{"text_format":"1","workbook":"xlsx","n_sheets":4,"sheets":["Form","Database","TaxIDSearch","NPISearch"],"not_rendered":{"charts":0,"images":0,"macros":1,"external_links":0,"defined_names":3,"comments":0,"pivot_tables":0},"unopened":[],"bounds":{"document_bytes":16777216,"sheet_cells":100000,"rows_first":2000,"rows_last":500,"rows_between":2000,"halvings":0,"cell_chars":16384,"cell_head_chars":4096},"cells_cut":0,"cells_raw":0,"read":"whole","date_system":"1900"}

{"sheet":"Form","index":0,"n_rows":0,"n_cols":0,"rows_kept":0,"cut":false,"hidden":false,"merged":[]}

{"sheet":"Database","index":1,"n_rows":10686,"n_cols":19,"rows_kept":4500,"cut":true,"hidden":true,"merged":[],"bounds":{"rows_first":2000,"rows_last":500,"rows_between":2000,"halvings":0}}
["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"]
["Douglas J Colson, MD",1790767119,"75-2656723","TX","PE - Premier Family Care I, Inc","Caprock (CapStar)","Participating","Enrollment Complete","2018-08-30","1790767119","","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"]
["Douglas J Colson, MD",1790767119,"75-2656723","TX","PE - Premier Family Care I, Inc","Cigna","Terminated","Terminated","2018-08-31","1790767119","","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"]
["Douglas J Colson, MD",1790767119,"75-2656723","TX","PE - Premier Family Care I, Inc","Superior","Participating","Enrollment Complete","2018-10-01","1790767119","","2020-07-14","07/14/2020 - Rec'd email from the payer stating this provider is EFF under PRIMED DELEGATED agreement - Stacey Hudak"]
["Douglas J Colson, MD",1790767119,"75-2656723","TX","PE - Premier Family Care I, 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."]
["Douglas J Colson, MD",1790767119,"75-2656723","ME","PE - Premier Family Care I, Inc","Cigna","Participating","Enrollment Complete","2021-03-31","","","2021-08-25","8/25/2021 Received an email from PDMCOGZ@cigna.com confirming provider is now participating under group Tax ID and location effective 3/31/2021 with assigned provider ID 6670877. KFrazier"]
["Douglas J Colson, MD",1790767119,"75-2656723","TX","PE - Premier Family Care I, Inc","Aetna","Participating","Enrollment Complete","2018-09-01","1790767119","","2020-02-03","02/03/2020 - Rec'd confirmation from the payer that this provider is EFF 9-1-2018 with a DIRECT CONTRACT. The proper service location is in file - Stacey Hudak"]
["Douglas J Colson, MD",1790767119,"75-2656723","TX","PE - Premier Family Care I, Inc","Tricare Prime","Participating","Enrollment Complete","2018-07-14","","","2020-10-08","10/8/2020 Confirmed via Self-Service Portal provider is participating under Tax ID and location. Kimberly Frazier"]
["Douglas J Colson, MD",1790767119,"75-2656723","TX","PE - Premier Family Care I, Inc","United Health Care","Participating","Enrollment Complete","2018-07-10","1790767119","","2020-07-30","7/30/2020 - moved to completed status after reviewing follow up complete note - Stacey Hudak"]
["Douglas J Colson, MD",1790767119,"75-2656723","TX","PE - Premier Family Care I, Inc","Boon Chapman","Participating","Enrollment Complete","2018-08-01","","","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 8/1/2018.  DCannon"]
["Douglas J Colson, MD",1790767119,"75-2656723","TX","PE - Premier Family Care I, Inc","Scott&White (First Care)","Participating","Enrollment Complete","2019-01-11","1790767119","","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\n\n**Rec'd confirmation from the payer that this provider is tied to this TIN/Service location and networked with: \nFirstCare MyChoice PPO\nCHIP\nFirstCare Select Benefit Network\nHMO Enhanced Benefit Network\nMedicaid (FC)\nMedicare (FC)\nPPO Limited Benefit Network"]
["Douglas J Colson, MD",1790767119,"75-2656723","TX","PE - Premier Family Care I, Inc","Triwest VA","Facility Enrollment","Application Submitted","","","","2022-11-23","08/19/2022 - Submitted application to TriWest VA (sent to Scarlett Abigail, Scarlett_Abigail@bcbstx.com)"]
["Douglas J Colson, MD",1790767119,"75-2656723","TX","","Triwest VA","Facility Enrollment","Application Submitted","","","","2022-11-23","08/19/2022 - Submitted application to TriWest VA (sent to Scarlett Abigail, Scarlett_Abigail@bcbstx.com)"]
["Douglas J Colson, MD",1790767119,"75-2656723","TX","PE - Premier Family Care I, Inc","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.\""]
["Douglas J Colson, MD",1790767119,"75-2656723","TX","","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.\""]
["Douglas J Colson, MD",1790767119,"75-2656723","TX","PE - Premier Family Care I, Inc","Amerigroup","Participating","Enrollment Complete","2018-08-29","1790767119","","2020-02-11","2/11/2020 – Received Roster from Amerigroup and provider is now PAR- Tisha Rader\n\n3/18/2020 - rec'd confirmation from Multiplan/Texas True Choice that this is correct - Stacey Hudak"]
["Douglas J Colson, MD",1790767119,"75-2656723","TX","PE - Premier Family Care I, Inc","Medicare","Participating","Enrollment Complete","2018-07-01","679507","0008AH","2020-01-29","01/29/2020 - confirmed EFF through PECOS group enrollment - Stacey Hudak"]
["Douglas J Colson, MD",1790767119,"75-2656723","TX","PE - Premier Family Care I, Inc","First Health Coventry","Participating","Enrollment Complete","2018-08-01","1046218","","2020-03-24","3/24/2020-received email with roster from payor stating provider is PAR 8/1/2018 PID # 1046218\ntisha rader"]
["Douglas J Colson, MD",1790767119,"75-2656723","TX","PE - Premier Family Care I, Inc","Omni PPO","Participating","Enrollment Complete","2018-08-30","1790767119","","2020-07-14",""]
["Douglas J Colson, MD",1790767119,"75-2656723","TX","PE - Premier Family Care I, Inc","Medicaid","Participating","Enrollment Complete","","386238501","079837301","2020-01-29","01/29/2020 - Found provider PAR through payer portal. This provider is linked to the following plans: FirstCare - Lubbock, TRADITIONAL MEDICAID, Amerigroup - MRSA West, FirstCare - MRSA West, Amerigroup Texas, Inc. - MRSA West - Stacey Hudak"]
["Douglas J Colson, MD",1790767119,"75-2656723","TX","PE - Premier Family Care I, Inc","Multiplan","Participating","Enrollment Complete","2018-08-01","1790767119","","2020-02-12","02/12/2020 - this provider has been confirmed to be effective through the payer portal. EFF 8-1-2018 THROUGH WEST TEXAS PHYSICIANS ALLIANCE DELEGATED PARTY - networked to MPI. - Stacey Hudak"]
["Douglas J Colson, MD",1790767119,"75-2656723","TX","PE - Premier Family Care I, Inc","TriCare Standard","Participating","Enrollment Complete","2018-07-14","","","2020-11-03","11/3/2020 Upon review of the self-service portal provider reflects as 'complete'. Kimberly Frazier"]
["Douglas J Colson, MD",1790767119,"75-2656723","TX","PE - Premier Family Care I, Inc","Humana","Participating","Enrollment Complete","2020-01-01","1790767119","","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"]
["Douglas J Colson, MD",1790767119,"75-2656723","TX","PE - Premier Family Care I, Inc","USA PPO","Participating","Enrollment Complete","2018-08-29","1790767119","752656723","2020-08-18","Confirmed provider is enrolled and participating under delegated agreement with the PPO and H&W networks (list attached in images). Kimberly Frazier"]
["Douglas J Colson, MD",1790767119,"75-2656723","TX","PE - Premier Family Care I, Inc","Galaxy Health","Participating","Enrollment Complete","2018-08-01","1790767119","","2020-07-10","07/10/2020 - updated payer line to enrollment complete status instead of \"Delegated status\" for report running purposes - Stacey Hudak"]
["Douglas J Colson, MD",1790767119,"75-2656723","TX","PE - Premier Family Care I, Inc","HealthSmart PPO","Participating","Enrollment Complete","2018-08-28","1790767119","","2020-06-05","06/05/2020 - Rec'd email from the payer stating this provider is EFF - Stacey Hudak"]
["Douglas J Colson, MD",1790767119,"75-2656723","TX","PE - Premier Family Care I, 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"]
["Douglas J Colson, MD",1790767119,"75-2656723","TX","PE - Premier Family Care I, Inc","IMS","Participating","Enrollment Complete","2018-08-30","1790767119","","2020-06-22","06/22/2020 0- Rec'd email from the payer confirming this provider is PAR with this group/service location - Stacey Hudak"]
["Douglas J Colson, MD",1790767119,"75-2656723","TX","PE - Premier Family Care I, Inc","CAQH","Participating","CAQH Reattested","2023-01-25","11483093","","2022-10-18","10/18/2022 CAQH reviewed and re-attested.  Uploaded current malpractice COI.  DCannon"]
["Lori Ann Reeves, FNP-C",1023520830,"75-2656723","TX","PE - Premier Family Care I, 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, FNP-C",1023520830,"75-2656723","TX","PE - Premier Family Care I, Inc","Caprock (CapStar)","Participating","Enrollment Complete","2019-09-01","","","2020-09-11",""]
["Lori Ann Reeves, FNP-C",1023520830,"75-2656723","TX","PE - Premier Family Care I, Inc","Galaxy Health","Participating","Enrollment Complete","2018-05-02","1023520830","","2020-07-10","07/10/2020 - updated payer line to enrollment complete status instead of \"Delegated status\" for report running purposes - Stacey Hudak"]
["Lori Ann Reeves, FNP-C",1023520830,"75-2656723","TX","PE - Premier Family Care I, Inc","TriCare Standard","Participating","Enrollment Complete","2020-06-20","","","2021-03-24","3/24/2021 Confirmed provider is already certified as a non-network provider. KFrazier"]
["Lori Ann Reeves, FNP-C",1023520830,"75-2656723","TX","PE - Premier Family Care I, 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, FNP-C",1023520830,"75-2656723","TX","PE - Premier Family Care I, Inc","Aetna","Participating","Enrollment Complete","2019-09-01","1023520830","","2020-08-27","08/27/2020 - moved to completed status after reviewing the follow up complete note - Stacey Hudak"]
["Lori Ann Reeves, FNP-C",1023520830,"75-2656723","TX","PE - Premier Family Care I, Inc","United Health Care","Participating","Enrollment Complete","2019-11-01","1023520830","","2020-08-27","08/27/2020 - moved to completed status after reviewing follow up complete note - Stacey Hudak"]
["Lori Ann Reeves, FNP-C",1023520830,"75-2656723","TX","PE - Premier Family Care I, Inc","Tricare Prime","Participating","Enrollment Complete","2020-11-10","","","2021-09-14","9/14/2021 Per Tricare portal, provider is participating with TaxID as of 11/10/2020. Cbankston"]
["Lori Ann Reeves, FNP-C",1023520830,"75-2656723","TX","PE - Premier Family Care I, Inc","Medicare","Participating","Enrollment Complete","2018-03-19","626806YPVD","0008AH","2020-07-21","07/21/20220 - Rec'd email confirmation that this name change has been completed. Signed into PECOS to verify - Stacey Hudak"]
["Lori Ann Reeves, FNP-C",1023520830,"75-2656723","TX","PE - Premier Family Care I, Inc","Humana","Participating","Enrollment Complete","2020-01-01","1023520830","","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"]
["Lori Ann Reeves, FNP-C",1023520830,"75-2656723","TX","PE - Premier Family Care I, 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."]
["Lori Ann Reeves, FNP-C",1023520830,"75-2656723","TX","PE - Premier Family Care I, Inc","Medicaid","Participating","Enrollment Complete","","382485601","079837301","2020-01-29","01/29/2020 - provider found through payer portal. Provider is PAR with the following plans: FirstCare - Lubbock, TRADITIONAL MEDICAID, Amerigroup - MRSA West, Amerigroup - MRSA West, FirstCare - MRSA West, Amerigroup Texas, Inc. - MRSA West - Stacey Hudak"]
["Lori Ann Reeves, FNP-C",1023520830,"75-2656723","TX","PE - Premier Family Care I, Inc","Boon Chapman","Participating","Enrollment Complete","2018-06-15","1023520830","","2020-10-05","Enrolled thru PHCS"]
["Lori Ann Reeves, FNP-C",1023520830,"75-2656723","TX","PE - Premier Family Care I, 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, FNP-C",1023520830,"75-2656723","TX","PE - Premier Family Care I, 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"]
["Lori Ann Reeves, FNP-C",1023520830,"75-2656723","TX","PE - Premier Family Care I, Inc","HealthSmart PPO","Participating","Enrollment Complete","2018-05-30","1023520830","","2020-06-05","06/05/2020 - Rec'd email from payer stating this provider is EFF - Stacey Hudak"]
["Lori Ann Reeves, FNP-C",1023520830,"75-2656723","TX","PE - Premier Family Care I, 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"]
["Lori Ann Reeves, FNP-C",1023520830,"75-2656723","TX","PE - Premier Family Care I, Inc","CAQH","Participating","CAQH Reattested","2023-01-25","14145595","","2023-01-25","1/25/2023 CAQH reviewed and re-attested.  DCannon"]
["Lori Ann Reeves, FNP-C",1023520830,"75-2656723","TX","PE - Premier Family Care I, Inc","Amerigroup","Participating","Enrollment Complete","2020-06-29","1023520830","","2020-07-09","07/09/2020 - Rec'd welcome letter from Multiplan stating provider is covered for all governmental payers - Amerigroup is covered (STAR, Star Plus, Star Kids) - Stacey Hudak"]
["Lori Ann Reeves, FNP-C",1023520830,"75-2656723","TX","PE - Premier Family Care I, Inc","Cigna","Participating","Enrollment Complete","2020-05-19","12623755","","2021-08-05","7/26/2021 Received an email from PDMCOGZ@cigna.com with confirmation provider is now participating under group Tax ID effective 5/19/2020 with assigned provider number 12623755. KFrazier"]
["Lori Ann Reeves, FNP-C",1023520830,"75-2656723","TX","PE - Premier Family Care I, Inc","Omni PPO","Participating","Enrollment Complete","2019-09-01","1023520830","","2020-07-27","IMS is complete"]
["Lori Ann Reeves, FNP-C",1023520830,"75-2656723","TX","PE - Premier Family Care I, Inc","Superior","Participating","Enrollment Complete","2020-09-01","1023520830","","2020-09-02","09/02/2020 - Rec'd email from the payer stating this providers name update from Brown to Reeves has been completed EFF 9-1-2020 - Stacey Hudak"]
["Lori Ann Reeves, FNP-C",1023520830,"75-2656723","TX","PE - Premier Family Care I, Inc","Triwest VA","Facility Enrollment","Application Submitted","","","","2022-11-23","08/19/2022 - Submitted application to TriWest VA (sent to Scarlett Abigail, Scarlett_Abigail@bcbstx.com)"]
["Lori Ann Reeves, FNP-C",1023520830,"75-2656723","TX","","Triwest VA","Facility Enrollment","Application Submitted","","","","2022-11-23","08/19/2022 - Submitted application to TriWest VA (sent to Scarlett Abigail, Scarlett_Abigail@bcbstx.com)"]
["Lori Ann Reeves, FNP-C",1023520830,"75-2656723","TX","PE - Premier Family Care I, Inc","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.\""]
["Lori Ann Reeves, FNP-C",1023520830,"75-2656723","TX","","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.\""]
["Lori Ann Reeves, FNP-C",1023520830,"75-2656723","TX","PE - Premier Family Care I, Inc","First Health Coventry","Participating","Enrollment Complete","2018-05-01","3128029","","2020-03-24","3/24/2020-received email with roster from payor stating provider is PAR 5/1/2018 PID # 3128029\ntisha rader"]
["Coby R Robins, MD",1104237015,"75-2133441","TX","PE - Midland Pediatric Associates, PLLC","HealthSmart PPO","Participating","Enrollment Complete","2018-07-27","1104237015","","2020-06-05","06/05/2020 -Rec'd email from the payer stating provider is EFF - Stacey Hudak"]
["Coby R Robins, MD",1104237015,"75-2133441","TX","PE - Midland Pediatric Associates, PLLC","First Health Coventry","Participating","Enrollment Complete","2017-09-01","3094146","","2020-03-24","3/24/2020-received email with roster from payor stating provider PAR 9/1/2017 PID # 3094146\ntisha rader"]
["Coby R Robins, MD",1104237015,"75-2133441","TX","PE - Midland Pediatric Associates, PLLC","IMS","Participating","Enrollment Complete","2018-07-01","1790767119","","2020-06-22","06/22/2020- Rec'd email from the payer confirming this provider is PAR with this group/service location - Stacey Hudak"]
["Coby R Robins, MD",1104237015,"75-2133441","TX","PE - Midland Pediatric Associates, PLLC","Caprock (CapStar)","Participating","Enrollment Complete","2018-06-19","1104237015","","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"]
["Coby R Robins, MD",1104237015,"75-2133441","TX","PE - Midland Pediatric Associates, PLLC","Tricare Prime","Participating","Enrollment Complete","2018-07-11","","","2020-10-08","10/8/2020 Confirmed via Self-Service Portal provider is participating under Tax ID and location. Kimberly Frazier"]
["Coby R Robins, MD",1104237015,"75-2133441","TX","PE - Midland Pediatric Associates, PLLC","Aetna","Participating","Enrollment Complete","2018-08-01","1104237015","","2020-06-09","06/09/2020 - S/W Nathan of Aetna @ 8003531232, provider NPI# is on file for the provider and is participating effective 08/01/2018 under the group and TIN#. Provider is direct contract with Aertna. Physical location is on file. Call ref# 5309689188. - Stacey Hudak"]
["Coby R Robins, MD",1104237015,"75-2133441","TX","PE - Midland Pediatric Associates, PLLC","Scott&White (First Care)","Participating","Enrollment Complete","2018-04-16","1104237015","","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\n\n**Verified that this provider is networked with:\nFirstCare MyChoice PPO\nFirstCare Select Benefit Network\nHMO Enhanced Benefit Network\nPPO Limited Benefit Network"]
["Coby R Robins, MD",1104237015,"75-2133441","TX","PE - Midland Pediatric Associates, PLLC","CAQH","Participating","CAQH Reattested","2022-12-29","14218808","","2022-12-29","12/29/2022 CAQH re-attested.  DCannon"]
["Coby R Robins, MD",1104237015,"75-2133441","TX","PE - Midland Pediatric Associates, PLLC","Galaxy Health","Participating","Enrollment Complete","2018-06-19","","","2020-07-17","7/17/2020- Received a spreadsheet from the payer stating this provider is effective as of  6/19/2018. – Elonah Grace B. Gelig"]
["Coby R Robins, MD",1104237015,"75-2133441","TX","PE - Midland Pediatric Associates, PLLC","Multiplan","Participating","Enrollment Complete","2018-08-13","1104237015","","2020-08-27","08/27/2020 - Rec'd email back from the payer stating \"Thank 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: - Coby Robins-Effective 08/13/2018\"  - Stacey Hudak"]
["Coby R Robins, MD",1104237015,"75-2133441","TX","PE - Midland Pediatric Associates, PLLC","TriCare Standard","Participating","Enrollment Complete","2018-07-11","","","2020-11-03","11/3/2020 Confirmed via self-service portal provider is participating effective 7/11/2018 with the correct practice location. Kimberly Frazier"]
["Coby R Robins, MD",1104237015,"75-2133441","TX","PE - Midland Pediatric Associates, PLLC","Boon Chapman","Participating","Enrollment Complete","2018-08-13","1104237015","","2020-10-05","Enrollment thru PHCS"]
["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"]
["Coby R Robins, MD",1104237015,"75-2133441","TX","PE - Midland Pediatric Associates, PLLC","USA PPO","Participating","Enrollment Complete","2018-07-31","1104237015","752133441","2020-08-18","Confirmed provider is participating with PPO and H&W networks (list of networks attached). Kim Frazier"]
["Coby R Robins, MD",1104237015,"75-2133441","TX","PE - Midland Pediatric Associates, PLLC","Cigna","Participating","Enrollment Complete","2018-10-11","1104237015","","2020-04-15","04/15/2020 - Rec'd follow up team statement saying \"S/W Francis of Cigna@ 8008824462, provider NPI is on file for the provider and participating effective 10/11/18 under the group and TIN with Direct contract. Physical location is on file. Call ref# FRANCIS04142020. \"  PROVIDER IS PART OF A DIRECT CONTRACT - Stacey Hudak"]
["Coby R Robins, MD",1104237015,"75-2133441","TX","PE - Midland Pediatric Associates, PLLC","United Health Care","Participating","Enrollment Complete","2017-09-17","1104237015","","2020-07-30","7/30/2020 - moved to completed status after reviewing follow up complete note - Stacey Hudak"]
["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","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","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","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","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","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","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","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","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","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","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","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","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","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","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","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","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","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","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","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","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","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","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","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","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","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","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","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","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","Zurich","Pending Other Enrollment","Pending Other Enrollment","","","","2023-02-03","2.3.23 Plan pends enrollment with Coventry WC. ABoles"]
["Chisom Nwoye, MD",1841780806,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Zurich","Pending Other Enrollment","Pending Other Enrollment","","","","2023-02-03","2.3.23 Plan pends enrollment with Coventry WC. ABoles"]
["Chisom Nwoye, MD",1841780806,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Zurich","Pending Other Enrollment","Pending Other Enrollment","","","","2023-02-03","2.3.23 Plan pends enrollment with Coventry WC. ABoles"]
["Chisom Nwoye, MD",1841780806,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Zurich","Pending Other Enrollment","Pending Other Enrollment","","","","2023-02-03","2.3.23 Plan pends enrollment with Coventry WC. ABoles"]
["Chisom Nwoye, MD",1841780806,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Zurich","Pending Other Enrollment","Pending Other Enrollment","","","","2023-02-03","2.3.23 Plan pends enrollment with Coventry WC. ABoles"]
["Chisom Nwoye, MD",1841780806,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Zurich","Pending Other Enrollment","Pending Other Enrollment","","","","2023-02-03","2.3.23 Plan pends enrollment with Coventry WC. ABoles"]
["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","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","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","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","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","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","Coventry Workers Comp","In Process","Payor Follow Up","","","","2023-03-06","03.06.2023 S/W Warren of Coventry WC @800-937-6824. Per rep, provider is not in network with Coventry. Application was received on 02/16/2023 however it was closed on 02/27/2023 due to no documentation received. Rep sent a documentation request to aboles@symplr.com using pccdocsub@mitchell.com. Rep advised to reply to that email and attach a Letter of Intent and W9 form. Per rep, if we didn't reply within 5 business days, the application will be automatically close. TAT for us to send the documents is 5 business days. Call ref# 11782375."]
["Chisom Nwoye, MD",1841780806,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Coventry Workers Comp","In Process","Payor Follow Up","","","","2023-03-06","03.06.2023 S/W Warren of Coventry WC @800-937-6824. Per rep, provider is not in network with Coventry. Application was received on 02/16/2023 however it was closed on 02/27/2023 due to no documentation received. Rep sent a documentation request to aboles@symplr.com using pccdocsub@mitchell.com. Rep advised to reply to that email and attach a Letter of Intent and W9 form. Per rep, if we didn't reply within 5 business days, the application will be automatically close. TAT for us to send the documents is 5 business days. Call ref# 11782375."]
["Chisom Nwoye, MD",1841780806,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Coventry Workers Comp","In Process","Payor Follow Up","","","","2023-03-06","03.06.2023 S/W Warren of Coventry WC @800-937-6824. Per rep, provider is not in network with Coventry. Application was received on 02/16/2023 however it was closed on 02/27/2023 due to no documentation received. Rep sent a documentation request to aboles@symplr.com using pccdocsub@mitchell.com. Rep advised to reply to that email and attach a Letter of Intent and W9 form. Per rep, if we didn't reply within 5 business days, the application will be automatically close. TAT for us to send the documents is 5 business days. Call ref# 11782375."]
["Chisom Nwoye, MD",1841780806,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Coventry Workers Comp","In Process","Payor Follow Up","","","","2023-03-06","03.06.2023 S/W Warren of Coventry WC @800-937-6824. Per rep, provider is not in network with Coventry. Application was received on 02/16/2023 however it was closed on 02/27/2023 due to no documentation received. Rep sent a documentation request to aboles@symplr.com using pccdocsub@mitchell.com. Rep advised to reply to that email and attach a Letter of Intent and W9 form. Per rep, if we didn't reply within 5 business days, the application will be automatically close. TAT for us to send the documents is 5 business days. Call ref# 11782375."]
["Chisom Nwoye, MD",1841780806,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Coventry Workers Comp","In Process","Payor Follow Up","","","","2023-03-06","03.06.2023 S/W Warren of Coventry WC @800-937-6824. Per rep, provider is not in network with Coventry. Application was received on 02/16/2023 however it was closed on 02/27/2023 due to no documentation received. Rep sent a documentation request to aboles@symplr.com using pccdocsub@mitchell.com. Rep advised to reply to that email and attach a Letter of Intent and W9 form. Per rep, if we didn't reply within 5 business days, the application will be automatically close. TAT for us to send the documents is 5 business days. Call ref# 11782375."]
["Chisom Nwoye, MD",1841780806,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Coventry Workers Comp","In Process","Payor Follow Up","","","","2023-03-06","03.06.2023 S/W Warren of Coventry WC @800-937-6824. Per rep, provider is not in network with Coventry. Application was received on 02/16/2023 however it was closed on 02/27/2023 due to no documentation received. Rep sent a documentation request to aboles@symplr.com using pccdocsub@mitchell.com. Rep advised to reply to that email and attach a Letter of Intent and W9 form. Per rep, if we didn't reply within 5 business days, the application will be automatically close. TAT for us to send the documents is 5 business days. Call ref# 11782375."]
["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","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","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","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","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","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","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","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","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","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","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","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","Multiplan","In Process","Application Submitted","","","","2022-09-15","9/15/2022 Submitted monthly delegation roster to Multiplan to add provider to delegation roster.  DCannon"]
["Chisom Nwoye, MD",1841780806,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Multiplan","In Process","Application Submitted","","","","2022-09-15","9/15/2022 Submitted monthly delegation roster to Multiplan to add provider to delegation roster.  DCannon"]
["Chisom Nwoye, MD",1841780806,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Multiplan","In Process","Application Submitted","","","","2022-09-15","9/15/2022 Submitted monthly delegation roster to Multiplan to add provider to delegation roster.  DCannon"]
["Chisom Nwoye, MD",1841780806,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Multiplan","In Process","Application Submitted","","","","2022-09-15","9/15/2022 Submitted monthly delegation roster to Multiplan to add provider to delegation roster.  DCannon"]
["Chisom Nwoye, MD",1841780806,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Multiplan","In Process","Application Submitted","","","","2022-09-15","9/15/2022 Submitted monthly delegation roster to Multiplan to add provider to delegation roster.  DCannon"]
["Chisom Nwoye, MD",1841780806,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Multiplan","In Process","Application Submitted","","","","2022-09-15","9/15/2022 Submitted monthly delegation roster to Multiplan to add provider to delegation roster.  DCannon"]
["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","Triwest VA","In House Enrollment","In House Enrollment","","","","2022-04-27",""]
["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","Triwest VA","In House Enrollment","In House Enrollment","","","","2022-04-27",""]
["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","Triwest VA","In House Enrollment","In House Enrollment","","","","2022-04-27",""]
["Chisom Nwoye, MD",1841780806,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Liberty Mutual","Pending Other Enrollment","Pending Other Enrollment","","","","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"]
["Chisom Nwoye, MD",1841780806,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Liberty Mutual","Pending Other Enrollment","Pending Other Enrollment","","","","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"]
["Chisom Nwoye, MD",1841780806,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Liberty Mutual","Pending Other Enrollment","Pending Other Enrollment","","","","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"]
["Chisom Nwoye, MD",1841780806,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Liberty Mutual","Pending Other Enrollment","Pending Other Enrollment","","","","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"]
["Chisom Nwoye, MD",1841780806,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Liberty Mutual","Pending Other Enrollment","Pending Other Enrollment","","","","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"]
["Chisom Nwoye, MD",1841780806,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Liberty Mutual","Pending Other Enrollment","Pending Other Enrollment","","","","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"]
["Chisom Nwoye, MD",1841780806,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Texas Mutual","In Process","Payor Follow Up","","","","2023-01-31","1.31.23 Emailed Matt Gorman <MGorman@texasmutual.com> for status update on provider. A Boles"]
["Chisom Nwoye, MD",1841780806,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Texas Mutual","In Process","Payor Follow Up","","","","2023-01-31","1.31.23 Emailed Matt Gorman <MGorman@texasmutual.com> for status update on provider. A Boles"]
["Chisom Nwoye, MD",1841780806,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Texas Mutual","In Process","Payor Follow Up","","","","2023-01-31","1.31.23 Emailed Matt Gorman <MGorman@texasmutual.com> for status update on provider. A Boles"]
["Chisom Nwoye, MD",1841780806,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Texas Mutual","In Process","Payor Follow Up","","","","2023-01-31","1.31.23 Emailed Matt Gorman <MGorman@texasmutual.com> for status update on provider. A Boles"]
["Chisom Nwoye, MD",1841780806,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Texas Mutual","In Process","Payor Follow Up","","","","2023-01-31","1.31.23 Emailed Matt Gorman <MGorman@texasmutual.com> for status update on provider. A Boles"]
["Chisom Nwoye, MD",1841780806,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Texas Mutual","In Process","Payor Follow Up","","","","2023-01-31","1.31.23 Emailed Matt Gorman <MGorman@texasmutual.com> for status update on provider. A Boles"]
["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","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","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","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","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","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","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","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","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","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","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","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","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","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","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","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","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","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","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","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","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","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","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","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","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","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","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","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","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","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","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","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","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","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","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","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","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","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","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","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","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","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","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","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","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","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","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","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","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","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","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","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","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","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","Pending Other Enrollment","Pending Other Enrollment","","","","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"]
["Chisom Nwoye, MD",1841780806,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Gallagher","Pending Other Enrollment","Pending Other Enrollment","","","","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"]
["Chisom Nwoye, MD",1841780806,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Gallagher","Pending Other Enrollment","Pending Other Enrollment","","","","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"]
["Chisom Nwoye, MD",1841780806,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Gallagher","Pending Other Enrollment","Pending Other Enrollment","","","","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"]
["Chisom Nwoye, MD",1841780806,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Gallagher","Pending Other Enrollment","Pending Other Enrollment","","","","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"]
["Chisom Nwoye, MD",1841780806,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Gallagher","Pending Other Enrollment","Pending Other Enrollment","","","","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"]
["Chisom Nwoye, MD",1841780806,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Sedgwick","Participating","Enrollment Complete","2022-11-08","","","2022-12-12","12/12/2022 Received email from Karina_Garcia@Corvel.com with welcome letter effective 11/8/2022. Approval Documents have been saved to providers file. MS.  DCannon"]
["Chisom Nwoye, MD",1841780806,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Sedgwick","Participating","Enrollment Complete","2022-11-08","","","2022-12-12","12/12/2022 Received email from Karina_Garcia@Corvel.com with welcome letter effective 11/8/2022. Approval Documents have been saved to providers file. MS.  DCannon"]
["Chisom Nwoye, MD",1841780806,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Sedgwick","Participating","Enrollment Complete","2022-11-08","","","2022-12-12","12/12/2022 Received email from Karina_Garcia@Corvel.com with welcome letter effective 11/8/2022. Approval Documents have been saved to providers file. MS.  DCannon"]
["Chisom Nwoye, MD",1841780806,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Sedgwick","Participating","Enrollment Complete","2022-11-08","","","2022-12-12","12/12/2022 Received email from Karina_Garcia@Corvel.com with welcome letter effective 11/8/2022. Approval Documents have been saved to providers file. MS.  DCannon"]
["Chisom Nwoye, MD",1841780806,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Sedgwick","Participating","Enrollment Complete","2022-11-08","","","2022-12-12","12/12/2022 Received email from Karina_Garcia@Corvel.com with welcome letter effective 11/8/2022. Approval Documents have been saved to providers file. MS.  DCannon"]
["Chisom Nwoye, MD",1841780806,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Sedgwick","Participating","Enrollment Complete","2022-11-08","","","2022-12-12","12/12/2022 Received email from Karina_Garcia@Corvel.com with welcome letter effective 11/8/2022. Approval Documents have been saved to providers file. MS.  DCannon"]
["Chisom Nwoye, MD",1841780806,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Travelers WC","Pending Other Enrollment","Pending Other Enrollment","","","","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"]
["Chisom Nwoye, MD",1841780806,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Travelers WC","Pending Other Enrollment","Pending Other Enrollment","","","","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"]
["Chisom Nwoye, MD",1841780806,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Travelers WC","Pending Other Enrollment","Pending Other Enrollment","","","","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"]
["Chisom Nwoye, MD",1841780806,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Travelers WC","Pending Other Enrollment","Pending Other Enrollment","","","","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"]
["Chisom Nwoye, MD",1841780806,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Travelers WC","Pending Other Enrollment","Pending Other Enrollment","","","","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"]
["Chisom Nwoye, MD",1841780806,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Travelers WC","Pending Other Enrollment","Pending Other Enrollment","","","","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"]
["Chisom Nwoye, MD",1841780806,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","CAQH","Participating","CAQH Reattested","2022-12-29","","","2022-12-29","12/29/2022 CAQH re-attested.   DCannon"]
["Chisom Nwoye, MD",1841780806,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","CAQH","Participating","CAQH Reattested","2022-12-29","","","2022-12-29","12/29/2022 CAQH re-attested.   DCannon"]
["Chisom Nwoye, MD",1841780806,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","CAQH","Participating","CAQH Reattested","2022-12-29","","","2022-12-29","12/29/2022 CAQH re-attested.   DCannon"]
["Chisom Nwoye, MD",1841780806,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","CAQH","Participating","CAQH Reattested","2022-12-29","","","2022-12-29","12/29/2022 CAQH re-attested.   DCannon"]
["Chisom Nwoye, MD",1841780806,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","CAQH","Participating","CAQH Reattested","2022-12-29","","","2022-12-29","12/29/2022 CAQH re-attested.   DCannon"]
["Chisom Nwoye, MD",1841780806,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","CAQH","Participating","CAQH Reattested","2022-12-29","","","2022-12-29","12/29/2022 CAQH re-attested.   DCannon"]
["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","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","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","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","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","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","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","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","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","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","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","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","Pending Other Enrollment","Pending Other Enrollment","","","","2022-04-27","4/27/2022 Pending Multiplan enrollment.  Once PAR w/ Multiplan provider will be PAR in Boon Chapman.  DCannon"]
["Chisom Nwoye, MD",1841780806,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Boon Chapman","Pending Other Enrollment","Pending Other Enrollment","","","","2022-04-27","4/27/2022 Pending Multiplan enrollment.  Once PAR w/ Multiplan provider will be PAR in Boon Chapman.  DCannon"]
["Chisom Nwoye, MD",1841780806,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Boon Chapman","Pending Other Enrollment","Pending Other Enrollment","","","","2022-04-27","4/27/2022 Pending Multiplan enrollment.  Once PAR w/ Multiplan provider will be PAR in Boon Chapman.  DCannon"]
["Chisom Nwoye, MD",1841780806,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Boon Chapman","Pending Other Enrollment","Pending Other Enrollment","","","","2022-04-27","4/27/2022 Pending Multiplan enrollment.  Once PAR w/ Multiplan provider will be PAR in Boon Chapman.  DCannon"]
["Chisom Nwoye, MD",1841780806,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Boon Chapman","Pending Other Enrollment","Pending Other Enrollment","","","","2022-04-27","4/27/2022 Pending Multiplan enrollment.  Once PAR w/ Multiplan provider will be PAR in Boon Chapman.  DCannon"]
["Chisom Nwoye, MD",1841780806,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Boon Chapman","Pending Other Enrollment","Pending Other Enrollment","","","","2022-04-27","4/27/2022 Pending Multiplan enrollment.  Once PAR w/ Multiplan provider will be PAR in Boon Chapman.  DCannon"]
["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","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","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-C",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-C",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-C",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-C",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-C",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-C",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-C",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-C",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-C",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-C",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-C",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-C",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-C",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-C",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-C",1346807278,"46-0950925","TX","PE - Urgent Orthopedic Specialists, PLLC","Triwest VA","In Process","Payor Follow Up","","","","2022-11-11","11/08/2022  - updated COI submitted"]
["Pamela F Doughty, PA-C",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-C",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"]
["Gautham S Gadiraju, MD",1649462987,"47-5554737","TX","PE - Midland Inpatient Medical Association","USA PPO","Participating","Enrollment Complete","2018-10-26","1649462987","475554737","2020-08-18","Confirmed provider is participating with PPO and H&W Networks (list of networks attached). Kimberly Frazier"]
["Gautham S Gadiraju, MD",1649462987,"47-5554737","TX","PE - Midland Inpatient Medical Association","CAQH","Participating","CAQH Reattested","2022-12-28","","","2022-12-28","12/28/2022 CAQH reviewed  and re-attested.  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","United Health Care","Participating","Enrollment Complete","2018-08-01","1649462987","","2020-08-31","08/31/2020 - moved to completed status after reviewing follow up complete status - Stacey Hudak"]
["Gautham S Gadiraju, MD",1649462987,"47-5554737","TX","PE - Midland Inpatient Medical Association","First Health Coventry","Participating","Enrollment Complete","2018-10-01","2506877","","2020-03-20","03/20/2020 - Rec'd email from the payer stating this provider is EFF under PID# 2506877 - Stacey Hudak"]
["Gautham S Gadiraju, MD",1649462987,"47-5554737","TX","PE - Midland Inpatient Medical Association","Aetna","Participating","Enrollment Complete","2018-11-15","1649462987","","2020-02-03","02/03/2020 - Rec'd confirmation from the follow up team that this provider is \"in network-participating-DIRECT contracted\" EFF 11-15-2018. Unfortunately, no reval date was provided, but it was confirmed that this service location is linked to the provider. - Stacey Hudak"]
["Gautham S Gadiraju, MD",1649462987,"47-5554737","TX","PE - Midland Inpatient Medical Association","Medicare","Participating","Enrollment Complete","2018-08-01","685085","519061","2020-04-22","04/22/2020 - found EFF info through group PECOS enrollment - Stacey Hudak"]
["Gautham S Gadiraju, MD",1649462987,"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"]
["Gautham S Gadiraju, MD",1649462987,"47-5554737","TX","PE - Midland Inpatient Medical Association","Scott&White (First Care)","Participating","Enrollment Complete","2018-10-26","1649462987","","2020-08-19","8/19/2020 - Rec'd a new spreadsheet from Baylor Scott & White after they merged databases with First Care. Updated the effective date and this provider is showing up affilaited 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"]
["Gautham S Gadiraju, MD",1649462987,"47-5554737","TX","PE - Midland Inpatient Medical Association","Omni PPO","Participating","Enrollment Complete","2018-10-22","","","2020-06-22","06/22/2020- Rec'd email from the payer confirming this provider is PAR with this group/service location - Stacey Hudak"]
["Gautham S Gadiraju, MD",1649462987,"47-5554737","TX","PE - Midland Inpatient Medical Association","Rail Road Medicare","Participating","Enrollment Complete","2018-08-01","P02179384","DW7662","2020-04-22","04/22/2020 - Confirmed provider EFF info through payer portal - Stacey Hudak"]
["Gautham S Gadiraju, MD",1649462987,"47-5554737","TX","PE - Midland Inpatient Medical Association","Superior","Participating","Enrollment Complete","2018-12-01","1649462987","","2020-07-14","07/14/2020 - Rec'd spreadsheet from the delegated team stating this provider has been linked to the PriMed contract since 12-1-2018  **see the other enrollment complete line to see details about when this provider became effective with various specific products** - stacey Hudak"]
["Gautham S Gadiraju, MD",1649462987,"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"]
["Gautham S Gadiraju, MD",1649462987,"47-5554737","TX","PE - Midland Inpatient Medical Association","Amerigroup","Participating","Enrollment Complete","2018-11-30","1649462987","","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"]
["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","Humana","Participating","Enrollment Complete","2020-01-01","1407149883","","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"]
["Vamsi K Korrapati, MD",1407149883,"47-5554737","TX","PE - Midland Inpatient Medical Association","TriCare Standard","Participating","Enrollment Complete","2019-02-12","1407149883","","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"]
["Vamsi K Korrapati, MD",1407149883,"47-5554737","TX","PE - Midland Inpatient Medical Association","Multiplan","Participating","Enrollment Complete","2020-08-27","1407149883","","2020-09-23","09/23/2020 - Reviewed follow up complete note and moved to completed status - Stacey Hudak"]
["Vamsi K Korrapati, MD",1407149883,"47-5554737","TX","PE - Midland Inpatient Medical Association","CAQH","Participating","CAQH Reattested","2023-03-10","","","2023-03-10","3/10/2023 CAQH reviewed and re-attested.  DCannon"]
["Vamsi K Korrapati, MD",1407149883,"47-5554737","TX","PE - Midland Inpatient Medical Association","Triwest VA","Enrollment Stopped","Enrollment Stopped","","","","","Practice is hospital-based; not eligible for TriWest VA enrollment"]
["Vamsi K Korrapati, MD",1407149883,"47-5554737","TX","PE - Midland Inpatient Medical Association","Amerigroup","Participating","Enrollment Complete","2018-11-30","1407149883","","2020-03-19","03/19/2020 - Rec'd email from the payer (Multiplan/Texas True Choice) confirming that this provider is EFF with Amerigroup at this serivce location. - 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","First Health Coventry","Participating","Enrollment Complete","2018-10-01","3060094","","2020-03-20","03/20/2020 - Rec'd email from the payer stating this provider is EFF under PID# 3060094 - Stacey Hudak"]
["Vamsi K Korrapati, MD",1407149883,"47-5554737","TX","PE - Midland Inpatient Medical Association","Cigna","Participating","Enrollment Complete","2018-08-01","1407149883","","2020-02-20","02/20/2020 - Payer confirmed that this provider is EFF as of 8-1-2018 at this service location under a DIRECT CONTRACT with this payer - Stacey Hudak"]
["Vamsi K Korrapati, MD",1407149883,"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"]
["Vamsi K Korrapati, MD",1407149883,"47-5554737","TX","PE - Midland Inpatient Medical Association","Galaxy Health","Participating","Enrollment Complete","2018-10-26","1407149883","","2020-07-10","07/10/2020 - updated payer line to enrollment complete status instead of \"Delegated status\" for report running purposes - Stacey Hudak"]
["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","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."]
