandra Maerzacker, MD","PE - Sari Nabulsi, MD, LTD, LLP","Ambetter","Participating","Enrollment Complete","2022-04-01",null,null,"2022-06-13","6/13/2022 Received April Monthly Validation roster from Superior and provider is PAR and linked effective 4/1/2022.  DCannon"]
["Sandra Maerzacker, MD","PE - Sari Nabulsi, MD, LTD, LLP","Superior","Participating","Enrollment Complete","2021-09-01",null,null,"2021-10-06","10/6/2021 Rcvd email from Superior that monthly delegation roster for August/September is complete and providers are loaded under TIN/locations effective 9/1/2021.  DCannon"]
["Sandra Maerzacker, MD","PE - Sari Nabulsi, MD, LTD, LLP","CAQH","In House Enrollment","In House Enrollment",null,null,null,"2021-07-18","7/18/2021 Provider maintains profile. KFrazier"]
["Sandra Maerzacker, MD","PE - Sari Nabulsi, MD, LTD, LLP","Omni PPO","Participating","Enrollment Complete","2021-08-13",null,null,"2021-10-22","9/24/2021 Rcvd email from German Aviles at IMS/OMNI that delegation roster for July & August have been completed and updated in their system effective 8/13/2021.  DCannon"]
["Sandra Maerzacker, MD","PE - Sari Nabulsi, MD, LTD, LLP","USA PPO","Participating","Enrollment Complete","2021-08-13",null,null,"2021-12-03","12/3/2021  In following up with USAMCO (800-872-3860) I was told that you can confirm participating via the USA MCO website  https://providersearch.usamco.com/hwprovsearch.  Provider is PAR and linked to location/TIN effective 8/13/2021.  DCannon"]
["Sandra Maerzacker, MD","PE - Sari Nabulsi, MD, LTD, LLP","Cigna","Participating","Enrollment Complete","2021-09-08",9669133,null,"2021-10-28","10/28/2021 Per follow-up notes.  Provider NPI# is on file for the provider and is participating effective 09/08/2021 under the group and TIN#. PIN 9669133. Physical location is on file. Call ref# ariana10272021.  DCannon"]
["Sandra Maerzacker, MD","PE - Sari Nabulsi, MD, LTD, LLP","Triwest VA","Enrollment Stopped","Enrollment Stopped",null,null,null,"2022-11-22","10/17/2022 - Received roster from Scarlett of TriWest VA; provider status: \"No Action.  TIN consists of Pediatrics.\""]
["Sandra Maerzacker, MD","PE - Sari Nabulsi, MD, LTD, LLP","TriCare Standard","Participating","Enrollment Complete","2021-12-14",null,null,"2021-12-14","12/14/2021 Per Tricare portal, provider is eff 12.14.2021. Cbankston"]
["Sandra Maerzacker, MD","PE - Sari Nabulsi, MD, LTD, LLP","Galaxy Health","Participating","Enrollment Complete","2021-08-13",null,null,"2021-10-06","10/6/2021 Rcvd email from Karen Avalos at Galaxy confirming that the August delegated roser provider load has been completed and providers are loaded under TIN/locations effective 8/13/2021.  DCannon"]
["Sandra Maerzacker, MD","PE - Sari Nabulsi, MD, LTD, LLP","Wellcare","Participating","Enrollment Complete","2021-11-01",null,null,"2022-12-01","12/1/2022 Per roster received from Wellcare provider is PAR and linked to group TIN/location effective 11/1/2021.  DCannon"]
["Sandra Maerzacker, MD","PE - Sari Nabulsi, MD, LTD, LLP","Medicaid","Participating","Enrollment Complete","2021-07-22",405626904,null,"2021-08-09","8/9/2021 Upon review of the self-service portal, provider has been approved with assigned TPI 405626904 effective 7/22/2021 and revalidation due 7/22/2026. KFrazier"]
["Sandra Maerzacker, MD","PE - Sari Nabulsi, MD, LTD, LLP","United Health Care","Participating","Enrollment Complete","2019-11-14",null,null,"2022-02-22","2/22/2022 Received email from NMRT networkhelp@uhc.com, provider is par with location as of 11/14/2019. Cbankston"]
["Sandra Maerzacker, MD","PE - Sari Nabulsi, MD, LTD, LLP","HealthSmart PPO","Participating","Enrollment Complete","2021-08-13",null,null,"2021-10-06","10/6/2021 Per Healthsmart website provider is PAR and loaded under TIN/location effective 8/13/2021.  DCannon"]
["Sandra Maerzacker, MD","PE - Sari Nabulsi, MD, LTD, LLP","IMS","Participating","Enrollment Complete","2021-08-13",null,null,"2021-09-24","9/24/2021 Rcvd email from German Aviles at IMS/OMNI that delegation roster for July & August have been completed and updated in their system effective 8/13/2021.  DCannon"]
["Sandra Maerzacker, MD","PE - Sari Nabulsi, MD, LTD, LLP","Amerigroup","Participating","Enrollment Complete","2021-08-13",null,null,"2021-10-21","10/21/2021  Rcvd full roster from Joe Rodriguez at Amerigroup listing provider as PAR w/ group TIN and location effective 8/13/2021.  DCannon"]
["Sandra Maerzacker, MD","PE - Sari Nabulsi, MD, LTD, LLP","Boon Chapman","Participating","Enrollment Complete","2021-08-13",null,null,"2021-09-15","9/15/2021 Received welcome letter from Multiplan listing provider has PAR under group TIN/location effective 8/13/2021."]