["Vamsi K Korrapati, MD",1407149883,"47-5554737","TX","PE - Midland Inpatient Medical Association","Superior","Participating","Enrollment Complete","2018-12-01","1407149883","","2020-07-14","07/14/2020 - Rec'd spreadsheet from the delegated team stating this provider has been linked to the PriMed contract since 12-1-2018 **see the other enrollment complete line to see details about when this provider became effective with various specific products** - stacey Hudak"]
["Vamsi K Korrapati, MD",1407149883,"47-5554737","TX","PE - Midland Inpatient Medical Association","Medicaid","Participating","Enrollment Complete","","377470502","364596201","2020-02-19","02/19/2020 - Per payer portal, this provider is linked to group TPI 364596201 and affiliated with the following plans; FirstCare - Lubbock, TRADITIONAL MEDICAID, Amerigroup - MRSA West, FirstCare - MRSA West, Amerigroup Texas, Inc. - MRSA West - Stacey Hudak"]
["Vamsi K Korrapati, MD",1407149883,"47-5554737","TX","PE - Midland Inpatient Medical Association","Aetna","Participating","Enrollment Complete","2018-11-15","1407149883","","2020-02-03","02/03/2020 - Rec'd confirmation from the follow up team that this provider is \"in network-participating-DIRECT contracted\" EFF 11-15-2018. Unfortunately, no reval date was provided, but it was confirmed that this service location is linked to the provider. - Stacey Hudak"]
["Vamsi K Korrapati, MD",1407149883,"47-5554737","TX","PE - Midland Inpatient Medical Association","Omni PPO","Participating","Enrollment Complete","2018-10-22","1407149883","","2020-06-25",""]
["Vamsi K Korrapati, MD",1407149883,"47-5554737","TX","PE - Midland Inpatient Medical Association","Medicare","Participating","Enrollment Complete","2018-09-01","691156","519061","2020-02-19","02/19/2020 - Rec'd PECOS login .Signed in to find that this provider is successfully enrolled with Medicare/MIMA as of 9-1-2018. - Stacey Hudak"]
["Vamsi K Korrapati, MD",1407149883,"47-5554737","TX","PE - Midland Inpatient Medical Association","IMS","Participating","Enrollment Complete","2018-10-22","1407149883","","2020-06-22","06/22/2020- Rec'd email from the payer confirming this provider is PAR with this group/service location - 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"]
["Vamsi K Korrapati, MD",1407149883,"47-5554737","TX","PE - Midland Inpatient Medical Association","Scott&White (First Care)","Participating","Enrollment Complete","2018-10-26","1407149883","","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"]
["Vamsi K Korrapati, MD",1407149883,"47-5554737","TX","PE - Midland Inpatient Medical Association","United Health Care","Participating","Enrollment Complete","2018-08-01","1407149883","","2020-07-30","7/30/2020 - moved to completed status after reviewing followup complete note - Stacey Hudak"]
["Vamsi K Korrapati, MD",1407149883,"47-5554737","TX","PE - Midland Inpatient Medical Association","Boon Chapman","Participating","Enrollment Complete","2020-08-27","","","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 8/27/2020.  DCannon"]
["Kevin W Benson, MD",1326061086,"75-2133441","TX","PE - Midland Pediatric Associates, PLLC","HealthSmart PPO","Participating","Enrollment Complete","2018-10-26","1326061086","","2020-06-05","06/05/2020 - Rec'd email from the payer stating this provider is EFF - Stacey Hudak"]
["Kevin W Benson, MD",1326061086,"75-2133441","TX","PE - Midland Pediatric Associates, PLLC","First Health Coventry","Participating","Enrollment Complete","2018-10-01","1397856","","2020-03-24","3/24/2020-received email with roster from payor stating provider PAR 10/01/2018 PID # 1397856\ntisha rader"]
["Kevin W Benson, MD",1326061086,"75-2133441","TX","PE - Midland Pediatric Associates, PLLC","Tricare Prime","Participating","Enrollment Complete","2018-12-19","","","2020-10-08","10/8/2020 Confirmed via Self-Service Portal provider is participating under Tax ID and location. Kimberly Frazier"]
["Kevin W Benson, MD",1326061086,"75-2133441","TX","PE - Midland Pediatric Associates, 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"]
["Kevin W Benson, MD",1326061086,"75-2133441","TX","PE - Midland Pediatric Associates, PLLC","Galaxy Health","Participating","Enrollment Complete","2018-10-26","1326061086","","2020-07-20","7/20/2020- Received a spreadsheet from the payer stating this provider is effective as of 10/26/2018. – Jerha Gayorgor"]
["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","USA PPO","Participating","Enrollment Complete","2018-10-26","1326061086","752302928","2020-08-18","Confirmed provider is participating with PPO and H&W networks (list of networks attached). Kimberly Frazier"]
["Kevin W Benson, MD",1326061086,"75-2133441","TX","PE - Midland Pediatric Associates, PLLC","Aetna","Participating","Enrollment Complete","2018-11-15","1326061086","","2020-06-09","06/09/2020 - S/W Bella of Aetna @ 8003531232, provider NPI# is on file for the provider and is participating effective 11/15/2018 under the group and TIN#. Provider is DELEGATED TO PRIMED  Network. Physical location is on file. Call ref# 5309719262. - Stacey Hudak"]
["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"]
["Kevin W Benson, MD",1326061086,"75-2133441","TX","PE - Midland Pediatric Associates, PLLC","CAQH","Participating","CAQH Reattested","2022-12-29","10450267","","2022-12-29","12/29/2022 CAQH re-attested.   DCannon"]
["Kevin W Benson, MD",1326061086,"75-2133441","TX","PE - Midland Pediatric Associates, PLLC","Cigna","Participating","Enrollment Complete","2008-11-01","1326061086","","2020-04-22","04/22/2020--SW Red of Cigna @ 8008824462, Provider NPI# is on file and participating under the group and TIN# effective 11/1/2018. Location is on file. Call ref# red4202020.\n-copied note from spreadsheet-tisha rader"]
["Kevin W Benson, MD",1326061086,"75-2133441","TX","PE - Midland Pediatric Associates, PLLC","IMS","Participating","Enrollment Complete","2018-10-22","1326061086","","2020-06-22","06/22/2020- Rec'd email from the payer confirming this provider is PAR with this group/service location - Stacey Hudak"]
["Kevin W Benson, MD",1326061086,"75-2133441","TX","PE - Midland Pediatric Associates, PLLC","Humana","Participating","Enrollment Complete","2018-10-22","1326061086","","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"]
["Kevin W Benson, MD",1326061086,"75-2133441","TX","PE - Midland Pediatric Associates, PLLC","Boon Chapman","Participating","Enrollment Complete","2018-09-18","1326061086","","2020-10-05","Enrolled through PHCS"]
["Kevin W Benson, MD",1326061086,"75-2133441","TX","PE - Midland Pediatric Associates, PLLC","Caprock (CapStar)","Participating","Enrollment Complete","2018-10-22","1326061086","","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"]
["Kevin W Benson, MD",1326061086,"75-2133441","TX","PE - Midland Pediatric Associates, PLLC","Multiplan","Participating","Enrollment Complete","2018-09-18","1326061086","","2020-08-27","08/27/2020 - Rec'd email from the payer stating this provider \"Thank 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: - Kevin Benson-Effective 09/18/2018\" - Stacey Hudak"]
["Ubaldo Estrada, FNP",1740723725,"75-1997880","TX","PE - Andrews County Hospital District","Medicare","Facility Enrollment","Facility Enrollment","2018-01-16","560990YSCJ","290001","2020-07-24","7/24/2020 - Confirmed this provider is linked to Quick Care Clinic Part B group PTAN 290001 - 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","Boon Chapman","Participating","Enrollment Complete","2020-07-17","","","2022-09-15","9/15/2022 Per email from Marcie Eckhart-Havens Multiplan July delegated roster has been completed  and provider is PAR and linked to group TIN effective 7/17/2020.  DCannon"]
["Ubaldo Estrada, FNP",1740723725,"75-1997880","TX","PE - Andrews County Hospital District","Molina","Pending Other Enrollment","Pending Contracting","","","","2021-08-05","8/5/2021 Pending contracting on the RHC level, which currently remains in process. KFrazier"]
["Ubaldo Estrada, FNP",1740723725,"75-1997880","TX","PE - Andrews County Hospital District","Triwest VA","Enrollment on Hold","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"]
["Ubaldo Estrada, FNP",1740723725,"75-1997880","TX","","Triwest VA","Enrollment on Hold","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"]
["Ubaldo Estrada, FNP",1740723725,"75-1997880","TX","PE - Andrews County Hospital District","Triwest VA","Enrollment on Hold","Enrollment on Hold","","","","","RHC."]
["Ubaldo Estrada, FNP",1740723725,"75-1997880","TX","","Triwest VA","Enrollment on Hold","Enrollment on Hold","","","","","RHC."]
["Ubaldo Estrada, FNP",1740723725,"75-1997880","TX","PE - Andrews County Hospital District","Superior","Participating","Enrollment Complete","2020-10-01","1740723725","","2020-10-02","10/02/2020 - Rec'd email from the payer stating this provider has been added to the PriMed roster - Stacey Hudak"]
["Ubaldo Estrada, FNP",1740723725,"75-1997880","TX","PE - Andrews County Hospital District","Humana","Participating","Enrollment Complete","2018-07-01","","","2021-11-18","11/18/2021 Rcvd full roster from Humana listing provider as PAR and linked to group TIN/location effective 7/1/2018.  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","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"]
["Ubaldo Estrada, FNP",1740723725,"75-1997880","TX","PE - Andrews County Hospital District","HealthSmart PPO","Participating","Enrollment Complete","2020-07-17","","","2021-12-03","12/3/2021 Per Healthsmart website provider is PAR and loaded under TIN/location effective 7/17/2020.  DCannon"]
["Ubaldo Estrada, FNP",1740723725,"75-1997880","TX","PE - Andrews County Hospital District","Cigna","Participating","Enrollment Complete","2018-04-30","1740723725","","2020-07-23","07/23/2020 - moved to completed status after reviewing follow up complete note - Stacey Hudak"]
["Ubaldo Estrada, FNP",1740723725,"75-1997880","TX","PE - Andrews County Hospital District","Scott&White (First Care)","Participating","Enrollment Complete","2020-09-02","1740723725","","2020-08-20","08/20/2020 - Rec'd spreadsheet from the payer stating this provider has been added to the PRIMED DELEGATED AGREEMNT under this TIN/Service Location. The provider is networked with:\nFirstCare MyChoice PPO\nFirstCare Select Benefit Network\nHMO Enhanced Benefit Network\nMedicare (FC)\nPPO Limited Benefit Network\n- Stacey Hudak"]
["Ubaldo Estrada, FNP",1740723725,"75-1997880","TX","PE - Andrews County Hospital District","United Health Care","Participating","Enrollment Complete","2019-11-01","1740723725","","2020-07-30","7/30/2020 - moved to completed status after reviewing follow up complete - Stacey Hudak"]
["Ubaldo Estrada, FNP",1740723725,"75-1997880","TX","PE - Andrews County Hospital District","TriCare Standard","Participating","Enrollment Complete","2018-04-01","","","2020-09-24","Confirmed via self-service portal, provider is participating under group Tax ID and location. Kimberly Frazier"]
["Ubaldo Estrada, FNP",1740723725,"75-1997880","TX","PE - Andrews County Hospital District","Caprock (CapStar)","Participating","Enrollment Complete","2019-09-01","1740723725","","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"]
["Ubaldo Estrada, FNP",1740723725,"75-1997880","TX","PE - Andrews County Hospital District","Galaxy Health","Participating","Enrollment Complete","2020-01-01","1740723725","","2020-10-05","10/5/2020 - Rec'd email back from the payer stating this enrollment has been completed - Stacey"]
["Ubaldo Estrada, FNP",1740723725,"75-1997880","TX","PE - Andrews County Hospital District","Medicaid","Participating","Enrollment Complete","2018-01-16","378143702","324676101","2021-02-10","2/10/2021 Per email received from Stacy Salazar, she processed provider's application, which has been approved and assigned TPI 378143702 effective 1/16/2018. KFrazier"]
["Ubaldo Estrada, FNP",1740723725,"75-1997880","TX","PE - Andrews County Hospital District","Multiplan","Participating","Enrollment Complete","2020-07-17","","","2022-08-23","8/23/2022 Per email from Multiplan provider is PAR and linked to group TIN/location effective 7/17/2021.  DCannon"]
["Ubaldo Estrada, FNP",1740723725,"75-1997880","TX","PE - Andrews County Hospital District","CAQH","Participating","CAQH Reattested","2022-12-15","","","2022-12-15","12/15/2022 CAQH re-attested.  DCannon"]
["Morgan Sims, PA-C",1952865057,"473465832: P","TX","PE - WesTex Urgent Care, PLLC","United Health Care","Participating","Enrollment Complete","2022-01-31","007021658","","2022-04-08","4/8/2022 Received email from united_healthcare_provider_operations@uhc.com, provider is complete. MPIN 007021658. Cbankston"]
["Morgan Sims, PA-C",1952865057,"473465832: P","TX","PE - WesTex Urgent Care, PLLC","United Health Care","Participating","Enrollment Complete","2022-01-31","007021658","","2022-04-08","4/8/2022 Received email from united_healthcare_provider_operations@uhc.com, provider is complete. MPIN 007021658. Cbankston"]
["Morgan Sims, PA-C",1952865057,"473465832: S","TX","PE - WesTex Urgent Care, PLLC","United Health Care","Participating","Enrollment Complete","2022-01-31","007021658","","2022-04-08","4/8/2022 Received email from united_healthcare_provider_operations@uhc.com, provider is complete. MPIN 007021658. Cbankston"]
["Morgan Sims, PA-C",1952865057,"473465832: S","TX","PE - WesTex Urgent Care, PLLC","United Health Care","Participating","Enrollment Complete","2022-01-31","007021658","","2022-04-08","4/8/2022 Received email from united_healthcare_provider_operations@uhc.com, provider is complete. MPIN 007021658. Cbankston"]
["Morgan Sims, PA-C",1952865057,"473465832: T","TX","PE - WesTex Urgent Care, PLLC","United Health Care","Participating","Enrollment Complete","2022-01-31","007021658","","2022-04-08","4/8/2022 Received email from united_healthcare_provider_operations@uhc.com, provider is complete. MPIN 007021658. Cbankston"]
["Morgan Sims, PA-C",1952865057,"473465832: T","TX","PE - WesTex Urgent Care, PLLC","United Health Care","Participating","Enrollment Complete","2022-01-31","007021658","","2022-04-08","4/8/2022 Received email from united_healthcare_provider_operations@uhc.com, provider is complete. MPIN 007021658. Cbankston"]
["Morgan Sims, PA-C",1952865057,"473465832: P","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,"473465832: P","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,"473465832: S","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,"473465832: S","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,"473465832: T","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,"473465832: T","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,"473465832: P","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,"473465832: P","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,"473465832: S","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,"473465832: S","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,"473465832: T","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,"473465832: T","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,"473465832: P","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,"473465832: P","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,"473465832: S","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,"473465832: S","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,"473465832: T","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,"473465832: T","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,"473465832: P","TX","PE - WesTex Urgent Care, PLLC","First Health Coventry","In Process","Enrollment Complete","","","","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,"473465832: P","TX","PE - WesTex Urgent Care, PLLC","First Health Coventry","In Process","Enrollment Complete","","","","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,"473465832: S","TX","PE - WesTex Urgent Care, PLLC","First Health Coventry","In Process","Enrollment Complete","","","","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,"473465832: S","TX","PE - WesTex Urgent Care, PLLC","First Health Coventry","In Process","Enrollment Complete","","","","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,"473465832: T","TX","PE - WesTex Urgent Care, PLLC","First Health Coventry","In Process","Enrollment Complete","","","","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,"473465832: T","TX","PE - WesTex Urgent Care, PLLC","First Health Coventry","In Process","Enrollment Complete","","","","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,"473465832: P","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,"473465832: P","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,"473465832: S","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,"473465832: S","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,"473465832: T","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,"473465832: T","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,"473465832: P","TX","PE - WesTex Urgent Care, PLLC","Sedgwick","In Process","Action Needed","","","","2023-01-31","1.31.23 Per response from SPNEAST@sedgwickcms.com there is no application on file for provider. Advised to submit new application. ABoles"]
["Morgan Sims, PA-C",1952865057,"473465832: P","TX","PE - WesTex Urgent Care, PLLC","Sedgwick","In Process","Action Needed","","","","2023-01-31","1.31.23 Per response from SPNEAST@sedgwickcms.com there is no application on file for provider. Advised to submit new application. ABoles"]
["Morgan Sims, PA-C",1952865057,"473465832: S","TX","PE - WesTex Urgent Care, PLLC","Sedgwick","In Process","Action Needed","","","","2023-01-31","1.31.23 Per response from SPNEAST@sedgwickcms.com there is no application on file for provider. Advised to submit new application. ABoles"]
["Morgan Sims, PA-C",1952865057,"473465832: S","TX","PE - WesTex Urgent Care, PLLC","Sedgwick","In Process","Action Needed","","","","2023-01-31","1.31.23 Per response from SPNEAST@sedgwickcms.com there is no application on file for provider. Advised to submit new application. ABoles"]
["Morgan Sims, PA-C",1952865057,"473465832: T","TX","PE - WesTex Urgent Care, PLLC","Sedgwick","In Process","Action Needed","","","","2023-01-31","1.31.23 Per response from SPNEAST@sedgwickcms.com there is no application on file for provider. Advised to submit new application. ABoles"]
["Morgan Sims, PA-C",1952865057,"473465832: T","TX","PE - WesTex Urgent Care, PLLC","Sedgwick","In Process","Action Needed","","","","2023-01-31","1.31.23 Per response from SPNEAST@sedgwickcms.com there is no application on file for provider. Advised to submit new application. ABoles"]
["Morgan Sims, PA-C",1952865057,"473465832: P","TX","PE - WesTex Urgent Care, PLLC","Zurich","Pending Other Enrollment","Pending Other Enrollment","","","","2023-02-03","2.3.23 Plan pends enrollment with Coventry WC. ABoles"]
["Morgan Sims, PA-C",1952865057,"473465832: P","TX","PE - WesTex Urgent Care, PLLC","Zurich","Pending Other Enrollment","Pending Other Enrollment","","","","2023-02-03","2.3.23 Plan pends enrollment with Coventry WC. ABoles"]
["Morgan Sims, PA-C",1952865057,"473465832: S","TX","PE - WesTex Urgent Care, PLLC","Zurich","Pending Other Enrollment","Pending Other Enrollment","","","","2023-02-03","2.3.23 Plan pends enrollment with Coventry WC. ABoles"]
["Morgan Sims, PA-C",1952865057,"473465832: S","TX","PE - WesTex Urgent Care, PLLC","Zurich","Pending Other Enrollment","Pending Other Enrollment","","","","2023-02-03","2.3.23 Plan pends enrollment with Coventry WC. ABoles"]
["Morgan Sims, PA-C",1952865057,"473465832: T","TX","PE - WesTex Urgent Care, PLLC","Zurich","Pending Other Enrollment","Pending Other Enrollment","","","","2023-02-03","2.3.23 Plan pends enrollment with Coventry WC. ABoles"]
["Morgan Sims, PA-C",1952865057,"473465832: T","TX","PE - WesTex Urgent Care, PLLC","Zurich","Pending Other Enrollment","Pending Other Enrollment","","","","2023-02-03","2.3.23 Plan pends enrollment with Coventry WC. ABoles"]
["Morgan Sims, PA-C",1952865057,"473465832: P","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,"473465832: P","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,"473465832: S","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,"473465832: S","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,"473465832: T","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,"473465832: T","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,"473465832: P","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,"473465832: P","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,"473465832: S","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,"473465832: S","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,"473465832: T","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,"473465832: T","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,"473465832: P","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,"473465832: P","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,"473465832: S","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,"473465832: S","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,"473465832: T","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,"473465832: T","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,"473465832: P","TX","PE - WesTex Urgent Care, PLLC","Liberty Mutual","Pending Other Enrollment","Pending Other Enrollment","","","","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"]
["Morgan Sims, PA-C",1952865057,"473465832: P","TX","PE - WesTex Urgent Care, PLLC","Liberty Mutual","Pending Other Enrollment","Pending Other Enrollment","","","","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"]
["Morgan Sims, PA-C",1952865057,"473465832: S","TX","PE - WesTex Urgent Care, PLLC","Liberty Mutual","Pending Other Enrollment","Pending Other Enrollment","","","","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"]
["Morgan Sims, PA-C",1952865057,"473465832: S","TX","PE - WesTex Urgent Care, PLLC","Liberty Mutual","Pending Other Enrollment","Pending Other Enrollment","","","","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"]
["Morgan Sims, PA-C",1952865057,"473465832: T","TX","PE - WesTex Urgent Care, PLLC","Liberty Mutual","Pending Other Enrollment","Pending Other Enrollment","","","","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"]
["Morgan Sims, PA-C",1952865057,"473465832: T","TX","PE - WesTex Urgent Care, PLLC","Liberty Mutual","Pending Other Enrollment","Pending Other Enrollment","","","","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"]
["Morgan Sims, PA-C",1952865057,"473465832: P","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,"473465832: P","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,"473465832: S","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,"473465832: S","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,"473465832: T","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,"473465832: T","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,"473465832: P","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,"473465832: P","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,"473465832: S","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,"473465832: S","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,"473465832: T","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,"473465832: T","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,"473465832: P","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,"473465832: P","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,"473465832: S","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,"473465832: S","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,"473465832: T","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,"473465832: T","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,"473465832: P","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,"473465832: P","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,"473465832: S","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,"473465832: S","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,"473465832: T","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,"473465832: T","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,"473465832: P","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,"473465832: P","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,"473465832: S","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,"473465832: S","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,"473465832: T","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,"473465832: T","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,"473465832: P","TX","PE - WesTex Urgent Care, PLLC","Gallagher","Pending Other Enrollment","Pending Other Enrollment","","","","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"]
["Morgan Sims, PA-C",1952865057,"473465832: P","TX","PE - WesTex Urgent Care, PLLC","Gallagher","Pending Other Enrollment","Pending Other Enrollment","","","","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"]
["Morgan Sims, PA-C",1952865057,"473465832: S","TX","PE - WesTex Urgent Care, PLLC","Gallagher","Pending Other Enrollment","Pending Other Enrollment","","","","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"]
["Morgan Sims, PA-C",1952865057,"473465832: S","TX","PE - WesTex Urgent Care, PLLC","Gallagher","Pending Other Enrollment","Pending Other Enrollment","","","","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"]
["Morgan Sims, PA-C",1952865057,"473465832: T","TX","PE - WesTex Urgent Care, PLLC","Gallagher","Pending Other Enrollment","Pending Other Enrollment","","","","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"]
["Morgan Sims, PA-C",1952865057,"473465832: T","TX","PE - WesTex Urgent Care, PLLC","Gallagher","Pending Other Enrollment","Pending Other Enrollment","","","","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"]
["Morgan Sims, PA-C",1952865057,"473465832: P","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,"473465832: P","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,"473465832: S","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,"473465832: S","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,"473465832: T","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,"473465832: T","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,"473465832: P","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,"473465832: P","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,"473465832: S","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,"473465832: S","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,"473465832: T","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,"473465832: T","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,"473465832: P","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"]
["Morgan Sims, PA-C",1952865057,"473465832: P","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"]
["Morgan Sims, PA-C",1952865057,"473465832: S","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"]
["Morgan Sims, PA-C",1952865057,"473465832: S","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"]
["Morgan Sims, PA-C",1952865057,"473465832: T","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"]
["Morgan Sims, PA-C",1952865057,"473465832: T","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"]
["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","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","2023-02-09","","","2023-02-09","2/9/2023 CAQH reviewed and re-attested.  DCannon"]
["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","2019-04-10","1588857874","","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"]
["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","2019-05-21","1164778767","","2020-12-31","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"]
["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","2023-02-12","","","2023-02-12","2/12/2023 CAQH reviewed and re-attested.  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","Aetna","Participating","Enrollment Complete","2019-06-01","1164778767","","2020-02-03","02/03/2020 - Rec'd confirmation from the payer that this provider is EFF 6-1-2019 under a DELEGATED AGREEMENT with Permian Basin Healthcare - Effective date 8/15/2019. This service location is on file. Must contact Permian for more info - Stacey Hudak"]
["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","Delegated - Third Party","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","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","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","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","Delegated - Third Party","Delegated - Third Party","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"]
["Rachel K Longacre, FNP-C",1639524861,"75-2656723","TX","PE - Premier Family Care I, 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 I, Inc","Omni PPO","Participating","Enrollment Complete","2019-05-21","1639524861","","2020-06-25",""]
["Rachel K Longacre, FNP-C",1639524861,"75-2656723","TX","PE - Premier Family Care I, Inc","Medicare","Participating","Enrollment Complete","2019-05-01","793339","0008AH","2020-01-29","01/29/2020 - confirmed EFF through PECOS group enrollment - Stacey Hudak"]
["Rachel K Longacre, FNP-C",1639524861,"75-2656723","TX","PE - Premier Family Care I, Inc","CAQH","Participating","CAQH Reattested","2023-01-25","13859704","","2023-01-25","1/25/2023 CAQH reviewed and re-attested.  DCannon"]
["Rachel K Longacre, FNP-C",1639524861,"75-2656723","TX","PE - Premier Family Care I, Inc","Triwest VA","Facility Enrollment","Application Submitted","","","","2022-11-28","08/19/2022 - Submitted application to TriWest VA (sent to Scarlett Abigail, Scarlett_Abigail@bcbstx.com)"]
["Rachel K Longacre, FNP-C",1639524861,"75-2656723","TX","","Triwest VA","Facility Enrollment","Application Submitted","","","","2022-11-28","08/19/2022 - Submitted application to TriWest VA (sent to Scarlett Abigail, Scarlett_Abigail@bcbstx.com)"]
["Rachel K Longacre, FNP-C",1639524861,"75-2656723","TX","PE - Premier Family Care I, Inc","Triwest VA","Facility 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.\""]
["Rachel K Longacre, FNP-C",1639524861,"75-2656723","TX","","Triwest VA","Facility 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.\""]
["Rachel K Longacre, FNP-C",1639524861,"75-2656723","TX","PE - Premier Family Care I, Inc","Humana","Participating","Enrollment Complete","2020-01-01","1639524861","","2020-07-17","7/17/2020 - 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"]
["Rachel K Longacre, FNP-C",1639524861,"75-2656723","TX","PE - Premier Family Care I, Inc","First Health Coventry","Participating","Enrollment Complete","2019-05-01","3041792","","2020-03-24","3/24/2020-received email with roster from payor stating provider PAR 5/1/2019 PID # 3041792\ntisha rader"]
["Rachel K Longacre, FNP-C",1639524861,"75-2656723","TX","PE - Premier Family Care I, Inc","Galaxy Health","Participating","Enrollment Complete","2019-05-03","1639524861","","2020-07-10","07/10/2020 - updated payer line to enrollment complete status instead of \"Delegated status\" for report running purposes - Stacey Hudak"]
["Rachel K Longacre, FNP-C",1639524861,"75-2656723","TX","PE - Premier Family Care I, Inc","USA PPO","Participating","Enrollment Complete","2019-05-31","1639524861","752656723","2020-08-18","Confirmed provider is participating with PPO and H&W networks (list of networks attached). Kimberly Frazier"]
["Rachel K Longacre, FNP-C",1639524861,"75-2656723","TX","PE - Premier Family Care I, 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 I, Inc","IMS","Participating","Enrollment Complete","2019-05-21","1639524861","","2020-06-22","06/22/2020- Rec'd email from the payer confirming this provider is PAR with this group/service location - Stacey Hudak"]
["Rachel K Longacre, FNP-C",1639524861,"75-2656723","TX","PE - Premier Family Care I, Inc","Boon Chapman","Participating","Enrollment Complete","2019-04-16","","","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 4/16/2019.  DCannon"]
["Rachel K Longacre, FNP-C",1639524861,"75-2656723","TX","PE - Premier Family Care I, Inc","HealthSmart PPO","Participating","Enrollment Complete","2019-05-31","1639524861","","2020-06-05","06/05/2020 - Rec'd email from the payer stating this provider is EFF - Stacey Hudak"]
["Rachel K Longacre, FNP-C",1639524861,"75-2656723","TX","PE - Premier Family Care I, 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 I, Inc","United Health Care","Participating","Enrollment Complete","2017-06-26","1639524861","","2020-08-03","8/3/2020 - moved to completed status after reviewing follow up complete note - Stacey Hudak"]
["Rachel K Longacre, FNP-C",1639524861,"75-2656723","TX","PE - Premier Family Care I, Inc","Aetna","Participating","Enrollment Complete","2020-09-15","1639524861","","2020-09-23","09/23/2020 - moved to completed status after reviewing follow up complete note - Stacey Hudak"]
["Rachel K Longacre, FNP-C",1639524861,"75-2656723","TX","PE - Premier Family Care I, Inc","Scott&White (First Care)","Participating","Enrollment Complete","2019-10-15","1639524861","","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"]
["Rachel K Longacre, FNP-C",1639524861,"75-2656723","TX","PE - Premier Family Care I, 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"]
["Rachel K Longacre, FNP-C",1639524861,"75-2656723","TX","PE - Premier Family Care I, Inc","Cigna","Terminated","Terminated","2020-03-01","1639524861","","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"]
["Rachel K Longacre, FNP-C",1639524861,"75-2656723","TX","PE - Premier Family Care I, 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 I, Inc","Tricare Prime","Participating","Enrollment Complete","2020-01-05","","","2020-10-08","10/8/2020 Confirmed via Self-Service Portal provider is participating under Tax ID and location. Kimberly Frazier"]
["Rachel K Longacre, FNP-C",1639524861,"75-2656723","TX","PE - Premier Family Care I, 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"]
["Rachel K Longacre, FNP-C",1639524861,"75-2656723","TX","PE - Premier Family Care I, Inc","TriCare Standard","Participating","Enrollment Complete","2020-10-27","","","2020-11-03","11/3/2020 Confirmed via self-service portal provider is approved and participating under Group Tax ID and location effective 10/27/2020. Kimberly Frazier"]
["Rachel K Longacre, FNP-C",1639524861,"75-2656723","TX","PE - Premier Family Care I, Inc","Superior","Participating","Enrollment Complete","2019-08-01","1639524861","","2020-07-14","07/14/2020 - Rec'd email from the payer stating this provider is EFF under PRIMED DELEGATED agreement - Stacey Hudak"]
["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","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","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"]
["Madhavi Gadiraju, MD",1932541406,"75-2656723","TX","PE - Premier Family Care I, Inc","Superior","Participating","Enrollment Complete","2019-11-01","1932541406","","2020-07-14","07/14/2020 - Rec'd spreadsheet from the delegated team stating this provider has been linked to the PriMed contract since 11-1-2019 **see the other enrollment complete line to see details about when this provider became effective with various specific products** - stacey Hudak"]
["Madhavi Gadiraju, MD",1932541406,"75-2656723","TX","PE - Premier Family Care I, 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."]
["Madhavi Gadiraju, MD",1932541406,"75-2656723","TX","PE - Premier Family Care I, Inc","CAQH","Participating","CAQH Reattested","2023-01-03","13876531","","2023-01-03","1/3/2023 CAQH reviewed and re-attested.  DCannon"]
["Madhavi Gadiraju, MD",1932541406,"75-2656723","TX","PE - Premier Family Care I, Inc","Humana","Participating","Enrollment Complete","2020-01-01","1932541406","","2020-07-17","7/17/2020 - 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"]
["Madhavi Gadiraju, MD",1932541406,"75-2656723","TX","PE - Premier Family Care I, Inc","IMS","Participating","Enrollment Complete","2019-09-30","1932541406","","2020-06-22","06/22/2020- Rec'd email from the payer confirming this provider is PAR with this group/service location - Stacey Hudak"]
["Madhavi Gadiraju, MD",1932541406,"75-2656723","TX","PE - Premier Family Care I, Inc","Triwest VA","Facility Enrollment","Application Submitted","","","","2022-11-23","08/19/2022 - Submitted application to TriWest VA (sent to Scarlett Abigail, Scarlett_Abigail@bcbstx.com)"]
["Madhavi Gadiraju, MD",1932541406,"75-2656723","TX","","Triwest VA","Facility Enrollment","Application Submitted","","","","2022-11-23","08/19/2022 - Submitted application to TriWest VA (sent to Scarlett Abigail, Scarlett_Abigail@bcbstx.com)"]
["Madhavi Gadiraju, MD",1932541406,"75-2656723","TX","PE - Premier Family Care I, Inc","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.\""]
["Madhavi Gadiraju, MD",1932541406,"75-2656723","TX","","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.\""]
["Madhavi Gadiraju, MD",1932541406,"75-2656723","TX","PE - Premier Family Care I, Inc","USA PPO","Participating","Enrollment Complete","2019-09-30","1932541406","752656723","2020-08-18","Confirmed provider is participating with PPO, H&W and WIN networks (list of all networks attached). Kimberly Frazier"]
["Madhavi Gadiraju, MD",1932541406,"75-2656723","TX","PE - Premier Family Care I, Inc","TriCare Standard","Participating","Enrollment Complete","2019-07-02","1932541406","","2020-09-14","Upon review of the Self-Service portal, provider is completed and loaded as participating under practice location. Kimberly Frazier"]
["Madhavi Gadiraju, MD",1932541406,"75-2656723","TX","PE - Premier Family Care I, Inc","United Health Care","Participating","Enrollment Complete","2019-04-15","1932541406","","2020-07-30","7/30/2020 - Moved to completed status after reviewing follow up complete note - Stacey Hudak"]
["Madhavi Gadiraju, MD",1932541406,"75-2656723","TX","PE - Premier Family Care I, Inc","Amerigroup","Participating","Enrollment Complete","2019-09-30","1932541406","","2020-02-11","2/11/2020 – Received Roster from Amerigroup and provider is now PAR- Tisha Rader\n\n3/18/2020 - Rec'd email confirmation from Multiplan/Texas True Chioce stating EFF information is correct - Stacey Hudak"]
["Madhavi Gadiraju, MD",1932541406,"75-2656723","TX","PE - Premier Family Care I, Inc","Boon Chapman","Participating","Enrollment Complete","2019-07-20","","","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 7/20/2019.  DCannon"]
["Madhavi Gadiraju, MD",1932541406,"75-2656723","TX","PE - Premier Family Care I, Inc","Medicare","Participating","Enrollment Complete","2019-05-01","804641","0008AH","2020-01-29","01/29/2020 - confirmed EFF through PECOS group enrollment - Stacey Hudak"]
["Madhavi Gadiraju, MD",1932541406,"75-2656723","TX","PE - Premier Family Care I, Inc","Cigna","Participating","Enrollment Complete","2019-08-14","1932541406","","2020-02-20","02/20/2020 - Rec'd verification from the payer that this provider is EFF 8-14-2019 and linked to this service location under a DIRECT CONTRACT with this payer - Stacey Hudak"]
["Madhavi Gadiraju, MD",1932541406,"75-2656723","TX","PE - Premier Family Care I, Inc","Multiplan","Participating","Enrollment Complete","2019-07-20","1932541406","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 7-20-2019. Provider is networked with Beechstreet. - Stacey Hudak"]
["Madhavi Gadiraju, MD",1932541406,"75-2656723","TX","PE - Premier Family Care I, Inc","Medicaid","Participating","Enrollment Complete","2019-05-01","397298601","079837301","2021-10-06","10/6/2021 Confirmed license update complete via TMHP Portal.  DCannon"]
["Madhavi Gadiraju, MD",1932541406,"75-2656723","TX","PE - Premier Family Care I, Inc","Caprock (CapStar)","Participating","Enrollment Complete","2019-06-12","1932541406","","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"]
["Madhavi Gadiraju, MD",1932541406,"75-2656723","TX","PE - Premier Family Care I, 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 I, Inc","First Health Coventry","Participating","Enrollment Complete","2019-09-01","3002056","","2020-03-24","3/24/2020-received email with roster from payor stating provider PAR 9/1/2019 PID # 3002056\ntisha rader"]
["Madhavi Gadiraju, MD",1932541406,"75-2656723","TX","PE - Premier Family Care I, Inc","Galaxy Health","Participating","Enrollment Complete","2019-06-12","1932541406","","2020-07-10","07/10/2020 - updated payer line to enrollment complete status instead of \"Delegated status\" for report running purposes - Stacey Hudak"]
["Madhavi Gadiraju, MD",1932541406,"75-2656723","TX","PE - Premier Family Care I, 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"]
["Madhavi Gadiraju, MD",1932541406,"75-2656723","TX","PE - Premier Family Care I, Inc","Aetna","Participating","Enrollment Complete","2019-05-01","1932541406","","2020-02-03","02/03/2020 - Rec'd confirmation from the payer that this provider is under DIRECT CONTRACT EFF 5-1-2019 - Stacey Hudak"]
["Madhavi Gadiraju, MD",1932541406,"75-2656723","TX","PE - Premier Family Care I, Inc","Omni PPO","Participating","Enrollment Complete","2019-09-30","1932541406","","2020-06-25",""]
["Deborah A Frempong, APRN-FNP-BC",1811423981,"75-2656723","TX","PE - Premier Family Care I, 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 I, Inc","Caprock (CapStar)","Participating","Enrollment Complete","2019-08-26","1811423981","","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"]
["Deborah A Frempong, APRN-FNP-BC",1811423981,"75-2656723","TX","PE - Premier Family Care I, Inc","Multiplan","Participating","Enrollment Complete","2020-07-01","1811423981","","2020-09-09","09/09/2020 - moved to completed status after reviewing last note - Stacey Hudak"]
["Deborah A Frempong, APRN-FNP-BC",1811423981,"75-2656723","TX","PE - Premier Family Care I, Inc","Amerigroup","Participating","Enrollment Complete","2019-08-30","1811423981","","2020-02-11","2/11/2020 – Received Roster from Amerigroup and provider is now PAR- Tisha Rader\n\n3/18/2020 - rec'd email from the payer Multiplan/Texas True Choie stating that this effective info is true - Stacey Hudak"]
["Deborah A Frempong, APRN-FNP-BC",1811423981,"75-2656723","TX","PE - Premier Family Care I, Inc","Cigna","Participating","Enrollment Complete","2020-04-07","1811423981","","2020-07-20","07/20/2020 - Moved to completed status after reviewing follow up complete note - Stacey Hudak"]
["Deborah A Frempong, APRN-FNP-BC",1811423981,"75-2656723","TX","PE - Premier Family Care I, 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."]
["Deborah A Frempong, APRN-FNP-BC",1811423981,"75-2656723","TX","PE - Premier Family Care I, Inc","HealthSmart PPO","Participating","Enrollment Complete","2019-06-26","1811423981","","2020-06-05","06/05/2020 - Rec'd email from the payer stating this provider is EFF - Stacey Hudak"]
["Deborah A Frempong, APRN-FNP-BC",1811423981,"75-2656723","TX","PE - Premier Family Care I, 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"]
["Deborah A Frempong, APRN-FNP-BC",1811423981,"75-2656723","TX","PE - Premier Family Care I, 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 I, Inc","USA PPO","Participating","Enrollment Complete","2019-08-30","1811423981","752656723","2020-08-18","Confirmed provider is participating with PPO and H&W networks (list of networks attached). Kimberly Frazier"]
["Deborah A Frempong, APRN-FNP-BC",1811423981,"75-2656723","TX","PE - Premier Family Care I, Inc","TriCare Standard","Participating","Enrollment Complete","2019-01-01","","","2020-10-30","10/30/2020 Provider is certified as non-network effective 1/1/2019, as she is currently participating under group Tax ID and location is being updated. Kimberly Frazier"]
["Deborah A Frempong, APRN-FNP-BC",1811423981,"75-2656723","TX","PE - Premier Family Care I, Inc","Humana","Participating","Enrollment Complete","2020-01-01","1811423981","","2020-07-19","7/19/2020 - Received email spredsheet from the payor confirming that this provider is EFF at this service location and PAR with the PRIMED DELEGATED agreement - Pam Porter"]
["Deborah A Frempong, APRN-FNP-BC",1811423981,"75-2656723","TX","PE - Premier Family Care I, Inc","Scott&White (First Care)","Participating","Enrollment Complete","2019-06-01","1811423981","","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"]
["Deborah A Frempong, APRN-FNP-BC",1811423981,"75-2656723","TX","PE - Premier Family Care I, Inc","Omni PPO","Participating","Enrollment Complete","2019-08-26","1811423981","","2020-06-25",""]
["Deborah A Frempong, APRN-FNP-BC",1811423981,"75-2656723","TX","PE - Premier Family Care I, Inc","Aetna","Participating","Enrollment Complete","2020-06-15","6103957","","2020-06-08","06/08/2020 - Rec'd email from the payer stating this provider is PAR with the network effective 6/15/2020. Your Provider Identification Number (PIN) is: 6103957 - Stacey Hudak"]
["Deborah A Frempong, APRN-FNP-BC",1811423981,"75-2656723","TX","PE - Premier Family Care I, Inc","Superior","Participating","Enrollment Complete","2019-10-01","1811423981","","2020-07-14","07/14/2020 - Rec'd spreadsheet from the delegated team stating this provider has been linked to the PriMed contract since 10-1-2019 **see the other enrollment complete line to see details about when this provider became effective with various specific products** - stacey Hudak"]
["Deborah A Frempong, APRN-FNP-BC",1811423981,"75-2656723","TX","PE - Premier Family Care I, Inc","Medicare","Participating","Enrollment Complete","2019-06-01","805590","0008AH","2020-01-29","01/29/2020 - confirmed EFF through PECOS group enrollment - Stacey Hudak"]
["Deborah A Frempong, APRN-FNP-BC",1811423981,"75-2656723","TX","PE - Premier Family Care I, Inc","Tricare Prime","Participating","Enrollment Complete","2020-10-23","","","2020-12-04","12/4/2020 Upon review of self-service portal provider is now participating under Group Tax ID and location. KFrazier"]
["Deborah A Frempong, APRN-FNP-BC",1811423981,"75-2656723","TX","PE - Premier Family Care I, Inc","CAQH","Participating","CAQH Reattested","2023-01-09","14074150","","2023-01-09","1/9/2023 CAQH reviewed and re-attested.  DCannon"]
["Deborah A Frempong, APRN-FNP-BC",1811423981,"75-2656723","TX","PE - Premier Family Care I, 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 I, Inc","Triwest VA","Facility Enrollment","Application Submitted","","","","2022-11-23","08/19/2022 - Submitted application to TriWest VA (sent to Scarlett Abigail, Scarlett_Abigail@bcbstx.com)"]
["Deborah A Frempong, APRN-FNP-BC",1811423981,"75-2656723","TX","","Triwest VA","Facility Enrollment","Application Submitted","","","","2022-11-23","08/19/2022 - Submitted application to TriWest VA (sent to Scarlett Abigail, Scarlett_Abigail@bcbstx.com)"]
["Deborah A Frempong, APRN-FNP-BC",1811423981,"75-2656723","TX","PE - Premier Family Care I, Inc","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.\""]
["Deborah A Frempong, APRN-FNP-BC",1811423981,"75-2656723","TX","","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.\""]
["Deborah A Frempong, APRN-FNP-BC",1811423981,"75-2656723","TX","PE - Premier Family Care I, Inc","United Health Care","Participating","Enrollment Complete","2019-06-01","6730214","","2020-07-30","7/30/2020 - 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 I, 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"]
["Deborah A Frempong, APRN-FNP-BC",1811423981,"75-2656723","TX","PE - Premier Family Care I, Inc","First Health Coventry","Participating","Enrollment Complete","2019-08-01","3304172","","2020-03-24","3/24/2020-receieved email with roster from payor stating provider PAR 8/1/2019 PID # 3304172\ntisha rader"]
["Richard E Winn, MD",1073672994,"75-2656723","TX","PE - Premier Family Care I, Inc","Boon Chapman","Participating","Enrollment Complete","2019-09-30","","","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 9/30/2019.  DCannon"]
["Richard E Winn, MD",1073672994,"75-2656723","TX","PE - Premier Family Care I, Inc","Cigna","Terminated","Terminated","2020-07-21","","","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"]
["Richard E Winn, MD",1073672994,"75-2656723","TX","PE - Premier Family Care I, Inc","IMS","Participating","Enrollment Complete","2019-09-15","","","2020-08-25","Confirmed provider is participating under delegation effective 9/15/2019. Kimberly Frazier"]
["Richard E Winn, MD",1073672994,"75-2656723","TX","PE - Premier Family Care I, 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 I, Inc","Omni PPO","Participating","Enrollment Complete","2019-09-15","","","2020-08-25","Confirmed provider is participating under delegation effective 9/15/2019. Kimberly Frazier"]
["Richard E Winn, MD",1073672994,"75-2656723","TX","PE - Premier Family Care I, Inc","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"]
["Richard E Winn, MD",1073672994,"75-2656723","TX","PE - Premier Family Care I, Inc","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"]
["Richard E Winn, MD",1073672994,"75-2656723","TX","PE - Premier Family Care I, Inc","TriCare Standard","Participating","Enrollment Complete","2019-08-12","","","2020-12-22","12/22/2020 Upon review of the Self-Service portal, provider is participating under group Tax ID, which confirmed provider is certified as non-network provider since that's a requirement before able to become a PAR provider. KFrazier"]
["Richard E Winn, MD",1073672994,"75-2656723","TX","PE - Premier Family Care I, Inc","Medicaid","Participating","Enrollment Complete","2019-07-01","129062909","","2020-08-07","8/7/2020 - rec'd welcome letter from the clinic stating this provider is EFF and linked to TIN - Stacey Hudak"]
["Richard E Winn, MD",1073672994,"75-2656723","TX","PE - Premier Family Care I, Inc","United Health Care","Participating","Enrollment Complete","2019-07-01","","","2020-11-20","11/20/20 - Rcvd confirmation email from UHC confirming enrollment at this location.  DCannon"]
["Richard E Winn, MD",1073672994,"75-2656723","TX","PE - Premier Family Care I, Inc","Triwest VA","Facility Enrollment","Application Submitted","","","","2022-11-28","08/19/2022 - Submitted application to TriWest VA (sent to Scarlett Abigail, Scarlett_Abigail@bcbstx.com)"]
["Richard E Winn, MD",1073672994,"75-2656723","TX","","Triwest VA","Facility Enrollment","Application Submitted","","","","2022-11-28","08/19/2022 - Submitted application to TriWest VA (sent to Scarlett Abigail, Scarlett_Abigail@bcbstx.com)"]
["Richard E Winn, MD",1073672994,"75-2656723","TX","PE - Premier Family Care I, Inc","Triwest VA","Facility 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.\""]
["Richard E Winn, MD",1073672994,"75-2656723","TX","","Triwest VA","Facility 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.\""]
["Richard E Winn, MD",1073672994,"75-2656723","TX","PE - Premier Family Care I, Inc","Caprock (CapStar)","Participating","Enrollment Complete","2019-09-18","1073672994","","2020-09-24",""]
["Richard E Winn, MD",1073672994,"75-2656723","TX","PE - Premier Family Care I, Inc","Humana","Participating","Enrollment Complete","2019-09-18","","","2021-11-18","11/18/2021 Rcvd full roster from Humana listing provider as PAR and linked to group TIN/location effective 9/18/2019.  DCannon"]
["Richard E Winn, MD",1073672994,"75-2656723","TX","PE - Premier Family Care I, Inc","Multiplan","Participating","Enrollment Complete","2019-09-30","1073672994","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 9-30-2019. Provider is networked with Beechstreet. - Stacey Hudak"]
["Richard E Winn, MD",1073672994,"75-2656723","TX","PE - Premier Family Care I, Inc","First Health Coventry","Participating","Enrollment Complete","2020-09-01","1073672994","","2020-11-02","11/2/2020 - moved to completed status due to follow up note -Stacey Hudak"]
["Richard E Winn, MD",1073672994,"75-2656723","TX","PE - Premier Family Care I, 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 I, 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 I, Inc","Aetna","Participating","Enrollment Complete","2019-09-01","","","2020-12-09","12/9/2020 - Rcvd confirmation from payor that provider is now active and linked to this location.  DCannon"]
["Richard E Winn, MD",1073672994,"75-2656723","TX","PE - Premier Family Care I, Inc","CAQH","Participating","CAQH Reattested","2023-01-25","10606333","","2023-01-25","1/25/2023 CAQH reviewed and re-attested.  DCannon"]
["Richard E Winn, MD",1073672994,"75-2656723","TX","PE - Premier Family Care I, Inc","Cigna","Participating","Enrollment Complete","2021-03-31","2740972","","2021-07-27","7/27/2021 Received an email from PDMCOGZ@cigna.com with confirmation of approval for participation effective 3/31/2021 with assigned provider ID 2740972. KFrazier"]
["Richard E Winn, MD",1073672994,"75-2656723","TX","PE - Premier Family Care I, Inc","USA PPO","Participating","Enrollment Complete","2019-09-30","1073672994","752656723","2020-08-18","Confirmed provider is participating with PPO and H&W networks (list of networks attached). Kimberly Frazier"]
["Richard E Winn, MD",1073672994,"75-2656723","TX","PE - Premier Family Care I, Inc","Scott&White (First Care)","Participating","Enrollment Complete","2019-08-23","","","2021-03-15","3/15/2021 Rcvd email from Christelle Tchampo at Scott & White confirming provider is participating under TIN and at location effective 8/23/2019.  DCannon"]
["Richard E Winn, MD",1073672994,"75-2656723","TX","PE - Premier Family Care I, 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"]
["Richard E Winn, MD",1073672994,"75-2656723","TX","PE - Premier Family Care I, Inc","Galaxy Health","Participating","Enrollment Complete","2020-01-01","1073672994","","2020-10-05","10/5/2020 - Rec'd email back from the payer stating this enrollment has been completed - Stacey"]
["Richard E Winn, MD",1073672994,"75-2656723","TX","PE - Premier Family Care I, 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"]
["Purshotham R Ginne, MD",1255584397,"47-5554737","TX","PE - Midland Inpatient Medical Association","Caprock (CapStar)","Participating","Enrollment Complete","2020-03-01","1255584397","","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"]
["Purshotham R Ginne, MD",1255584397,"47-5554737","TX","PE - Midland Inpatient Medical Association","Omni PPO","Participating","Enrollment Complete","2019-08-26","1255584397","","2020-06-25",""]
["Purshotham R Ginne, MD",1255584397,"47-5554737","TX","PE - Midland Inpatient Medical Association","HealthSmart PPO","Participating","Enrollment Complete","2019-09-26","1255584397","","2020-06-05","06/05/2020 - rec'd email from the payer stating this provider is enrolled - Stacey Hudak"]
["Purshotham R Ginne, MD",1255584397,"47-5554737","TX","PE - Midland Inpatient Medical Association","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"]
["Purshotham R Ginne, MD",1255584397,"47-5554737","TX","PE - Midland Inpatient Medical Association","Galaxy Health","Participating","Enrollment Complete","2019-10-02","1255584397","","2020-07-10","07/10/2020 - updated payer line to enrollment complete status instead of \"Delegated status\" for report running purposes - Stacey Hudak"]
["Purshotham R Ginne, MD",1255584397,"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"]
["Purshotham R Ginne, MD",1255584397,"47-5554737","TX","PE - Midland Inpatient Medical Association","CAQH","Participating","CAQH Reattested","2023-01-09","","","2023-01-09","1/9/2023 CAQH reviewed and re=attested.  DCannon"]
["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","USA PPO","Participating","Enrollment Complete","2019-08-30","1255584397","830358685","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","Superior","Participating","Enrollment Complete","2020-08-01","1255584397","","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"]
["Purshotham R Ginne, MD",1255584397,"47-5554737","TX","PE - Midland Inpatient Medical Association","Cigna","Terminated","Terminated","2021-03-31","1255584397","","2021-05-24","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"]
["Purshotham R Ginne, MD",1255584397,"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"]
["Purshotham R Ginne, MD",1255584397,"47-5554737","TX","PE - Midland Inpatient Medical Association","Humana","Participating","Enrollment Complete","2020-01-01","1255584397","","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"]
["Purshotham R Ginne, MD",1255584397,"47-5554737","TX","PE - Midland Inpatient Medical Association","Scott&White (First Care)","Participating","Enrollment Complete","2019-07-01","1255584397","","2020-02-13","02/13/2020 - Rec'd emailed confirmation from the payer (Irma from First Care) that this provider is EFF as of 7/1/2019 and DIRECT CONTRACTED under this TIN - Stacey Hudak"]
["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"]
["Purshotham R Ginne, MD",1255584397,"47-5554737","TX","PE - Midland Inpatient Medical Association","First Health Coventry","Participating","Enrollment Complete","2019-06-01","1255584397","","2020-11-02","11/2/2020 - Moved to completed status after reviewing follow up note - Stacey Hudak"]
["Purshotham R Ginne, MD",1255584397,"47-5554737","TX","PE - Midland Inpatient Medical Association","Amerigroup","Participating","Enrollment Complete","2020-06-29","1255584397","","2020-07-09","07/09/2020 - Rec'd welcome letter stating this provider is PAR with Amerigroup STAR, STAR PLUS & Star Kids products through Texas True Choice - Stacey Hudak"]
["Purshotham R Ginne, MD",1255584397,"47-5554737","TX","PE - Midland Inpatient Medical Association","Medicare","Participating","Enrollment Complete","2019-07-01","833803","519061","2020-02-20","02/20/2020 - Updated information with EFF letter rec'd from Medicare - Stacey Hudak"]
["Purshotham R Ginne, MD",1255584397,"47-5554737","TX","PE - Midland Inpatient Medical Association","Medicaid","Participating","Enrollment Complete","2020-02-19","408008701","","2020-04-07","04/07/2020 - Rec'd letter from the payer stating this provider has been approved with TRADITIONAL medicaid only. - Stacey Hudak"]
["Purshotham R Ginne, MD",1255584397,"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"]
["Purshotham R Ginne, MD",1255584397,"47-5554737","TX","PE - Midland Inpatient Medical Association","United Health Care","Participating","Enrollment Complete","2011-07-29","1255584397","","2020-07-30","7-30-2020 - moved to completed status after reviewing follow up complete note - Stacey Hudak"]
["Purshotham R Ginne, MD",1255584397,"47-5554737","TX","PE - Midland Inpatient Medical Association","Aetna","Participating","Enrollment Complete","2020-08-06","1255584397","","2020-08-31","08/31/2020 - moved to completed status after reviewing follow up complete note - Stacey Hudak"]
["Purshotham R Ginne, MD",1255584397,"47-5554737","TX","PE - Midland Inpatient Medical Association","Cigna","Participating","Enrollment Complete","2021-06-23","5186048","","2021-07-27","7/27/2021 Received an email from PDMnotification@cigna.com with confirmation of approval for participation effective 6/23/2021 with assigned provider ID 5186048. KFrazier"]
["Purshotham R Ginne, MD",1255584397,"47-5554737","TX","PE - Midland Inpatient Medical Association","IMS","Participating","Enrollment Complete","2019-08-26","1255584397","","2020-06-22","06/22/2020- Rec'd email from the payer confirming this provider is PAR with this group/service location - Stacey Hudak"]
["Megan Casselman, NP-C",1528619525,"75-2656723","TX","PE - Premier Family Care I, Inc","CAQH","Participating","CAQH Reattested","2023-03-13","14530139","","2023-03-13","3/13/2023 CAQH reviewed and re-attested.  DCannon"]
["Megan Casselman, NP-C",1528619525,"75-2656723","TX","PE - Premier Family Care I, Inc","Humana","Participating","Enrollment Complete","2020-01-01","1528619525","","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"]
["Megan Casselman, NP-C",1528619525,"75-2656723","TX","PE - Premier Family Care I, Inc","Medicaid","Participating","Enrollment Complete","","403199901","079837301","2020-01-29","01/29/2020 - Found provider through payer portal. Provider is par with Traditional Medicaid only - Stacey Hudak"]
["Megan Casselman, NP-C",1528619525,"75-2656723","TX","PE - Premier Family Care I, Inc","Superior","Participating","Enrollment Complete","2020-08-01","1528619525","","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"]
["Megan Casselman, NP-C",1528619525,"75-2656723","TX","PE - Premier Family Care I, Inc","Galaxy Health","Participating","Enrollment Complete","2019-09-01","1528619525","","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"]
["Megan Casselman, NP-C",1528619525,"75-2656723","TX","PE - Premier Family Care I, Inc","Caprock (CapStar)","Participating","Enrollment Complete","2019-12-11","1528619525","","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"]
["Megan Casselman, NP-C",1528619525,"75-2656723","TX","PE - Premier Family Care I, Inc","USA PPO","Participating","Enrollment Complete","2021-01-26","1312274","","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"]
["Megan Casselman, NP-C",1528619525,"75-2656723","TX","PE - Premier Family Care I, Inc","Aetna","Participating","Enrollment Complete","2020-07-01","6345073","","2020-07-10","07/10/2020 - Rec'd EFF email from the payer stating \"Welcome to the provider network effective 7/1/2020. Your Provider Identification Number (PIN) is: 6345073\" - Stacey Hudak"]
["Megan Casselman, NP-C",1528619525,"75-2656723","TX","PE - Premier Family Care I, Inc","Medicare","Participating","Enrollment Complete","2019-10-01","869041","0008AH","2020-01-29","01/29/2020 - confirmed EFF through PECOS group enrollment - Stacey Hudak"]
["Megan Casselman, NP-C",1528619525,"75-2656723","TX","PE - Premier Family Care I, 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 I, 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 I, 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."]
["Megan Casselman, NP-C",1528619525,"75-2656723","TX","PE - Premier Family Care I, 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"]
["Megan Casselman, NP-C",1528619525,"75-2656723","TX","PE - Premier Family Care I, Inc","Amerigroup","Participating","Enrollment Complete","2020-01-01","09832854","","2021-02-13","2/13/2021 - Rcvd complete roster from Amerigroup provider is participating and linked to TIN and location for the following plans CHIP, CHIP-PERINATAL, STAR, STAR-KIDS, STAR-PLUS.  DCannon"]
["Megan Casselman, NP-C",1528619525,"75-2656723","TX","PE - Premier Family Care I, Inc","IMS","Participating","Enrollment Complete","2019-09-01","1528619525","","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"]
["Megan Casselman, NP-C",1528619525,"75-2656723","TX","PE - Premier Family Care I, Inc","Omni PPO","Participating","Enrollment Complete","2020-09-01","1528619525","","2020-07-27","IMS complete"]
["Megan Casselman, NP-C",1528619525,"75-2656723","TX","PE - Premier Family Care I, Inc","Triwest VA","Facility Enrollment","Application Submitted","","","","2022-11-23","08/19/2022 - Submitted application to TriWest VA (sent to Scarlett Abigail, Scarlett_Abigail@bcbstx.com)"]
["Megan Casselman, NP-C",1528619525,"75-2656723","TX","","Triwest VA","Facility Enrollment","Application Submitted","","","","2022-11-23","08/19/2022 - Submitted application to TriWest VA (sent to Scarlett Abigail, Scarlett_Abigail@bcbstx.com)"]
["Megan Casselman, NP-C",1528619525,"75-2656723","TX","PE - Premier Family Care I, Inc","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.\""]
["Megan Casselman, NP-C",1528619525,"75-2656723","TX","","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.\""]
["Megan Casselman, NP-C",1528619525,"75-2656723","TX","PE - Premier Family Care I, Inc","Boon Chapman","Participating","Enrollment Complete","2019-12-30","","","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 12/30/2019.  DCannon"]
["Megan Casselman, NP-C",1528619525,"75-2656723","TX","PE - Premier Family Care I, Inc","Scott&White (First Care)","Participating","Enrollment Complete","2019-10-01","1528619525","","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"]
["Megan Casselman, NP-C",1528619525,"75-2656723","TX","PE - Premier Family Care I, Inc","TriCare Standard","Participating","Enrollment Complete","2020-04-01","1528619525","","2020-09-24","09/24/2020 - moved to completed after reviewing follow up complete - Stacey Hudak"]
["Megan Casselman, NP-C",1528619525,"75-2656723","TX","PE - Premier Family Care I, Inc","HealthSmart PPO","Participating","Enrollment Complete","2019-12-11","13706552","","2020-07-21","07/21/2020 - Rec'd spreadsheet from the payer stating this provider/TIN/service location are PAR with WEST TEXAS PHYSICIANS ALLIANCE Delegated  - Stacey Hudak"]
["Megan Casselman, NP-C",1528619525,"75-2656723","TX","PE - Premier Family Care I, 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"]
["Megan Casselman, NP-C",1528619525,"75-2656723","TX","PE - Premier Family Care I, Inc","Multiplan","Participating","Enrollment Complete","2019-12-13","1528619525","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 12-13-2019. Provider is networked with Beechstreet. - Stacey Hudak"]
["Venessa Saldana, APRN-FNP-BC",1922658319,752656723,"TX","PE - Premier Family Care I, Inc","Triwest VA","Facility 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 Saldana, APRN-FNP-BC",1922658319,752656723,"TX","PE - Premier Family Care I, Inc","Triwest VA","Facility 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 Saldana, APRN-FNP-BC",1922658319,752656723,"TX","PE - Premier Family Care I, Inc","Triwest VA","Facility 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 Saldana, APRN-FNP-BC",1922658319,752656723,"TX","PE - Premier Family Care I, Inc","Triwest VA","Facility 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 Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care I, Inc","Triwest VA","Facility 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 Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care I, Inc","Triwest VA","Facility 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 Saldana, APRN-FNP-BC",1922658319,752656723,"TX","PE - Premier Family Care I, Inc","Triwest VA","Facility 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 Saldana, APRN-FNP-BC",1922658319,752656723,"TX","PE - Premier Family Care I, Inc","Triwest VA","Facility 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 Saldana, APRN-FNP-BC",1922658319,752656723,"TX","PE - Premier Family Care I, Inc","Triwest VA","Facility 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 Saldana, APRN-FNP-BC",1922658319,752656723,"TX","PE - Premier Family Care I, Inc","Triwest VA","Facility 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 Saldana, APRN-FNP-BC",1922658319,"","TX","PE - Premier Family Care I, Inc","Triwest VA","Facility 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 Saldana, APRN-FNP-BC",1922658319,"","TX","PE - Premier Family Care I, Inc","Triwest VA","Facility 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 Saldana, APRN-FNP-BC",1922658319,"","TX","PE - Premier Family Care I, Inc","Triwest VA","Facility 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 Saldana, APRN-FNP-BC",1922658319,"","TX","PE - Premier Family Care I, Inc","Triwest VA","Facility 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 Saldana, APRN-FNP-BC",1922658319,"","TX","PE - Premier Family Care I, Inc","Triwest VA","Facility 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 Saldana, APRN-FNP-BC",1922658319,"","TX","PE - Premier Family Care I, Inc","Triwest VA","Facility 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 Saldana, APRN-FNP-BC",1922658319,"","TX","PE - Premier Family Care I, Inc","Triwest VA","Facility 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 Saldana, APRN-FNP-BC",1922658319,"","TX","PE - Premier Family Care I, Inc","Triwest VA","Facility 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 Saldana, APRN-FNP-BC",1922658319,"","TX","PE - Premier Family Care I, Inc","Triwest VA","Facility 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 Saldana, APRN-FNP-BC",1922658319,"","TX","PE - Premier Family Care I, Inc","Triwest VA","Facility 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 Saldana, APRN-FNP-BC",1922658319,"","TX","PE - Premier Family Care I, Inc","Triwest VA","Facility 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 Saldana, APRN-FNP-BC",1922658319,"","TX","PE - Premier Family Care I, Inc","Triwest VA","Facility 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 Saldana, APRN-FNP-BC",1922658319,"","TX","PE - Premier Family Care I, Inc","Triwest VA","Facility 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 Saldana, APRN-FNP-BC",1922658319,"","TX","PE - Premier Family Care I, Inc","Triwest VA","Facility 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 Saldana, APRN-FNP-BC",1922658319,"","TX","PE - Premier Family Care I, Inc","Triwest VA","Facility 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 Saldana, APRN-FNP-BC",1922658319,"","TX","PE - Premier Family Care I, Inc","Triwest VA","Facility 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 Saldana, APRN-FNP-BC",1922658319,"","TX","PE - Premier Family Care I, Inc","Triwest VA","Facility 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 Saldana, APRN-FNP-BC",1922658319,"","TX","PE - Premier Family Care I, Inc","Triwest VA","Facility 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 Saldana, APRN-FNP-BC",1922658319,752656723,"TX","PE - Premier Family Care I, 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 Saldana, APRN-FNP-BC",1922658319,752656723,"TX","PE - Premier Family Care I, 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 Saldana, APRN-FNP-BC",1922658319,752656723,"TX","PE - Premier Family Care I, 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 Saldana, APRN-FNP-BC",1922658319,752656723,"TX","PE - Premier Family Care I, 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 Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care I, 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 Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care I, 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 Saldana, APRN-FNP-BC",1922658319,752656723,"TX","PE - Premier Family Care I, 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 Saldana, APRN-FNP-BC",1922658319,752656723,"TX","PE - Premier Family Care I, 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 Saldana, APRN-FNP-BC",1922658319,752656723,"TX","PE - Premier Family Care I, 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 Saldana, APRN-FNP-BC",1922658319,752656723,"TX","PE - Premier Family Care I, 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 Saldana, APRN-FNP-BC",1922658319,"","TX","PE - Premier Family Care I, 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 Saldana, APRN-FNP-BC",1922658319,"","TX","PE - Premier Family Care I, 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 Saldana, APRN-FNP-BC",1922658319,"","TX","PE - Premier Family Care I, 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 Saldana, APRN-FNP-BC",1922658319,"","TX","PE - Premier Family Care I, 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 Saldana, APRN-FNP-BC",1922658319,"","TX","PE - Premier Family Care I, 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 Saldana, APRN-FNP-BC",1922658319,"","TX","PE - Premier Family Care I, 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 Saldana, APRN-FNP-BC",1922658319,"","TX","PE - Premier Family Care I, 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 Saldana, APRN-FNP-BC",1922658319,"","TX","PE - Premier Family Care I, 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 Saldana, APRN-FNP-BC",1922658319,"","TX","PE - Premier Family Care I, 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 Saldana, APRN-FNP-BC",1922658319,"","TX","PE - Premier Family Care I, 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 Saldana, APRN-FNP-BC",1922658319,"","TX","PE - Premier Family Care I, 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 Saldana, APRN-FNP-BC",1922658319,"","TX","PE - Premier Family Care I, 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 Saldana, APRN-FNP-BC",1922658319,"","TX","PE - Premier Family Care I, 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 Saldana, APRN-FNP-BC",1922658319,"","TX","PE - Premier Family Care I, 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 Saldana, APRN-FNP-BC",1922658319,"","TX","PE - Premier Family Care I, 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 Saldana, APRN-FNP-BC",1922658319,"","TX","PE - Premier Family Care I, 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 Saldana, APRN-FNP-BC",1922658319,"","TX","PE - Premier Family Care I, 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 Saldana, APRN-FNP-BC",1922658319,"","TX","PE - Premier Family Care I, 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 Saldana, APRN-FNP-BC",1922658319,752656723,"TX","PE - Premier Family Care I, 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 Saldana, APRN-FNP-BC",1922658319,752656723,"TX","PE - Premier Family Care I, 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 Saldana, APRN-FNP-BC",1922658319,752656723,"TX","PE - Premier Family Care I, 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 Saldana, APRN-FNP-BC",1922658319,752656723,"TX","PE - Premier Family Care I, 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 Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care I, 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 Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care I, 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 Saldana, APRN-FNP-BC",1922658319,752656723,"TX","PE - Premier Family Care I, 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 Saldana, APRN-FNP-BC",1922658319,752656723,"TX","PE - Premier Family Care I, 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 Saldana, APRN-FNP-BC",1922658319,752656723,"TX","PE - Premier Family Care I, 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 Saldana, APRN-FNP-BC",1922658319,752656723,"TX","PE - Premier Family Care I, 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 Saldana, APRN-FNP-BC",1922658319,"","TX","PE - Premier Family Care I, 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 Saldana, APRN-FNP-BC",1922658319,"","TX","PE - Premier Family Care I, 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 Saldana, APRN-FNP-BC",1922658319,"","TX","PE - Premier Family Care I, 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 Saldana, APRN-FNP-BC",1922658319,"","TX","PE - Premier Family Care I, 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 Saldana, APRN-FNP-BC",1922658319,"","TX","PE - Premier Family Care I, 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 Saldana, APRN-FNP-BC",1922658319,"","TX","PE - Premier Family Care I, 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 Saldana, APRN-FNP-BC",1922658319,"","TX","PE - Premier Family Care I, 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 Saldana, APRN-FNP-BC",1922658319,"","TX","PE - Premier Family Care I, 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 Saldana, APRN-FNP-BC",1922658319,"","TX","PE - Premier Family Care I, 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 Saldana, APRN-FNP-BC",1922658319,"","TX","PE - Premier Family Care I, 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 Saldana, APRN-FNP-BC",1922658319,"","TX","PE - Premier Family Care I, 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 Saldana, APRN-FNP-BC",1922658319,"","TX","PE - Premier Family Care I, 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 Saldana, APRN-FNP-BC",1922658319,"","TX","PE - Premier Family Care I, 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 Saldana, APRN-FNP-BC",1922658319,"","TX","PE - Premier Family Care I, 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 Saldana, APRN-FNP-BC",1922658319,"","TX","PE - Premier Family Care I, 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 Saldana, APRN-FNP-BC",1922658319,"","TX","PE - Premier Family Care I, 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 Saldana, APRN-FNP-BC",1922658319,"","TX","PE - Premier Family Care I, 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 Saldana, APRN-FNP-BC",1922658319,"","TX","PE - Premier Family Care I, 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 Saldana, APRN-FNP-BC",1922658319,752656723,"TX","PE - Premier Family Care I, 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 Saldana, APRN-FNP-BC",1922658319,752656723,"TX","PE - Premier Family Care I, 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 Saldana, APRN-FNP-BC",1922658319,752656723,"TX","PE - Premier Family Care I, 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 Saldana, APRN-FNP-BC",1922658319,752656723,"TX","PE - Premier Family Care I, 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 Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care I, 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 Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care I, 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 Saldana, APRN-FNP-BC",1922658319,752656723,"TX","PE - Premier Family Care I, 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 Saldana, APRN-FNP-BC",1922658319,752656723,"TX","PE - Premier Family Care I, 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 Saldana, APRN-FNP-BC",1922658319,752656723,"TX","PE - Premier Family Care I, 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 Saldana, APRN-FNP-BC",1922658319,752656723,"TX","PE - Premier Family Care I, 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 Saldana, APRN-FNP-BC",1922658319,"","TX","PE - Premier Family Care I, 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 Saldana, APRN-FNP-BC",1922658319,"","TX","PE - Premier Family Care I, 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 Saldana, APRN-FNP-BC",1922658319,"","TX","PE - Premier Family Care I, 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 Saldana, APRN-FNP-BC",1922658319,"","TX","PE - Premier Family Care I, 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 Saldana, APRN-FNP-BC",1922658319,"","TX","PE - Premier Family Care I, 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 Saldana, APRN-FNP-BC",1922658319,"","TX","PE - Premier Family Care I, 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 Saldana, APRN-FNP-BC",1922658319,"","TX","PE - Premier Family Care I, 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 Saldana, APRN-FNP-BC",1922658319,"","TX","PE - Premier Family Care I, 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 Saldana, APRN-FNP-BC",1922658319,"","TX","PE - Premier Family Care I, 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 Saldana, APRN-FNP-BC",1922658319,"","TX","PE - Premier Family Care I, 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 Saldana, APRN-FNP-BC",1922658319,"","TX","PE - Premier Family Care I, 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 Saldana, APRN-FNP-BC",1922658319,"","TX","PE - Premier Family Care I, 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 Saldana, APRN-FNP-BC",1922658319,"","TX","PE - Premier Family Care I, 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 Saldana, APRN-FNP-BC",1922658319,"","TX","PE - Premier Family Care I, 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 Saldana, APRN-FNP-BC",1922658319,"","TX","PE - Premier Family Care I, 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 Saldana, APRN-FNP-BC",1922658319,"","TX","PE - Premier Family Care I, 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 Saldana, APRN-FNP-BC",1922658319,"","TX","PE - Premier Family Care I, 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 Saldana, APRN-FNP-BC",1922658319,"","TX","PE - Premier Family Care I, 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 Saldana, APRN-FNP-BC",1922658319,752656723,"TX","PE - Premier Family Care I, 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 Saldana, APRN-FNP-BC",1922658319,752656723,"TX","PE - Premier Family Care I, 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 Saldana, APRN-FNP-BC",1922658319,752656723,"TX","PE - Premier Family Care I, 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 Saldana, APRN-FNP-BC",1922658319,752656723,"TX","PE - Premier Family Care I, 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 Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care I, 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 Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care I, 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 Saldana, APRN-FNP-BC",1922658319,752656723,"TX","PE - Premier Family Care I, 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 Saldana, APRN-FNP-BC",1922658319,752656723,"TX","PE - Premier Family Care I, 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 Saldana, APRN-FNP-BC",1922658319,752656723,"TX","PE - Premier Family Care I, 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 Saldana, APRN-FNP-BC",1922658319,752656723,"TX","PE - Premier Family Care I, 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 Saldana, APRN-FNP-BC",1922658319,"","TX","PE - Premier Family Care I, 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 Saldana, APRN-FNP-BC",1922658319,"","TX","PE - Premier Family Care I, 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 Saldana, APRN-FNP-BC",1922658319,"","TX","PE - Premier Family Care I, 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 Saldana, APRN-FNP-BC",1922658319,"","TX","PE - Premier Family Care I, 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 Saldana, APRN-FNP-BC",1922658319,"","TX","PE - Premier Family Care I, 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 Saldana, APRN-FNP-BC",1922658319,"","TX","PE - Premier Family Care I, 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 Saldana, APRN-FNP-BC",1922658319,"","TX","PE - Premier Family Care I, 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 Saldana, APRN-FNP-BC",1922658319,"","TX","PE - Premier Family Care I, 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 Saldana, APRN-FNP-BC",1922658319,"","TX","PE - Premier Family Care I, 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 Saldana, APRN-FNP-BC",1922658319,"","TX","PE - Premier Family Care I, 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 Saldana, APRN-FNP-BC",1922658319,"","TX","PE - Premier Family Care I, 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 Saldana, APRN-FNP-BC",1922658319,"","TX","PE - Premier Family Care I, 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 Saldana, APRN-FNP-BC",1922658319,"","TX","PE - Premier Family Care I, 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 Saldana, APRN-FNP-BC",1922658319,"","TX","PE - Premier Family Care I, 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 Saldana, APRN-FNP-BC",1922658319,"","TX","PE - Premier Family Care I, 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 Saldana, APRN-FNP-BC",1922658319,"","TX","PE - Premier Family Care I, 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 Saldana, APRN-FNP-BC",1922658319,"","TX","PE - Premier Family Care I, 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 Saldana, APRN-FNP-BC",1922658319,"","TX","PE - Premier Family Care I, 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 Saldana, APRN-FNP-BC",1922658319,752656723,"TX","PE - Premier Family Care I, 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 Saldana, APRN-FNP-BC",1922658319,752656723,"TX","PE - Premier Family Care I, 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 Saldana, APRN-FNP-BC",1922658319,752656723,"TX","PE - Premier Family Care I, 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 Saldana, APRN-FNP-BC",1922658319,752656723,"TX","PE - Premier Family Care I, 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 Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care I, 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 Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care I, 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 Saldana, APRN-FNP-BC",1922658319,752656723,"TX","PE - Premier Family Care I, 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 Saldana, APRN-FNP-BC",1922658319,752656723,"TX","PE - Premier Family Care I, 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 Saldana, APRN-FNP-BC",1922658319,752656723,"TX","PE - Premier Family Care I, 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 Saldana, APRN-FNP-BC",1922658319,752656723,"TX","PE - Premier Family Care I, 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 Saldana, APRN-FNP-BC",1922658319,"","TX","PE - Premier Family Care I, 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 Saldana, APRN-FNP-BC",1922658319,"","TX","PE - Premier Family Care I, 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 Saldana, APRN-FNP-BC",1922658319,"","TX","PE - Premier Family Care I, 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 Saldana, APRN-FNP-BC",1922658319,"","TX","PE - Premier Family Care I, 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 Saldana, APRN-FNP-BC",1922658319,"","TX","PE - Premier Family Care I, 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 Saldana, APRN-FNP-BC",1922658319,"","TX","PE - Premier Family Care I, 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 Saldana, APRN-FNP-BC",1922658319,"","TX","PE - Premier Family Care I, 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 Saldana, APRN-FNP-BC",1922658319,"","TX","PE - Premier Family Care I, 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 Saldana, APRN-FNP-BC",1922658319,"","TX","PE - Premier Family Care I, 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 Saldana, APRN-FNP-BC",1922658319,"","TX","PE - Premier Family Care I, 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 Saldana, APRN-FNP-BC",1922658319,752656723,"TX","PE - Premier Family Care I, 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 Saldana, APRN-FNP-BC",1922658319,752656723,"TX","PE - Premier Family Care I, 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 Saldana, APRN-FNP-BC",1922658319,752656723,"TX","PE - Premier Family Care I, 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 Saldana, APRN-FNP-BC",1922658319,752656723,"TX","PE - Premier Family Care I, 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 Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care I, 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 Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care I, 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 Saldana, APRN-FNP-BC",1922658319,752656723,"TX","PE - Premier Family Care I, 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 Saldana, APRN-FNP-BC",1922658319,752656723,"TX","PE - Premier Family Care I, 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 Saldana, APRN-FNP-BC",1922658319,752656723,"TX","PE - Premier Family Care I, 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 Saldana, APRN-FNP-BC",1922658319,752656723,"TX","PE - Premier Family Care I, 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 Saldana, APRN-FNP-BC",1922658319,"","TX","PE - Premier Family Care I, 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 Saldana, APRN-FNP-BC",1922658319,"","TX","PE - Premier Family Care I, 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 Saldana, APRN-FNP-BC",1922658319,"","TX","PE - Premier Family Care I, 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 Saldana, APRN-FNP-BC",1922658319,"","TX","PE - Premier Family Care I, 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 Saldana, APRN-FNP-BC",1922658319,"","TX","PE - Premier Family Care I, 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 Saldana, APRN-FNP-BC",1922658319,"","TX","PE - Premier Family Care I, 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 Saldana, APRN-FNP-BC",1922658319,"","TX","PE - Premier Family Care I, 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 Saldana, APRN-FNP-BC",1922658319,"","TX","PE - Premier Family Care I, 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 Saldana, APRN-FNP-BC",1922658319,"","TX","PE - Premier Family Care I, 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 Saldana, APRN-FNP-BC",1922658319,"","TX","PE - Premier Family Care I, 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 Saldana, APRN-FNP-BC",1922658319,"","TX","PE - Premier Family Care I, 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 Saldana, APRN-FNP-BC",1922658319,"","TX","PE - Premier Family Care I, 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 Saldana, APRN-FNP-BC",1922658319,"","TX","PE - Premier Family Care I, 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 Saldana, APRN-FNP-BC",1922658319,"","TX","PE - Premier Family Care I, 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 Saldana, APRN-FNP-BC",1922658319,"","TX","PE - Premier Family Care I, 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 Saldana, APRN-FNP-BC",1922658319,"","TX","PE - Premier Family Care I, 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 Saldana, APRN-FNP-BC",1922658319,"","TX","PE - Premier Family Care I, 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 Saldana, APRN-FNP-BC",1922658319,"","TX","PE - Premier Family Care I, 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 Saldana, APRN-FNP-BC",1922658319,752656723,"TX","PE - Premier Family Care I, 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 Saldana, APRN-FNP-BC",1922658319,752656723,"TX","PE - Premier Family Care I, 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 Saldana, APRN-FNP-BC",1922658319,752656723,"TX","PE - Premier Family Care I, 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 Saldana, APRN-FNP-BC",1922658319,752656723,"TX","PE - Premier Family Care I, 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 Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care I, 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 Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care I, 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 Saldana, APRN-FNP-BC",1922658319,752656723,"TX","PE - Premier Family Care I, 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 Saldana, APRN-FNP-BC",1922658319,752656723,"TX","PE - Premier Family Care I, 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 Saldana, APRN-FNP-BC",1922658319,752656723,"TX","PE - Premier Family Care I, 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 Saldana, APRN-FNP-BC",1922658319,752656723,"TX","PE - Premier Family Care I, 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 Saldana, APRN-FNP-BC",1922658319,"","TX","PE - Premier Family Care I, 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 Saldana, APRN-FNP-BC",1922658319,"","TX","PE - Premier Family Care I, 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 Saldana, APRN-FNP-BC",1922658319,"","TX","PE - Premier Family Care I, 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 Saldana, APRN-FNP-BC",1922658319,"","TX","PE - Premier Family Care I, 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 Saldana, APRN-FNP-BC",1922658319,"","TX","PE - Premier Family Care I, 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 Saldana, APRN-FNP-BC",1922658319,"","TX","PE - Premier Family Care I, 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 Saldana, APRN-FNP-BC",1922658319,"","TX","PE - Premier Family Care I, 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 Saldana, APRN-FNP-BC",1922658319,"","TX","PE - Premier Family Care I, 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 Saldana, APRN-FNP-BC",1922658319,"","TX","PE - Premier Family Care I, 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 Saldana, APRN-FNP-BC",1922658319,"","TX","PE - Premier Family Care I, 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 Saldana, APRN-FNP-BC",1922658319,"","TX","PE - Premier Family Care I, 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 Saldana, APRN-FNP-BC",1922658319,"","TX","PE - Premier Family Care I, 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 Saldana, APRN-FNP-BC",1922658319,"","TX","PE - Premier Family Care I, 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 Saldana, APRN-FNP-BC",1922658319,"","TX","PE - Premier Family Care I, 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 Saldana, APRN-FNP-BC",1922658319,"","TX","PE - Premier Family Care I, 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 Saldana, APRN-FNP-BC",1922658319,"","TX","PE - Premier Family Care I, 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 Saldana, APRN-FNP-BC",1922658319,"","TX","PE - Premier Family Care I, 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 Saldana, APRN-FNP-BC",1922658319,"","TX","PE - Premier Family Care I, 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 Saldana, APRN-FNP-BC",1922658319,752656723,"TX","PE - Premier Family Care I, Inc","CAQH","Participating","CAQH Reattested","2023-02-12","","","2023-02-12","2/12/2023 CAQH reviewed and re-attested.  DCannon"]
["Venessa Saldana, APRN-FNP-BC",1922658319,752656723,"TX","PE - Premier Family Care I, Inc","CAQH","Participating","CAQH Reattested","2023-02-12","","","2023-02-12","2/12/2023 CAQH reviewed and re-attested.  DCannon"]
["Venessa Saldana, APRN-FNP-BC",1922658319,752656723,"TX","PE - Premier Family Care I, Inc","CAQH","Participating","CAQH Reattested","2023-02-12","","","2023-02-12","2/12/2023 CAQH reviewed and re-attested.  DCannon"]
["Venessa Saldana, APRN-FNP-BC",1922658319,752656723,"TX","PE - Premier Family Care I, Inc","CAQH","Participating","CAQH Reattested","2023-02-12","","","2023-02-12","2/12/2023 CAQH reviewed and re-attested.  DCannon"]
["Venessa Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care I, Inc","CAQH","Participating","CAQH Reattested","2023-02-12","","","2023-02-12","2/12/2023 CAQH reviewed and re-attested.  DCannon"]
["Venessa Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care I, Inc","CAQH","Participating","CAQH Reattested","2023-02-12","","","2023-02-12","2/12/2023 CAQH reviewed and re-attested.  DCannon"]
["Venessa Saldana, APRN-FNP-BC",1922658319,752656723,"TX","PE - Premier Family Care I, Inc","CAQH","Participating","CAQH Reattested","2023-02-12","","","2023-02-12","2/12/2023 CAQH reviewed and re-attested.  DCannon"]
["Venessa Saldana, APRN-FNP-BC",1922658319,752656723,"TX","PE - Premier Family Care I, Inc","CAQH","Participating","CAQH Reattested","2023-02-12","","","2023-02-12","2/12/2023 CAQH reviewed and re-attested.  DCannon"]
["Venessa Saldana, APRN-FNP-BC",1922658319,752656723,"TX","PE - Premier Family Care I, Inc","CAQH","Participating","CAQH Reattested","2023-02-12","","","2023-02-12","2/12/2023 CAQH reviewed and re-attested.  DCannon"]
["Venessa Saldana, APRN-FNP-BC",1922658319,752656723,"TX","PE - Premier Family Care I, Inc","CAQH","Participating","CAQH Reattested","2023-02-12","","","2023-02-12","2/12/2023 CAQH reviewed and re-attested.  DCannon"]
["Venessa Saldana, APRN-FNP-BC",1922658319,"","TX","PE - Premier Family Care I, Inc","CAQH","Participating","CAQH Reattested","2023-02-12","","","2023-02-12","2/12/2023 CAQH reviewed and re-attested.  DCannon"]
["Venessa Saldana, APRN-FNP-BC",1922658319,"","TX","PE - Premier Family Care I, Inc","CAQH","Participating","CAQH Reattested","2023-02-12","","","2023-02-12","2/12/2023 CAQH reviewed and re-attested.  DCannon"]
["Venessa Saldana, APRN-FNP-BC",1922658319,"","TX","PE - Premier Family Care I, Inc","CAQH","Participating","CAQH Reattested","2023-02-12","","","2023-02-12","2/12/2023 CAQH reviewed and re-attested.  DCannon"]
["Venessa Saldana, APRN-FNP-BC",1922658319,"","TX","PE - Premier Family Care I, Inc","CAQH","Participating","CAQH Reattested","2023-02-12","","","2023-02-12","2/12/2023 CAQH reviewed and re-attested.  DCannon"]
["Venessa Saldana, APRN-FNP-BC",1922658319,"","TX","PE - Premier Family Care I, Inc","CAQH","Participating","CAQH Reattested","2023-02-12","","","2023-02-12","2/12/2023 CAQH reviewed and re-attested.  DCannon"]
["Venessa Saldana, APRN-FNP-BC",1922658319,"","TX","PE - Premier Family Care I, Inc","CAQH","Participating","CAQH Reattested","2023-02-12","","","2023-02-12","2/12/2023 CAQH reviewed and re-attested.  DCannon"]
["Venessa Saldana, APRN-FNP-BC",1922658319,"","TX","PE - Premier Family Care I, Inc","CAQH","Participating","CAQH Reattested","2023-02-12","","","2023-02-12","2/12/2023 CAQH reviewed and re-attested.  DCannon"]
["Venessa Saldana, APRN-FNP-BC",1922658319,"","TX","PE - Premier Family Care I, Inc","CAQH","Participating","CAQH Reattested","2023-02-12","","","2023-02-12","2/12/2023 CAQH reviewed and re-attested.  DCannon"]
["Venessa Saldana, APRN-FNP-BC",1922658319,"","TX","PE - Premier Family Care I, Inc","CAQH","Participating","CAQH Reattested","2023-02-12","","","2023-02-12","2/12/2023 CAQH reviewed and re-attested.  DCannon"]
["Venessa Saldana, APRN-FNP-BC",1922658319,"","TX","PE - Premier Family Care I, Inc","CAQH","Participating","CAQH Reattested","2023-02-12","","","2023-02-12","2/12/2023 CAQH reviewed and re-attested.  DCannon"]
["Venessa Saldana, APRN-FNP-BC",1922658319,"","TX","PE - Premier Family Care I, Inc","CAQH","Participating","CAQH Reattested","2023-02-12","","","2023-02-12","2/12/2023 CAQH reviewed and re-attested.  DCannon"]
["Venessa Saldana, APRN-FNP-BC",1922658319,"","TX","PE - Premier Family Care I, Inc","CAQH","Participating","CAQH Reattested","2023-02-12","","","2023-02-12","2/12/2023 CAQH reviewed and re-attested.  DCannon"]
["Venessa Saldana, APRN-FNP-BC",1922658319,"","TX","PE - Premier Family Care I, Inc","CAQH","Participating","CAQH Reattested","2023-02-12","","","2023-02-12","2/12/2023 CAQH reviewed and re-attested.  DCannon"]
["Venessa Saldana, APRN-FNP-BC",1922658319,"","TX","PE - Premier Family Care I, Inc","CAQH","Participating","CAQH Reattested","2023-02-12","","","2023-02-12","2/12/2023 CAQH reviewed and re-attested.  DCannon"]
["Venessa Saldana, APRN-FNP-BC",1922658319,"","TX","PE - Premier Family Care I, Inc","CAQH","Participating","CAQH Reattested","2023-02-12","","","2023-02-12","2/12/2023 CAQH reviewed and re-attested.  DCannon"]
["Venessa Saldana, APRN-FNP-BC",1922658319,"","TX","PE - Premier Family Care I, Inc","CAQH","Participating","CAQH Reattested","2023-02-12","","","2023-02-12","2/12/2023 CAQH reviewed and re-attested.  DCannon"]
["Venessa Saldana, APRN-FNP-BC",1922658319,"","TX","PE - Premier Family Care I, Inc","CAQH","Participating","CAQH Reattested","2023-02-12","","","2023-02-12","2/12/2023 CAQH reviewed and re-attested.  DCannon"]
["Venessa Saldana, APRN-FNP-BC",1922658319,"","TX","PE - Premier Family Care I, Inc","CAQH","Participating","CAQH Reattested","2023-02-12","","","2023-02-12","2/12/2023 CAQH reviewed and re-attested.  DCannon"]