["Sandra Maerzacker, MD","PE - Sari Nabulsi, MD, LTD, LLP","Aetna","Participating","Enrollment Complete","2021-09-01",6162182,null,"2021-09-09","9/9/2021 Rcvd full roster from Jamie Roberts at Aetna on 9/8/2021 confirming that provider is PAR and linked to group TIN/locations effective 9/1/2021.  PID # 6962182 DCannon"]
["Sandra Maerzacker, MD","PE - Sari Nabulsi, MD, LTD, LLP","First Health Coventry","Enrollment Stopped","Enrollment Stopped",null,null,null,"2023-11-20","11/20/2023 Provider practices under own TIN which is now enrolled in First Health.  DCannon"]
["Sandra Maerzacker, MD","PE - Sari Nabulsi, MD, LTD, LLP","Scott&White (First Care)","Participating","Enrollment Complete","2021-08-13",null,null,"2022-02-23","2/23/2022 Received email from Scott & White HPDELEGATION@BSWHealth.org that provider load from August has been completed and provider is PAR effective 8/13/2021.  DCannon"]
["Sandra Maerzacker, MD","PE - Sari Nabulsi, MD, LTD, LLP","Humana","Participating","Enrollment Complete","2021-09-01",null,null,"2021-11-18","11/18/2021 Rcvd full roster from Humana listing provider as PAR and linked to group TIN/location effective 9/1/2021.  DCannon"]
["Sandra Maerzacker, MD","Sandra Maerzacker, MD, PLLC","Omni PPO","Participating","Enrollment Complete","2023-01-03",null,null,"2023-05-17","5/17//2023 Rcvd email from German Aviles at IMS/OMNI that delegation roster for July & August have been completed and updated in their system effective 1/3/2023.  DCannon"]
["Sandra Maerzacker, MD","Sandra Maerzacker, MD, PLLC","Caprock (CapStar)","Participating","Enrollment Complete","2023-01-03",null,null,"2023-03-20","3/20/2023 Rcvd email from Caprock that March delegation roster load has been completed.  Provider is PAR and linked to group TIN/location effective 1/3/2023.  DCannon"]
["Sandra Maerzacker, MD","Sandra Maerzacker, MD, PLLC","United Health Care","Participating","Enrollment Complete","2023-09-06",7274702,null,"2023-09-07","9/7/2023 Per email received from Priscilla Albertine at MQA provider is PAR and linked to group TIN/location effective 9/6/2023.  DCannon"]
["Sandra Maerzacker, MD","Sandra Maerzacker, MD, PLLC","Multiplan","Participating","Enrollment Complete","2021-08-13",null,null,"2023-06-21","Rcvd effective date of 08/13/2021 from jessica.bess@MultiPlan.com.\nJen Videan"]
["Sandra Maerzacker, MD","Sandra Maerzacker, MD, PLLC","Ambetter","Participating","Enrollment Complete","2023-04-01",null,null,"2023-07-17","7/17/2023 Rcvd email from Superior that provider is PAR and linked to new group TIN via group delegated roster effective 4/1/2023.  DCannon"]
["Sandra Maerzacker, MD","Sandra Maerzacker, MD, PLLC","USA PPO","Participating","Enrollment Complete","2023-03-15",null,null,"2023-10-18","10/18/2023 Per USA MCO roster received correct effective date is 3/15/2023.  DCannon"]
["Sandra Maerzacker, MD","Sandra Maerzacker, MD, PLLC","Galaxy Health","Participating","Enrollment Complete","2023-01-03",null,null,"2023-04-25","4/25/2023 Per email from Karen Avalos at Galaxy March delegated roster has been completed.  Provider is PAR and linked to group TIN/location effective 1/3/2023.  DCannon"]
["Sandra Maerzacker, MD","Sandra Maerzacker, MD, PLLC","Scott&White (First Care)","In Process","Payor Follow Up",null,null,null,"2023-10-13","10/13/2023 Sent email to Scott & White to check provider status.  DCannon"]