["Venessa Saldana, APRN-FNP-BC",1922658319,752656723,"TX","PE - Premier Family Care I, 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 Saldana, APRN-FNP-BC",1922658319,752656723,"TX","PE - Premier Family Care I, 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 Saldana, APRN-FNP-BC",1922658319,752656723,"TX","PE - Premier Family Care I, 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 Saldana, APRN-FNP-BC",1922658319,752656723,"TX","PE - Premier Family Care I, 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 Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care I, 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 Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care I, 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 Saldana, APRN-FNP-BC",1922658319,752656723,"TX","PE - Premier Family Care I, 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 Saldana, APRN-FNP-BC",1922658319,752656723,"TX","PE - Premier Family Care I, 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 Saldana, APRN-FNP-BC",1922658319,752656723,"TX","PE - Premier Family Care I, 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 Saldana, APRN-FNP-BC",1922658319,752656723,"TX","PE - Premier Family Care I, 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 Saldana, APRN-FNP-BC",1922658319,"","TX","PE - Premier Family Care I, 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 Saldana, APRN-FNP-BC",1922658319,"","TX","PE - Premier Family Care I, 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 Saldana, APRN-FNP-BC",1922658319,"","TX","PE - Premier Family Care I, 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 Saldana, APRN-FNP-BC",1922658319,"","TX","PE - Premier Family Care I, 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 Saldana, APRN-FNP-BC",1922658319,"","TX","PE - Premier Family Care I, 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 Saldana, APRN-FNP-BC",1922658319,"","TX","PE - Premier Family Care I, 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 Saldana, APRN-FNP-BC",1922658319,"","TX","PE - Premier Family Care I, 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 Saldana, APRN-FNP-BC",1922658319,"","TX","PE - Premier Family Care I, 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 Saldana, APRN-FNP-BC",1922658319,"","TX","PE - Premier Family Care I, 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 Saldana, APRN-FNP-BC",1922658319,"","TX","PE - Premier Family Care I, 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 Saldana, APRN-FNP-BC",1922658319,"","TX","PE - Premier Family Care I, 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 Saldana, APRN-FNP-BC",1922658319,"","TX","PE - Premier Family Care I, 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 Saldana, APRN-FNP-BC",1922658319,"","TX","PE - Premier Family Care I, 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 Saldana, APRN-FNP-BC",1922658319,"","TX","PE - Premier Family Care I, 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 Saldana, APRN-FNP-BC",1922658319,"","TX","PE - Premier Family Care I, 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 Saldana, APRN-FNP-BC",1922658319,"","TX","PE - Premier Family Care I, 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 Saldana, APRN-FNP-BC",1922658319,"","TX","PE - Premier Family Care I, 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 Saldana, APRN-FNP-BC",1922658319,"","TX","PE - Premier Family Care I, 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 Saldana, APRN-FNP-BC",1922658319,752656723,"TX","PE - Premier Family Care I, 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 Saldana, APRN-FNP-BC",1922658319,752656723,"TX","PE - Premier Family Care I, 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 Saldana, APRN-FNP-BC",1922658319,752656723,"TX","PE - Premier Family Care I, 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 Saldana, APRN-FNP-BC",1922658319,752656723,"TX","PE - Premier Family Care I, 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 Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care I, 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 Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care I, 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 Saldana, APRN-FNP-BC",1922658319,752656723,"TX","PE - Premier Family Care I, 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 Saldana, APRN-FNP-BC",1922658319,752656723,"TX","PE - Premier Family Care I, 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 Saldana, APRN-FNP-BC",1922658319,752656723,"TX","PE - Premier Family Care I, 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 Saldana, APRN-FNP-BC",1922658319,752656723,"TX","PE - Premier Family Care I, 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 Saldana, APRN-FNP-BC",1922658319,"","TX","PE - Premier Family Care I, 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 Saldana, APRN-FNP-BC",1922658319,"","TX","PE - Premier Family Care I, 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 Saldana, APRN-FNP-BC",1922658319,"","TX","PE - Premier Family Care I, 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 Saldana, APRN-FNP-BC",1922658319,"","TX","PE - Premier Family Care I, 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 Saldana, APRN-FNP-BC",1922658319,"","TX","PE - Premier Family Care I, 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 Saldana, APRN-FNP-BC",1922658319,"","TX","PE - Premier Family Care I, 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 Saldana, APRN-FNP-BC",1922658319,"","TX","PE - Premier Family Care I, 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 Saldana, APRN-FNP-BC",1922658319,"","TX","PE - Premier Family Care I, 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 Saldana, APRN-FNP-BC",1922658319,"","TX","PE - Premier Family Care I, 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 Saldana, APRN-FNP-BC",1922658319,"","TX","PE - Premier Family Care I, 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 Saldana, APRN-FNP-BC",1922658319,"","TX","PE - Premier Family Care I, 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 Saldana, APRN-FNP-BC",1922658319,"","TX","PE - Premier Family Care I, 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 Saldana, APRN-FNP-BC",1922658319,"","TX","PE - Premier Family Care I, 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 Saldana, APRN-FNP-BC",1922658319,"","TX","PE - Premier Family Care I, 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 Saldana, APRN-FNP-BC",1922658319,"","TX","PE - Premier Family Care I, 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 Saldana, APRN-FNP-BC",1922658319,"","TX","PE - Premier Family Care I, 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 Saldana, APRN-FNP-BC",1922658319,"","TX","PE - Premier Family Care I, 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 Saldana, APRN-FNP-BC",1922658319,"","TX","PE - Premier Family Care I, 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 Saldana, APRN-FNP-BC",1922658319,752656723,"TX","PE - Premier Family Care I, 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 Saldana, APRN-FNP-BC",1922658319,752656723,"TX","PE - Premier Family Care I, 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 Saldana, APRN-FNP-BC",1922658319,752656723,"TX","PE - Premier Family Care I, 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 Saldana, APRN-FNP-BC",1922658319,752656723,"TX","PE - Premier Family Care I, 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 Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care I, 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 Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care I, 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 Saldana, APRN-FNP-BC",1922658319,752656723,"TX","PE - Premier Family Care I, 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 Saldana, APRN-FNP-BC",1922658319,752656723,"TX","PE - Premier Family Care I, 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 Saldana, APRN-FNP-BC",1922658319,752656723,"TX","PE - Premier Family Care I, 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 Saldana, APRN-FNP-BC",1922658319,752656723,"TX","PE - Premier Family Care I, 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 Saldana, APRN-FNP-BC",1922658319,"","TX","PE - Premier Family Care I, 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 Saldana, APRN-FNP-BC",1922658319,"","TX","PE - Premier Family Care I, 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 Saldana, APRN-FNP-BC",1922658319,"","TX","PE - Premier Family Care I, 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 Saldana, APRN-FNP-BC",1922658319,"","TX","PE - Premier Family Care I, 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 Saldana, APRN-FNP-BC",1922658319,"","TX","PE - Premier Family Care I, 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 Saldana, APRN-FNP-BC",1922658319,"","TX","PE - Premier Family Care I, 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 Saldana, APRN-FNP-BC",1922658319,"","TX","PE - Premier Family Care I, 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 Saldana, APRN-FNP-BC",1922658319,"","TX","PE - Premier Family Care I, 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 Saldana, APRN-FNP-BC",1922658319,"","TX","PE - Premier Family Care I, 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 Saldana, APRN-FNP-BC",1922658319,"","TX","PE - Premier Family Care I, 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 Saldana, APRN-FNP-BC",1922658319,"","TX","PE - Premier Family Care I, 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 Saldana, APRN-FNP-BC",1922658319,"","TX","PE - Premier Family Care I, 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 Saldana, APRN-FNP-BC",1922658319,"","TX","PE - Premier Family Care I, 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 Saldana, APRN-FNP-BC",1922658319,"","TX","PE - Premier Family Care I, 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 Saldana, APRN-FNP-BC",1922658319,"","TX","PE - Premier Family Care I, 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 Saldana, APRN-FNP-BC",1922658319,"","TX","PE - Premier Family Care I, 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 Saldana, APRN-FNP-BC",1922658319,"","TX","PE - Premier Family Care I, 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 Saldana, APRN-FNP-BC",1922658319,"","TX","PE - Premier Family Care I, 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 Saldana, APRN-FNP-BC",1922658319,752656723,"TX","PE - Premier Family Care I, 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 Saldana, APRN-FNP-BC",1922658319,752656723,"TX","PE - Premier Family Care I, 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 Saldana, APRN-FNP-BC",1922658319,752656723,"TX","PE - Premier Family Care I, 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 Saldana, APRN-FNP-BC",1922658319,752656723,"TX","PE - Premier Family Care I, 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 Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care I, 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 Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care I, 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 Saldana, APRN-FNP-BC",1922658319,752656723,"TX","PE - Premier Family Care I, 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 Saldana, APRN-FNP-BC",1922658319,752656723,"TX","PE - Premier Family Care I, 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 Saldana, APRN-FNP-BC",1922658319,752656723,"TX","PE - Premier Family Care I, 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 Saldana, APRN-FNP-BC",1922658319,752656723,"TX","PE - Premier Family Care I, 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 Saldana, APRN-FNP-BC",1922658319,"","TX","PE - Premier Family Care I, 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 Saldana, APRN-FNP-BC",1922658319,"","TX","PE - Premier Family Care I, 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 Saldana, APRN-FNP-BC",1922658319,"","TX","PE - Premier Family Care I, 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 Saldana, APRN-FNP-BC",1922658319,"","TX","PE - Premier Family Care I, 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 Saldana, APRN-FNP-BC",1922658319,"","TX","PE - Premier Family Care I, 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 Saldana, APRN-FNP-BC",1922658319,"","TX","PE - Premier Family Care I, 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 Saldana, APRN-FNP-BC",1922658319,"","TX","PE - Premier Family Care I, 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 Saldana, APRN-FNP-BC",1922658319,"","TX","PE - Premier Family Care I, 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 Saldana, APRN-FNP-BC",1922658319,"","TX","PE - Premier Family Care I, 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 Saldana, APRN-FNP-BC",1922658319,"","TX","PE - Premier Family Care I, 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 Saldana, APRN-FNP-BC",1922658319,752656723,"TX","PE - Premier Family Care I, 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 Saldana, APRN-FNP-BC",1922658319,752656723,"TX","PE - Premier Family Care I, 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 Saldana, APRN-FNP-BC",1922658319,752656723,"TX","PE - Premier Family Care I, 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 Saldana, APRN-FNP-BC",1922658319,752656723,"TX","PE - Premier Family Care I, 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 Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care I, 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 Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care I, 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 Saldana, APRN-FNP-BC",1922658319,752656723,"TX","PE - Premier Family Care I, 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 Saldana, APRN-FNP-BC",1922658319,752656723,"TX","PE - Premier Family Care I, 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 Saldana, APRN-FNP-BC",1922658319,752656723,"TX","PE - Premier Family Care I, 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 Saldana, APRN-FNP-BC",1922658319,752656723,"TX","PE - Premier Family Care I, 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 Saldana, APRN-FNP-BC",1922658319,"","TX","PE - Premier Family Care I, 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 Saldana, APRN-FNP-BC",1922658319,"","TX","PE - Premier Family Care I, 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 Saldana, APRN-FNP-BC",1922658319,"","TX","PE - Premier Family Care I, 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 Saldana, APRN-FNP-BC",1922658319,"","TX","PE - Premier Family Care I, 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 Saldana, APRN-FNP-BC",1922658319,"","TX","PE - Premier Family Care I, 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 Saldana, APRN-FNP-BC",1922658319,"","TX","PE - Premier Family Care I, 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 Saldana, APRN-FNP-BC",1922658319,"","TX","PE - Premier Family Care I, 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 Saldana, APRN-FNP-BC",1922658319,"","TX","PE - Premier Family Care I, 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 Saldana, APRN-FNP-BC",1922658319,"","TX","PE - Premier Family Care I, 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 Saldana, APRN-FNP-BC",1922658319,"","TX","PE - Premier Family Care I, 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 Saldana, APRN-FNP-BC",1922658319,"","TX","PE - Premier Family Care I, 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 Saldana, APRN-FNP-BC",1922658319,"","TX","PE - Premier Family Care I, 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 Saldana, APRN-FNP-BC",1922658319,"","TX","PE - Premier Family Care I, 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 Saldana, APRN-FNP-BC",1922658319,"","TX","PE - Premier Family Care I, 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 Saldana, APRN-FNP-BC",1922658319,"","TX","PE - Premier Family Care I, 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 Saldana, APRN-FNP-BC",1922658319,"","TX","PE - Premier Family Care I, 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 Saldana, APRN-FNP-BC",1922658319,"","TX","PE - Premier Family Care I, 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 Saldana, APRN-FNP-BC",1922658319,"","TX","PE - Premier Family Care I, 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 Saldana, APRN-FNP-BC",1922658319,752656723,"TX","PE - Premier Family Care I, Inc","Boon Chapman","Pending Other Enrollment","Pending Other Enrollment","","","","2022-07-20","7/20/2022 Pending Multiplan enrollment.  DCannon"]
["Venessa Saldana, APRN-FNP-BC",1922658319,752656723,"TX","PE - Premier Family Care I, Inc","Boon Chapman","Pending Other Enrollment","Pending Other Enrollment","","","","2022-07-20","7/20/2022 Pending Multiplan enrollment.  DCannon"]
["Venessa Saldana, APRN-FNP-BC",1922658319,752656723,"TX","PE - Premier Family Care I, Inc","Boon Chapman","Pending Other Enrollment","Pending Other Enrollment","","","","2022-07-20","7/20/2022 Pending Multiplan enrollment.  DCannon"]
["Venessa Saldana, APRN-FNP-BC",1922658319,752656723,"TX","PE - Premier Family Care I, Inc","Boon Chapman","Pending Other Enrollment","Pending Other Enrollment","","","","2022-07-20","7/20/2022 Pending Multiplan enrollment.  DCannon"]
["Venessa Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care I, Inc","Boon Chapman","Pending Other Enrollment","Pending Other Enrollment","","","","2022-07-20","7/20/2022 Pending Multiplan enrollment.  DCannon"]
["Venessa Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care I, Inc","Boon Chapman","Pending Other Enrollment","Pending Other Enrollment","","","","2022-07-20","7/20/2022 Pending Multiplan enrollment.  DCannon"]
["Venessa Saldana, APRN-FNP-BC",1922658319,752656723,"TX","PE - Premier Family Care I, Inc","Boon Chapman","Pending Other Enrollment","Pending Other Enrollment","","","","2022-07-20","7/20/2022 Pending Multiplan enrollment.  DCannon"]
["Venessa Saldana, APRN-FNP-BC",1922658319,752656723,"TX","PE - Premier Family Care I, Inc","Boon Chapman","Pending Other Enrollment","Pending Other Enrollment","","","","2022-07-20","7/20/2022 Pending Multiplan enrollment.  DCannon"]
["Venessa Saldana, APRN-FNP-BC",1922658319,752656723,"TX","PE - Premier Family Care I, Inc","Boon Chapman","Pending Other Enrollment","Pending Other Enrollment","","","","2022-07-20","7/20/2022 Pending Multiplan enrollment.  DCannon"]
["Venessa Saldana, APRN-FNP-BC",1922658319,752656723,"TX","PE - Premier Family Care I, Inc","Boon Chapman","Pending Other Enrollment","Pending Other Enrollment","","","","2022-07-20","7/20/2022 Pending Multiplan enrollment.  DCannon"]
["Venessa Saldana, APRN-FNP-BC",1922658319,"","TX","PE - Premier Family Care I, Inc","Boon Chapman","Pending Other Enrollment","Pending Other Enrollment","","","","2022-07-20","7/20/2022 Pending Multiplan enrollment.  DCannon"]
["Venessa Saldana, APRN-FNP-BC",1922658319,"","TX","PE - Premier Family Care I, Inc","Boon Chapman","Pending Other Enrollment","Pending Other Enrollment","","","","2022-07-20","7/20/2022 Pending Multiplan enrollment.  DCannon"]
["Venessa Saldana, APRN-FNP-BC",1922658319,"","TX","PE - Premier Family Care I, Inc","Boon Chapman","Pending Other Enrollment","Pending Other Enrollment","","","","2022-07-20","7/20/2022 Pending Multiplan enrollment.  DCannon"]
["Venessa Saldana, APRN-FNP-BC",1922658319,"","TX","PE - Premier Family Care I, Inc","Boon Chapman","Pending Other Enrollment","Pending Other Enrollment","","","","2022-07-20","7/20/2022 Pending Multiplan enrollment.  DCannon"]
["Venessa Saldana, APRN-FNP-BC",1922658319,"","TX","PE - Premier Family Care I, Inc","Boon Chapman","Pending Other Enrollment","Pending Other Enrollment","","","","2022-07-20","7/20/2022 Pending Multiplan enrollment.  DCannon"]
["Venessa Saldana, APRN-FNP-BC",1922658319,"","TX","PE - Premier Family Care I, Inc","Boon Chapman","Pending Other Enrollment","Pending Other Enrollment","","","","2022-07-20","7/20/2022 Pending Multiplan enrollment.  DCannon"]
["Venessa Saldana, APRN-FNP-BC",1922658319,"","TX","PE - Premier Family Care I, Inc","Boon Chapman","Pending Other Enrollment","Pending Other Enrollment","","","","2022-07-20","7/20/2022 Pending Multiplan enrollment.  DCannon"]
["Venessa Saldana, APRN-FNP-BC",1922658319,"","TX","PE - Premier Family Care I, Inc","Boon Chapman","Pending Other Enrollment","Pending Other Enrollment","","","","2022-07-20","7/20/2022 Pending Multiplan enrollment.  DCannon"]
["Venessa Saldana, APRN-FNP-BC",1922658319,"","TX","PE - Premier Family Care I, Inc","Boon Chapman","Pending Other Enrollment","Pending Other Enrollment","","","","2022-07-20","7/20/2022 Pending Multiplan enrollment.  DCannon"]
["Venessa Saldana, APRN-FNP-BC",1922658319,"","TX","PE - Premier Family Care I, Inc","Boon Chapman","Pending Other Enrollment","Pending Other Enrollment","","","","2022-07-20","7/20/2022 Pending Multiplan enrollment.  DCannon"]
["Venessa Saldana, APRN-FNP-BC",1922658319,"","TX","PE - Premier Family Care I, Inc","Boon Chapman","Pending Other Enrollment","Pending Other Enrollment","","","","2022-07-20","7/20/2022 Pending Multiplan enrollment.  DCannon"]
["Venessa Saldana, APRN-FNP-BC",1922658319,"","TX","PE - Premier Family Care I, Inc","Boon Chapman","Pending Other Enrollment","Pending Other Enrollment","","","","2022-07-20","7/20/2022 Pending Multiplan enrollment.  DCannon"]
["Venessa Saldana, APRN-FNP-BC",1922658319,"","TX","PE - Premier Family Care I, Inc","Boon Chapman","Pending Other Enrollment","Pending Other Enrollment","","","","2022-07-20","7/20/2022 Pending Multiplan enrollment.  DCannon"]
["Venessa Saldana, APRN-FNP-BC",1922658319,"","TX","PE - Premier Family Care I, Inc","Boon Chapman","Pending Other Enrollment","Pending Other Enrollment","","","","2022-07-20","7/20/2022 Pending Multiplan enrollment.  DCannon"]
["Venessa Saldana, APRN-FNP-BC",1922658319,"","TX","PE - Premier Family Care I, Inc","Boon Chapman","Pending Other Enrollment","Pending Other Enrollment","","","","2022-07-20","7/20/2022 Pending Multiplan enrollment.  DCannon"]
["Venessa Saldana, APRN-FNP-BC",1922658319,"","TX","PE - Premier Family Care I, Inc","Boon Chapman","Pending Other Enrollment","Pending Other Enrollment","","","","2022-07-20","7/20/2022 Pending Multiplan enrollment.  DCannon"]
["Venessa Saldana, APRN-FNP-BC",1922658319,"","TX","PE - Premier Family Care I, Inc","Boon Chapman","Pending Other Enrollment","Pending Other Enrollment","","","","2022-07-20","7/20/2022 Pending Multiplan enrollment.  DCannon"]
["Venessa Saldana, APRN-FNP-BC",1922658319,"","TX","PE - Premier Family Care I, Inc","Boon Chapman","Pending Other Enrollment","Pending Other Enrollment","","","","2022-07-20","7/20/2022 Pending Multiplan enrollment.  DCannon"]
["Venessa Saldana, APRN-FNP-BC",1922658319,752656723,"TX","PE - Premier Family Care I, 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 Saldana, APRN-FNP-BC",1922658319,752656723,"TX","PE - Premier Family Care I, 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 Saldana, APRN-FNP-BC",1922658319,752656723,"TX","PE - Premier Family Care I, 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 Saldana, APRN-FNP-BC",1922658319,752656723,"TX","PE - Premier Family Care I, 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 Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care I, 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 Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care I, 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 Saldana, APRN-FNP-BC",1922658319,752656723,"TX","PE - Premier Family Care I, 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 Saldana, APRN-FNP-BC",1922658319,752656723,"TX","PE - Premier Family Care I, 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 Saldana, APRN-FNP-BC",1922658319,752656723,"TX","PE - Premier Family Care I, 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 Saldana, APRN-FNP-BC",1922658319,752656723,"TX","PE - Premier Family Care I, 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 Saldana, APRN-FNP-BC",1922658319,"","TX","PE - Premier Family Care I, 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 Saldana, APRN-FNP-BC",1922658319,"","TX","PE - Premier Family Care I, 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 Saldana, APRN-FNP-BC",1922658319,"","TX","PE - Premier Family Care I, 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 Saldana, APRN-FNP-BC",1922658319,"","TX","PE - Premier Family Care I, 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 Saldana, APRN-FNP-BC",1922658319,"","TX","PE - Premier Family Care I, 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 Saldana, APRN-FNP-BC",1922658319,"","TX","PE - Premier Family Care I, 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 Saldana, APRN-FNP-BC",1922658319,"","TX","PE - Premier Family Care I, 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 Saldana, APRN-FNP-BC",1922658319,"","TX","PE - Premier Family Care I, 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 Saldana, APRN-FNP-BC",1922658319,"","TX","PE - Premier Family Care I, 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 Saldana, APRN-FNP-BC",1922658319,"","TX","PE - Premier Family Care I, 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 Saldana, APRN-FNP-BC",1922658319,"","TX","PE - Premier Family Care I, 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 Saldana, APRN-FNP-BC",1922658319,"","TX","PE - Premier Family Care I, 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 Saldana, APRN-FNP-BC",1922658319,"","TX","PE - Premier Family Care I, 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 Saldana, APRN-FNP-BC",1922658319,"","TX","PE - Premier Family Care I, 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 Saldana, APRN-FNP-BC",1922658319,"","TX","PE - Premier Family Care I, 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 Saldana, APRN-FNP-BC",1922658319,"","TX","PE - Premier Family Care I, 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 Saldana, APRN-FNP-BC",1922658319,"","TX","PE - Premier Family Care I, 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 Saldana, APRN-FNP-BC",1922658319,"","TX","PE - Premier Family Care I, 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 Saldana, APRN-FNP-BC",1922658319,752656723,"TX","PE - Premier Family Care I, 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 Saldana, APRN-FNP-BC",1922658319,752656723,"TX","PE - Premier Family Care I, 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 Saldana, APRN-FNP-BC",1922658319,752656723,"TX","PE - Premier Family Care I, 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 Saldana, APRN-FNP-BC",1922658319,752656723,"TX","PE - Premier Family Care I, 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 Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care I, 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 Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care I, 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 Saldana, APRN-FNP-BC",1922658319,752656723,"TX","PE - Premier Family Care I, 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 Saldana, APRN-FNP-BC",1922658319,752656723,"TX","PE - Premier Family Care I, 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 Saldana, APRN-FNP-BC",1922658319,752656723,"TX","PE - Premier Family Care I, 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 Saldana, APRN-FNP-BC",1922658319,752656723,"TX","PE - Premier Family Care I, 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 Saldana, APRN-FNP-BC",1922658319,"","TX","PE - Premier Family Care I, 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 Saldana, APRN-FNP-BC",1922658319,"","TX","PE - Premier Family Care I, 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 Saldana, APRN-FNP-BC",1922658319,"","TX","PE - Premier Family Care I, 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 Saldana, APRN-FNP-BC",1922658319,"","TX","PE - Premier Family Care I, 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 Saldana, APRN-FNP-BC",1922658319,"","TX","PE - Premier Family Care I, 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 Saldana, APRN-FNP-BC",1922658319,"","TX","PE - Premier Family Care I, 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 Saldana, APRN-FNP-BC",1922658319,"","TX","PE - Premier Family Care I, 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 Saldana, APRN-FNP-BC",1922658319,"","TX","PE - Premier Family Care I, 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 Saldana, APRN-FNP-BC",1922658319,"","TX","PE - Premier Family Care I, 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 Saldana, APRN-FNP-BC",1922658319,"","TX","PE - Premier Family Care I, 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 Saldana, APRN-FNP-BC",1922658319,"","TX","PE - Premier Family Care I, 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 Saldana, APRN-FNP-BC",1922658319,"","TX","PE - Premier Family Care I, 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 Saldana, APRN-FNP-BC",1922658319,"","TX","PE - Premier Family Care I, 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 Saldana, APRN-FNP-BC",1922658319,"","TX","PE - Premier Family Care I, 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 Saldana, APRN-FNP-BC",1922658319,"","TX","PE - Premier Family Care I, 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 Saldana, APRN-FNP-BC",1922658319,"","TX","PE - Premier Family Care I, 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 Saldana, APRN-FNP-BC",1922658319,"","TX","PE - Premier Family Care I, 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 Saldana, APRN-FNP-BC",1922658319,"","TX","PE - Premier Family Care I, 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 Saldana, APRN-FNP-BC",1922658319,752656723,"TX","PE - Premier Family Care I, 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 Saldana, APRN-FNP-BC",1922658319,752656723,"TX","PE - Premier Family Care I, 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 Saldana, APRN-FNP-BC",1922658319,752656723,"TX","PE - Premier Family Care I, 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 Saldana, APRN-FNP-BC",1922658319,752656723,"TX","PE - Premier Family Care I, 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 Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care I, 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 Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care I, 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 Saldana, APRN-FNP-BC",1922658319,752656723,"TX","PE - Premier Family Care I, 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 Saldana, APRN-FNP-BC",1922658319,752656723,"TX","PE - Premier Family Care I, 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 Saldana, APRN-FNP-BC",1922658319,752656723,"TX","PE - Premier Family Care I, 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 Saldana, APRN-FNP-BC",1922658319,752656723,"TX","PE - Premier Family Care I, 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 Saldana, APRN-FNP-BC",1922658319,"","TX","PE - Premier Family Care I, 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 Saldana, APRN-FNP-BC",1922658319,"","TX","PE - Premier Family Care I, 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 Saldana, APRN-FNP-BC",1922658319,"","TX","PE - Premier Family Care I, 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 Saldana, APRN-FNP-BC",1922658319,"","TX","PE - Premier Family Care I, 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 Saldana, APRN-FNP-BC",1922658319,"","TX","PE - Premier Family Care I, 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 Saldana, APRN-FNP-BC",1922658319,"","TX","PE - Premier Family Care I, 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 Saldana, APRN-FNP-BC",1922658319,"","TX","PE - Premier Family Care I, 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 Saldana, APRN-FNP-BC",1922658319,"","TX","PE - Premier Family Care I, 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 Saldana, APRN-FNP-BC",1922658319,"","TX","PE - Premier Family Care I, 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 Saldana, APRN-FNP-BC",1922658319,"","TX","PE - Premier Family Care I, 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 Saldana, APRN-FNP-BC",1922658319,"","TX","PE - Premier Family Care I, 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 Saldana, APRN-FNP-BC",1922658319,"","TX","PE - Premier Family Care I, 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 Saldana, APRN-FNP-BC",1922658319,"","TX","PE - Premier Family Care I, 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 Saldana, APRN-FNP-BC",1922658319,"","TX","PE - Premier Family Care I, 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 Saldana, APRN-FNP-BC",1922658319,"","TX","PE - Premier Family Care I, 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 Saldana, APRN-FNP-BC",1922658319,"","TX","PE - Premier Family Care I, 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 Saldana, APRN-FNP-BC",1922658319,"","TX","PE - Premier Family Care I, 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 Saldana, APRN-FNP-BC",1922658319,"","TX","PE - Premier Family Care I, 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 Saldana, APRN-FNP-BC",1922658319,752656723,"TX","PE - Premier Family Care I, 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 Saldana, APRN-FNP-BC",1922658319,752656723,"TX","PE - Premier Family Care I, 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 Saldana, APRN-FNP-BC",1922658319,752656723,"TX","PE - Premier Family Care I, 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 Saldana, APRN-FNP-BC",1922658319,752656723,"TX","PE - Premier Family Care I, 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 Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care I, 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 Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care I, 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 Saldana, APRN-FNP-BC",1922658319,752656723,"TX","PE - Premier Family Care I, 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 Saldana, APRN-FNP-BC",1922658319,752656723,"TX","PE - Premier Family Care I, 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 Saldana, APRN-FNP-BC",1922658319,752656723,"TX","PE - Premier Family Care I, 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 Saldana, APRN-FNP-BC",1922658319,752656723,"TX","PE - Premier Family Care I, 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 Saldana, APRN-FNP-BC",1922658319,"","TX","PE - Premier Family Care I, 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 Saldana, APRN-FNP-BC",1922658319,"","TX","PE - Premier Family Care I, 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 Saldana, APRN-FNP-BC",1922658319,"","TX","PE - Premier Family Care I, 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 Saldana, APRN-FNP-BC",1922658319,"","TX","PE - Premier Family Care I, 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 Saldana, APRN-FNP-BC",1922658319,"","TX","PE - Premier Family Care I, 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 Saldana, APRN-FNP-BC",1922658319,"","TX","PE - Premier Family Care I, 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 Saldana, APRN-FNP-BC",1922658319,"","TX","PE - Premier Family Care I, 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 Saldana, APRN-FNP-BC",1922658319,"","TX","PE - Premier Family Care I, 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 Saldana, APRN-FNP-BC",1922658319,"","TX","PE - Premier Family Care I, 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 Saldana, APRN-FNP-BC",1922658319,"","TX","PE - Premier Family Care I, 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 Saldana, APRN-FNP-BC",1922658319,"","TX","PE - Premier Family Care I, 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 Saldana, APRN-FNP-BC",1922658319,"","TX","PE - Premier Family Care I, 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 Saldana, APRN-FNP-BC",1922658319,"","TX","PE - Premier Family Care I, 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 Saldana, APRN-FNP-BC",1922658319,"","TX","PE - Premier Family Care I, 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 Saldana, APRN-FNP-BC",1922658319,"","TX","PE - Premier Family Care I, 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 Saldana, APRN-FNP-BC",1922658319,"","TX","PE - Premier Family Care I, 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 Saldana, APRN-FNP-BC",1922658319,"","TX","PE - Premier Family Care I, 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 Saldana, APRN-FNP-BC",1922658319,"","TX","PE - Premier Family Care I, 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 Saldana, APRN-FNP-BC",1922658319,752656723,"TX","PE - Premier Family Care I, 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 Saldana, APRN-FNP-BC",1922658319,752656723,"TX","PE - Premier Family Care I, 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 Saldana, APRN-FNP-BC",1922658319,752656723,"TX","PE - Premier Family Care I, 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 Saldana, APRN-FNP-BC",1922658319,752656723,"TX","PE - Premier Family Care I, 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 Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care I, 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 Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care I, 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 Saldana, APRN-FNP-BC",1922658319,752656723,"TX","PE - Premier Family Care I, 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 Saldana, APRN-FNP-BC",1922658319,752656723,"TX","PE - Premier Family Care I, 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 Saldana, APRN-FNP-BC",1922658319,752656723,"TX","PE - Premier Family Care I, 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 Saldana, APRN-FNP-BC",1922658319,752656723,"TX","PE - Premier Family Care I, 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 Saldana, APRN-FNP-BC",1922658319,"","TX","PE - Premier Family Care I, 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 Saldana, APRN-FNP-BC",1922658319,"","TX","PE - Premier Family Care I, 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 Saldana, APRN-FNP-BC",1922658319,"","TX","PE - Premier Family Care I, 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 Saldana, APRN-FNP-BC",1922658319,"","TX","PE - Premier Family Care I, 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 Saldana, APRN-FNP-BC",1922658319,"","TX","PE - Premier Family Care I, 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 Saldana, APRN-FNP-BC",1922658319,"","TX","PE - Premier Family Care I, 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 Saldana, APRN-FNP-BC",1922658319,"","TX","PE - Premier Family Care I, 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 Saldana, APRN-FNP-BC",1922658319,"","TX","PE - Premier Family Care I, 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 Saldana, APRN-FNP-BC",1922658319,"","TX","PE - Premier Family Care I, 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 Saldana, APRN-FNP-BC",1922658319,"","TX","PE - Premier Family Care I, 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 Saldana, APRN-FNP-BC",1922658319,"","TX","PE - Premier Family Care I, 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 Saldana, APRN-FNP-BC",1922658319,"","TX","PE - Premier Family Care I, 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 Saldana, APRN-FNP-BC",1922658319,"","TX","PE - Premier Family Care I, 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 Saldana, APRN-FNP-BC",1922658319,"","TX","PE - Premier Family Care I, 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 Saldana, APRN-FNP-BC",1922658319,"","TX","PE - Premier Family Care I, 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 Saldana, APRN-FNP-BC",1922658319,"","TX","PE - Premier Family Care I, 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 Saldana, APRN-FNP-BC",1922658319,"","TX","PE - Premier Family Care I, 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 Saldana, APRN-FNP-BC",1922658319,"","TX","PE - Premier Family Care I, 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 Saldana, APRN-FNP-BC",1922658319,752656723,"TX","PE - Premier Family Care I, 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 Saldana, APRN-FNP-BC",1922658319,752656723,"TX","PE - Premier Family Care I, 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 Saldana, APRN-FNP-BC",1922658319,752656723,"TX","PE - Premier Family Care I, 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 Saldana, APRN-FNP-BC",1922658319,752656723,"TX","PE - Premier Family Care I, 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 Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care I, 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 Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care I, 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 Saldana, APRN-FNP-BC",1922658319,752656723,"TX","PE - Premier Family Care I, 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 Saldana, APRN-FNP-BC",1922658319,752656723,"TX","PE - Premier Family Care I, 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 Saldana, APRN-FNP-BC",1922658319,752656723,"TX","PE - Premier Family Care I, 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 Saldana, APRN-FNP-BC",1922658319,752656723,"TX","PE - Premier Family Care I, 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 Saldana, APRN-FNP-BC",1922658319,"","TX","PE - Premier Family Care I, 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 Saldana, APRN-FNP-BC",1922658319,"","TX","PE - Premier Family Care I, 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 Saldana, APRN-FNP-BC",1922658319,"","TX","PE - Premier Family Care I, 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 Saldana, APRN-FNP-BC",1922658319,"","TX","PE - Premier Family Care I, 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 Saldana, APRN-FNP-BC",1922658319,"","TX","PE - Premier Family Care I, 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 Saldana, APRN-FNP-BC",1922658319,"","TX","PE - Premier Family Care I, 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 Saldana, APRN-FNP-BC",1922658319,"","TX","PE - Premier Family Care I, 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 Saldana, APRN-FNP-BC",1922658319,"","TX","PE - Premier Family Care I, 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 Saldana, APRN-FNP-BC",1922658319,"","TX","PE - Premier Family Care I, 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 Saldana, APRN-FNP-BC",1922658319,"","TX","PE - Premier Family Care I, 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 Saldana, APRN-FNP-BC",1922658319,"","TX","PE - Premier Family Care I, 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 Saldana, APRN-FNP-BC",1922658319,"","TX","PE - Premier Family Care I, 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 Saldana, APRN-FNP-BC",1922658319,"","TX","PE - Premier Family Care I, 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 Saldana, APRN-FNP-BC",1922658319,"","TX","PE - Premier Family Care I, 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 Saldana, APRN-FNP-BC",1922658319,"","TX","PE - Premier Family Care I, 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 Saldana, APRN-FNP-BC",1922658319,"","TX","PE - Premier Family Care I, 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 Saldana, APRN-FNP-BC",1922658319,"","TX","PE - Premier Family Care I, 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 Saldana, APRN-FNP-BC",1922658319,"","TX","PE - Premier Family Care I, 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 Saldana, APRN-FNP-BC",1922658319,752656723,"TX","PE - Premier Family Care I, 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 Saldana, APRN-FNP-BC",1922658319,752656723,"TX","PE - Premier Family Care I, 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 Saldana, APRN-FNP-BC",1922658319,752656723,"TX","PE - Premier Family Care I, 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 Saldana, APRN-FNP-BC",1922658319,752656723,"TX","PE - Premier Family Care I, 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 Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care I, 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 Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care I, 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 Saldana, APRN-FNP-BC",1922658319,752656723,"TX","PE - Premier Family Care I, 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 Saldana, APRN-FNP-BC",1922658319,752656723,"TX","PE - Premier Family Care I, 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 Saldana, APRN-FNP-BC",1922658319,752656723,"TX","PE - Premier Family Care I, 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 Saldana, APRN-FNP-BC",1922658319,752656723,"TX","PE - Premier Family Care I, 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 Saldana, APRN-FNP-BC",1922658319,"","TX","PE - Premier Family Care I, 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 Saldana, APRN-FNP-BC",1922658319,"","TX","PE - Premier Family Care I, 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 Saldana, APRN-FNP-BC",1922658319,"","TX","PE - Premier Family Care I, 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 Saldana, APRN-FNP-BC",1922658319,"","TX","PE - Premier Family Care I, 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 Saldana, APRN-FNP-BC",1922658319,"","TX","PE - Premier Family Care I, 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 Saldana, APRN-FNP-BC",1922658319,"","TX","PE - Premier Family Care I, 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 Saldana, APRN-FNP-BC",1922658319,"","TX","PE - Premier Family Care I, 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 Saldana, APRN-FNP-BC",1922658319,"","TX","PE - Premier Family Care I, 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 Saldana, APRN-FNP-BC",1922658319,"","TX","PE - Premier Family Care I, 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 Saldana, APRN-FNP-BC",1922658319,"","TX","PE - Premier Family Care I, 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 Saldana, APRN-FNP-BC",1922658319,"","TX","PE - Premier Family Care I, 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 Saldana, APRN-FNP-BC",1922658319,"","TX","PE - Premier Family Care I, 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 Saldana, APRN-FNP-BC",1922658319,"","TX","PE - Premier Family Care I, 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 Saldana, APRN-FNP-BC",1922658319,"","TX","PE - Premier Family Care I, 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 Saldana, APRN-FNP-BC",1922658319,"","TX","PE - Premier Family Care I, 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 Saldana, APRN-FNP-BC",1922658319,"","TX","PE - Premier Family Care I, 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 Saldana, APRN-FNP-BC",1922658319,"","TX","PE - Premier Family Care I, 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 Saldana, APRN-FNP-BC",1922658319,"","TX","PE - Premier Family Care I, 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 Saldana, APRN-FNP-BC",1922658319,752656723,"TX","PE - Premier Family Care I, Inc","Multiplan","In Process","Application Submitted","","","","2022-08-15","8/15/2022 Emailed monthly delegated roster to Multiplan to have providers loaded.  DCannon"]
["Venessa Saldana, APRN-FNP-BC",1922658319,752656723,"TX","PE - Premier Family Care I, Inc","Multiplan","In Process","Application Submitted","","","","2022-08-15","8/15/2022 Emailed monthly delegated roster to Multiplan to have providers loaded.  DCannon"]
["Venessa Saldana, APRN-FNP-BC",1922658319,752656723,"TX","PE - Premier Family Care I, Inc","Multiplan","In Process","Application Submitted","","","","2022-08-15","8/15/2022 Emailed monthly delegated roster to Multiplan to have providers loaded.  DCannon"]
["Venessa Saldana, APRN-FNP-BC",1922658319,752656723,"TX","PE - Premier Family Care I, Inc","Multiplan","In Process","Application Submitted","","","","2022-08-15","8/15/2022 Emailed monthly delegated roster to Multiplan to have providers loaded.  DCannon"]
["Venessa Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care I, Inc","Multiplan","In Process","Application Submitted","","","","2022-08-15","8/15/2022 Emailed monthly delegated roster to Multiplan to have providers loaded.  DCannon"]
["Venessa Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care I, Inc","Multiplan","In Process","Application Submitted","","","","2022-08-15","8/15/2022 Emailed monthly delegated roster to Multiplan to have providers loaded.  DCannon"]
["Venessa Saldana, APRN-FNP-BC",1922658319,752656723,"TX","PE - Premier Family Care I, Inc","Multiplan","In Process","Application Submitted","","","","2022-08-15","8/15/2022 Emailed monthly delegated roster to Multiplan to have providers loaded.  DCannon"]
["Venessa Saldana, APRN-FNP-BC",1922658319,752656723,"TX","PE - Premier Family Care I, Inc","Multiplan","In Process","Application Submitted","","","","2022-08-15","8/15/2022 Emailed monthly delegated roster to Multiplan to have providers loaded.  DCannon"]
["Venessa Saldana, APRN-FNP-BC",1922658319,752656723,"TX","PE - Premier Family Care I, Inc","Multiplan","In Process","Application Submitted","","","","2022-08-15","8/15/2022 Emailed monthly delegated roster to Multiplan to have providers loaded.  DCannon"]
["Venessa Saldana, APRN-FNP-BC",1922658319,752656723,"TX","PE - Premier Family Care I, Inc","Multiplan","In Process","Application Submitted","","","","2022-08-15","8/15/2022 Emailed monthly delegated roster to Multiplan to have providers loaded.  DCannon"]
["Venessa Saldana, APRN-FNP-BC",1922658319,"","TX","PE - Premier Family Care I, Inc","Multiplan","In Process","Application Submitted","","","","2022-08-15","8/15/2022 Emailed monthly delegated roster to Multiplan to have providers loaded.  DCannon"]
["Venessa Saldana, APRN-FNP-BC",1922658319,"","TX","PE - Premier Family Care I, Inc","Multiplan","In Process","Application Submitted","","","","2022-08-15","8/15/2022 Emailed monthly delegated roster to Multiplan to have providers loaded.  DCannon"]
["Venessa Saldana, APRN-FNP-BC",1922658319,"","TX","PE - Premier Family Care I, Inc","Multiplan","In Process","Application Submitted","","","","2022-08-15","8/15/2022 Emailed monthly delegated roster to Multiplan to have providers loaded.  DCannon"]
["Venessa Saldana, APRN-FNP-BC",1922658319,"","TX","PE - Premier Family Care I, Inc","Multiplan","In Process","Application Submitted","","","","2022-08-15","8/15/2022 Emailed monthly delegated roster to Multiplan to have providers loaded.  DCannon"]
["Venessa Saldana, APRN-FNP-BC",1922658319,"","TX","PE - Premier Family Care I, Inc","Multiplan","In Process","Application Submitted","","","","2022-08-15","8/15/2022 Emailed monthly delegated roster to Multiplan to have providers loaded.  DCannon"]
["Venessa Saldana, APRN-FNP-BC",1922658319,"","TX","PE - Premier Family Care I, Inc","Multiplan","In Process","Application Submitted","","","","2022-08-15","8/15/2022 Emailed monthly delegated roster to Multiplan to have providers loaded.  DCannon"]
["Venessa Saldana, APRN-FNP-BC",1922658319,"","TX","PE - Premier Family Care I, Inc","Multiplan","In Process","Application Submitted","","","","2022-08-15","8/15/2022 Emailed monthly delegated roster to Multiplan to have providers loaded.  DCannon"]
["Venessa Saldana, APRN-FNP-BC",1922658319,"","TX","PE - Premier Family Care I, Inc","Multiplan","In Process","Application Submitted","","","","2022-08-15","8/15/2022 Emailed monthly delegated roster to Multiplan to have providers loaded.  DCannon"]
["Venessa Saldana, APRN-FNP-BC",1922658319,"","TX","PE - Premier Family Care I, Inc","Multiplan","In Process","Application Submitted","","","","2022-08-15","8/15/2022 Emailed monthly delegated roster to Multiplan to have providers loaded.  DCannon"]
["Venessa Saldana, APRN-FNP-BC",1922658319,"","TX","PE - Premier Family Care I, Inc","Multiplan","In Process","Application Submitted","","","","2022-08-15","8/15/2022 Emailed monthly delegated roster to Multiplan to have providers loaded.  DCannon"]
["Venessa Saldana, APRN-FNP-BC",1922658319,"","TX","PE - Premier Family Care I, Inc","Multiplan","In Process","Application Submitted","","","","2022-08-15","8/15/2022 Emailed monthly delegated roster to Multiplan to have providers loaded.  DCannon"]
["Venessa Saldana, APRN-FNP-BC",1922658319,"","TX","PE - Premier Family Care I, Inc","Multiplan","In Process","Application Submitted","","","","2022-08-15","8/15/2022 Emailed monthly delegated roster to Multiplan to have providers loaded.  DCannon"]
["Venessa Saldana, APRN-FNP-BC",1922658319,"","TX","PE - Premier Family Care I, Inc","Multiplan","In Process","Application Submitted","","","","2022-08-15","8/15/2022 Emailed monthly delegated roster to Multiplan to have providers loaded.  DCannon"]
["Venessa Saldana, APRN-FNP-BC",1922658319,"","TX","PE - Premier Family Care I, Inc","Multiplan","In Process","Application Submitted","","","","2022-08-15","8/15/2022 Emailed monthly delegated roster to Multiplan to have providers loaded.  DCannon"]
["Venessa Saldana, APRN-FNP-BC",1922658319,"","TX","PE - Premier Family Care I, Inc","Multiplan","In Process","Application Submitted","","","","2022-08-15","8/15/2022 Emailed monthly delegated roster to Multiplan to have providers loaded.  DCannon"]
["Venessa Saldana, APRN-FNP-BC",1922658319,"","TX","PE - Premier Family Care I, Inc","Multiplan","In Process","Application Submitted","","","","2022-08-15","8/15/2022 Emailed monthly delegated roster to Multiplan to have providers loaded.  DCannon"]
["Venessa Saldana, APRN-FNP-BC",1922658319,"","TX","PE - Premier Family Care I, Inc","Multiplan","In Process","Application Submitted","","","","2022-08-15","8/15/2022 Emailed monthly delegated roster to Multiplan to have providers loaded.  DCannon"]
["Venessa Saldana, APRN-FNP-BC",1922658319,"","TX","PE - Premier Family Care I, Inc","Multiplan","In Process","Application Submitted","","","","2022-08-15","8/15/2022 Emailed monthly delegated roster to Multiplan to have providers loaded.  DCannon"]
["Venessa Saldana, APRN-FNP-BC",1922658319,752656723,"TX","PE - Premier Family Care I, 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 Saldana, APRN-FNP-BC",1922658319,752656723,"TX","PE - Premier Family Care I, 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 Saldana, APRN-FNP-BC",1922658319,752656723,"TX","PE - Premier Family Care I, 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 Saldana, APRN-FNP-BC",1922658319,752656723,"TX","PE - Premier Family Care I, 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 Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care I, 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 Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care I, 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 Saldana, APRN-FNP-BC",1922658319,752656723,"TX","PE - Premier Family Care I, 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 Saldana, APRN-FNP-BC",1922658319,752656723,"TX","PE - Premier Family Care I, 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 Saldana, APRN-FNP-BC",1922658319,752656723,"TX","PE - Premier Family Care I, 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 Saldana, APRN-FNP-BC",1922658319,752656723,"TX","PE - Premier Family Care I, 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 Saldana, APRN-FNP-BC",1922658319,"","TX","PE - Premier Family Care I, 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 Saldana, APRN-FNP-BC",1922658319,"","TX","PE - Premier Family Care I, 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 Saldana, APRN-FNP-BC",1922658319,"","TX","PE - Premier Family Care I, 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 Saldana, APRN-FNP-BC",1922658319,"","TX","PE - Premier Family Care I, 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 Saldana, APRN-FNP-BC",1922658319,"","TX","PE - Premier Family Care I, 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 Saldana, APRN-FNP-BC",1922658319,"","TX","PE - Premier Family Care I, 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 Saldana, APRN-FNP-BC",1922658319,"","TX","PE - Premier Family Care I, 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 Saldana, APRN-FNP-BC",1922658319,"","TX","PE - Premier Family Care I, 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 Saldana, APRN-FNP-BC",1922658319,"","TX","PE - Premier Family Care I, 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 Saldana, APRN-FNP-BC",1922658319,"","TX","PE - Premier Family Care I, 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 Saldana, APRN-FNP-BC",1922658319,"","TX","PE - Premier Family Care I, 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 Saldana, APRN-FNP-BC",1922658319,"","TX","PE - Premier Family Care I, 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 Saldana, APRN-FNP-BC",1922658319,"","TX","PE - Premier Family Care I, 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 Saldana, APRN-FNP-BC",1922658319,"","TX","PE - Premier Family Care I, 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 Saldana, APRN-FNP-BC",1922658319,"","TX","PE - Premier Family Care I, 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 Saldana, APRN-FNP-BC",1922658319,"","TX","PE - Premier Family Care I, 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 Saldana, APRN-FNP-BC",1922658319,"","TX","PE - Premier Family Care I, 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 Saldana, APRN-FNP-BC",1922658319,"","TX","PE - Premier Family Care I, 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",1437790284,"75-2656723","TX","PE - Premier Family Care I, Inc","Superior","Participating","Enrollment Complete","2020-12-01","","","2020-12-07","12/7/21020 - Rcvd confirmation email from Superior that provider has been loaded effective 12/1/2020.  DCannon"]
["Ana M Rodriguez, APRN-FNP",1437790284,"75-2656723","TX","PE - Premier Family Care I, Inc","HealthSmart PPO","Participating","Enrollment Complete","2020-10-13","13747034","","2020-12-23","12/23/2020 - Confirmed with HealthSmart that provider has been loaded effective 10/13/2020.  DCannon"]
["Ana M Rodriguez, APRN-FNP",1437790284,"75-2656723","TX","PE - Premier Family Care I, Inc","USA PPO","Participating","Enrollment Complete","2021-01-26","1312370","","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"]
["Ana M Rodriguez, APRN-FNP",1437790284,"75-2656723","TX","PE - Premier Family Care I, Inc","Triwest VA","Facility Enrollment","Application Submitted","","","","2022-11-23","08/19/2022 - Submitted application to TriWest VA (sent to Scarlett Abigail, Scarlett_Abigail@bcbstx.com)"]
["Ana M Rodriguez, APRN-FNP",1437790284,"75-2656723","TX","","Triwest VA","Facility Enrollment","Application Submitted","","","","2022-11-23","08/19/2022 - Submitted application to TriWest VA (sent to Scarlett Abigail, Scarlett_Abigail@bcbstx.com)"]
["Ana M Rodriguez, APRN-FNP",1437790284,"75-2656723","TX","PE - Premier Family Care I, Inc","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.\""]
["Ana M Rodriguez, APRN-FNP",1437790284,"75-2656723","TX","","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.\""]
["Ana M Rodriguez, APRN-FNP",1437790284,"75-2656723","TX","PE - Premier Family Care I, Inc","Triwest VA","Facility Enrollment","Facility Enrollment","","","","","10/17/2022 - Received roster from Scarlett; provider status: \"KJ to process.\""]
["Ana M Rodriguez, APRN-FNP",1437790284,"75-2656723","TX","","Triwest VA","Facility Enrollment","Facility Enrollment","","","","","10/17/2022 - Received roster from Scarlett; provider status: \"KJ to process.\""]
["Ana M Rodriguez, APRN-FNP",1437790284,"75-2656723","TX","PE - Premier Family Care I, Inc","Triwest VA","Facility Enrollment","Application Submitted","","","","","08/19/2022 - Submitted application to TriWest VA (sent to Scarlett Abigail, Scarlett_Abigail@bcbstx.com)"]
["Ana M Rodriguez, APRN-FNP",1437790284,"75-2656723","TX","","Triwest VA","Facility Enrollment","Application Submitted","","","","","08/19/2022 - Submitted application to TriWest VA (sent to Scarlett Abigail, Scarlett_Abigail@bcbstx.com)"]
["Ana M Rodriguez, APRN-FNP",1437790284,"75-2656723","TX","PE - Premier Family Care I, 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",1437790284,"75-2656723","TX","PE - Premier Family Care I, Inc","United Health Care","Participating","Enrollment Complete","2020-10-15","","","2020-11-20","11/20/20 - Rcvd confirmation email from UHC confirming enrollment at this location.  DCannon"]
["Ana M Rodriguez, APRN-FNP",1437790284,"75-2656723","TX","PE - Premier Family Care I, Inc","Tricare Prime","Participating","Enrollment Complete","2020-12-24","","","2021-05-09","5/9/2021 Upon review of the self-service portal, provider is participating under group Tax ID and practice location effective 12/24/2020. KFrazier"]
["Ana M Rodriguez, APRN-FNP",1437790284,"75-2656723","TX","PE - Premier Family Care I, Inc","Medicare","Participating","Enrollment Complete","2020-10-01","1J2798","0008AH","2020-11-18","11/18/2020 - Rcvd notification from Novitas that Change of Information app has been approved.  DCannon"]
["Ana M Rodriguez, APRN-FNP",1437790284,"75-2656723","TX","PE - Premier Family Care I, 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"]
["Ana M Rodriguez, APRN-FNP",1437790284,"75-2656723","TX","PE - Premier Family Care I, Inc","TriCare Standard","Participating","Enrollment Complete","2020-10-01","","","2020-10-09","10/9/2020 Confirmed provider is certified as a non-network provider with TriCare East. Kimberly Frazier"]
["Ana M Rodriguez, APRN-FNP",1437790284,"75-2656723","TX","PE - Premier Family Care I, 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."]
["Ana M Rodriguez, APRN-FNP",1437790284,"75-2656723","TX","PE - Premier Family Care I, Inc","Scott&White (First Care)","Participating","Enrollment Complete","2021-03-12","","","2021-03-18","3/18/2021 Received email from BSWHPEXPEDITES@BSWHealth.org confirming provider has been approved and is participating under group effective 3/12/3021. KFrazier"]
["Ana M Rodriguez, APRN-FNP",1437790284,"75-2656723","TX","PE - Premier Family Care I, Inc","Cigna","Participating","Enrollment Complete","2021-02-09","1299432","","2021-02-20","2/20/2021 - Rcvd email from Cigna that provider has been approved effective 2/09/2021 PIN # 1299432.  DCannon"]
["Ana M Rodriguez, APRN-FNP",1437790284,"75-2656723","TX","PE - Premier Family Care I, Inc","IMS","Participating","Enrollment Complete","2020-10-13","","","2020-11-25","11/25/2020 - Rcvd email confirmation that Nov monthly roster was processed and this provider was made effective with the requested eff date of 10/13/2020.  DCannon"]
["Ana M Rodriguez, APRN-FNP",1437790284,"75-2656723","TX","PE - Premier Family Care I, Inc","Galaxy Health","Participating","Enrollment Complete","2020-10-13","","","2020-12-14","12/14/2020 - Rcvd email confirmation from Galaxy Health that the November Delegation Roster was completed. DCannon"]
["Ana M Rodriguez, APRN-FNP",1437790284,"75-2656723","TX","PE - Premier Family Care I, Inc","Boon Chapman","Participating","Enrollment Complete","2021-12-01","3873524","","2022-03-23","3/23/2022 Per follow-up note - 03.10.2022.S/W Lania of Boon Chapman @ 800-950-7040. Provider NPI# is on file  and is participating effective 12/1/2021 under the group and TIN #. Provider ID#3873524.  Physical location is on file.Call ref# 7943427.- DCannon"]
["Ana M Rodriguez, APRN-FNP",1437790284,"75-2656723","TX","PE - Premier Family Care I, Inc","CAQH","Participating","CAQH Reattested","2022-12-09","14485629","","2022-12-09","12/9/2022 CAQH re-attested.  DCannon"]
["Ana M Rodriguez, APRN-FNP",1437790284,"75-2656723","TX","PE - Premier Family Care I, Inc","Aetna","Participating","Enrollment Complete","2021-04-01","","","2021-03-24","3/19/21 (kstrickland) Called Atena SW Daniel Call Ref# 6008130068. He stated provider is in network but couldn't get me a provider ID bc they are waiting for the demographics team to load the date. It will take 30 days. But then you can call back to get a provider id.  DCannon"]
["Ana M Rodriguez, APRN-FNP",1437790284,"75-2656723","TX","PE - Premier Family Care I, Inc","Amerigroup","Participating","Enrollment Complete","2020-10-13","","","2021-08-26","8/26/2021 Rcvd full roster from Joe Rodriguez at Amerigroup listing provider as PAR w/ group TIN and location effective 10/13/2020.  DCannon"]
["Ana M Rodriguez, APRN-FNP",1437790284,"75-2656723","TX","PE - Premier Family Care I, Inc","Caprock (CapStar)","Participating","Enrollment Complete","2020-10-13","","","2021-08-06","8/6/2021 Rcvd confirmation from Caprock that provider is par and linked to TIN/locations effective 10/13/2020.  DCannon"]
["Ana M Rodriguez, APRN-FNP",1437790284,"75-2656723","TX","PE - Premier Family Care I, Inc","First Health Coventry","Participating","Enrollment Complete","2020-10-13","3546328","","2022-08-10","8/10/2022 Per First Health web portal provider is PAR and linked to group TIN/location effective 10/13/2020.  PID # 3546238.  DCannon"]
["Olufemi Aduroja, MD",1366762874,"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"]
["Olufemi Aduroja, MD",1366762874,"47-5554737","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"]
["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","Cigna","Participating","Enrollment Complete","2013-11-01","9477656","","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 11/1/2019 , the physical location is on file and the Provider ID is 9477656.  DCannon"]
["Olufemi Aduroja, MD",1366762874,"47-5554737","TX","","Cigna","Participating","Enrollment Complete","2013-11-01","9477656","","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 11/1/2019 , the physical location is on file and the Provider ID is 9477656.  DCannon"]
["Olufemi Aduroja, MD",1366762874,"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"]
["Olufemi Aduroja, MD",1366762874,"47-5554737","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"]
["Olufemi Aduroja, MD",1366762874,"47-5554737","TX","PE - Midland Inpatient Medical Association","Medicare","Participating","Enrollment Complete","2019-11-01","885680","519061","2020-03-10","03/10/2020 - Confirmed this proivder is linked to the group through PECOS group login - Stacey Hudak"]
["Olufemi Aduroja, MD",1366762874,"47-5554737","TX","","Medicare","Participating","Enrollment Complete","2019-11-01","885680","519061","2020-03-10","03/10/2020 - Confirmed this proivder is linked to the group through PECOS group login - Stacey Hudak"]
["Olufemi Aduroja, MD",1366762874,"47-5554737","TX","PE - Midland Inpatient Medical Association","TriCare Standard","Participating","Enrollment Complete","2020-03-31","1366762874","","2020-04-30","04/30/2020 - Signed into MMH group enrollment and found this provider is linked to the group at this serivce location EFF 3-31-2020. - Stacey Hudak"]
["Olufemi Aduroja, MD",1366762874,"47-5554737","TX","","TriCare Standard","Participating","Enrollment Complete","2020-03-31","1366762874","","2020-04-30","04/30/2020 - Signed into MMH group enrollment and found this provider is linked to the group at this serivce location EFF 3-31-2020. - Stacey Hudak"]
["Olufemi Aduroja, MD",1366762874,"47-5554737","TX","PE - Midland Inpatient Medical Association","Amerigroup","Participating","Enrollment Complete","2020-02-13","1366762874","","2020-03-17","03/17/2020 - Rec'd email confirmation from the payer via a spreadsheet stating this provider is EFF at this service location - Stacey Hudak"]
["Olufemi Aduroja, MD",1366762874,"47-5554737","TX","","Amerigroup","Participating","Enrollment Complete","2020-02-13","1366762874","","2020-03-17","03/17/2020 - Rec'd email confirmation from the payer via a spreadsheet stating this provider is EFF at this service location - Stacey Hudak"]
["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","","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","CAQH","Participating","CAQH Reattested","2022-12-30","","","2022-12-30","12/30/2022 CAQH re-attested.  DCannon"]
["Olufemi Aduroja, MD",1366762874,"47-5554737","TX","","CAQH","Participating","CAQH Reattested","2022-12-30","","","2022-12-30","12/30/2022 CAQH re-attested.  DCannon"]
["Olufemi Aduroja, MD",1366762874,"47-5554737","TX","PE - Midland Inpatient Medical Association","United Health Care","Participating","Enrollment Complete","2016-01-02","1366762874","","2020-07-30","7/30/2020 - moved to completed status after reviewing follow up complete note - Stacey Hudak"]
["Olufemi Aduroja, MD",1366762874,"47-5554737","TX","","United Health Care","Participating","Enrollment Complete","2016-01-02","1366762874","","2020-07-30","7/30/2020 - moved to completed status after reviewing follow up complete note - 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","PE - Midland Inpatient Medical Association","Multiplan","Participating","Enrollment Complete","2020-02-10","1366762874","West Texas Physicians Alliance","2020-07-08","07/08/2020 - Rec'd email from the payer stating this provider is EFF: \"Thank you for contacting our Customer Service Department at Multiplan/PHCS. At this time we show that Olufemi Aduroja is currently participating with the Multiplan, PHCS, and BeechStreet networks. The participation is through West Texas Physicians Alliance.\n\nEffective Dates:\nMultiplan-01/08/2020\nPHCS- 02/10/2020\nBeechStreet-02/10/2020\" - Stacey Hudak"]
["Olufemi Aduroja, MD",1366762874,"47-5554737","TX","","Multiplan","Participating","Enrollment Complete","2020-02-10","1366762874","West Texas Physicians Alliance","2020-07-08","07/08/2020 - Rec'd email from the payer stating this provider is EFF: \"Thank you for contacting our Customer Service Department at Multiplan/PHCS. At this time we show that Olufemi Aduroja is currently participating with the Multiplan, PHCS, and BeechStreet networks. The participation is through West Texas Physicians Alliance.\n\nEffective Dates:\nMultiplan-01/08/2020\nPHCS- 02/10/2020\nBeechStreet-02/10/2020\" - Stacey Hudak"]
["Olufemi Aduroja, MD",1366762874,"47-5554737","TX","PE - Midland Inpatient Medical Association","Galaxy Health","Participating","Enrollment Complete","2020-01-01","1366762874","","2020-10-05","10/5/2020 - Rec'd email back from the payer stating this enrollment has been completed - Stacey"]
["Olufemi Aduroja, MD",1366762874,"47-5554737","TX","","Galaxy Health","Participating","Enrollment Complete","2020-01-01","1366762874","","2020-10-05","10/5/2020 - Rec'd email back from the payer stating this enrollment has been completed - Stacey"]
["Olufemi Aduroja, MD",1366762874,"47-5554737","TX","PE - Midland Inpatient Medical Association","Caprock (CapStar)","Participating","Enrollment Complete","2020-02-01","1366762874","","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"]
["Olufemi Aduroja, MD",1366762874,"47-5554737","TX","","Caprock (CapStar)","Participating","Enrollment Complete","2020-02-01","1366762874","","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"]
["Olufemi Aduroja, MD",1366762874,"47-5554737","TX","PE - Midland Inpatient Medical Association","First Health Coventry","Participating","Enrollment Complete","2020-05-01","1366762874","","2020-06-12","06/12/2020 - Rec'd spreadsheet back stating this provider is EFF with the payer - PID# 2923799\n- Stacey Hudak"]
["Olufemi Aduroja, MD",1366762874,"47-5554737","TX","","First Health Coventry","Participating","Enrollment Complete","2020-05-01","1366762874","","2020-06-12","06/12/2020 - Rec'd spreadsheet back stating this provider is EFF with the payer - PID# 2923799\n- Stacey Hudak"]
["Olufemi Aduroja, MD",1366762874,"47-5554737","TX","PE - Midland Inpatient Medical Association","Rail Road Medicare","Participating","Enrollment Complete","2019-11-01","P02428265","DW7662","2020-08-28","08/28/2020 - moved to completed status after finding EFF info through payer portal - Stacey Hudak"]
["Olufemi Aduroja, MD",1366762874,"47-5554737","TX","","Rail Road Medicare","Participating","Enrollment Complete","2019-11-01","P02428265","DW7662","2020-08-28","08/28/2020 - moved to completed status after finding EFF info through payer portal - Stacey Hudak"]
["Olufemi Aduroja, MD",1366762874,"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","","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","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"]
["Olufemi Aduroja, MD",1366762874,"47-5554737","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"]
["Olufemi Aduroja, MD",1366762874,"47-5554737","TX","PE - Midland Inpatient Medical Association","Aetna","Participating","Enrollment Complete","2020-08-01","1366762874","","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"]
["Olufemi Aduroja, MD",1366762874,"47-5554737","TX","","Aetna","Participating","Enrollment Complete","2020-08-01","1366762874","","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"]
["Olufemi Aduroja, MD",1366762874,"47-5554737","TX","PE - Midland Inpatient Medical Association","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","","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","PE - Midland Inpatient Medical Association","Boon Chapman","Participating","Enrollment Complete","2020-02-10","1366762874","","2020-10-05","Enrolled thru PHCS"]
["Olufemi Aduroja, MD",1366762874,"47-5554737","TX","","Boon Chapman","Participating","Enrollment Complete","2020-02-10","1366762874","","2020-10-05","Enrolled thru PHCS"]
["Olufemi Aduroja, MD",1366762874,"47-5554737","TX","PE - Midland Inpatient Medical Association","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"]
["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"]
["Olufemi Aduroja, MD",1366762874,"47-5554737","TX","PE - Midland Inpatient Medical Association","Omni PPO","Participating","Enrollment Complete","2020-01-31","1366762874","","2020-06-25",""]
["Olufemi Aduroja, MD",1366762874,"47-5554737","TX","","Omni PPO","Participating","Enrollment Complete","2020-01-31","1366762874","","2020-06-25",""]
["Olufemi Aduroja, MD",1366762874,"47-5554737","TX","PE - Midland Inpatient Medical Association","Medicaid","Participating","Enrollment Complete","2025-03-16","386007403","364596201","2020-08-13","8/13/2020 - signed onto TMHP and confirmed this provider is EFF and affilaited with the group - Stacey Hudak"]
["Olufemi Aduroja, MD",1366762874,"47-5554737","TX","","Medicaid","Participating","Enrollment Complete","2025-03-16","386007403","364596201","2020-08-13","8/13/2020 - signed onto TMHP and confirmed this provider is EFF and affilaited with the group - Stacey Hudak"]
["James D Richardson, MD",1306827266,"75-2656723","TX","PE - Premier Family Care I, Inc","Amerigroup","Participating","Enrollment Complete","2020-05-04","","","2021-08-26","8/26/2021 Rcvd full roster from Joe Rodriguez at Amerigroup listing provider as PAR w/ group TIN and location effective 5/4/2020.  DCannon"]
["James D Richardson, MD",1306827266,"75-2656723","TX","PE - Premier Family Care I, Inc","Scott&White (First Care)","Participating","Enrollment Complete","2020-05-08","1306827266","","2020-08-14","8/14/2020 - Rec'd email response from the payer to verify that this provider is effective - Stacey Hudak"]
["James D Richardson, MD",1306827266,"75-2656723","TX","PE - Premier Family Care I, Inc","CAQH","Participating","CAQH Reattested","2023-01-25","","","2023-01-25","1/25/2023 CAQH reviewed and re-attested.  DCannon"]
["James D Richardson, MD",1306827266,"75-2656723","TX","PE - Premier Family Care I, 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 D Richardson, MD",1306827266,"75-2656723","TX","PE - Premier Family Care I, Inc","Medicaid","Participating","Enrollment Complete","2020-04-09","408517701","079837301","2020-09-17","09/17/2020 - address added to medicare. address successfully added to TMHP group and as of today, the address has been linked to this providers account. - Stacey Hudak"]
["James D Richardson, MD",1306827266,"75-2656723","TX","PE - Premier Family Care I, Inc","Multiplan","Participating","Enrollment Complete","2020-02-14","1306827266","52669 - West Texas Physicians Alliance","2020-08-13","8/13/2020 - Rec'd email response from the payer stating \"The MultiPlan / PHCS Network Application for Richardson, James is complete.\n\nNetwork participation became effective as of 02/14/2020 with PHCS. The provider’s network participation is through 23655 - West Texas Physicians Alliance contract.\n\nNetwork participation became effective as of 02/12/2020 with MPI. The provider’s network participation is through 5026 - West Texas Physicians Alliance contract.\n\nNetwork participation became effective as of 02/14/2020 with MPI. The provider’s network participation is through 52669 - West Texas Physicians Alliance contract.\"  - Stacey Hudak"]
["James D Richardson, MD",1306827266,"75-2656723","TX","PE - Premier Family Care I, Inc","IMS","Participating","Enrollment Complete","2019-09-01","1306827266","","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"]
["James D Richardson, MD",1306827266,"75-2656723","TX","PE - Premier Family Care I, 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"]
["James D Richardson, MD",1306827266,"75-2656723","TX","PE - Premier Family Care I, Inc","Triwest VA","Facility Enrollment","Application Submitted","","","","2022-11-23","08/19/2022 - Submitted application to TriWest VA (sent to Scarlett Abigail, Scarlett_Abigail@bcbstx.com)"]
["James D Richardson, MD",1306827266,"75-2656723","TX","","Triwest VA","Facility Enrollment","Application Submitted","","","","2022-11-23","08/19/2022 - Submitted application to TriWest VA (sent to Scarlett Abigail, Scarlett_Abigail@bcbstx.com)"]
["James D Richardson, MD",1306827266,"75-2656723","TX","PE - Premier Family Care I, Inc","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.\""]
["James D Richardson, MD",1306827266,"75-2656723","TX","","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.\""]
["James D Richardson, MD",1306827266,"75-2656723","TX","PE - Premier Family Care I, Inc","Medicare","Participating","Enrollment Complete","2020-01-24","937962","0008AH","2020-03-04","03/04/2020 - rec'd welcome letter from the payer stating APPROVED eff 1-24-2020 and linked to group PTAN 0008AH - Stacey Hudak"]
["James D Richardson, MD",1306827266,"75-2656723","TX","PE - Premier Family Care I, Inc","Superior","Participating","Enrollment Complete","2020-08-01","1306827266","","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"]
["James D Richardson, MD",1306827266,"75-2656723","TX","PE - Premier Family Care I, Inc","Boon Chapman","Participating","Enrollment Complete","2020-02-14","1306827266","","2020-10-05","Enrollment thru PHCS"]
["James D Richardson, MD",1306827266,"75-2656723","TX","PE - Premier Family Care I, Inc","Aetna","Participating","Enrollment Complete","2020-06-01","1306827266","","2020-05-01","05/01/2020 - Rec'd email from the payer stating \"Welcome to the provider network effective 6/1/2020.\" - Stacey Hudak"]
["James D Richardson, MD",1306827266,"75-2656723","TX","PE - Premier Family Care I, 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 I, Inc","TriCare Standard","Participating","Enrollment Complete","2020-06-11","","","2020-11-03","11/3/2020 Confirmed via self-service portal provider is participating under Group Tax ID and correct location effective 6/11/2020. Kimberly Frazier"]
["James D Richardson, MD",1306827266,"75-2656723","TX","PE - Premier Family Care I, Inc","HealthSmart PPO","Participating","Enrollment Complete","2020-02-12","","","2020-07-21","07/21/2020 - moved to completed status. Provider is enrolled with this TIN under WEST TEXAS PHYSICIANS ALLIANCE MDDO Delegated group - Stacey Hudak"]
["James D Richardson, MD",1306827266,"75-2656723","TX","PE - Premier Family Care I, Inc","Humana","Participating","Enrollment Complete","2020-02-11","","","2021-11-18","11/18/2021 Rcvd full roster from Humana listing provider as PAR and linked to group TIN/location effective 2/11/2020.  DCannon"]
["James D Richardson, MD",1306827266,"75-2656723","TX","PE - Premier Family Care I, Inc","United Health Care","Participating","Enrollment Complete","2020-02-04","1306827266","","2020-10-14","10/14/2020 - moved to completed status after reviewing follow up complete note - Stacey Hudak"]
["James D Richardson, MD",1306827266,"75-2656723","TX","PE - Premier Family Care I, Inc","Galaxy Health","Participating","Enrollment Complete","2019-09-01","1306827266","","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"]
["James D Richardson, MD",1306827266,"75-2656723","TX","PE - Premier Family Care I, Inc","Cigna","Participating","Enrollment Complete","2020-05-05","6886462","","2020-05-06","05/06/2020 - Rec;d email from the payer stating \"Congratulations! Your application to participate in the Cigna network has been approved. Your effective date is 05/05/2020. Your provider identification number is? ?6886462.\" - Stacey Hudak"]
["James D Richardson, MD",1306827266,"75-2656723","TX","PE - Premier Family Care I, Inc","Omni PPO","Participating","Enrollment Complete","2019-09-01","1306827266","","2020-07-27","IMS complete"]
["James D Richardson, MD",1306827266,"75-2656723","TX","PE - Premier Family Care I, Inc","First Health Coventry","Participating","Enrollment Complete","2020-09-01","1306827266","","2020-10-01","10/01/2020 - moved to completed status after getting confirmation effective email from the payer - Stacey Hudak"]
["James D Richardson, MD",1306827266,"75-2656723","TX","PE - Premier Family Care I, Inc","Caprock (CapStar)","Participating","Enrollment Complete","2019-09-01","1306827266","","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"]
["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","Provider Load","Provider Load","","","","2022-11-21",""]
["Stephanie D Crawford, FNP",1265081616,"27-4061759","TX","PE - Permian Cardiology Inc.","First Health Coventry","Pending Other Enrollment","Pending Other Enrollment","","","","2022-11-28","11/28/2022 Pending Aetna enrollment.  Once Aetna enrollment is complete will enroll provider in First Health.  DCannon"]
["Stephanie D Crawford, FNP",1265081616,"27-4061759","TX","PE - Permian Cardiology Inc.","USA PPO","In Process","Application Submitted","","","","2023-01-14","1/14/2023 Emailed monthly delegated roster to USA PPO to add provider to delegated roster.  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","Pending Other Enrollment","Provider Load","","","","2022-11-21",""]
["Stephanie D Crawford, FNP",1265081616,"27-4061759","TX","","Boon Chapman","Pending Other Enrollment","Provider Load","","","","2022-11-21",""]
["Stephanie D Crawford, FNP",1265081616,"27-4061759","TX","PE - Permian Cardiology Inc.","Boon Chapman","Pending Other Enrollment","Pending Other Enrollment","","","","2022-11-28","11/28/2022 Pending Multiplan enrollment.  DCannon"]
["Stephanie D Crawford, FNP",1265081616,"27-4061759","TX","","Boon Chapman","Pending Other Enrollment","Pending Other Enrollment","","","","2022-11-28","11/28/2022 Pending Multiplan enrollment.  DCannon"]
["Stephanie D Crawford, FNP",1265081616,"27-4061759","TX","PE - Permian Cardiology Inc.","Ambetter","Pending Other Enrollment","Pending Other Enrollment","","","","2022-11-28","11/28/2022 Pending Superior enrollment.  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","Provider Load","Provider Load","","","","2022-11-21",""]
["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)","In Process","Payor Follow Up","","","","2023-02-17","02.17.2023: Called Scott&White (First Care) @1-737-401-9207 however unable to reach a live representative and was routed to voicemail. Per IVR, Paul Cuter is not available at the moment. Leave detailed message including provider's information and consultant's email address and phone number for the call back. Verification request has been emailed to hpdelegation@bswhealth.org to verify provider credentialing status. - Danico Gabriel Melendres"]
["Stephanie D Crawford, FNP",1265081616,"27-4061759","TX","PE - Permian Cardiology Inc.","Wellcare","Pending Other Enrollment","Pending Other Enrollment","","","","2022-11-28","11/28/2022 Pending Superior enrollment.  DCannon"]
["Stephanie D Crawford, FNP",1265081616,"27-4061759","TX","PE - Permian Cardiology Inc.","Humana","In Process","Application Submitted","","","","2023-01-14","1/14/2023 Emailed monthly delegated roster to Vernita Young at Humana to add provider to delegated roster.  DCannon"]
["Stephanie D Crawford, FNP",1265081616,"27-4061759","TX","PE - Permian Cardiology Inc.","Aetna","In Process","Payor Follow Up","","","","2023-02-16","02.16.2023 S/W Ian of Aetna @ 800-353-1232. Per rep, provider is on file and link under the Tax ID but showing as not in network. As per rep, they received the application on 11/28/2022 and still in process. Tracking# is 02200325. Allow more time and no further document. Rep advised to call them back on 02/23 or 02/24 to check the status of the application. TAT of 60 business days. Call ref#:6133795635. -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","In Process","Application Submitted","","","","2023-01-14","1/14/2023 Emailed monthly delegated roster to Multiplan to add provider to delegated roster.  DCannon"]
["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"]
["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 Process","Payor Follow Up","","","","","10/17/2022 - Received roster from Scarlett; provider status: \"The provider is in CCN activation process with a target effective date of 11/01/2022. Please allow 7 days to be finalized."]
["Rachelle M Campos, APRN-FNP-BC",1447882915,"46-3131679","TX","","Triwest VA","In Process","Payor Follow Up","","","","","10/17/2022 - Received roster from Scarlett; provider status: \"The provider is in CCN activation process with a target effective date of 11/01/2022. Please allow 7 days to be finalized."]
["Rachelle M Campos, APRN-FNP-BC",1447882915,"46-3131679","TX","PE - Midland Texas Orthopedic Group Inc","Triwest VA","In Process","Application Submitted","","","","","08/19/2022 - Submitted application to TriWest VA (sent to Scarlett Abigail, Scarlett_Abigail@bcbstx.com)"]
["Rachelle M Campos, APRN-FNP-BC",1447882915,"46-3131679","TX","","Triwest VA","In Process","Application Submitted","","","","","08/19/2022 - Submitted application to TriWest VA (sent to Scarlett Abigail, Scarlett_Abigail@bcbstx.com)"]
["Rachelle M Campos, APRN-FNP-BC",1447882915,"46-3131679","TX","PE - Midland Texas Orthopedic Group Inc","Aetna","Participating","Enrollment Complete","2020-10-01","6185643","","2020-09-04","09/04/2020 - Rec'd email from the payer stating \"Welcome to the provider network effective 10/1/2020. Your Provider Identification Number (PIN) is: 6185643\" - Stacey Hudak"]
["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","2020-07-24","10337649","","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"]
["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","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","2023-02-16","","","2023-02-16",""]
["Challis M Long, APRN-NP",1861962391,"46-3131679","TX","PE - Midland Texas Orthopedic Group Inc","Rail Road Medicare","Participating","Enrollment Complete","2020-01-20","Q00268177","DU5783","2022-05-27","5/27/2022 Rcvd RR Medicare approval letter. RR Medicare PTAN #  Q00268177 - effective 1/20/2020.  DCannon"]
["Challis M Long, APRN-NP",1861962391,"46-3131679","TX","PE - Midland Texas Orthopedic Group Inc","Humana","Participating","Enrollment Complete","2020-01-01","1861962391","","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"]
["Challis M Long, APRN-NP",1861962391,"46-3131679","TX","PE - Midland Texas Orthopedic Group Inc","First Health Coventry","Participating","Enrollment Complete","2020-05-01","1861962391","","2020-06-12","06/12/2020 - Rec'd info from the payer stating this provider is EFF: PID# 3205097 - Stacey Hudak"]
["Challis M Long, APRN-NP",1861962391,"46-3131679","TX","PE - Midland Texas Orthopedic Group Inc","Tricare Prime","Participating","Enrollment Complete","2020-05-29","","","2020-10-08","10/8/2020 Confirmed via Self-Service Portal provider is participating under Tax ID and location. Kimberly Frazier"]
["Challis M Long, APRN-NP",1861962391,"46-3131679","TX","PE - Midland Texas Orthopedic Group Inc","Boon Chapman","Participating","Enrollment Complete","2020-05-29","","","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 5/29/2020.  DCannon"]
["Challis M Long, APRN-NP",1861962391,"46-3131679","TX","PE - Midland Texas Orthopedic Group Inc","Medicare","Participating","Enrollment Complete","2020-01-20","934341","320497","2020-02-18","02/18/2020 - Rec'd email from the payer stating APPROVED. Signed into PECOS to get provider PTAN: 934341 and confirmed that provider is linked to MIDLAND TEXAS ORTHOPEDIC GROUP INC group PTAN: 320497 as of 1-20-2020. - Stacey Hudak"]
["Challis M Long, APRN-NP",1861962391,"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"]
["Challis M Long, APRN-NP",1861962391,"46-3131679","TX","PE - Midland Texas Orthopedic Group Inc","Zurich","Participating","Enrollment Complete","2020-05-01","","","2022-02-12","2/12/2022 Per Coventry Workers Comp web portal provider is PAR in Zurich and linked to group TIN effective 5/1/2020.  DCannon"]
["Challis M Long, APRN-NP",1861962391,"46-3131679","TX","PE - Midland Texas Orthopedic Group Inc","Caprock (CapStar)","Participating","Enrollment Complete","2019-02-19","1861962391","","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"]
["Challis M Long, APRN-NP",1861962391,"46-3131679","TX","PE - Midland Texas Orthopedic Group Inc","CAQH","Participating","CAQH Reattested","2023-01-04","","","2023-01-04","1/4/2023 Updated COI, reviewed and re-attested.  DCannon"]
["Challis M Long, APRN-NP",1861962391,"46-3131679","TX","PE - Midland Texas Orthopedic Group Inc","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"]
["Challis M Long, APRN-NP",1861962391,"46-3131679","TX","PE - Midland Texas Orthopedic Group Inc","Multiplan","Participating","Enrollment Complete","2020-05-29","","West Texas Physician Aliance","2020-09-23","09/23/2020 - moved to completed status after reviewing followup note - Stacey Hudak"]
["Challis M Long, APRN-NP",1861962391,"46-3131679","TX","PE - Midland Texas Orthopedic Group Inc","TriCare Standard","Participating","Enrollment Complete","2020-05-29","","","2020-11-03","11/3/2020 Confirmed via self-service portal provider is loaded under Group Tax ID and location effective 5/29/2020. Kimberly Frazier"]
["Challis M Long, APRN-NP",1861962391,"46-3131679","TX","PE - Midland Texas Orthopedic Group Inc","Superior","Participating","Enrollment Complete","2020-08-01","1861962391","","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"]
["Challis M Long, APRN-NP",1861962391,"46-3131679","TX","PE - Midland Texas Orthopedic Group Inc","Medicaid","Participating","Enrollment Complete","2020-01-20","393281602","331090601","2023-02-25","2/25/2023 Per TMHP web portal license update has been approved.  DCannon"]
["Challis M Long, APRN-NP",1861962391,"46-3131679","TX","PE - Midland Texas Orthopedic Group Inc","IMS","Participating","Enrollment Complete","2019-09-01","1861962391","","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"]
["Challis M Long, APRN-NP",1861962391,"46-3131679","TX","PE - Midland Texas Orthopedic Group Inc","Sedgwick","Participating","Enrollment Complete","2020-05-29","1277834","","2021-01-26","1/26/2021 - Per follow-up notes provider is par with TIN and location effective 5/29/2020.  DCannon"]
["Challis M Long, APRN-NP",1861962391,"46-3131679","TX","PE - Midland Texas Orthopedic Group Inc","USA PPO","Participating","Enrollment Complete","2019-02-25","1861962391","830358685","2020-08-18","Confirmed provider is participating with PPO and H&W networks (list of networks attached). Kimberly Frazier"]
["Challis M Long, APRN-NP",1861962391,"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"]
["Challis M Long, APRN-NP",1861962391,"46-3131679","TX","PE - Midland Texas Orthopedic Group Inc","HealthSmart PPO","Participating","Enrollment Complete","2019-02-20","1861962391","","2020-06-05","06/05/2020 - Rec'd email from the payer stating this provider is EFF - Stacey Hudak"]
["Challis M Long, APRN-NP",1861962391,"46-3131679","TX","PE - Midland Texas Orthopedic Group Inc","Aetna","Participating","Enrollment Complete","2020-08-01","6366193","","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: 6366193\" - Stacey Hudak"]
["Challis M Long, APRN-NP",1861962391,"46-3131679","TX","PE - Midland Texas Orthopedic Group Inc","Galaxy Health","Participating","Enrollment Complete","2019-09-01","1861962391","","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"]
["Challis M Long, APRN-NP",1861962391,"46-3131679","TX","PE - Midland Texas Orthopedic Group Inc","United Health Care","Participating","Enrollment Complete","2020-01-16","1861962391","","2020-06-09","06/09/2020 - rec'd email from the payer stating \"provider is part of a direct group contract\" - Stacey Hudak"]
["Challis M Long, APRN-NP",1861962391,"46-3131679","TX","PE - Midland Texas Orthopedic Group Inc","Gallagher","Participating","Enrollment Complete","2019-02-01","","","2020-08-28","08/28/2020 - S/W Kim of Gallagher @ 800-243-2336, provider NPI is on file and participating effective 02/01/19 under the group and TIN. Physical location is on file. Call ref#  181602659 - Moises Cipriano"]
["Challis M Long, APRN-NP",1861962391,"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"]
["Challis M Long, APRN-NP",1861962391,"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"]
["Challis M Long, APRN-NP",1861962391,"46-3131679","TX","PE - Midland Texas Orthopedic Group Inc","Tricare Prime","Participating","Enrollment Complete","2020-05-29","","","2020-11-03","11/3/2020 Confirmed via self-service portal provider is loaded as a participating network provider under Group Tax ID and location effective 5/29/2020. Kimberly Frazier"]
["Challis M Long, APRN-NP",1861962391,"46-3131679","TX","PE - Midland Texas Orthopedic Group Inc","Omni PPO","Participating","Enrollment Complete","2019-09-01","1861962391","","2020-07-27","IMS complete"]
["Challis M Long, APRN-NP",1861962391,"46-3131679","TX","PE - Midland Texas Orthopedic Group Inc","Cigna","Participating","Enrollment Complete","2020-05-28","1861962391","","2020-07-20","07/20/2020 - moved to completed status after reviewing follow up complete note - Stacey Hudak"]
["Challis M Long, APRN-NP",1861962391,"46-3131679","TX","PE - Midland Texas Orthopedic Group Inc","Liberty Mutual","Participating","Enrollment Complete","2020-05-01","","","2021-08-06","8/6/2021 Moved to enrollment complete per notes from First Health/Coventry. Provider is effective 5/1/2020. Kfrazier"]
["Challis M Long, APRN-NP",1861962391,"46-3131679","TX","PE - Midland Texas Orthopedic Group Inc","Triwest VA","In Process","Payor Follow Up","","","","","10/17/2022 - Received roster from Scarlett; provider status: \"The provider is in CCN activation process with a target effective date of 11/01/2022. Please allow 7 days to be finalized.\""]
["Challis M Long, APRN-NP",1861962391,"46-3131679","TX","","Triwest VA","In Process","Payor Follow Up","","","","","10/17/2022 - Received roster from Scarlett; provider status: \"The provider is in CCN activation process with a target effective date of 11/01/2022. Please allow 7 days to be finalized.\""]
["Challis M Long, APRN-NP",1861962391,"46-3131679","TX","PE - Midland Texas Orthopedic Group Inc","Triwest VA","In Process","Application Submitted","","","","","08/19/2022 - Submitted application to TriWest VA (sent to Scarlett Abigail, Scarlett_Abigail@bcbstx.com)"]
["Challis M Long, APRN-NP",1861962391,"46-3131679","TX","","Triwest VA","In Process","Application Submitted","","","","","08/19/2022 - Submitted application to TriWest VA (sent to Scarlett Abigail, Scarlett_Abigail@bcbstx.com)"]
["Cindy Marriner, FNP",1922008234,"75-2656723: P","TX","PE - Premier Family Care I, Inc","Rail Road Medicare","Participating","Enrollment Complete","2014-11-01","P01415478","CE1588","2020-03-25","3/25/2020--3/25/2020-Per online check, provider is now PAR effective 11/01/2014 with provider number P01415478. Attached welcome letter to payor line.-Elonah Grace B.Gelig"]
["Cindy Marriner, FNP",1922008234,"75-2656723: S","TX","PE - Premier Family Care I, Inc","Scott&White (First Care)","Participating","Enrollment Complete","2018-05-11","1922008234","","2020-10-02","10/02/2020 - moved to completed status after reviewing follow up complete note - Stacey Hudak"]
["Cindy Marriner, FNP",1922008234,"75-2656723: P","TX","PE - Premier Family Care I, Inc","CAQH","Participating","CAQH Reattested","2022-12-28","12080988","","2022-12-28","12/28/2022 CAQH reviewed and re-attested.  DCannon"]
["Cindy Marriner, FNP",1922008234,"75-2656723: P","TX","PE - Premier Family Care I, 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: S","TX","PE - Premier Family Care I, Inc","United Health Care","Participating","Enrollment Complete","2020-07-29","1922008234","","2020-07-31","7/31/2020 - Rec'd an emaill from the payer stating \"Good news! We’ve completed the provider/group updates you requested on Jul 29, 2020 11:53:03 AM. Your request was assigned reference number PR-5410462 .\" - Stacey Hudak"]
["Cindy Marriner, FNP",1922008234,"75-2656723: P","TX","PE - Premier Family Care I, Inc","Cigna","Participating","Enrollment Complete","2014-09-01","","","2020-02-20","02/20/2020 - Rec'd verification from the payer that this provider is EFF 9-1-2014 and linked to this service location under a DIRECT CONTRACT with this payer - Stacey Hudak"]
["Cindy Marriner, FNP",1922008234,"75-2656723: S","TX","PE - Premier Family Care I, Inc","IMS","Participating","Enrollment Complete","2019-09-01","1922008234","","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"]
["Cindy Marriner, FNP",1922008234,"75-2656723: P","TX","PE - Premier Family Care I, Inc","USA PPO","Participating","Enrollment Complete","2014-02-05","1198630","","2021-01-26","1/26/2021 - Per follow-up notes provider is par with TIN and location effective 2/5/2014.  DCannon"]
["Cindy Marriner, FNP",1922008234,"75-2656723: S","TX","PE - Premier Family Care I, 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 I, Inc","Medicare","Participating","Enrollment Complete","2014-11-01","372052YPVD","0008AH","2020-01-29","01/29/2020 - confirmed EFF through PECOS group enrollment - Stacey Hudak"]
["Cindy Marriner, FNP",1922008234,"75-2656723: P","TX","PE - Premier Family Care I, Inc","Omni PPO","Participating","Enrollment Complete","2019-09-01","1922008234","","2020-07-27","IMS complete"]
["Cindy Marriner, FNP",1922008234,"75-2656723: P","TX","PE - Premier Family Care I, Inc","Medicaid","Participating","Enrollment Complete","","154421503","079837301","2020-01-29","01/29/2020 - Found provider through payer portal. Provider is linked to the following plans: SUPERIOR - FOSTER CARE, FirstCare - Lubbock, 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, FirstCare - MRSA West, Amerigroup Texas, Inc. - MRSA West, Superior Health Plan - MRSA West - Stacey Hudak"]
["Cindy Marriner, FNP",1922008234,"75-2656723: S","TX","PE - Premier Family Care I, Inc","Medicaid","Participating","Enrollment Complete","","154421503","079837301","2020-01-29","01/29/2020 - Found provider through payer portal. Provider is linked to the following plans: SUPERIOR - FOSTER CARE, FirstCare - Lubbock, 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, FirstCare - MRSA West, Amerigroup Texas, Inc. - MRSA West, Superior Health Plan - MRSA West - Stacey Hudak"]
["Cindy Marriner, FNP",1922008234,"75-2656723: S","TX","PE - Premier Family Care I, Inc","Tricare Prime","Participating","Enrollment Complete","2018-11-26","","","2020-10-08","10/8/2020 Confirmed via Self-Service Portal provider is participating under Tax ID and location. Kimberly Frazier"]
["Cindy Marriner, FNP",1922008234,"75-2656723: S","TX","PE - Premier Family Care I, Inc","Caprock (CapStar)","Participating","Enrollment Complete","2014-12-01","1922008234","","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"]
["Cindy Marriner, FNP",1922008234,"75-2656723: S","TX","PE - Premier Family Care I, Inc","USA PPO","Participating","Enrollment Complete","2020-01-01","","","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"]
["Cindy Marriner, FNP",1922008234,"75-2656723: P","TX","PE - Premier Family Care I, Inc","Caprock (CapStar)","Participating","Enrollment Complete","2014-12-01","1922008234","","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"]
["Cindy Marriner, FNP",1922008234,"75-2656723: P","TX","PE - Premier Family Care I, 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"]
["Cindy Marriner, FNP",1922008234,"75-2656723: P","TX","PE - Premier Family Care I, 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"]
["Cindy Marriner, FNP",1922008234,"75-2656723: P","TX","PE - Premier Family Care I, 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"]
["Cindy Marriner, FNP",1922008234,"75-2656723: S","TX","PE - Premier Family Care I, 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"]
["Cindy Marriner, FNP",1922008234,"75-2656723: S","TX","PE - Premier Family Care I, 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"]
["Cindy Marriner, FNP",1922008234,"75-2656723: P","TX","PE - Premier Family Care I, Inc","Medicare","Participating","Enrollment Complete","2014-11-01","372052YPVD","0008AH","2020-01-29","01/29/2020 - confirmed EFF through PECOS group enrollment - Stacey Hudak"]
["Cindy Marriner, FNP",1922008234,"75-2656723: P","TX","PE - Premier Family Care I, Inc","IMS","Participating","Enrollment Complete","2019-09-01","1922008234","","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"]
["Cindy Marriner, FNP",1922008234,"75-2656723: P","TX","PE - Premier Family Care I, Inc","Triwest VA","Facility Enrollment","Application Submitted","","","","2022-11-23","08/19/2022 - Submitted application to TriWest VA (sent to Scarlett Abigail, Scarlett_Abigail@bcbstx.com)"]
["Cindy Marriner, FNP",1922008234,"75-2656723: P","TX","","Triwest VA","Facility Enrollment","Application Submitted","","","","2022-11-23","08/19/2022 - Submitted application to TriWest VA (sent to Scarlett Abigail, Scarlett_Abigail@bcbstx.com)"]
["Cindy Marriner, FNP",1922008234,"75-2656723: P","TX","PE - Premier Family Care I, Inc","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.\""]
["Cindy Marriner, FNP",1922008234,"75-2656723: P","TX","","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.\""]
["Cindy Marriner, FNP",1922008234,"75-2656723: S","TX","PE - Premier Family Care I, 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 I, Inc","Amerigroup","Participating","Enrollment Complete","2019-07-19","","","2021-03-15","3/15/2021 Rcvd roster from Amerigroup listing provider effective and participating under TIN effective 7/19/2019.  DCannon"]
["Cindy Marriner, FNP",1922008234,"75-2656723: P","TX","PE - Premier Family Care I, 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."]