["Sandra Maerzacker, MD","Sandra Maerzacker, MD, PLLC","Boon Chapman","Participating","Enrollment Complete","2021-08-13",null,null,"2023-08-21","8/21/2023 Provider PAR w/ Multiplan effective 8/13/2021.  DCannon"]
["Sandra Maerzacker, MD","Sandra Maerzacker, MD, PLLC","BCBSTX","Participating","Enrollment Complete","2023-06-08",null,null,null,"06/08/2023 - effective date. Participating with the following products: Blue Advantage HMO, BlueChoice PPO, Health Select, Blue Essentials, Medicare Advantage HMO, Medicare Advantage PPO, Dual Eligible Special Needs Plan, Wellmed MA HMO\n-PA"]
["Sandra Maerzacker, MD","Sandra Maerzacker, MD, PLLC","IMS","Participating","Enrollment Complete","2023-01-03",null,null,"2023-05-17","5/17//2023 Rcvd email from German Aviles at IMS/OMNI that delegation roster for July & August have been completed and updated in their system effective 1/3/2023.  DCannon"]
["Sandra Maerzacker, MD","Sandra Maerzacker, MD, PLLC","Wellcare","Participating","Enrollment Complete","2023-04-01",null,null,"2023-07-17","7/17/2023 Rcvd email from Superior that provider is PAR and linked to new group TIN via group delegated roster effective 4/1/2023.  DCannon"]
["Sandra Maerzacker, MD","Sandra Maerzacker, MD, PLLC","Superior","Participating","Enrollment Complete","2023-04-01",null,null,"2023-07-17","7/17/2023 Rcvd email from Superior that provider is PAR and linked to new group TIN via group delegated roster effective 4/1/2023.  DCannon"]
["Sandra Maerzacker, MD","Sandra Maerzacker, MD, PLLC","First Health Coventry","Participating","Enrollment Complete","2023-11-01",null,null,"2023-10-31","10/31/2023 Rcvd copy of signed and executed contract from First Health.  Provider and group are PAR effective 11/1/2023.  DCannon"]
["Sandra Maerzacker, MD","Sandra Maerzacker, MD, PLLC","Cigna","Participating","Enrollment Complete","2023-01-03",null,null,"2023-08-14","08.14.2023 S/W Tom of Cigna @ 1-800-882-4462, Provider is showing participating and link under the Group and TIN with an Effective date 01/03/2023. Provider ID 9669133. Service address is on file. Call ref#:TomF08142023.-Danico Gabriel Melendres"]
["Sandra Maerzacker, MD","Sandra Maerzacker, MD, PLLC","Aetna","Participating","Enrollment Complete","2023-01-03",null,null,"2023-08-21","8/21/2023 Rcvd email from Priscilla Albertine at MQA with correct effective date for provider should be 1/3/2023.  DCannon"]
["Sandra Maerzacker, MD","Sandra Maerzacker, MD, PLLC","Triwest VA","In House Enrollment","In House Enrollment",null,null,null,"2023-03-24"]
["Sandra Maerzacker, MD","Sandra Maerzacker, MD, PLLC","HealthSmart PPO","Participating","Enrollment Complete","2023-01-03",null,null,"2023-11-13","11/13/2023 Per phone conversation w/ Lee Kinard at Healthsmart provider is PAR and linked to group TIN effective 1/3/2023.  DCannon"]
["Sandra Maerzacker, MD","Sandra Maerzacker, MD, PLLC","Medicaid","In Process","Action Needed",null,null,null,"2023-11-22","Please provide a status update. MS"]
["Sandra Maerzacker, MD","Sandra Maerzacker, MD, PLLC","Amerigroup","Participating","Enrollment Complete","2021-08-13",null,null,"2023-10-18","10/18/2023 Per email received from Jessica Bess at  Multiplan provider is PAR with Amerigroup and linked to group TIN/locations thru Multiplan enrollment effective 8/13/2021.  DCannon"]