["Cindy Marriner, FNP",1922008234,"75-2656723: P","TX","PE - Premier Family Care I, 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."]
["Cindy Marriner, FNP",1922008234,"75-2656723: S","TX","PE - Premier Family Care I, 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."]
["Cindy Marriner, FNP",1922008234,"75-2656723: S","TX","PE - Premier Family Care I, 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."]
["Cindy Marriner, FNP",1922008234,"75-2656723: P","TX","PE - Premier Family Care I, Inc","Amerigroup","Participating","Enrollment Complete","2016-10-05","1922008234","","2020-02-11","2/11/2020 – Received Roster from Amerigroup and provider is now PAR- Roster shows additional effective dates of: 7/19/19 and 11/1/16---Tisha Rader"]
["Cindy Marriner, FNP",1922008234,"75-2656723: S","TX","PE - Premier Family Care I, Inc","TriCare Standard","Participating","Enrollment Complete","2020-10-22","","","2021-03-31","3/31/2021 Confirmed provider certified via Humana-Military portal effective 10/22/2020.  DCannon"]
["Cindy Marriner, FNP",1922008234,"75-2656723: S","TX","PE - Premier Family Care I, Inc","HealthSmart PPO","Participating","Enrollment Complete","2016-04-25","1922008234","","2020-06-05","06/05/2016 - 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 I, Inc","Aetna","Participating","Enrollment Complete","2020-08-01","1922008234","","2020-09-17","09/17/2020 - Rec'd email confirmation from the payer stating this location update has been made - Stacey Hudak"]
["Cindy Marriner, FNP",1922008234,"75-2656723: S","TX","PE - Premier Family Care I, Inc","Boon Chapman","Participating","Enrollment Complete","2014-12-04","1922008234","","2020-10-05","Enrollment thru PHCS"]
["Cindy Marriner, FNP",1922008234,"75-2656723: S","TX","PE - Premier Family Care I, Inc","Rail Road Medicare","Participating","Enrollment Complete","2014-11-01","P01415478","CE1588","2020-03-25","3/25/2020--3/25/2020-Per online check, provider is now PAR effective 11/01/2014 with provider number P01415478. Attached welcome letter to payor line.-Elonah Grace B.Gelig"]
["Cindy Marriner, FNP",1922008234,"75-2656723: P","TX","PE - Premier Family Care I, Inc","United Health Care","Participating","Enrollment Complete","2014-01-30","3841788","","2020-07-29","07/29/2020 - moved to enrollment complete after reviewing follow up complete note - Stacey Hudak"]
["Cindy Marriner, FNP",1922008234,"75-2656723: S","TX","PE - Premier Family Care I, Inc","Omni PPO","Participating","Enrollment Complete","2019-09-01","1922008234","","2020-07-27","IMS complete"]
["Cindy Marriner, FNP",1922008234,"75-2656723: P","TX","PE - Premier Family Care I, Inc","TriCare Standard","Participating","Enrollment Complete","2015-03-28","1922008234","","2020-09-23","09/23/2020 - Moved to completed status after reviewing follow up complete note - Stacey Hudak"]
["Cindy Marriner, FNP",1922008234,"75-2656723: S","TX","PE - Premier Family Care I, 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"]
["Cindy Marriner, FNP",1922008234,"75-2656723: P","TX","PE - Premier Family Care I, Inc","Superior","Participating","Enrollment Complete","2020-08-01","1922008234","","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"]
["Cindy Marriner, FNP",1922008234,"75-2656723: P","TX","PE - Premier Family Care I, Inc","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"]
["Cindy Marriner, FNP",1922008234,"75-2656723: P","TX","PE - Premier Family Care I, Inc","Multiplan","Participating","Enrollment Complete","2014-06-04","1922008234","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 6-4-2014. Provider is networked with Beechstreet. - Stacey Hudak"]
["Cindy Marriner, FNP",1922008234,"75-2656723: P","TX","PE - Premier Family Care I, Inc","HealthSmart PPO","Participating","Enrollment Complete","2016-04-25","1922008234","","2020-06-05","06/05/2016 - 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 I, Inc","Galaxy Health","Participating","Enrollment Complete","2019-09-01","1922008234","","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"]
["Cindy Marriner, FNP",1922008234,"75-2656723: P","TX","PE - Premier Family Care I, Inc","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"]
["Cindy Marriner, FNP",1922008234,"75-2656723: S","TX","PE - Premier Family Care I, Inc","Multiplan","Participating","Enrollment Complete","2014-12-01","1922008234","West Texas Physicians Alliance","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 Marriner, Cindy:\n\nNetwork:  MPI, MPI Auto and MPI WC\nNetwork Participation effective:12/01/2014 for Tax ID provided.\nContract Source Group contract through: 5026 - West Texas Physicians Alliance\n\nNetwork: PHCS\nNetwork Participation effective:12/01/2014 for Tax ID provided.\nContract Source Group contract through: 23655 - West Texas Physicians Alliance\n\nNetwork: Beech St.\nNetwork Participation effective:12/01/2014 for Tax ID provided.\nContract Source Group contract through: 52669 - West Texas Physicians Alliance\" - Stacey Hudak"]
["Cindy Marriner, FNP",1922008234,"75-2656723: S","TX","PE - Premier Family Care I, Inc","Superior","Participating","Enrollment Complete","2020-08-01","1922008234","","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"]
["Cindy Marriner, FNP",1922008234,"75-2656723: P","TX","PE - Premier Family Care I, 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"]
["Cindy Marriner, FNP",1922008234,"75-2656723: P","TX","PE - Premier Family Care I, Inc","Aetna","Participating","Enrollment Complete","2014-12-01","1922008234","","2020-02-03","02/03/2020 - Rec'd confirmation from the payer that this provider is EFF with the group as of 12-1-2014. The service location is linked to the provider. This provider is under DIRECT CONTRACT. No reval due dates are assigned to midlevel providers -Stacey Hudak"]
["Cindy Marriner, FNP",1922008234,"75-2656723: S","TX","PE - Premier Family Care I, Inc","Triwest VA","Facility 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"]
["Cindy Marriner, FNP",1922008234,"75-2656723: S","TX","","Triwest VA","Facility 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"]
["Cindy Marriner, FNP",1922008234,"75-2656723: S","TX","PE - Premier Family Care I, Inc","Triwest VA","Facility Enrollment","Facility Enrollment","","","","","10/17/2022 - Received roster from Scarlett; provider status: \"No Action.  TIN is CCN participating under own DCN.\""]
["Cindy Marriner, FNP",1922008234,"75-2656723: S","TX","","Triwest VA","Facility Enrollment","Facility Enrollment","","","","","10/17/2022 - Received roster from Scarlett; provider status: \"No Action.  TIN is CCN participating under own DCN.\""]
["Cindy Marriner, FNP",1922008234,"75-2656723: S","TX","PE - Premier Family Care I, Inc","Triwest VA","Facility Enrollment","Application Submitted","","","","","08/19/2022 - Submitted application to TriWest VA (sent to Scarlett Abigail, Scarlett_Abigail@bcbstx.com)"]
["Cindy Marriner, FNP",1922008234,"75-2656723: S","TX","","Triwest VA","Facility Enrollment","Application Submitted","","","","","08/19/2022 - Submitted application to TriWest VA (sent to Scarlett Abigail, Scarlett_Abigail@bcbstx.com)"]
["Edward Maurice Lopez, FNP",1538479969,"90-0858471","TX","PE - Premila Johnson, MD, LP","Caprock (CapStar)","Participating","Enrollment Complete","2019-09-01","1538479969","","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"]
["Edward Maurice Lopez, FNP",1538479969,"90-0858471","TX","PE - Premila Johnson, MD, LP","Multiplan","Participating","Enrollment Complete","2014-06-04","1538479969","West Texas Physicians Alliance","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 Lopez, Edward:\n\nNetwork:  Beech St, MPI, & PHCS\nNetwork Participation effective: See below Contract Source Group contract through: See below\n\nEff Date – 06/04/2014 - Contract 5026 - West Texas Physicians Alliance - MPI\n\nEff Date – 11/01/2012 - Contract 5208 - West Texas Physicians Alliance – Midlevel - MPI\n\nEff Date – 11/01/2012 - Contract 52669 - West Texas Physicians Alliance - Beech St.\n\nEff Date – 11/01/2012 - Contract 53655 - West Texas Physicians Alliance - PHCS\" - Stacey Hudak"]
["Edward Maurice Lopez, FNP",1538479969,"90-0858471","TX","PE - Premila Johnson, MD, LP","USA PPO","Participating","Enrollment Complete","2021-01-26","1312326","","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"]
["Edward Maurice Lopez, FNP",1538479969,"90-0858471","TX","PE - Premila Johnson, MD, LP","United Health Care","Participating","Enrollment Complete","2020-07-02","3751745","","2020-07-30","7/30/2020 - moved to completed status after reviewing follow up complete note - Stacey Hudak"]
["Edward Maurice Lopez, FNP",1538479969,"90-0858471","TX","PE - Premila Johnson, MD, LP","Aetna","Participating","Enrollment Complete","2020-10-01","9086729","","2020-09-04","09/04/2020 - Rec'd email from the payer stating \"Welcome to the provider network effective 10/1/2020. Your Provider Identification Number (PIN) is: 9086729\" - Stacey Hudak"]
["Edward Maurice Lopez, FNP",1538479969,"90-0858471","TX","PE - Premila Johnson, MD, LP","Humana","Delegated - Third Party","Delegated - Third Party","2012-11-01","1538479969","delegated  with  West Texas Physician Alliance","2020-09-24","09/24/2020 - moved to completed status - DELEGATED UNDER WTPA - Stacey Hudak"]
["Edward Maurice Lopez, FNP",1538479969,"90-0858471","TX","PE - Premila Johnson, MD, LP","Scott&White (First Care)","Participating","Enrollment Complete","2020-09-28","","","2021-01-29",""]
["Edward Maurice Lopez, FNP",1538479969,"90-0858471","TX","PE - Premila Johnson, MD, LP","IMS","Participating","Enrollment Complete","2020-02-20","1538479969","","2020-06-29","06/29/2020 -"]
["Edward Maurice Lopez, FNP",1538479969,"90-0858471","TX","PE - Premila Johnson, MD, LP","Boon Chapman","Participating","Enrollment Complete","2014-06-01","1538479969","","2020-10-05","Enrollment thru PHCS"]
["Edward Maurice Lopez, FNP",1538479969,"90-0858471","TX","PE - Premila Johnson, MD, LP","Omni PPO","Participating","Enrollment Complete","2020-02-20","1538479969","","2020-07-06","07/06/2020 - IMS is effective, therefore this enrollment is complete also - Stacey Hudak"]
["Edward Maurice Lopez, FNP",1538479969,"90-0858471","TX","PE - Premila Johnson, MD, LP","CAQH","In House Enrollment","In House Enrollment","2021-02-11","12237351","","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"]
["Swetha Reddy Jangangari, MD",1750796009,"83-0358685","TX","PE - Midland Community Healthcare Services","Aetna","Participating","Enrollment Complete","2021-06-01","6186781","","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 # 6186781  DCannon"]
["Swetha Reddy Jangangari, MD",1750796009,"83-0358685","TX","PE - Midland Community Healthcare Services","Triwest VA","Panel Closed","Panel Closed","","","","2021-08-05","8/5/2021 Payor is no longer accepting new providers into network unless provide significant amount of patients to be seen; therefore, per direction of MQA staff, they will no longer pursue enrollment.  DCannon"]
["Swetha Reddy Jangangari, MD",1750796009,"83-0358685","TX","PE - Midland Community Healthcare Services","Triwest VA","Panel Closed","Panel Closed","","","","2021-08-05","8/5/2021 Payor is no longer accepting new providers into network unless provide significant amount of patients to be seen; therefore, per direction of MQA staff, they will no longer pursue enrollment.  DCannon"]
["Swetha Reddy Jangangari, MD",1750796009,"83-0358685","TX","PE - Midland Community Healthcare Services","Caprock (CapStar)","Participating","Enrollment Complete","2021-06-01","","","2021-08-06","8/6/2021 Rcvd email from Caprock ProviderServices.T8@90degreebenefits.com that monthly delegated roster provider load is complete and provider is loaded under TIN at location effective 6/1/2021.  DCannon"]
["Swetha Reddy Jangangari, MD",1750796009,"83-0358685","TX","PE - Midland Community Healthcare Services","Galaxy Health","Participating","Enrollment Complete","2019-09-01","1750796009","","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"]
["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","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","TriCare Standard","Participating","Enrollment Complete","2021-12-08","","","2022-02-10","12/10/2022 Per Tricare portal, provider is linked to location as of 12.8.2021. Cbankston"]
["Swetha Reddy Jangangari, MD",1750796009,"83-0358685","TX","PE - Midland Community Healthcare Services","Scott&White (First Care)","Participating","Enrollment Complete","2018-10-29","","","2021-01-29","1/29/2021 - Rcvd roster from Scott&White (First Care) confirming participation of provider with TIN and location effective dates.  DCannon"]
["Swetha Reddy Jangangari, MD",1750796009,"83-0358685","TX","PE - Midland Community Healthcare Services","Humana","Participating","Enrollment Complete","2018-02-28","","","2021-11-18","11/18/2021 Rcvd full roster from Humana listing provider as PAR and linked to group TIN/location effective 2/28/2018.  DCannon"]
["Swetha Reddy Jangangari, MD",1750796009,"83-0358685","TX","PE - Midland Community Healthcare Services","IMS","Participating","Enrollment Complete","2020-08-01","","","2020-08-25","Confirmed provider is participating at this location as of 8/1/2020. Kimberly Frazier"]
["Swetha Reddy Jangangari, MD",1750796009,"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 06/01/2021.  DCannon"]
["Swetha Reddy Jangangari, MD",1750796009,"83-0358685","TX","PE - Midland Community Healthcare Services","Amerigroup","Participating","Enrollment Complete","2020-03-20","","","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 3/20/2020.   DCannon"]
["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","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"]
["Swetha Reddy Jangangari, MD",1750796009,"83-0358685","TX","PE - Midland Community Healthcare Services","Triwest VA","DO NOT ENROLL","DO NOT ENROLL","","","","2022-11-15","Provider did not select inclusion with this payor."]
["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","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"]
["Swetha Reddy Jangangari, MD",1750796009,"83-0358685","TX","PE - Midland Community Healthcare Services","Aetna","Participating","Enrollment Complete","2020-09-01","","","2020-12-09","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","Medicare","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","Superior","Participating","Enrollment Complete","2018-04-01","1750796009","","2020-07-14","07/14/2020 - Rec'd email from the payer stating this provider is EFF under PRIMED DELEGATED agreement - Stacey Hudak"]
["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","Humana","Participating","Enrollment Complete","2018-02-28","","","2021-11-18","11/18/2021 Rcvd full roster from Humana listing provider as PAR and linked to group TIN/location effective 2/28/2018.  DCannon"]
["Swetha Reddy Jangangari, MD",1750796009,"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"]
["Swetha Reddy Jangangari, MD",1750796009,"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"]
["Swetha Reddy Jangangari, MD",1750796009,"83-0358685","TX","PE - Midland Community Healthcare Services","United Health Care","Participating","Enrollment Complete","2019-12-01","1750796009","","2020-07-30","7/30/2020 - moved to enrollment completed after reviewing follow up complete note - Stacey Hudak"]
["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","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","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","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","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"]
["Swetha Reddy Jangangari, MD",1750796009,"83-0358685","TX","PE - Midland Community Healthcare Services","First Health Coventry","Participating","Enrollment Complete","2021-08-01","3169156","","2022-02-04","2/4/2022 Per roster received from First Health provider is PAR and linked to group TIN/location effective 8/1/2021.  DCannon"]
["Swetha Reddy Jangangari, MD",1750796009,"83-0358685","TX","PE - Midland Community Healthcare Services","Aetna","Participating","Enrollment Complete","2018-03-15","1750796009","","2020-06-09","06/09/2020 - S/W Anne of Aetna @ 8003531232. Per rep the Provider is on file, linked & participating under the GRP & TIN effective '3/15/2018. Physical Location is on file.  Provider ID #6186781. Call ref # 5312182868\n\nDIRECT CONTRACT - Stacey Hudak"]
["Swetha Reddy Jangangari, MD",1750796009,"83-0358685","TX","PE - Midland Community Healthcare Services","Multiplan","Participating","Enrollment Complete","2018-04-23","1750796009","Midland Community Healthcare Services","2020-07-06","07/06/2020 - Rec'd email from the payer stating:\n\"Thank you for contacting our Service Department at MultiPlan. Here is the following information we have on file for Jangangari, Swetha Reddy:\n\nNetwork:  MPI/PHCS\nNetwork Participation effective:4/23/2018 Contract Source Group contract through: Midland Community Healthcare Services\n\nAs for Beech Street the provider is not affiliated with Beech.  Due to integration, without an existing group contract with a Beech Street affiliation we would not credential providers with that particular provider network.\"  - Stacey Hudak"]
["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","TriCare Standard","Participating","Enrollment Complete","2021-12-08","","","2022-02-10","12/10/2022 Per Tricare portal, provider is linked to location as of 12.8.2021. Cbankston"]
["Swetha Reddy Jangangari, MD",1750796009,"83-0358685","TX","PE - Midland Community Healthcare Services","Humana","Participating","Enrollment Complete","2018-02-28","1750796009","","2020-06-30","6/30/2020 -  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"]
["Swetha Reddy Jangangari, MD",1750796009,"83-0358685","TX","PE - Midland Community Healthcare Services","United Health Care","Participating","Enrollment Complete","2019-12-01","","","2021-08-31","8/31/2021 Email response \"Thank you for contacting the Network Management Resource Team. Swetha Reddy Jangangari is linked to the Tax Id effective 12/1/2019, both locations are loaded. \nPlease let us know if we can assist further via email.\nThank you,\nJamie Edmondson\nUnitedHealthcare\nNetwork Management Resource Team (NMRT)\" Cbankston"]
["Swetha Reddy Jangangari, MD",1750796009,"83-0358685","TX","PE - Midland Community Healthcare Services","HealthSmart PPO","Participating","Enrollment Complete","2018-02-28","","","2021-01-27","1/27/2021 - Rcvd email from payer showing provider as participating at location and linked to TIN effective 2/28/2018.  DCannon"]
["Swetha Reddy Jangangari, MD",1750796009,"83-0358685","TX","PE - Midland Community Healthcare Services","Scott&White (First Care)","Participating","Enrollment Complete","2018-10-29","1750796009","","2020-04-16","04/16/2020 - Rec'd email spreadsheet confirmation from the payer stating this provider is linked to PRI MED DELEGATED agreement with all products under this TIN/Service location - Stacey Hudak\n\n**Verified the provider is networked with:\nFirstCare MyChoice PPO\nCHIP\nFirstCare Select Benefit Network\nHMO Enhanced Benefit Network\nMedicaid (FC)\nMedicare (FC)\nPPO Limited Benefit Network"]
["Swetha Reddy Jangangari, MD",1750796009,"83-0358685","TX","PE - Midland Community Healthcare Services","First Health Coventry","Participating","Enrollment Complete","2021-08-01","3169156","","2022-02-04","2/4/2022 Per roster received from First Health provider is PAR and linked to group TIN/location effective 8/1/2021.  DCannon"]
["Swetha Reddy Jangangari, MD",1750796009,"83-0358685","TX","PE - Midland Community Healthcare Services","TriCare Standard","Participating","Enrollment Complete","2018-04-21","","","2021-04-23","4/23/2021 Upon review of the self-service portal, provider is non-network under group Tax ID effective 4/21/2018. 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","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"]
["Swetha Reddy Jangangari, MD",1750796009,"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"]
["Swetha Reddy Jangangari, MD",1750796009,"83-0358685","TX","PE - Midland Community Healthcare Services","Molina","Participating","Enrollment Complete","2018-08-03","","","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 8/3/2018.  DCannon"]
["Swetha Reddy Jangangari, MD",1750796009,"83-0358685","TX","PE - Midland Community Healthcare Services","Amerigroup","Participating","Enrollment Complete","2020-03-20","","","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 3/20/2020.   DCannon"]
["Swetha Reddy Jangangari, MD",1750796009,"83-0358685","TX","PE - Midland Community Healthcare Services","IMS","Participating","Enrollment Complete","2018-02-28","1750796009","","2020-06-22","06/22/2020- Rec'd email from the payer confirming this provider is PAR with this group/service location - Stacey Hudak"]
["Swetha Reddy Jangangari, MD",1750796009,"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"]
["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","Caprock (CapStar)","Participating","Enrollment Complete","2018-02-28","1750796009","","2020-09-16","09/16/2020 - moved to complete status after reviewing spreadsheet from the payer stating the roster updates were done - stacey Hudak"]
["Swetha Reddy Jangangari, MD",1750796009,"83-0358685","TX","PE - Midland Community Healthcare Services","Omni PPO","Participating","Enrollment Complete","2018-02-28","1750796009","","2020-06-26",""]
["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","Amerigroup","Participating","Enrollment Complete","2020-03-20","1750796009","","2020-03-19","03/19/2020 - Rec'd email from the payer (Multiplan/Texas True Choice) confirming that this provider is EFF with Amerigroup at this serivce location. - Stacey Hudak"]
["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","Medicare","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","Medicare","Participating","In House Enrollment","2017-08-21","595054YM2M","00304W","2020-02-07","02/07/2020 - note on Payer List provided by the doctor states \"We credential our own Medicare.\" - Stacey Hudak"]
["Swetha Reddy Jangangari, MD",1750796009,"83-0358685","TX","PE - Midland Community Healthcare Services","Medicaid","Participating","Enrollment Complete","1900-01-02","376949901","","2020-05-18","05/18/2020 - I was given this providers TPI#, but I do not know the GROUP TPI or the effective date for this provider. Used 1-1-1900 as a placeholder - Stacey Hudak"]
["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"]
["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","Caprock (CapStar)","Participating","Enrollment Complete","2021-06-01","","","2021-08-06","8/6/2021 Rcvd email from Caprock ProviderServices.T8@90degreebenefits.com that monthly delegated roster provider load is complete and provider is loaded under TIN at location 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","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","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","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","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","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","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","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","TriCare Standard","Participating","Enrollment Complete","2018-04-21","","","2020-11-03","11/3/2020 Confirmed via self-service portal provider is certified as non-network under group Tax ID and location effective 4/21/2018. Kimberly Frazier"]
["Swetha Reddy Jangangari, MD",1750796009,"83-0358685","TX","PE - Midland Community Healthcare Services","Humana","Participating","Enrollment Complete","2018-02-28","","","2021-11-18","11/18/2021 Rcvd full roster from Humana listing provider as PAR and linked to group TIN/location effective 2/28/2018.  DCannon"]
["Swetha Reddy Jangangari, MD",1750796009,"83-0358685","TX","PE - Midland Community Healthcare Services","CAQH","In House Enrollment","In House Enrollment","2020-06-11","14085237","","2020-06-11","06/11/2020 - Provider did not supply CAQH login. Provider will maintain this info in-house - Stacey Hudak"]
["Swetha Reddy Jangangari, MD",1750796009,"83-0358685","TX","PE - Midland Community Healthcare Services","First Health Coventry","Participating","Enrollment Complete","2018-08-01","1750796009","","2020-11-02","11/2/2020 - moved to completed status after reviewing follow up complete note - Stacey Hudak"]
["Swetha Reddy Jangangari, MD",1750796009,"83-0358685","TX","PE - Midland Community Healthcare Services","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"]
["Swetha Reddy Jangangari, MD",1750796009,"83-0358685","TX","PE - Midland Community Healthcare Services","Medicare","Participating","In House Enrollment","2020-08-01","595054YM2M","00304W","2020-09-22","9/22/2020 - rec'd email from the clinic stating this service location has been approved by the group medicaid enrollment - Stacey Hudak"]
["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","Boon Chapman","Participating","Enrollment Complete","2020-03-20","1750796009","","2020-03-20","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"]
["Swetha Reddy Jangangari, MD",1750796009,"83-0358685","TX","PE - Midland Community Healthcare Services","Boon Chapman","Participating","Enrollment Complete","2018-04-23","1750796009","","2020-10-05","enrolled thru PHCS"]
["Swetha Reddy Jangangari, MD",1750796009,"83-0358685","TX","PE - Midland Community Healthcare Services","Aetna","Participating","Enrollment Complete","2021-06-01","6186781","","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 # 6186781  DCannon"]
["Swetha Reddy Jangangari, MD",1750796009,"83-0358685","TX","PE - Midland Community Healthcare Services","HealthSmart PPO","Participating","Enrollment Complete","2018-02-28","","","2020-06-04","06/04/2020 - Rec'd email from the payer stating this provider was EFF - Stacey Hudak"]
["Swetha Reddy Jangangari, MD",1750796009,"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"]
["Swetha Reddy Jangangari, MD",1750796009,"83-0358685","TX","PE - Midland Community Healthcare Services","Galaxy Health","Participating","Enrollment Complete","2019-09-01","1750796009","","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"]
["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","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"]
["Swetha Reddy Jangangari, MD",1750796009,"83-0358685","TX","PE - Midland Community Healthcare Services","USA PPO","Participating","Enrollment Complete","2021-06-01","","","2022-04-13","4/13/2022 Per roster from USA MCO provider is PAR and linked to group TIN/location effective 6/1/2021.  DCannon"]
["Swetha Reddy Jangangari, MD",1750796009,"83-0358685","TX","PE - Midland Community Healthcare Services","Molina","Participating","Enrollment Complete","2018-08-03","","","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 8/3/2018.  DCannon"]
["Swetha Reddy Jangangari, MD",1750796009,"83-0358685","TX","PE - Midland Community Healthcare Services","First Health Coventry","Participating","Enrollment Complete","2018-08-01","3169156","","2020-03-20","3/20/2020-receieved email with roster stating provider PAR 8/1/2018 PID # 3169156-tisha rader"]
["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"]
["Swetha Reddy Jangangari, MD",1750796009,"83-0358685","TX","PE - Midland Community Healthcare Services","United Health Care","Participating","Enrollment Complete","2019-12-01","","","2021-10-13","10/12/21 Received email from aldean_mosley@uhc.com, provider is par at this location as of 12/1/19. Cbankston"]
["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"]
["Trinidad Marquez, FNP",1447701602,"83-0358685","TX","PE - Midland Community Healthcare Services","Medicare","Participating","In House Enrollment","2020-08-01","551665YM2M","00304W","2020-09-22","09/22/2020 - Rec'd confirmation from the clinic that this service location has been added to the group enrollment - Stacey Hudak"]
["Trinidad Marquez, FNP",1447701602,"83-0358685","TX","PE - Midland Community Healthcare Services","Cigna","Participating","Enrollment Complete","2020-09-01","1547832","","2020-08-27","08/27/2020 - Rec'd email from the payer stating this providers demo update has been made - Stacey Hudak"]
["Trinidad Marquez, FNP",1447701602,"83-0358685","TX","PE - Midland Community Healthcare Services","TriCare Standard","Participating","Enrollment Complete","2018-09-19","1447701602","","2020-09-09","09/09/2020 - moved to completed status after reviewing the last note - Stacey Hudak"]
["Trinidad Marquez, FNP",1447701602,"83-0358685","TX","PE - Midland Community Healthcare Services","Humana","Participating","Enrollment Complete","2017-02-10","","","2021-11-18","11/18/2021 Rcvd full roster from Humana listing provider as PAR and linked to group TIN/location effective 2/10/2017.  DCannon"]
["Trinidad Marquez, FNP",1447701602,"83-0358685","TX","PE - Midland Community Healthcare Services","Superior","Participating","Enrollment Complete","2020-09-01","1447701602","","2020-09-02","09/02/2020 - Rec'd email from the payer stating this service location has been added - Stacey Hudak"]
["Trinidad Marquez, FNP",1447701602,"83-0358685","TX","PE - Midland Community Healthcare Services","United Health Care","Participating","Enrollment Complete","2019-12-01","1447701602","","2020-07-30","7-30-2020 - moved to completed status after reviewing follow up complete note - stacey hudak"]
["Trinidad Marquez, FNP",1447701602,"83-0358685","TX","PE - Midland Community Healthcare Services","Boon Chapman","Participating","Enrollment Complete","2017-05-23","13574654","","2022-03-23","03/23/2022 Per follow-up note - S/W Asia of Boon Chapman @ 800-950-7040. Provider NPI# is on file  and is participating effective 5/23/2017 under the group and TIN#. Provider ID# 13574654.Physical location is on file.Call ref# 7943427.-DCannon"]
["Trinidad Marquez, FNP",1447701602,"83-0358685","TX","PE - Midland Community Healthcare Services","Triwest VA","DO NOT ENROLL","DO NOT ENROLL","","","","2022-11-15","Provider did not select inclusion with this payor."]
["Trinidad Marquez, FNP",1447701602,"83-0358685","TX","PE - Midland Community Healthcare Services","Caprock (CapStar)","Participating","Enrollment Complete","2021-06-01","","","2021-08-06","8/6/2021 Rcvd email from Caprock ProviderServices.T8@90degreebenefits.com that monthly delegated roster provider load is complete and provider is loaded under TIN at location effective 6/1/2021.  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","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"]
["Trinidad Marquez, FNP",1447701602,"83-0358685","TX","PE - Midland Community Healthcare Services","Cigna","Participating","Enrollment Complete","2020-07-06","1547832","","2020-07-07","07/07/2020 - Rec'd email from the payer stating \"Your effective date is 07/06/2020. Your provider identification number is 1547832. \" - Stacey Hudak"]
["Trinidad Marquez, FNP",1447701602,"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."]
["Trinidad Marquez, FNP",1447701602,"83-0358685","TX","PE - Midland Community Healthcare Services","Amerigroup","Participating","Enrollment Complete","2020-04-07","","","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 4/7/2020.   DCannon"]
["Trinidad Marquez, FNP",1447701602,"83-0358685","TX","PE - Midland Community Healthcare Services","Cigna","Participating","Enrollment Complete","2020-07-06","1547832","","2020-07-07","07/07/2020 - Rec'd email from the payer stating \"Your effective date is 07/06/2020. Your provider identification number is 1547832. \" - Stacey Hudak"]
["Trinidad Marquez, FNP",1447701602,"83-0358685","TX","PE - Midland Community Healthcare Services","Humana","Participating","Enrollment Complete","2017-02-10","1447701602","","2020-06-30","6/30/2020 - Received email spreadsheet from the payor confirmaing that this provider is EFF at this service location and PAR with the PRIMED DELEGATED agreement - Pam Porter"]
["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","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"]
["Trinidad Marquez, FNP",1447701602,"83-0358685","TX","PE - Midland Community Healthcare Services","Scott&White (First Care)","Participating","Enrollment Complete","2017-01-31","1447701602","","2020-08-20","08/20/2020 - Rec'd spreadsheet from the payer confirming this provider is affiliated with PRIMED DELEGATION under this TIN/Service LOcation. THis provider is networked with: \nFirstCare MyChoice PPO\nCHIP\nFirstCare Select Benefit Network\nHMO Enhanced Benefit Network\nMedicare (FC)\nPPO Limited Benefit Network\n- Stacey Hudak"]
["Trinidad Marquez, FNP",1447701602,"83-0358685","TX","PE - Midland Community Healthcare Services","Molina","Participating","Enrollment Complete","2018-08-03","","","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 8/3/2018.  DCannon"]
["Trinidad Marquez, FNP",1447701602,"83-0358685","TX","PE - Midland Community Healthcare Services","United Health Care","Participating","Enrollment Complete","2019-12-01","","","2021-01-18","1/18/2021 - Per follow-up notes provider NPI# is on file for the provider and is participating effective 12/01/2019 for Commercial Choice, 09/20/2017 for Community and State and 06/01/2020 for Medicare under the group and TIN#. Physical location is on file.  DCannon"]
["Trinidad Marquez, FNP",1447701602,"83-0358685","TX","PE - Midland Community Healthcare Services","United Health Care","Participating","Enrollment Complete","2019-12-01","1447701602","","2020-07-30","7-30-2020 - moved to completed status after reviewing follow up complete note - stacey hudak"]
["Trinidad Marquez, FNP",1447701602,"83-0358685","TX","PE - Midland Community Healthcare Services","Rail Road Medicare","Participating","Enrollment Complete","2016-12-01","P02500701","DC8592","2020-08-28","08/28/2020 - this provider has been moved to EFF status after confirming through payer portal - Stacey Hudak"]
["Trinidad Marquez, FNP",1447701602,"83-0358685","TX","PE - Midland Community Healthcare Services","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"]
["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","Scott&White (First Care)","Participating","Enrollment Complete","2017-01-31","1447701602","","2020-08-20","08/20/2020 - Rec'd spreadsheet from the payer confirming this provider is affiliated with PRIMED DELEGATION under this TIN/Service LOcation. THis provider is networked with: \nFirstCare MyChoice PPO\nCHIP\nFirstCare Select Benefit Network\nHMO Enhanced Benefit Network\nMedicare (FC)\nPPO Limited Benefit Network\n- Stacey Hudak"]
["Trinidad Marquez, FNP",1447701602,"83-0358685","TX","PE - Midland Community Healthcare Services","Cigna","Participating","Enrollment Complete","2021-06-01","1547832","","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 1547832. KFrazier"]
["Trinidad Marquez, FNP",1447701602,"83-0358685","TX","PE - Midland Community Healthcare Services","Multiplan","Participating","Enrollment Complete","2017-09-01","1447701602","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 9-1-2017. This provider is par under network MPI - 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","Medicare","In House Enrollment","In House Enrollment","","","","2021-07-31","7/31/2021 This will be processed by group. KFrazier"]
["Trinidad Marquez, FNP",1447701602,"83-0358685","TX","PE - Midland Community Healthcare Services","Rail Road Medicare","Participating","Enrollment Complete","2016-12-01","P02500701","DC8592","2020-08-28","08/28/2020 - this provider has been moved to EFF status after confirming through payer portal - Stacey Hudak"]
["Trinidad Marquez, FNP",1447701602,"83-0358685","TX","PE - Midland Community Healthcare Services","Aetna","Participating","Enrollment Complete","2020-09-01","","","2020-12-09","12/9/2020 - Rcvd confirmation from payor that provider is now active and linked to this location.  DCannon"]
["Trinidad Marquez, FNP",1447701602,"83-0358685","TX","PE - Midland Community Healthcare Services","Amerigroup","Participating","Enrollment Complete","2018-08-03","1447701602","","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"]
["Trinidad Marquez, FNP",1447701602,"83-0358685","TX","PE - Midland Community Healthcare Services","Multiplan","Participating","Enrollment Complete","2017-09-01","1447701602","Midland Community Healthcare Services","2020-07-06","07/06/2020 - Rec'd email from the payer stating :\n\"Thank you for contacting our Service Department at MultiPlan. Here is the following information we have on file for Marquez, Trinidad:\n\nNetwork:  MPI/PHCS\nNetwork Participation effective:09/01/2017 Contract Source Group contract through: Midland Community Healthcare Services\"\n- Stacey Hudak"]
["Trinidad Marquez, FNP",1447701602,"83-0358685","TX","PE - Midland Community Healthcare Services","Boon Chapman","Participating","Enrollment Complete","2017-09-01","1447701602","","2020-10-05","Enrolled thru PHCS"]
["Trinidad Marquez, FNP",1447701602,"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"]
["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","Medicaid","In House Enrollment","In House Enrollment","","","","2021-07-31","7/31/2021 This will be processed by group. KFrazier"]
["Trinidad Marquez, FNP",1447701602,"83-0358685","TX","PE - Midland Community Healthcare Services","HealthSmart PPO","Participating","Enrollment Complete","2017-01-13","","","2021-01-27","1/27/2021 - Rcvd email from payer showing provider as participating at location and linked to TIN effective 1/13/2017.  DCannon"]
["Trinidad Marquez, FNP",1447701602,"83-0358685","TX","PE - Midland Community Healthcare Services","Aetna","Participating","Enrollment Complete","2018-01-18","1447701602","","2020-03-24","3/24/2020--Called Aetna @ 8008723862 but per rep, any inquiries about credentialing must call credentialing department @ 8003531232. Called 8003531232 and SW JR, Per rep, Provider NPI# is on file and participating in-network under the group and TIN# effective 1/18/2018. DIRECT CONTRACT. Location is on file. Call ref# 5192494651.--tisha rader"]
["Trinidad Marquez, FNP",1447701602,"83-0358685","TX","PE - Midland Community Healthcare Services","Humana","Participating","Enrollment Complete","2017-02-10","","","2021-11-18","11/18/2021 Rcvd full roster from Humana listing provider as PAR and linked to group TIN/location effective 2/10/2017.  DCannon"]
["Trinidad Marquez, FNP",1447701602,"83-0358685","TX","PE - Midland Community Healthcare Services","First Health Coventry","Participating","Enrollment Complete","2021-08-01","3016142","","2022-02-04","2/4/2022 Per roster received from First Health provider is PAR and linked to group TIN/location effective 8/1/2021.  DCannon"]
["Trinidad Marquez, FNP",1447701602,"83-0358685","TX","PE - Midland Community Healthcare Services","Scott&White (First Care)","Participating","Enrollment Complete","2017-01-31","","","2021-01-29","1/29/2021 - Rcvd roster from Scott&White (First Care) confirming participation of provider with TIN and location effective dates.  DCannon"]
["Trinidad Marquez, FNP",1447701602,"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 06/01/2021.  DCannon"]
["Trinidad Marquez, FNP",1447701602,"83-0358685","TX","PE - Midland Community Healthcare Services","Aetna","Participating","Enrollment Complete","2018-01-01","1447701602","","2020-06-09","06/09/2020 - Rec'd email from the payer stating this provider is EFF 1-1-2018 under a DIRECT CONTRACT - Stacey Hudak"]
["Trinidad Marquez, FNP",1447701602,"83-0358685","TX","PE - Midland Community Healthcare Services","Aetna","Participating","Enrollment Complete","2021-06-01","5152938","","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 # 5152938  DCannon"]
["Trinidad Marquez, FNP",1447701602,"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"]
["Trinidad Marquez, FNP",1447701602,"83-0358685","TX","PE - Midland Community Healthcare Services","TriCare Standard","Participating","Enrollment Complete","2021-12-08","","","2021-12-14","12/14/2021 Per portal, provider linked to location as of 12/8/2021. Cbankston"]
["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","Caprock (CapStar)","Participating","Enrollment Complete","2017-02-10","1447701602","","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"]
["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","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","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","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","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","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","Amerigroup","Participating","Enrollment Complete","2018-08-03","1447701602","","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"]
["Trinidad Marquez, FNP",1447701602,"83-0358685","TX","PE - Midland Community Healthcare Services","Caprock (CapStar)","Participating","Enrollment Complete","2017-02-10","1447701602","","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"]
["Trinidad Marquez, FNP",1447701602,"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"]
["Trinidad Marquez, FNP",1447701602,"83-0358685","TX","PE - Midland Community Healthcare Services","Medicare","Participating","In House Enrollment","2016-12-01","551665YM2M","00304W","2020-07-15","07/15/2020 - Rec'd welcome letter from the clinic. Made this payer line to store EFF information, but this enrollment is maintained in house, not by Symplr - Stacey Hudak"]
["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"]
["Trinidad Marquez, FNP",1447701602,"83-0358685","TX","PE - Midland Community Healthcare Services","Humana","Participating","Enrollment Complete","2017-02-10","1447701602","","2020-06-30","6/30/2020 - Received email spreadsheet from the payor confirmaing that this provider is EFF at this service location and PAR with the PRIMED DELEGATED agreement - Pam Porter"]
["Trinidad Marquez, FNP",1447701602,"83-0358685","TX","PE - Midland Community Healthcare Services","TriCare Standard","Participating","Enrollment Complete","2021-04-10","","","2021-04-23","4/23/2021 Upon review of the self-service portal, provider is loaded as non-network under group location effective 4/10/2021. KFrazier"]
["Trinidad Marquez, FNP",1447701602,"83-0358685","TX","PE - Midland Community Healthcare Services","Caprock (CapStar)","Participating","Enrollment Complete","2017-02-10","","","2020-09-14",""]
["Trinidad Marquez, FNP",1447701602,"83-0358685","TX","PE - Midland Community Healthcare Services","TriCare Standard","Participating","Enrollment Complete","2021-05-25","","","2021-09-14","9/14/2021 Per Tricare Portal provider is certified with TaxID as of 5/25/2021. Cbankston"]
["Trinidad Marquez, FNP",1447701602,"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"]
["Chabacana Maxwell, FNP",1154767234,"83-0358685: P","TX","PE - Midland Community Healthcare Services","Scott&White (First Care)","Participating","Enrollment Complete","2018-11-06","1154767234","","2020-08-19","8/19/2020 - Rec'd email confirmation from the payer stating this provider IS LINKED TO THE PRIMED DELEGATED AGREEMENT under this TIN/Service Locaiton. Provider is 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"]
["Chabacana Maxwell, FNP",1154767234,"83-0358685: P","TX","PE - Midland Community Healthcare Services","United Health Care","Participating","Enrollment Complete","2015-08-20","5618134","","2020-07-30","7/30/2020 - moved to completed status after reviewing follow up complete note - Stacey Hudak"]
["Chabacana Maxwell, FNP",1154767234,"83-0358685: P","TX","PE - Midland Community Healthcare Services","HealthSmart PPO","Participating","Enrollment Complete","2015-08-20","1154767234","","2020-06-04","06/04/2020 - 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","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 06/01/2021.  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","TriCare Standard","Participating","Enrollment Complete","2016-11-07","1154767234","","2020-09-09","09/09/2020 - Reviewed previous note and moved to completed status - Stacey Hudak"]
["Chabacana Maxwell, FNP",1154767234,"83-0358685","TX","PE - Midland Community Healthcare Services","Molina","Participating","Enrollment Complete","2015-09-29","","","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 9/29/2015.  DCannon"]
["Chabacana Maxwell, FNP",1154767234,"83-0358685: P","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"]
["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","HealthSmart PPO","Participating","Enrollment Complete","2021-06-01","","","2021-08-18","8/18/2021 Per Healthsmart website provider is PAR and loaded under TIN/location effective 6/1/2021.  DCannon"]
["Chabacana Maxwell, FNP",1154767234,"83-0358685: S","TX","PE - Midland Community Healthcare Services","Rail Road Medicare","Participating","Enrollment Complete","2015-05-05","P02500765","DC8592","2020-08-28","08/28/2020 - moved to completed status after finding EFF info through payer site - Stacey Hudak"]
["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","Rail Road Medicare","Participating","Enrollment Complete","2015-05-05","P02500765","DC8592","2020-08-28","08/28/2020 - moved to completed status after finding EFF info through the site - Stacey Hudak"]
["Chabacana Maxwell, FNP",1154767234,"83-0358685: S","TX","PE - Midland Community Healthcare Services","Omni PPO","Participating","Enrollment Complete","2015-08-29","","","2022-04-13","4/13/2022 Per roster from IMS/Omni provider is PAR and linked to group TIN/location effective 8/29/2015.  DCannon"]
["Chabacana Maxwell, FNP",1154767234,"83-0358685: P","TX","PE - Midland Community Healthcare Services","First Health Coventry","Participating","Enrollment Complete","2015-09-01","2770971","","2020-03-20","3/20/2020-receieved email with roster stating provider PAR 10/1/2015 PID # 2770971-tisha rader"]
["Chabacana Maxwell, FNP",1154767234,"83-0358685: T","TX","PE - Midland Community Healthcare Services","Amerigroup","Participating","Enrollment Complete","2019-05-03","","","2021-08-26","8/26/2021 Rcvd full roster from Joe Rodriguez at Amerigroup listing provider as PAR w/ group TIN and location effective 5/3/2019.  DCannon"]
["Chabacana Maxwell, FNP",1154767234,"83-0358685","TX","PE - Midland Community Healthcare Services","Cigna","Participating","Enrollment Complete","2021-06-01","392062","","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 392062. KFrazier"]
["Chabacana Maxwell, FNP",1154767234,"83-0358685: T","TX","PE - Midland Community Healthcare Services","IMS","Participating","Enrollment Complete","2020-08-01","","","2020-08-25","Confirmed provider is participating at this location as of 8/1/2020. Kimberly Frazier"]
["Chabacana Maxwell, FNP",1154767234,"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"]
["Chabacana Maxwell, FNP",1154767234,"83-0358685: T","TX","PE - Midland Community Healthcare Services","HealthSmart PPO","Participating","Enrollment Complete","2015-08-20","","","2021-01-27","1/27/2021 - Rcvd email from payer showing provider as participating at location and linked to TIN effective 8/20/2015.  DCannon"]
["Chabacana Maxwell, FNP",1154767234,"83-0358685","TX","PE - Midland Community Healthcare Services","Triwest VA","In Process","Application Submitted","","","","2022-11-15"," 08/19/2022 - Application submitted to Scarlett Abigail (Scarlett_Abigail@bcbstx.com) of TriWest VA"]
["Chabacana Maxwell, FNP",1154767234,"83-0358685","TX","PE - Midland Community Healthcare Services","Aetna","Participating","Enrollment Complete","2021-06-01","5230889","","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 # 5230889  DCannon"]
["Chabacana Maxwell, FNP",1154767234,"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"]
["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: S","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: T","TX","PE - Midland Community Healthcare Services","First Health Coventry","Participating","Enrollment Complete","2015-11-01","1154767234","","2020-09-24","09/24/2020 - moved to completed status after reviewing follow up complete - Stacey Hudak"]
["Chabacana Maxwell, FNP",1154767234,"83-0358685: T","TX","PE - Midland Community Healthcare Services","Scott&White (First Care)","Participating","Enrollment Complete","2018-11-06","1154767234","","2020-08-19","8/19/2020 - Rec'd email confirmation from the payer stating this provider IS LINKED TO THE PRIMED DELEGATED AGREEMENT under this TIN/Service Locaiton. Provider is 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"]
["Chabacana Maxwell, FNP",1154767234,"83-0358685: P","TX","PE - Midland Community Healthcare Services","Medicaid","Participating","Enrollment Complete","2018-03-08","1154767234","","2020-03-24","3/24/2020--3/24/2020--Called Aetna @ 8008723862 but per rep, any inquiries about credentialing must call credentialing department @ 8003531232. Called 8003531232 and SW Ella, Per rep, Provider NPI# is on file and participating in-network under the group and TIN# effective 3/8/2018. DELEGATED CONTRACT under Primed Health. Location is on file. Call ref# 51992568633.\ntisha rader"]
["Chabacana Maxwell, FNP",1154767234,"83-0358685: S","TX","PE - Midland Community Healthcare Services","HealthSmart PPO","Participating","Enrollment Complete","2015-08-20","1154767234","","2020-06-04","06/04/2020 - Rec'd email from the payer stating this provider is EFF - Stacey Hudak"]
["Chabacana Maxwell, FNP",1154767234,"83-0358685: S","TX","PE - Midland Community Healthcare Services","USA PPO","Participating","Enrollment Complete","2020-03-20","","","2022-04-09","4/09/2022 Per roster from USA MCO provider is PAR and linked to group TIN/location effective 3/20/2020.  DCannon"]
["Chabacana Maxwell, FNP",1154767234,"83-0358685: P","TX","PE - Midland Community Healthcare Services","Omni PPO","Participating","Enrollment Complete","2020-03-20","","","2022-04-13","4/13/2022 Per roster from IMS/Omni provider is PAR and linked to group TIN/location effective 3/20/2020.  DCannon"]
["Chabacana Maxwell, FNP",1154767234,"83-0358685: S","TX","PE - Midland Community Healthcare Services","Caprock (CapStar)","Participating","Enrollment Complete","2015-08-30","1154767234","","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"]
["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","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"]
["Chabacana Maxwell, FNP",1154767234,"83-0358685: P","TX","PE - Midland Community Healthcare Services","Multiplan","Participating","Enrollment Complete","2016-07-26","","","2021-07-01","7/1/2021 Received roster from Multiplan confirming participation of providers with TIN /locations effective 07/26/2016.  DCannon"]
["Chabacana Maxwell, FNP",1154767234,"83-0358685: S","TX","PE - Midland Community Healthcare Services","Aetna","Participating","Enrollment Complete","2018-03-08","1154767234","","2020-03-24","3/24/2020--Called Aetna @ 8008723862 but per rep, any inquiries about credentialing must call credentialing department @ 8003531232. Called 8003531232 and SW Ella, Per rep, Provider NPI# is on file and participating in-network under the group and TIN# effective 3/8/2018. DELEGATED CONTRACT under Primed Health. Location is on file. Call ref# 51992568633.\ntisha rader"]
["Chabacana Maxwell, FNP",1154767234,"83-0358685","TX","PE - Midland Community Healthcare Services","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"]
["Chabacana Maxwell, FNP",1154767234,"83-0358685: T","TX","PE - Midland Community Healthcare Services","Cigna","Participating","Enrollment Complete","2020-10-15","","","2021-07-29","7/29/2021 Submitted demographic update to Intake_pdm@cigna.com on group level requesting practice location be added for provider. KFrazier"]
["Chabacana Maxwell, FNP",1154767234,"83-0358685: T","TX","PE - Midland Community Healthcare Services","Boon Chapman","Participating","Enrollment Complete","2017-09-01","","","2022-07-01","7/1/2022 Provider is PAR and linked to group TIN/location effective 9/1/2017."]
["Chabacana Maxwell, FNP",1154767234,"83-0358685","TX","PE - Midland Community Healthcare Services","First Health Coventry","Participating","Enrollment Complete","2021-06-01","","","2021-11-03","11/3/2021  Per First Health online provider directory provider is PAR and linked to group/locations  effective 6/1/2021.  DCannon"]
["Chabacana Maxwell, FNP",1154767234,"83-0358685: S","TX","PE - Midland Community Healthcare Services","First Health Coventry","Participating","Enrollment Complete","2015-09-01","2770971","","2020-03-20","3/20/2020-receieved email with roster stating provider PAR 10/1/2015 PID # 2770971-tisha rader"]
["Chabacana Maxwell, FNP",1154767234,"83-0358685: S","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: S","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: P","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: P","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","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","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","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","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","Caprock (CapStar)","Participating","Enrollment Complete","2015-08-30","","","2020-09-14",""]
["Chabacana Maxwell, FNP",1154767234,"83-0358685: P","TX","PE - Midland Community Healthcare Services","Caprock (CapStar)","Participating","Enrollment Complete","2015-08-30","1154767234","","2020-09-14",""]
["Chabacana Maxwell, FNP",1154767234,"83-0358685: P","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","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"]
["Chabacana Maxwell, FNP",1154767234,"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"]
["Chabacana Maxwell, FNP",1154767234,"83-0358685: T","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"]
["Chabacana Maxwell, FNP",1154767234,"83-0358685","TX","PE - Midland Community Healthcare Services","Amerigroup","Participating","Enrollment Complete","2019-05-03","","","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 5/3/2019.   DCannon"]
["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","Cigna","Participating","Enrollment Complete","2020-07-07","0392062","","2020-07-08","07/08/2020 - Rec'd email from the payer stating \"Your effective date is 07/07/2020. Your provider identification number is 0392062.\"  - 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","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: 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: 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: T","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: T","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","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","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: T","TX","PE - Midland Community Healthcare Services","Medicare","Participating","In House Enrollment","2020-08-01","418117YM2M","00304W","2020-09-22","09/22/2020 - Rec'd email from the clinic confirming that this service location has been approved under the group enrollment - Stacey Hudak"]
["Chabacana Maxwell, FNP",1154767234,"83-0358685: S","TX","PE - Midland Community Healthcare Services","IMS","Participating","Enrollment Complete","2015-08-29","","","2022-04-13","4/13/2022 Per roster from IMS/Omni provider is PAR and linked to group TIN/location effective 8/29/2015.  DCannon"]
["Chabacana Maxwell, FNP",1154767234,"83-0358685: S","TX","PE - Midland Community Healthcare Services","Scott&White (First Care)","Participating","Enrollment Complete","2018-11-06","1154767234","","2020-08-19","8/19/2020 - Rec'd email confirmation from the payer stating this provider IS LINKED TO THE PRIMED DELEGATED AGREEMENT under this TIN/Service Locaiton. Provider is 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"]
["Chabacana Maxwell, FNP",1154767234,"83-0358685: T","TX","PE - Midland Community Healthcare Services","Humana","Participating","Enrollment Complete","2015-10-07","","","2021-11-18","11/18/2021 Rcvd full roster from Humana listing provider as PAR and linked to group TIN/location effective 10/7/2015.  DCannon"]
["Chabacana Maxwell, FNP",1154767234,"83-0358685: S","TX","PE - Midland Community Healthcare Services","United Health Care","Participating","Enrollment Complete","2015-03-01","5618134","","2020-06-08","06/08/2020 - Rec'd email from the payer stating this service location/provider is EFF - Stacey Hudak"]
["Chabacana Maxwell, FNP",1154767234,"83-0358685: S","TX","PE - Midland Community Healthcare Services","Humana","Participating","Enrollment Complete","2015-10-07","1154767234","","2020-06-30","6/30/2020 - Receved email spreadsheet from the paayor confirmg that this provider is EFF this service location and PAR with the PRIMED DELEGATED agreement - Pam Porter"]
["Chabacana Maxwell, FNP",1154767234,"83-0358685: P","TX","PE - Midland Community Healthcare Services","Boon Chapman","Participating","Enrollment Complete","2016-07-26","","","2021-09-16","9/15/2021 Received roster from Multiplan listing provider as PAR under group TIN/location effective 7/26/2016.  DCannon"]
["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"]
["Chabacana Maxwell, FNP",1154767234,"83-0358685","TX","PE - Midland Community Healthcare Services","Medicare","In House Enrollment","In House Enrollment","","","","2021-07-31","7/31/2021 This will be processed by group. KFrazier"]
["Chabacana Maxwell, FNP",1154767234,"83-0358685","TX","PE - Midland Community Healthcare Services","Humana","Participating","Enrollment Complete","2015-10-07","","","2021-11-18","11/18/2021 Rcvd full roster from Humana listing provider as PAR and linked to group TIN/location effective 10/7/2015.  DCannon"]
["Chabacana Maxwell, FNP",1154767234,"83-0358685: P","TX","PE - Midland Community Healthcare Services","USA PPO","Participating","Enrollment Complete","2020-03-20","","","2022-04-09","4/09/2022 Per roster from USA MCO provider is PAR and linked to group TIN/location effective 3/20/2020.  DCannon"]
["Chabacana Maxwell, FNP",1154767234,"83-0358685: S","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"]
["Chabacana Maxwell, FNP",1154767234,"83-0358685: T","TX","PE - Midland Community Healthcare Services","Aetna","Participating","Enrollment Complete","2015-09-01","","","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"]
["Chabacana Maxwell, FNP",1154767234,"83-0358685: P","TX","PE - Midland Community Healthcare Services","Humana","Participating","Enrollment Complete","2015-10-07","1154767234","","2020-06-30","6/30/2020 - Receved email spreadsheet from the paayor confirmg that this provider is EFF this service location and PAR with the PRIMED DELEGATED agreement - Pam Porter"]
["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","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"]
["Chabacana Maxwell, FNP",1154767234,"83-0358685: S","TX","PE - Midland Community Healthcare Services","Cigna","Participating","Enrollment Complete","2020-07-07","0392062","","2020-07-08","07/08/2020 - Rec'd email from the payer stating \"Your effective date is 07/07/2020. Your provider identification number is 0392062. \" - Stacey Hudak"]
["Chabacana Maxwell, FNP",1154767234,"83-0358685: S","TX","PE - Midland Community Healthcare Services","Aetna","Participating","Enrollment Complete","2018-03-08","","","2022-04-12","4/12/2022 Per roster received from Aetna provider is PAR and linked to group TIN/location effective 6/1/2021.  DCannon"]
["Chabacana Maxwell, FNP",1154767234,"83-0358685: T","TX","PE - Midland Community Healthcare Services","United Health Care","Participating","Enrollment Complete","2020-10-07","1154767234","","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 12:05:19 PM. Your request was assigned reference number PR-5533533 .\" - Stacey Hudak"]
["Chabacana Maxwell, FNP",1154767234,"83-0358685","TX","PE - Midland Community Healthcare Services","Caprock (CapStar)","Participating","Enrollment Complete","2021-06-01","","","2021-08-06","8/6/2021 Rcvd email from Caprock ProviderServices.T8@90degreebenefits.com that monthly delegated roster provider load is complete and provider is loaded under TIN at location effective 6/1/2021.  DCannon"]
["Chabacana Maxwell, FNP",1154767234,"83-0358685: P","TX","PE - Midland Community Healthcare Services","TriCare Standard","Participating","Enrollment Complete","2021-06-04","","","2021-09-14","9/14/2021 Confirmed via self-service portal, provider is certified under group Tax ID effective 06/04/2021. Cbankston"]
["Chabacana Maxwell, FNP",1154767234,"83-0358685","TX","PE - Midland Community Healthcare Services","TriCare Standard","Participating","Enrollment Complete","2021-12-09","","","2022-02-10","2/10/2022 Pre Tricare portal, provider is linked to location as of 12.9.2021. Cbankston"]
["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","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"]
["Tonya Murphy, FNP",1891931341,"83-0358685","TX","PE - Midland Community Healthcare Services","Humana","Participating","Enrollment Complete","2019-02-20","1891931341","","2020-06-30","6/30/2020 - 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"]
["Tonya Murphy, FNP",1891931341,"83-0358685","TX","PE - Midland Community Healthcare Services","Multiplan","Participating","Enrollment Complete","2022-03-01","","","2022-09-13","9/13/2022 Per roster received from Multiplan provider is PAR and linked to group TIN/location effective 3/1/2022.  DCannon"]
["Tonya Murphy, FNP",1891931341,"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","First Health Coventry","Participating","Enrollment Complete","2021-06-01","","","2021-11-03","11/3/2021  Per First Health online provider directory provider is PAR and linked to group/locations  effective 6/1/2021.  DCannon"]
["Tonya Murphy, FNP",1891931341,"83-0358685","TX","PE - Midland Community Healthcare Services","United Health Care","Participating","Enrollment Complete","2019-12-01","","","2021-10-13","10/12/21 Received email from Mosley, Aldean D aldean_mosley@uhc.com, provider par at this location as of 12/1/2019. Cbankston"]
["Tonya Murphy, FNP",1891931341,"83-0358685","TX","PE - Midland Community Healthcare Services","Amerigroup","Participating","Enrollment Complete","2019-05-07","1891931341","","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"]
["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","Aetna","Participating","Enrollment Complete","2020-06-15","","","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"]
["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 effective6/1/2021.  DCannon"]
["Tonya Murphy, FNP",1891931341,"83-0358685","TX","PE - Midland Community Healthcare Services","Medicare","In House Enrollment","In House Enrollment","","","","2021-07-31","7/31/2021 This will be processed by group. KFrazier"]
["Tonya Murphy, FNP",1891931341,"83-0358685","TX","PE - Midland Community Healthcare Services","Caprock (CapStar)","Participating","Enrollment Complete","2019-02-19","1891931341","","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"]
["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","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","Triwest VA","DO NOT ENROLL","DO NOT ENROLL","","","","2022-11-15","Provider did not select inclusion with this payor; provider specialty pediatrics; not eligible for TriWest VA enrollment"]
["Tonya Murphy, FNP",1891931341,"83-0358685","TX","PE - Midland Community Healthcare Services","United Health Care","Participating","Enrollment Complete","2020-07-08","1891931341","","2020-07-21","07/21/2020 - Rec'd email from the payer stating \"Good news! We’ve completed the provider/group updates you requested on Jul 8, 2020 1:28:34 PM. Your request was assigned reference number PR-5374767 \" - Stacey Hudak"]
["Tonya Murphy, FNP",1891931341,"83-0358685","TX","PE - Midland Community Healthcare Services","First Health Coventry","Participating","Enrollment Complete","2021-09-04","2327745","","2022-02-04","2/4/2022 Per roster received from First Health provider is PAR and linked to group TIN/location effective 9/4/2021.  DCannon"]
["Tonya Murphy, FNP",1891931341,"83-0358685","TX","PE - Midland Community Healthcare Services","Amerigroup","Participating","Enrollment Complete","2015-05-20","","","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 5/20/2015.   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","United Health Care","Participating","Enrollment Complete","2019-12-01","","","2021-10-12","Received email from aldean_mosley@uhc.com, location par as of 12/1/19. Cbankston"]
["Tonya Murphy, FNP",1891931341,"83-0358685","TX","PE - Midland Community Healthcare Services","Amerigroup","Participating","Enrollment Complete","2015-05-20","","","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 5/20/2015.   DCannon"]
["Tonya Murphy, FNP",1891931341,"83-0358685","TX","PE - Midland Community Healthcare Services","Caprock (CapStar)","Participating","Enrollment Complete","2021-06-01","","","2021-08-06","8/6/2021 Rcvd email from Caprock ProviderServices.T8@90degreebenefits.com that monthly delegated roster provider load is complete and provider is loaded under TIN at location effective 6/1/2021.  DCannon"]
["Tonya Murphy, FNP",1891931341,"83-0358685","TX","PE - Midland Community Healthcare Services","Caprock (CapStar)","Participating","Enrollment Complete","2019-02-19","","","2020-09-14",""]
["Tonya Murphy, FNP",1891931341,"83-0358685","TX","PE - Midland Community Healthcare Services","Aetna","Participating","Enrollment Complete","2019-03-15","1891931341","","2020-03-24","3/24/2020--Called Aetna @ 8008723862 but per rep, any inquiries about credentialing must call credentialing department @ 8003531232. Called 8003531232 and SW Ella, Per rep, Provider NPI# is on file and participating in-network under the group and TIN# effective 3/15/2019. Delegated contract under Permian Basin Healthcare. Location is on file. Call ref# 51992568633.\ntisha rader"]
["Tonya Murphy, FNP",1891931341,"83-0358685","TX","PE - Midland Community Healthcare Services","Multiplan","Participating","Enrollment Complete","2019-06-05","13355149","","2022-02-24","2/24/2022 Per follow-up note from 2/17/2022 -  NPI# for the provider is on file and shows Linked and Par under group and TIN# effective 6/5/2019, the physical location is on file and the Provider ID is 13355149.  Case ref#7918618.  DCannon"]
["Tonya Murphy, FNP",1891931341,"83-0358685","TX","PE - Midland Community Healthcare Services","Boon Chapman","Participating","Enrollment Complete","2019-06-05","","","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 6/5/2019.  DCannon"]
["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","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 06/01/2021.  DCannon"]
["Tonya Murphy, FNP",1891931341,"83-0358685","TX","PE - Midland Community Healthcare Services","Boon Chapman","Participating","Enrollment Complete","2022-03-01","","","2022-09-13","9/13/2022 Per roster received from Multiplan provider is PAR and linked to group TIN/location effective 3/1/2022.  DCannon"]
["Tonya Murphy, FNP",1891931341,"83-0358685","TX","PE - Midland Community Healthcare Services","Galaxy Health","Participating","Enrollment Complete","2020-05-01","","","2022-04-09","4/9/2022 Per roster received from Galaxy provider is listed as PAR and linked to group TIN/location effective 5/1/2020.  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","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","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","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","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","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","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","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","Cigna","Participating","Enrollment Complete","2021-06-01","5244447","","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 5244447. KFrazier"]
["Tonya Murphy, FNP",1891931341,"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"]
["Tonya Murphy, FNP",1891931341,"83-0358685","TX","PE - Midland Community Healthcare Services","Superior","Participating","Enrollment Complete","2020-09-01","1891931341","","2020-09-02","09/02/2020 - Rec'd spreadsheet from the payer stating this location update has been made EFF 9-1-2020 - Stacey Hudak"]
["Tonya Murphy, FNP",1891931341,"83-0358685","TX","PE - Midland Community Healthcare Services","First Health Coventry","Participating","Enrollment Complete","2019-02-01"," 2327745","","2020-03-20","3/20/2020-receieved email with roster stating provider PAR 2/1/2019 PID # 2327745\ntisha rader"]
["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","Galaxy Health","Participating","Enrollment Complete","2020-05-01","","","2022-04-09","4/9/2022 Per roster received from Galaxy provider is listed as PAR and linked to group TIN/location effective 5/1/2020.  DCannon"]
["Tonya Murphy, FNP",1891931341,"83-0358685","TX","PE - Midland Community Healthcare Services","Medicare","Participating","In House Enrollment","2019-01-01","758005","00304W","2020-08-21","08/21/2020 - Added this payer line to store effective information. This enrollment is not maintained by Symplr - per the clinic, this will be maintained IN HOUSE - Stacey Hudak"]
["Tonya Murphy, FNP",1891931341,"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"]
["Tonya Murphy, FNP",1891931341,"83-0358685","TX","PE - Midland Community Healthcare Services","Medicare","In House Enrollment","In House Enrollment","","","","2021-07-31","7/31/2021 This will be processed by group. KFrazier"]
["Tonya Murphy, FNP",1891931341,"83-0358685","TX","PE - Midland Community Healthcare Services","HealthSmart PPO","Participating","Enrollment Complete","2019-02-20","1891931341","","2020-06-04","06/04/2020 - rec'd email from the payer stating this provider is EFF - Stacey Hudak"]
["Tonya Murphy, FNP",1891931341,"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"]
["Tonya Murphy, FNP",1891931341,"83-0358685","TX","PE - Midland Community Healthcare Services","Aetna","Participating","Enrollment Complete","2021-06-01","9085264","","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 # 9085264  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","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"]
["Tonya Murphy, FNP",1891931341,"83-0358685","TX","PE - Midland Community Healthcare Services","Cigna","Participating","Enrollment Complete","2019-09-01","5244447","","2020-05-13","05/13/2020 - rec'd email from the payer stating \"This is to confirm that your request has been completed.\" - Stacey Hudak"]
["Tonya Murphy, FNP",1891931341,"83-0358685","TX","PE - Midland Community Healthcare Services","Caprock (CapStar)","Participating","Enrollment Complete","2021-06-01","","","2021-08-06","8/6/2021 Rcvd email from Caprock ProviderServices.T8@90degreebenefits.com that monthly delegated roster provider load is complete and provider is loaded under TIN at location effective 6/1/2021.  DCannon"]
["Tonya Murphy, FNP",1891931341,"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"]
["Tonya Murphy, FNP",1891931341,"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"]
["Tonya Murphy, FNP",1891931341,"83-0358685","TX","PE - Midland Community Healthcare Services","Scott&White (First Care)","Participating","Enrollment Complete","2020-02-03","","","2021-01-29","1/29/2021 - Rcvd roster from Scott&White (First Care) confirming participation of provider with TIN and location effective dates.  DCannon"]
["Tonya Murphy, FNP",1891931341,"83-0358685","TX","PE - Midland Community Healthcare Services","Medicare","Participating","In House Enrollment","2020-08-01","758005","00304W","2020-09-22","09/22/2020 - Rec'd confirmation from the clinic that this service location has been approved under the group enrollment - 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","Triwest VA","DO NOT ENROLL","DO NOT ENROLL","","","","","Provider did not select inclusion with this payor; provider specialty pediatrics; not eligible for TriWest VA enrollment"]
["Tonya Murphy, FNP",1891931341,"83-0358685","TX","PE - Midland Community Healthcare Services","Cigna","Participating","Enrollment Complete","2020-09-01","5244447","","2020-09-28","09/28/2020 - Rec'd email from the payer stating \"Your effective date is 09/01/2020. Your provider identification number is 5244447. \" - Stacey Hudak"]
["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","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","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"]
["Tonya Murphy, FNP",1891931341,"83-0358685","TX","PE - Midland Community Healthcare Services","IMS","Participating","Enrollment Complete","2020-08-01","","","2020-08-25","Confirmed provider is participating at this location as of 8/1/2020. Kimberly Frazier"]
["Tonya Murphy, FNP",1891931341,"83-0358685","TX","PE - Midland Community Healthcare Services","IMS","Participating","Enrollment Complete","2019-02-19","1891931341","","2020-06-22","06/22/2020- Rec'd email from the payer confirming this provider is PAR with this group/service location - Stacey Hudak"]
["Tonya Murphy, FNP",1891931341,"83-0358685","TX","PE - Midland Community Healthcare Services","Aetna","Participating","Enrollment Complete","2021-06-01","9085264","","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 # 9085264  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","Cigna","Participating","Enrollment Complete","2021-06-01","5244447","","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 5244447. KFrazier"]
["Tonya Murphy, FNP",1891931341,"83-0358685","TX","PE - Midland Community Healthcare Services","Amerigroup","Participating","Enrollment Complete","2020-05-01","","","2021-08-26","8/26/2021 Rcvd full roster from Joe Rodriguez at Amerigroup listing provider as PAR w/ group TIN and location effective 5/1/2020.  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","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","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","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","Molina","Participating","Enrollment Complete","2019-05-07","","","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 5/7/2019.  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","USA PPO","Participating","Enrollment Complete","2021-06-01","","","2022-04-13","4/13/2022 Per roster from USA MCO provider is PAR and linked to group TIN/location effective 6/1/2021.  DCannon"]
["Tonya Murphy, FNP",1891931341,"83-0358685","TX","PE - Midland Community Healthcare Services","Molina","Participating","Enrollment Complete","2019-05-07","","","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 5/7/2019.  DCannon"]
["Tonya Murphy, FNP",1891931341,"83-0358685","TX","PE - Midland Community Healthcare Services","Scott&White (First Care)","Participating","Enrollment Complete","2020-02-03","","","2021-01-29","1/29/2021 - Rcvd roster from Scott&White (First Care) confirming participation of provider with TIN and location effective dates.  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"]
["Tonya Murphy, FNP",1891931341,"83-0358685","TX","PE - Midland Community Healthcare Services","USA PPO","Participating","Enrollment Complete","2020-05-01","","","2022-04-13","4/13/2022 Per roster from USA MCO provider is PAR and linked to group TIN/location effective 5/1/2020.  DCannon"]
["Michael Okoye, DO",1205299922,"83-0358685","TX","PE - Midland Community Healthcare Services","First Health Coventry","Participating","Enrollment Complete","2021-09-04","3313543","","2022-02-04","2/4/2022 Per roster received from First Health provider is PAR and linked to group TIN/location effective 9/4/2021.  DCannon"]
["Michael Okoye, DO",1205299922,"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"]
["Michael Okoye, DO",1205299922,"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"]
["Michael Okoye, DO",1205299922,"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"]
["Michael Okoye, DO",1205299922,"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"]
["Michael Okoye, DO",1205299922,"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"]
["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","Caprock (CapStar)","Participating","Enrollment Complete","2021-06-01","","","2021-08-06","8/6/2021 Rcvd email from Caprock ProviderServices.T8@90degreebenefits.com that monthly delegated roster provider load is complete and provider is loaded under TIN at location effective 6/1/2021.  DCannon"]
["Michael Okoye, DO",1205299922,"83-0358685","TX","PE - Midland Community Healthcare Services","Cigna","Participating","Enrollment Complete","2020-09-10","0522362","","2020-09-14","9/14/2020 - Rec'd email from the payer stating \"Your effective date is 09/10/2020. Your provider identification number is 0522362.\" - stacey Hudak"]
["Michael Okoye, DO",1205299922,"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"]
["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","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"]
["Michael Okoye, DO",1205299922,"83-0358685","TX","PE - Midland Community Healthcare Services","HealthSmart PPO","Participating","Enrollment Complete","2019-10-29","1205299922","","2020-06-04","06/04/2020 - Rec'd email from the payer stating this provider is EFF - Stacey Hudak"]
["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","Amerigroup","Participating","Enrollment Complete","2020-03-20","","","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 3/20/2020.   DCannon"]
["Michael Okoye, DO",1205299922,"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"]
["Michael Okoye, DO",1205299922,"83-0358685","TX","PE - Midland Community Healthcare Services","Aetna","Participating","Enrollment Complete","2021-06-01","6609675","","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 # 6609675 DCannon"]
["Michael Okoye, DO",1205299922,"83-0358685","TX","PE - Midland Community Healthcare Services","Superior","Participating","Enrollment Complete","2020-09-01","1205299922","","2020-09-02","09/02/2020 - Rec'd email from the payer stating this provider/location has been added to delegation - Stacey Hudak"]
["Michael Okoye, DO",1205299922,"83-0358685","TX","PE - Midland Community Healthcare Services","Amerigroup","Participating","Enrollment Complete","2020-01-15","1205299922","","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"]
["Michael Okoye, DO",1205299922,"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"]
["Michael Okoye, DO",1205299922,"83-0358685","TX","PE - Midland Community Healthcare Services","Multiplan","Participating","Enrollment Complete","2020-03-20","","","2022-08-23","8/23/2022 Per email from Multiplan provider is PAR and linked to group TIN/location effective 3/20/2020.  DCannon"]
["Michael Okoye, DO",1205299922,"83-0358685","TX","PE - Midland Community Healthcare Services","First Health Coventry","Participating","Enrollment Complete","2019-10-01","1205299922","","2020-09-23","09/23/2020 - moved to completed status after reviewing follow up note - Stacey Hudak"]
["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","Superior","Participating","Enrollment Complete","2020-08-01","1205299922","","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"]
["Michael Okoye, DO",1205299922,"83-0358685","TX","PE - Midland Community Healthcare Services","First Health Coventry","Participating","Enrollment Complete","2019-10-01","3313543","","2020-03-20","3/20/2020-receieved email with roster stating provider PAR 10/1/2019 PID # 3313543\ntisha rader"]
["Michael Okoye, DO",1205299922,"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"]
["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","","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","2022-04-01","","","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","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 Okoye, DO",1205299922,"83-0358685","TX","PE - Midland Community Healthcare Services","Medicaid","In House Enrollment","In House Enrollment","","","","2021-08-03","8/3/2021 Medicaid enrollment is done in-house by MCHS.  DCannon"]
["Michael Okoye, DO",1205299922,"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"]
["Michael Okoye, DO",1205299922,"83-0358685","TX","PE - Midland Community Healthcare Services","Cigna","Participating","Enrollment Complete","2020-09-10","0522362","","2020-09-14","9/14/2020 - Rec'd email from the payer stating \"Your effective date is 09/10/2020. Your provider identification number is 0522362.\" - stacey Hudak"]
["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","Caprock (CapStar)","Participating","Enrollment Complete","2021-06-01","","","2021-08-06","8/6/2021 Rcvd email from Caprock ProviderServices.T8@90degreebenefits.com that monthly delegated roster provider load is complete and provider is loaded under TIN at location effective 6/1/2021.  DCannon"]
["Jose Saucedo, FNP",1184265050,"83-0358685","TX","PE - Midland Community Healthcare Services","Caprock (CapStar)","Participating","Enrollment Complete","2020-03-01","1184265050","","",""]
["Jose Saucedo, FNP",1184265050,"83-0358685","TX","PE - Midland Community Healthcare Services","First Health Coventry","Participating","Enrollment Complete","2020-03-20","","","2021-11-03","11/3/2021  Per First Health online provider directory provider is PAR and linked to group/locations  effective 3/20/2020.  DCannon"]
["Jose Saucedo, FNP",1184265050,"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"]
["Jose Saucedo, FNP",1184265050,"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"]
["Jose Saucedo, FNP",1184265050,"83-0358685","TX","PE - Midland Community Healthcare Services","Medicaid","In House Enrollment","In House Enrollment","","","","2021-08-04","8/3/2021 Medicaid enrollment is done in-house by MCHS.  DCannon"]
["Jose Saucedo, FNP",1184265050,"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"]
["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","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","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"]
["Jose Saucedo, FNP",1184265050,"83-0358685","TX","PE - Midland Community Healthcare Services","Medicare","In House Enrollment","In House Enrollment","","","","2021-08-04","8/3/2021 Medicare enrollment is done in-house by MCHS.  DCannon"]
["Jose Saucedo, FNP",1184265050,"83-0358685","TX","PE - Midland Community Healthcare Services","Medicare","Participating","In House Enrollment","2020-08-01","888038","00304W","2020-09-21","09/21/2020 - Rec'd proof from the clinic that this service location has been added to the group - Stacey Hudak"]
["Jose Saucedo, FNP",1184265050,"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"]
["Jose Saucedo, FNP",1184265050,"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"]
["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","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","Cigna","Participating","Enrollment Complete","2020-08-03","9835482","","2020-08-04","8/4/2020 - Rec'd email from the payer stating \"Your effective date is 08/03/2020. Your provider identification number is 9835482. \" - Stacey Hudak"]
["Jose Saucedo, FNP",1184265050,"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"]
["Jose Saucedo, FNP",1184265050,"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"]
["Jose Saucedo, FNP",1184265050,"83-0358685","TX","PE - Midland Community Healthcare Services","Triwest VA","DO NOT ENROLL","DO NOT ENROLL","","","","2022-11-15","Provider did not select inclusion with this payor."]
["Justin D Shanks, APRN-FNP-BC",1205477874,"84-2617748","ME","PE - Midland Medicine PA","United Health Care","Participating","Enrollment Complete","2021-08-20","7772537","","2022-04-05","4/5/2022 Per email from UHC at networkhelp@uhc.com provider is PAR and linked to group TIN/location effective 8/20/2021.  MPIN # 7772537.  DCannon"]
["Justin D Shanks, APRN-FNP-BC",1205477874,"84-2617748","ME","PE - Midland Medicine PA","Triwest VA","In Process","Application Submitted","","","","","08/19/2022 - Submitted application to TriWest VA (sent to Scarlett Abigail, Scarlett_Abigail@bcbstx.com)"]
["Justin D Shanks, APRN-FNP-BC",1205477874,842617748,"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",1205477874,842617748,"TX","PE - Midland Medicine PA","Wellcare","Participating","Enrollment Complete","2022-07-01","","","2022-12-01","12/1/2022 Per roster received from Wellcare provider is PAR and linked to group TIN/location effective 7/1/2022.  DCannon"]
["Justin D Shanks, APRN-FNP-BC",1205477874,842617748,"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"]
["Justin D Shanks, APRN-FNP-BC",1205477874,842617748,"TX","PE - Midland Medicine 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."]
["Justin D Shanks, APRN-FNP-BC",1205477874,"84-2617748","ME","PE - Midland Medicine PA","Rail Road Medicare","Participating","Enrollment Complete","2021-04-01","Q00110014","EA8735","2021-08-03","8/3/2021 Rcvd RR Medicare PTAN instantly after applying via RR Medicare website.  PTAN # Q00110014 effective 4/1/2021.  DCannon"]
["Justin D Shanks, APRN-FNP-BC",1205477874,"84-2617748","ME","PE - Midland Medicine PA","TriCare Standard","Participating","Enrollment Complete","2022-02-25","","","2022-03-09","3/9/2022 Per Tircare portal provider is certified and linked to location as of 2/25/2022. Cbankston"]
["Justin D Shanks, APRN-FNP-BC",1205477874,842617748,"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"]
["Justin D Shanks, APRN-FNP-BC",1205477874,842617748,"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"]
["Justin D Shanks, APRN-FNP-BC",1205477874,"84-2617748","ME","PE - Midland Medicine PA","Medicaid","In Process","Application Submitted","","","","2022-03-16","3/16/2022 Application submitted online via TMHP web portal.  Request # 20037781.  DCannon"]
["Justin D Shanks, APRN-FNP-BC",1205477874,"84-2617748","ME","PE - Midland Medicine PA","Scott&White (First Care)","Participating","Enrollment Complete","2021-08-09","","","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 8/9/2021.  DCannon"]
["Justin D Shanks, APRN-FNP-BC",1205477874,842617748,"TX","PE - Midland Medicine PA","United Health Care","Participating","Enrollment Complete","2022-06-01","007772537","","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# 007772537.   DCannon"]
["Justin D Shanks, APRN-FNP-BC",1205477874,842617748,"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"]
["Justin D Shanks, APRN-FNP-BC",1205477874,"84-2617748","ME","PE - Midland Medicine PA","Multiplan","Participating","Enrollment Complete","2021-08-13","","","2021-09-15","9/15/2021 Received welcome letter from Multiplan listing provider has PAR under group TIN/location effective 8/13/2021.  DCannon"]
["Justin D Shanks, APRN-FNP-BC",1205477874,842617748,"TX","PE - Midland Medicine PA","First Health Coventry","Participating","Enrollment Complete","2021-08-01","3478864","","2022-07-28","07/28/2022 Per follow-up note:  07.15.22. S/W Ashley of First Health @ 800-226-5116. Provider NPI# is on file for the provider and is participating effective 08/01/21 under the group and TIN#. PIN 3478864. Physical location is on file. Ref# 355097 - Ria Dee Bieren  DCannon"]
["Justin D Shanks, APRN-FNP-BC",1205477874,"84-2617748: S","TX","","Triwest VA","In Process","Application Submitted","","","","2022-11-15","08/19/2022 - Application submitted to Scarlett Abigail (Scarlett_Abigail@bcbstx.com) of TriWest VA"]
["Justin D Shanks, APRN-FNP-BC",1205477874,"84-2617748: S","TX","PE - Midland Medicine PA","Medicare","Participating","Enrollment Complete","2021-04-01","1Q4173","1N5325","2021-06-17","6/17/2021 Received payor approval notice in which provider has been assigned PTAN 1Q4173 effective 4/1/2021. KFrazier"]
["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","Omni PPO","Participating","Enrollment Complete","2019-09-01","1922548890","","2020-07-27","IMS complete"]
["Hagos Z Aymut, MD",1922548890,"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"]
["Hagos Z Aymut, MD",1922548890,"47-5554737","TX","PE - Midland Inpatient Medical Association","Galaxy Health","Participating","Enrollment Complete","2019-09-01","1922548890","","2020-08-21",""]
["Hagos Z Aymut, MD",1922548890,"47-5554737","TX","PE - Midland Inpatient Medical Association","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"]
["Hagos Z Aymut, MD",1922548890,"47-5554737","TX","PE - Midland Inpatient Medical Association","Caprock (CapStar)","Participating","Enrollment Complete","2020-07-20","","","2020-07-20",""]
["Suresh K Ravuri, MD",1750539268,"47-5554737","TX","PE - Midland Inpatient Medical Association","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"]
["Suresh K Ravuri, MD",1750539268,"47-5554737","TX","PE - Midland Inpatient Medical Association","USA PPO","Participating","Enrollment Complete","2021-01-26","1312344","","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"]
["Suresh K Ravuri, MD",1750539268,"47-5554737","TX","PE - Midland Inpatient Medical Association","HealthSmart PPO","Participating","Enrollment Complete","2020-06-03","13729769","","2020-07-24","07/24/2020 - Rec'd spreadsheet from the payer stating this provider/service location/TIN are all affiliated under the PRIMED DELEGATED contract - Stacey Hudak"]
["Suresh K Ravuri, MD",1750539268,"47-5554737","TX","PE - Midland Inpatient Medical Association","Boon Chapman","Participating","Enrollment Complete","2020-06-30","","","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 6/30/2020.  DCannon"]
["Suresh K Ravuri, MD",1750539268,"47-5554737","TX","PE - Midland Inpatient Medical Association","Omni PPO","Participating","Enrollment Complete","2019-09-01","1750539268","","2020-07-27","IMS completed"]
["Colby S Brownlee, DO",1114289329,"75-2773462","TX","PE - Ingram Investments LLC","Cigna","Enrollment Stopped","Enrollment Stopped","","","","2021-01-14","12/22/2020 Received email from payor Rep Karla Payton (karla.payton@cigna.com) confirming they will stop processing provider's enrollment until he has admitting privileges at Midland Memorial Hospital, as this is required for his specialty. However, once the provider has active, not temporary or pending hospital privileges with a participating hospital, please send a request to MedicalOnboarding@Cigna.com to request the file be re-activated. Emailed the information to MQA and let them know if the situation and to confirm if he plans to apply for privileges at the facility. KFrazier"]
["Colby S Brownlee, DO",1114289329,"75-2773461","TX","PE - Eye Center of Midland, P.A.","Multiplan","Participating","Enrollment Complete","2020-04-15","","","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 4/15/2020.  DCannon"]
["Colby S Brownlee, DO",1114289329,"75-2773461","TX","PE - Eye Center of Midland, P.A.","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"]
["Colby S Brownlee, DO",1114289329,"75-2773461","TX","PE - Eye Center of Midland, P.A.","Boon Chapman","Participating","Enrollment Complete","2020-04-15","","","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 4/15/2020.  DCannon"]
["Colby S Brownlee, DO",1114289329,"75-2773462","TX","PE - Ingram Investments LLC","Medicare","In House Enrollment","In House Enrollment","","524699ZWA3","ASC023","2021-08-09","8/9/2021 Received provider's PTAN from Chelsea Franco as 524699ZWA3 under group PTAN ASC023, and pending effective date. KFrazier"]
["Haley D Brennan, PA-C",1528430865,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Liberty Mutual","Participating","Enrollment Complete","2019-07-01","","","2022-02-10","2/10/2022 - Per follow-up notes provider is on file and participating at location and under TIN effective 7/1/2019.  DCannon"]
["Haley D Brennan, PA-C",1528430865,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Multiplan","Facility Enrollment","Facility Enrollment","","","","2020-10-09","10/9/2020 - Rec'd email from the clinic contact, Regina Stieger, stating that this payer has a facility only contract  in place- Stacey Hudak"]
["Haley D Brennan, PA-C",1528430865,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Multiplan","Facility Enrollment","Facility Enrollment","","","","2020-10-09","10/9/2020 - Rec'd email from the clinic contact, Regina Stieger, stating that this payer has a facility only contract  in place- Stacey Hudak"]
["Haley D Brennan, PA-C",1528430865,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","TriCare Standard","Participating","Enrollment Complete","2020-02-12","1528430865","","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"]
["Haley D Brennan, PA-C",1528430865,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Caprock (CapStar)","Participating","Enrollment Complete","2018-11-20","","","2020-09-14",""]
["Haley D Brennan, PA-C",1528430865,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Rail Road Medicare","Participating","Enrollment Complete","2018-10-01","P02130942","DX4335","2020-07-09","07/09/2020 - Rec'd EFF info through payer site - Stacey Hduak"]
["Haley D Brennan, PA-C",1528430865,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","First Health Coventry","Participating","Enrollment Complete","2020-04-15","","","2021-08-06","8/6/2021 Moved to enrollment complete per notes from First Health/Coventry. Provider is effective 4/15/2020. Kfrazier"]
["Haley D Brennan, PA-C",1528430865,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Aetna","Participating","Enrollment Complete","2018-12-15","1528430865","","2020-04-15","04/15/2020 - rec'd response from the follow up team stating \"Called 800-872-3862 but in regards with credentialing call was forwaded to credentialing team @ 8003531232 and SW Mark of Aetna . Provider NPI# is on file Link and participating under the group and TIN# effective 12/15/2018. Location is on file. Provider is linked to PRIMED DELEGATED CONTRACT. Call ref# 5225933682. \"  - Stacey Hudak"]
["Haley D Brennan, PA-C",1528430865,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Caprock (CapStar)","Participating","Enrollment Complete","2018-11-20","","","2020-09-14",""]
["Haley D Brennan, PA-C",1528430865,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","HealthSmart PPO","Participating","Enrollment Complete","2019-07-18","1528430865","","2020-06-10","06/10/2020 - Rec'd email from the payer stating this provider is EFF - Stacey Hudak"]
["Haley D Brennan, PA-C",1528430865,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Rail Road Medicare","Participating","Enrollment Complete","2018-10-01","P02130942","DX4335","2020-07-09","07/09/2020 - Rec'd EFF info through payer site - Stacey Hduak"]
["Haley D Brennan, PA-C",1528430865,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Texas Mutual","Participating","Enrollment Complete","2018-12-01","","","2021-11-24","11/24/21 Received email from wwtxcontracts@texasmutual.com, recredentialing is complete. Cbankston"]
["Haley D Brennan, PA-C",1528430865,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","IMS","Participating","Enrollment Complete","2018-11-30","1528430865","","2020-06-22","06/22/2020- Rec'd email from the payer confirming this provider is PAR with this group/service location - Stacey Hudak"]
["Haley D Brennan, PA-C",1528430865,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Zurich","Participating","Enrollment Complete","2020-04-15","","","2021-08-06","8/6/2021 Moved to enrollment complete per notes from First Health/Coventry. Provider is effective 4/15/2020. Kfrazier"]
["Haley D Brennan, PA-C",1528430865,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Galaxy Health","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"]
["Haley D Brennan, PA-C",1528430865,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","United Health Care","Participating","Enrollment Complete","2020-04-22","1528430865","","2020-08-31","08/31/2020 - moved to completed status after reviewing follow up complete - Stacey Hudak"]
["Haley D Brennan, PA-C",1528430865,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Gallagher","Participating","Enrollment Complete","2020-04-15","","","2021-08-06","8/6/2021 Moved to enrollment complete per notes from First Health/Coventry. Provider is effective 4/15/2020. Kfrazier"]
["Haley D Brennan, PA-C",1528430865,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Superior","Participating","Enrollment Complete","2021-01-01","","","2021-01-05","1/5/2021 - Rcvd Validation Report from Superior confirming provider load with an effective date of 1/1/2021.  DCannon"]
["Haley D Brennan, PA-C",1528430865,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Multiplan","Facility Enrollment","Facility Enrollment","","","","2020-10-09","10/9/2020 - Rec'd email from the clinic contact, Regina Stieger, stating that this payer has a facility only contract  in place- Stacey Hudak"]
["Haley D Brennan, PA-C",1528430865,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Caprock (CapStar)","Participating","Enrollment Complete","2018-11-20","","","2020-09-14",""]
["Haley D Brennan, PA-C",1528430865,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","First Health Coventry","Participating","Enrollment Complete","2020-04-15","1528430865","","2021-08-06","8/6/2021 Moved to enrollment complete per notes from First Health/Coventry. Provider is effective 4/15/2020. Kfrazier"]
["Haley D Brennan, PA-C",1528430865,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","HealthSmart PPO","Participating","Enrollment Complete","2019-07-18","1528430865","","2020-06-10","06/10/2020 - Rec'd email from the payer stating this provider is EFF - Stacey Hudak"]
["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","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","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"]
["Mohammed F Rahman, MD",1518227537,"47-5554737","TX","","Medicare","Participating","Enrollment Complete","2020-07-01","1E0017","519061","2020-07-06","07/06/2020 - Rec'd email from the clinic stating this provider is EFF through Medicare. Signed onto group PECOS to confirm and update payer line - Stacey Hudak"]
["Mohammed F Rahman, MD",1518227537,"47-5554737","TX","PE - Midland Inpatient Medical Association","First Health Coventry","Participating","Enrollment Complete","2020-09-01","1518227537","","2020-09-23","09/23/2020 - moved to completed status after reviewing follow up complete note. \nEnrollment complete under PRIMED DELEGATION - Stacey Hudak"]
["Mohammed F Rahman, MD",1518227537,"47-5554737","TX","","Boon Chapman","Participating","Enrollment Complete","2020-06-03","","","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 6/3/2020.  DCannon"]
["Mohammed F Rahman, MD",1518227537,"47-5554737","TX","PE - Midland Inpatient Medical Association","Aetna","Participating","Enrollment Complete","2020-08-01","1518227537","","2020-08-31","08/31/2020 - Rec'd email from the payer stating \"I show this provider loaded under the TIN effective 8/1/2020.  However, they are loaded under PriMed's agreement.\" - Stacey Hudak"]
["Mohammed F Rahman, MD",1518227537,"47-5554737","TX","","Medicaid","Participating","Enrollment Complete","2020-07-11","357415403","364596201","2020-07-20","07/20/2020 - found provider effective through payer portal - moved to enrollment complete - Stacey Hudak"]
["Mohammed F Rahman, MD",1518227537,"47-5554737","TX","PE - Midland Inpatient Medical Association","Multiplan","Participating","Enrollment Complete","2020-06-03","","","2021-06-29","6/29/2021 Rcvd roster from Multiplan confirming provider is PAR under TIN effective 6/3/2020.  DCannon"]
["Mohammed F Rahman, MD",1518227537,"47-5554737","TX","","Galaxy Health","Participating","Enrollment Complete","2020-07-01","1518227537","","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"]
["Mohammed F Rahman, MD",1518227537,"47-5554737","TX","","Superior","Participating","Enrollment Complete","2020-08-01","1518227537","","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"]
["Mohammed F Rahman, MD",1518227537,"47-5554737","TX","PE - Midland Inpatient Medical Association","Rail Road Medicare","Participating","Enrollment Complete","2020-07-01","P02496104","DW7662","2020-08-28","08/28/2020 - moved to completed status after finding EFF info through payer site - Stacey Hudak"]
["Mohammed F Rahman, MD",1518227537,"47-5554737","TX","","HealthSmart PPO","Participating","Enrollment Complete","2020-06-03","","","2021-01-27","1/27/2021 - Rcvd email from payer showing provider as participating at location and linked to TIN effective 6/3/2020.  DCannon"]
["Mohammed F Rahman, MD",1518227537,"47-5554737","TX","PE - Midland Inpatient Medical Association","Scott&White (First Care)","Participating","Enrollment Complete","2020-09-28","","","2021-01-14","1/14/2021 - Rcvd email from payer that provider is participating and loaded under tax ID effective 9/28/2020.  DCannon"]
["Mohammed F Rahman, MD",1518227537,"47-5554737","TX","","Scott&White (First Care)","Participating","Enrollment Complete","2020-09-28","","","2021-01-14","1/14/2021 - Rcvd email from payer that provider is participating and loaded under tax ID effective 9/28/2020.  DCannon"]
["Satish Nayak, MD",1518053149,"57-1157825","TX","PE - Satish Nayak","Galaxy Health","Participating","Enrollment Complete","2021-07-06","","","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 7/6/2021.  DCannon"]
["Satish Nayak, MD",1518053149,"57-1157825","TX","PE - Satish Nayak","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"]
["Satish Nayak, MD",1518053149,"57-1157825","TX","PE - Satish Nayak","Aetna","Participating","Enrollment Complete","2021-07-06","5595574","","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 7/6/2021.  PID # 5595574 DCannon"]
["Satish Nayak, MD",1518053149,"57-1157825","TX","PE - Satish Nayak","Aetna","Participating","Enrollment Complete","2009-04-01","1518053149","","2020-06-09","06/09/2020 - SW kay of Aetna @ 8003531232. Provider NPI# is on file and in-network participating under the group and TIN# effective 4/1/2009. Location is on file. Call ref# 5310057759. - Stacey Hudak\n\n\n**Delegated Contract - payer did not say WHO the provider was delegated through"]
["Abiodun A Okin-Ayileka, MD",1922328079,"84-4724927","TX","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","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","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","TX","PE - ADA Adult and Children Family Clinic LLC","First Health Coventry","In Process","Payor Follow Up","","","","2023-03-06","03.06.2023 S/W Brenda of First Health @800-226-5116. Per rep, provider is not in the system or out of network. Informed rep that we submitted a request to join the network via aetna.com on 01/30/2023 however rep doesn't have an access to check pending request and advised me to allow more time for the process. TAT for the process is 180 business days. Call ref# 564081. - Mary Rose Acebedo"]
["Abiodun A Okin-Ayileka, MD",1922328079,"84-4724927","TX","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","TX","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"]
["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","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","Triwest VA","In Process","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","","Triwest VA","In Process","Application Submitted","","","","","08/19/2022 - Submitted application to TriWest VA (sent to Scarlett Abigail, Scarlett_Abigail@bcbstx.com)"]
["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","CAQH","Participating","CAQH Reattested","2023-02-12","","","2023-02-12","2/12/2023 CAQH reviewed and re-attested.  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","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"]
["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,"75-1997880","TX","PE - Andrews County Hospital District","Humana","Participating","Enrollment Complete","2017-03-30","","","2021-11-18","11/18/2021 Rcvd full roster from Humana listing provider as PAR and linked to group TIN/location effective 3/30/2017.  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,"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","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,"75-1997880","TX","PE - Andrews County Hospital District","Scott&White (First Care)","Participating","Enrollment Complete","2017-03-13","1225277833","","2020-07-15","07/15/2020 - Rec'd email from the payer stating this provider is EFF under this group TIN and group NPI# 1124054069 - Stacey Hudak"]
["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","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"]
["Wyn D Nguyen, MD",1366440059,"75-1997880","TX","PE - Andrews County Hospital District","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."]
["Wyn D Nguyen, MD",1366440059,"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"]
["Wyn D Nguyen, MD",1366440059,"75-1997880","TX","PE - Andrews County Hospital District","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"]
["Wyn D Nguyen, MD",1366440059,"26-3789190","TX","PE - Permian Physician Services","USA PPO","Participating","Enrollment Complete","2021-01-26","1312338","","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.  DCannonn"]
["Wyn D Nguyen, MD",1366440059,"75-1997880","TX","PE - Andrews County Hospital District","CAQH","Participating","CAQH Reattested","2023-01-23","","","2023-01-23","1/23/2023 CAQH reviewed and re-attested.  DCannon"]
["Wyn D Nguyen, MD",1366440059,"75-1997880","TX","PE - Andrews County Hospital District","Aetna","Participating","Enrollment Complete","2019-09-01","1366440059","","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"]
["Wyn D Nguyen, MD",1366440059,"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"]
["Wyn D Nguyen, MD",1366440059,"75-1997880","TX","PE - Andrews County Hospital District","Medicare","Facility Enrollment","Facility Enrollment","","RHC GROUP NPI - Part A Only","","2020-07-28","07/28/2020 - THIS SERVICE LOCATION AND GROUP NPI IS FOR AN RHC FACILITY (part A) only. \n\nThere is no provider link/reassignment for this group.\n\nThis provider is active with Medicare, but cannot be reassigned to this TIN/Group NPI. It bills under facility only, not by provider.  Moved to completed status to remove from work list - Stacey Hudak"]
["Wyn D Nguyen, MD",1366440059,"26-3789190","TX","PE - Permian Physician Services","Medicare","Participating","Enrollment Complete","2010-02-03","936789","0A3812","2020-09-25","09/25/2020 - rec'd email from the payer with confirmation of Medicare enrollment. - Stacey Hudak"]
["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","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","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,"75-1997880","TX","PE - Andrews County Hospital District","Amerigroup","Participating","Enrollment Complete","2020-07-14","04223194","","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","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,"75-1997880","TX","PE - Andrews County Hospital District","Caprock (CapStar)","Participating","Enrollment Complete","2016-10-26","","","2020-09-14",""]
["Alyssa Tochterman, MD",1972942209,"75-1997880","TX","PE - Andrews County Hospital District","United Health Care","Participating","Enrollment Complete","2019-11-01","6163991","","2020-08-18","8/18/2020 - moved to completed status after reviewing follow up complete note - Stacey Hudak"]
["Alyssa Tochterman, MD",1972942209,"75-1997880","TX","PE - Andrews County Hospital District","Cigna","Participating","Enrollment Complete","2016-10-04","8268061","","2020-06-25","6-25-2020 - Moved to completed status based on info rec'd during follow up complete call - Stacey Hudak"]
["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"]
["Margaret Merriam, DO",1083867147,"75-1997880","TX","PE - Andrews County Hospital District","Cigna","Participating","Enrollment Complete","2017-03-30","1083867147","","2020-08-31","08/31/2020 - moved to completed status after reviewing follow up complete note - Stacey Hudak"]
["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,"75-1997880","TX","PE - Andrews County Hospital District","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,"75-1997880","TX","PE - Andrews County Hospital District","Caprock (CapStar)","Participating","Enrollment Complete","2017-06-05","","","2020-09-14",""]
["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","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,"75-1997880","TX","PE - Andrews County Hospital District","Superior","Participating","Enrollment Complete","2017-07-01","1083867147","","2020-07-14","07/14/2020 - Rec'd email from the payer stating this provider is EFF under PRIMED DELEGATED agreement - 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","Caprock (CapStar)","Participating","Enrollment Complete","2017-06-05","","","2020-09-14",""]
["Margaret Merriam, DO",1083867147,"75-1997880","TX","PE - Andrews County Hospital District","CAQH","Participating","CAQH Reattested","2023-01-03","12776672","","2023-01-03","1/3/2022 CAQH reviewed and re-attested.  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, DPM",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, DPM",1669617981,"75-1997880","TX","PE - Andrews County Hospital District","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, DPM",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, DPM",1669617981,"75-1997880","TX","PE - Andrews County Hospital District","Alliance WC","Participating","Enrollment Complete","2019-05-03","","","2021-12-27","12/27/2021 Received email form michelle.killough@pswca.org, provider has been active with Tax ID  75-1997880 since 05/03/2019. Cbankston"]
["Jennifer B Hada-Ondriezek, DPM",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, DPM",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, DPM",1669617981,"75-1997880","TX","PE - Andrews County Hospital District","Aetna","Participating","Enrollment Complete","2010-01-15","","","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 B Hada-Ondriezek, DPM",1669617981,"75-1997880","TX","PE - Andrews County Hospital District","Liberty Mutual","Pending Other Enrollment","Pending Other Enrollment","","","","2023-02-03","2.3.23 Received confirmation from Texas Network@LibertyMutual.com, Providers must first be contracted in Coventry WC before they can be considered by Liberty Mutual, inclusion in the Coventry network does not guarantee inclusion in the Liberty Mutual HCN. ABoles"]
["Jennifer B Hada-Ondriezek, DPM",1669617981,"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"]
["Jennifer B Hada-Ondriezek, DPM",1669617981,"75-1997880","TX","PE - Andrews County Hospital District","United Health Care","Participating","Enrollment Complete","2019-12-26","1669617981","","2020-08-31","8/31/2020 - moved to completed status after reviewing follow up completed status - Stacey Hudak"]
["Jennifer B Hada-Ondriezek, DPM",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"]
["Shannan Clawson, NP",1972073906,"75-1997880","TX","PE - Andrews County Hospital District","Zurich","Enrollment Stopped","Enrollment Stopped","","","","2021-08-05","8/4/2021 Provider does not see WC patients; therefore, enrollment has stopped. KFrazier"]
["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","United Health Care","Participating","Enrollment Complete","2019-11-01","7004909","","2020-09-08","09/08/2020 - Reviewed the last note and the spreadsheet sent by the payer. THis can be made EFF - Stacey Hudak"]
["Shannan Clawson, NP",1972073906,"75-1997880","TX","PE - Andrews County Hospital District","Caprock (CapStar)","Participating","Enrollment Complete","2019-09-01","1972073906","","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"]
["Peggy Thurston, NP",1205941564,"75-1997880","TX","PE - Andrews County Hospital District","HealthSmart PPO","Participating","Enrollment Complete","2020-07-14","","","2021-12-03","12/3/2021 Per Healthsmart website provider is PAR and loaded under TIN/location effective 7/14/2020.  DCannon"]
["Peggy Thurston, NP",1205941564,"75-1997880","TX","PE - Andrews County Hospital District","Scott&White (First Care)","Participating","Enrollment Complete","2020-09-02","1205941564","","2020-08-20","8/20/2020 - Rec'd email 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\nFirstCare Select Benefit Network\nHMO Enhanced Benefit Network\nMedicare (FC)\nPPO Limited Benefit Network\n- Stacey Hudak"]
["Peggy Thurston, NP",1205941564,"75-1997880","TX","PE - Andrews County Hospital District","Aetna","Participating","Enrollment Complete","2014-03-25","9537752","","2020-06-26","06/26/2020 - moved to completed status after reviewing Follow Up Complete note - Stacey Hudak"]
["Peggy Thurston, NP",1205941564,"75-1997880","TX","PE - Andrews County Hospital District","USA PPO","Participating","Enrollment Complete","2021-01-26","1186660","","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"]
["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"]
["Kristie M Chu, MD",1780078089,"75-2656723","TX","PE - Premier Family Care I, 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"]
["Kristie M Chu, MD",1780078089,"75-2656723","TX","PE - Premier Family Care I, Inc","Multiplan","Participating","Enrollment Complete","2021-05-10","","","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 5/10/2021.  DCannon"]
["Kristie M Chu, MD",1780078089,"75-2656723","TX","PE - Premier Family Care I, Inc","Aetna","Participating","Enrollment Complete","2021-05-15","6198680","","2021-07-08","7/1/2021-S/W Mark of AETNA @ 8003531232, NPI# of the provider is on file and shows link and PAR under the group and TIN# effective 5/15/2021, physical location is on file. Provider ID is 6198680.   Rep confirmed that once provider is credentialed w/ Aetna automatically, provider is also credentialed w/First Health and Coventry. Call ref#6028239169. herminia Gilongos"]
["Kristie M Chu, MD",1780078089,"75-2656723","TX","PE - Premier Family Care I, Inc","Amerigroup","Participating","Enrollment Complete","2021-05-10","","","2021-08-26","8/26/2021 Rcvd full roster from Joe Rodriguez at Amerigroup listing provider as PAR w/ group TIN and location effective 5/10/2021.  DCannon"]
["Kristie M Chu, MD",1780078089,"75-2656723","TX","PE - Premier Family Care I, 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"]
["Kristie M Chu, MD",1780078089,"75-2656723","TX","PE - Premier Family Care I, 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"]
["Kristie M Chu, MD",1780078089,"75-2656723","TX","PE - Premier Family Care I, Inc","Alliance WC","Participating","Enrollment Complete","2021-05-21","","","2021-12-02","12/2/21 Received email from michelle.killough@pswca.org, provider eff 05/21/2021 with Tax ID 75-2656723. Cbankston"]
["Steve Saeed Ahmed, MD",1730149618,"41-2095892","TX","PE - Steve Ahmed, MD PA","USA PPO","Participating","Enrollment Complete","2018-11-30","1730149618","412095892","2020-08-19","Confirmed provider is participating with PPO and H&W networks (list of networks attached). Kimberly Frazier"]
["Steve Saeed Ahmed, MD",1730149618,"41-2095892","TX","PE - Steve Ahmed, MD PA","First Health Coventry","Participating","Enrollment Complete","2018-11-01","1730149618","","2020-07-10","07/10/2020 - moved to completed status per notes in Follow Up Complete  - Stacey Hudak"]
["Steve Saeed Ahmed, MD",1730149618,"41-2095892","TX","PE - Steve Ahmed, MD PA","TriCare Standard","Participating","Enrollment Complete","2003-10-01","1730149618","","2020-07-06","07/06/2020 - Rec'd notification that the portal has granted me access to this provider. Signed in and confimed that this provider IS EFF and IN NETWORK (certified and contracted) with Tricare/Tricare Prime at this service location - Stacey Hudak"]
["Steve Saeed Ahmed, MD",1730149618,"41-2095892","TX","PE - Steve Ahmed, MD PA","Caprock (CapStar)","Participating","Enrollment Complete","2012-03-01","","","",""]
["Barbara Norris, NP",1720353592,"75-1997880","TX","PE - Andrews County Hospital District","Caprock (CapStar)","Participating","Enrollment Complete","2014-05-15","","","2020-09-14",""]
["Barbara Norris, NP",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",1720353592,"75-1997880","TX","PE - Andrews County Hospital District","Scott&White (First Care)","Participating","Enrollment Complete","2016-01-01","1720353592","","2020-08-04","8/4/2020 - Rec'd email from the payer stating this provider is EFF with this group NPI# for Quick Care under the Delegated Agreement - Stacey Hudak\n\n**verified that this provider is networked with:\nCHIP\nFirstCare Select Benefit Network\nHMO Enhanced Benefit Network\nMedicaid (FC)\nMedicare (FC)\nPPO Limited Benefit Network"]
["Barbara Norris, NP",1720353592,"75-1997880","TX","PE - Andrews County Hospital District","Triwest VA","Facility Enrollment","Application Submitted","","","","2022-11-23","08/19/2022 - Submitted application to TriWest VA (sent to Scarlett Abigail, Scarlett_Abigail@bcbstx.com)"]
["Barbara Norris, NP",1720353592,"75-1997880","TX","PE - Andrews County Hospital District","Multiplan","Participating","Enrollment Complete","2020-07-13","","","2022-12-31","7/23/2022 Per email from Marcie Eckhart-Haven at Multiplan provider is PAR and linked to group TIN effective 7/13/2021.  DCannon"]
["Stephanie Jean Fitzgerald, MD",1184035313,"75-1997880","TX","PE - Andrews County Hospital District","Medicare","Facility Enrollment","Facility Enrollment","2020-08-22","RHC GROUP NPI - Part A Only","","2020-07-29","This is an RHC FACILITY ONLY \nRHC GROUP NPI ONLY\n\nYou cannot link providers to this location/group NPI\nFacility enrollment only\n\nMoved to completed status to remove from worklist - Stacey Hudak"]
["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,"75-1997880","TX","PE - Andrews County Hospital District","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,"75-1997880","TX","PE - Andrews County Hospital District","Travelers WC","Pending Other Enrollment","Pending Other Enrollment","","","","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,"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,"75-1997880","TX","PE - Andrews County Hospital District","Cigna","Participating","Enrollment Complete","2021-01-12","","","2021-03-08","3/8/2021 Rcvd confirmation from Cigna that provider is now participating under TIN and linked to location effective 1/12/2021.  CPID # 8214651.  DCannon"]
["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,"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"]
["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,"75-1997880","TX","PE - Andrews County Hospital District","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"]
["Cynthia A Hill, NP",1225271224,"75-1997880","TX","PE - Andrews County Hospital District","Triwest VA","Enrollment on Hold","Enrollment on Hold","","","","","RHC."]
["Cynthia A Hill, NP",1225271224,"75-1997880","TX","PE - Andrews County Hospital District","Medicaid","Participating","In House Enrollment","2020-03-31","205592303","324676101","2020-10-15","10/15/2020 - this enrollment is maintained by the clinic. Rec'd a copy of the effective letter to update the database for use with other payers - Stacey Hudak"]
["Cynthia A Hill, NP",1225271224,"75-1997880","TX","PE - Andrews County Hospital District","USA PPO","Participating","Enrollment Complete","2021-01-26","1312312","","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"]
["Cynthia A Hill, NP",1225271224,"75-1997880","TX","PE - Andrews County Hospital District","HealthSmart PPO","Participating","Enrollment Complete","2020-07-17","","","2021-12-03","12/3/2021 Per Healthsmart website provider is PAR and loaded under TIN/location effective 7/17/2020.  DCannon"]
["Cynthia A Hill, NP",1225271224,"75-1997880","TX","PE - Andrews County Hospital District","Scott&White (First Care)","Participating","Enrollment Complete","2020-09-02","","","2021-01-29","1/29/2021 - Rcvd roster from Scott&White (First Care) confirming participation of provider with TIN and location effective dates.  DCannon"]
["Cynthia A Hill, NP",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,"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,"75-1997880","TX","PE - Andrews County Hospital District","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,"75-1997880","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,"75-1997880","TX","PE - Andrews County Hospital District","Molina","Participating","Enrollment Complete","2016-03-16","","","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 3/16/2016.  DCannon"]
["Rahul Dinesh Puri, MD",1306928098,"75-1997880","TX","PE - Andrews County Hospital District","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","","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","PE - Andrews County Hospital District","TriCare Standard","Participating","Enrollment Complete","1996-12-03","","","2020-10-23","10/23/2020 Upon review of the self-service portal, provider is certified as a non-network provider, as well as participating under group with location. Kimberly Frazier"]
["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,"75-1997880","TX","PE - Andrews County Hospital District","USA PPO","Participating","Enrollment Complete","2016-03-16","1306928098","751997880","2020-08-19","Confirmed provider is participating with PPO and H&W (list of networks attached). Kimberly Frazier"]
["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,"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,"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,"75-1997880","TX","PE - Andrews County Hospital District","Medicare","Facility Enrollment","Facility Enrollment","","RHC GROUP NPI - Part A Only","","2020-07-28","RHC ENROLLMENT ONLY - Part A Only - Facility enrollment only. No providers can be linked to this enrollment.  \n\nMoved to enrollment complete to remove from worklist - Stacey Hudak"]
["Rahul Dinesh Puri, MD",1306928098,"75-1997880","TX","","Gallagher","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","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,"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,"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,"75-1997880","TX","PE - Andrews County Hospital District","Humana","Participating","Enrollment Complete","2016-04-01","","","2021-11-18","11/18/2021 Rcvd full roster from Humana listing provider as PAR and linked to group TIN/location effective 4/1/2016.  DCannon"]
["Rahul Dinesh Puri, MD",1306928098,"75-1997880","TX","","Humana","Participating","Enrollment Complete","2016-04-01","","","2021-11-18","11/18/2021 Rcvd full roster from Humana listing provider as PAR and linked to group TIN/location effective 4/1/2016.  DCannon"]
["Rahul Dinesh Puri, MD",1306928098,"26-3789190","TX","PE - Permian Physician Services","Sedgwick","Participating","Enrollment Complete","2016-03-16","1161265","","2021-01-26","1/26/2021 - Per follow-up notes provider is par with TIN and location effective 03/16/2016.  DCannon"]
["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","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","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"]
["Paul Slaughter, DO",1184626749,"75-1997880","TX","PE - Andrews County Hospital District","United Health Care","Participating","Enrollment Complete","2019-11-01","249667","","2020-09-08","09/08/2020 - Rev'd email rec'd from the payer and previous note - this provider is on file at this service location. Moved to completed status - Stacey Hudak"]
["Paul Slaughter, DO",1184626749,"75-1997880","TX","PE - Andrews County Hospital District","CAQH","Participating","CAQH Reattested","2023-01-03","","","2023-01-03","1/3/2023 CAQH reviewed and re-attested.  DCannon"]
["Paul Slaughter, DO",1184626749,"75-1997880","TX","PE - Andrews County Hospital District","Tricare Prime","Participating","Enrollment Complete","2013-11-01","","","2021-01-25","1/25/2021 Confirmed via Self-Service portal provider's recredentialing is complete, and effective date remains the same as 11/01/2013. KFrazier"]
["Paul Slaughter, DO",1184626749,"75-1997880","TX","PE - Andrews County Hospital District","Medicaid","Participating","Enrollment Complete","2013-08-26","138408315","324676101","2020-10-23","10/23/2020 - moved to completed status after receiving a copy of the approved medicaid letter - Stacey Hudak"]
["Maria Montero, MD",1508218843,752656723,"TX","","USA PPO","Participating","Enrollment Complete","2021-01-26","1312337","","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"]
["Maria Montero, MD",1508218843,752656723,"TX","","Triwest VA","Facility Enrollment","Payor Follow Up","","","","","10/17/2022 - Received roster from Scarlett; provider status: \"No Action.  TIN is CCN participating under own DCN.\""]
["Maria Montero, MD",1508218843,752656723,"TX","","Triwest VA","Facility Enrollment","Payor Follow Up","","","","","10/17/2022 - Received roster from Scarlett; provider status: \"No Action.  TIN is CCN participating under own DCN.\""]
["Maria Montero, MD",1508218843,752656723,"TX","","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",1508218843,752656723,"TX","PE - North Big Spring Family Care","Caprock (CapStar)","Participating","Enrollment Complete","2020-08-21","","","2021-04-09","4/9/2020 Rcvd roster from Mary Rodriguez <mary.rodriguez@90degreebenefits.com> at Caprock listing provider as participating under TIN.  DCannon"]
["Maria Montero, MD",1508218843,752656723,"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"]
["Maria Montero, MD",1508218843,752656723,"TX","PE - North Big Spring Family Care","Superior","Participating","Enrollment Complete","2020-10-01","1508218843","","2020-10-02","10/2/2020 - rec'd email from the payer stating this provider has been added to the primed roster - Stacey Hudak"]
["Maria Montero, MD",1508218843,752656723,"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"]
["Maria Montero, MD",1508218843,752656723,"TX","PE - North Big Spring Family Care","IMS","Participating","Enrollment Complete","2020-09-15","1508218843","","2020-10-06","10/06/2020 -Rec'd email response from the payer stating this provider has been added to the PriMed roster - Stacey Hudak"]
["Maria Montero, MD",1508218843,752656723,"TX","PE - North Big Spring Family Care","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."]
["Maria Montero, MD",1508218843,752656723,"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."]
["Maria Montero, MD",1508218843,752656723,"TX","PE - North Big Spring Family Care","Cigna","Participating","Enrollment Complete","2021-02-02","1181373","","2021-02-22","2/17/2021 - Rcvd confirmation email from CIGNA that provider is participating effective 2/2/2021 PIN 1181373.  DCannon"]
["Christopher Stansell, FNP",1285065946,"75-1997880","TX","PE - Andrews County Hospital District","Multiplan","Participating","Enrollment Complete","2020-08-21","","","2022-07-23","7/23/2022 Per email from Marcie Eckhart-Haven at Multiplan provider is PAR and linked to group TIN effective  8/21/2020. DCannon"]
["Christopher Stansell, FNP",1285065946,"75-1997880","TX","PE - Andrews County Hospital District","Caprock (CapStar)","Participating","Enrollment Complete","2020-08-21","","","2021-04-09","4/9/2020 Rcvd roster from Mary Rodriguez <mary.rodriguez@90degreebenefits.com> at Caprock listing provider as participating under TIN.  DCannon"]
["Christopher Stansell, FNP",1285065946,"75-1997880","TX","PE - Andrews County Hospital District","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."]
["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"]
["Christopher Stansell, FNP",1285065946,"75-1997880","TX","PE - Andrews County Hospital District","Triwest VA","Enrollment on Hold","Enrollment on Hold","","","","","RHC"]
["Leslie Michelle Rowland, FNP",1720111883,"75-2656723","TX","PE - Premier Family Care I, Inc","Boon Chapman","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"]
["Leslie Michelle Rowland, FNP",1720111883,"75-2656723","TX","PE - Premier Family Care I, Inc","Aetna","Participating","Enrollment Complete","2021-04-01","9212791","","2021-05-07","5/7/2021 Called Aetna (888-632-3862 spoke with Andrea (call ref # 6017548190) she informed me that provider is PAR and linked to TIN/location effective 4/1/2021 PID 9212791.  DCannon"]
["Leslie Michelle Rowland, FNP",1720111883,"75-2656723","TX","PE - Premier Family Care I, Inc","HealthSmart PPO","Participating","Enrollment Complete","2020-09-17","","","2021-01-27","1/27/2021 - Rcvd confirmation email that provider is participating and linked to location and TIN effective 9/17/2020.  DCannon"]
["Leslie Michelle Rowland, FNP",1720111883,"75-2656723","TX","PE - Premier Family Care I, 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 I, Inc","Caprock (CapStar)","Participating","Enrollment Complete","2020-09-17","","","2021-04-09","4/9/2020 Rcvd roster from Mary Rodriguez <mary.rodriguez@90degreebenefits.com> at Caprock listing provider as participating under TIN.  DCannon"]
["Leslie Michelle Rowland, FNP",1720111883,"75-2656723","TX","PE - Premier Family Care I, 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","","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.\""]
["Leslie Michelle Rowland, FNP",1720111883,"75-2656723","TX","PE - Premier Family Care I, 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 I, 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 I, 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 I, Inc","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"]
["Leslie Michelle Rowland, FNP",1720111883,"75-2656723","TX","PE - Premier Family Care I, 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 I, 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 I, Inc","Caprock (CapStar)","Participating","Enrollment Complete","2020-09-17","","","2021-04-09","4/9/2020 Rcvd roster from Mary Rodriguez <mary.rodriguez@90degreebenefits.com> at Caprock listing provider as participating under TIN.  DCannon"]
["Leslie Michelle Rowland, FNP",1720111883,"75-2656723","TX","PE - Premier Family Care I, 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 I, Inc","TriCare Standard","Participating","Enrollment Complete","2021-05-20","","","2021-08-03","8/3/2021 Per follow-up complete notes provider is PAR under the group and TIN# effective 5/20/2021 w/ no term date under this location. Provider ID is 75-2656723-79703-A004.  DCannon"]
["Leslie Michelle Rowland, FNP",1720111883,"75-2656723","TX","PE - Premier Family Care I, 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 I, 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 I, Inc","First Health Coventry","Participating","Enrollment Complete","2021-11-22","9212791","","2022-05-11","5/11/2022 Per follow-up note from 12/20/2021 provider is PAR and linked to group TIN/location effective 11/22/2021.  PID # 9212791.  DCannon"]
["Ni Adams, NP",1194355339,"75-2656723","TX","","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"]
["Ni Adams, NP",1194355339,"75-2656723","TX","PE - Premier Family Care I, Inc","Tricare Prime","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"]
["Ni Adams, NP",1194355339,"75-2656723","TX","PE - Premier Family Care I, Inc","Amerigroup","Participating","Enrollment Complete","2020-10-13","","","2021-08-26","8/26/2021 Rcvd full roster from Joe Rodriguez at Amerigroup listing provider as PAR w/ group TIN and location effective 10/13/2020.  DCannon"]
["Ni Adams, NP",1194355339,"75-2656723","TX","PE - Premier Family Care I, Inc","USA PPO","Participating","Enrollment Complete","2021-01-26","1312232","","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"]
["Ni Adams, NP",1194355339,"75-2656723","TX","PE - Premier Family Care I, Inc","Superior","Participating","Enrollment Complete","2020-12-01","","","2021-02-02","2/2/2021 - Rcvd confirmation from payer that provider is participating and linked to TIN effective 12/1/2020.  DCannon"]
["Ni Adams, NP",1194355339,"75-2656723","TX","PE - Premier Family Care I, Inc","Medicaid","Participating","Enrollment Complete","2020-10-01","4075624-02","0798373-01","2021-01-04","1/4/2021 Received forwarded approval notice from Candace Wynne in which provider has been assigned TPI 4075624-02, effective 10/1/2020. Revalidation due 12/28/2025. KFrazier"]
["Ni Adams, NP",1194355339,"75-2656723","TX","PE - Premier Family Care I, 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 Murphy, RD",1124637160,752656723,"TX","PE - Premier Family Care I, Inc","Scott&White (First Care)","Participating","Enrollment Complete","2021-01-29","","","2021-03-24","3/24/2021 Rcvd confirmation email from hpcredentialinggroup@BSWHealth.org that provider is participating with TIN and location effective 01/29/2021.  DCannon"]
["Rachel Murphy, RD",1124637160,752656723,"TX","PE - Premier Family Care I, 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 Murphy, RD",1124637160,752656723,"TX","PE - Premier Family Care I, Inc","Boon Chapman","Participating","Enrollment Complete","2020-12-07","","","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 12/7/2020.   DCannon"]
["Rachel Murphy, RD",1124637160,752656723,"TX","PE - Premier Family Care I, Inc","IMS","Participating","Enrollment Complete","2020-12-07","","","2021-01-06","1/6/2020 - Rcvd confirmation from payor that provider load is complete.  DCannon"]
["Eliana Kelley, NP",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, NP",1184278251,"75-1997880","TX","PE - Andrews County Hospital District","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"]
["Eliana Kelley, NP",1184278251,"75-1997880","TX","PE - Andrews County Hospital District","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."]
["Eliana Kelley, NP",1184278251,"75-1997880","TX","PE - Andrews County Hospital District","Tricare Prime","Participating","Enrollment Complete","2022-02-25","","","2022-03-09","3/9/2022 Per Tricare portal, provider is linked to location as of 2/25/2022. Cbankston"]
["Eliana Kelley, NP",1184278251,"75-1997880","TX","PE - Andrews County Hospital District","HealthSmart PPO","Participating","Enrollment Complete","2021-01-07","","","2021-03-01","3/1/2021 Rcvd confirmation that provider is participating with Healthsmart PPO effective 1/7/2021.  DCannon"]
["Eliana Kelley, NP",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, NP",1720538606,751997880,"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, NP",1720538606,751997880,"TX","PE - Andrews County Hospital District","Amerigroup","Participating","Enrollment Complete","2021-01-07","","","2021-10-09","10/9/2021 Rcvd full roster from Joe Rodriguez at Amerigroup listing provider as PAR w/ group TIN and location effective 1/7/2021.  DCannon"]
["Julie Parker, NP",1720538606,751997880,"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, NP",1720538606,751997880,"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"]
["Julie Parker, NP",1720538606,751997880,"TX","PE - Andrews County Hospital District","Triwest VA","Enrollment on Hold","Enrollment on Hold","","","","","RHC."]
["Julie Parker, NP",1720538606,751997880,"TX","","Triwest VA","Enrollment on Hold","Enrollment on Hold","","","","","RHC."]
["Daniel Jeremy Dominguez, APRN-FNP-BC",1720610447,"","TX","PE - Midland Community Healthcare Services","Humana","Participating","Enrollment Complete","2022-06-01","","","2022-10-06","10/6/2022 Per email from Vernita Young at Humana provider is PAR and linked to group TIN/locations effective 6/1/2022.  DCannon"]
["Daniel Jeremy Dominguez, APRN-FNP-BC",1720610447,"","TX","PE - Midland Community Healthcare Services","Cigna","Participating","Enrollment Complete","2022-06-01","3330657","","2022-10-31","10/31/2022 Rcvd email from Cigna that provider is PAR and linked to group TIN/locations effective 6/1/2022.  DCannon"]
["Daniel Jeremy Dominguez, APRN-FNP-BC",1720610447,"","TX","PE - Midland Community Healthcare Services","Cigna","Participating","Enrollment Complete","2022-06-01","3330657","","2022-10-31","10/31/2022 Rcvd email from Cigna that provider is PAR and linked to group TIN/locations effective 6/1/2022.  DCannon"]
["Daniel Jeremy Dominguez, APRN-FNP-BC",1720610447,"","TX","PE - Midland Community Healthcare Services","Scott&White (First Care)","In Process","Payor Follow Up","","","","2023-03-08","3/8/2023 Emailed Scott & White at bswhpexpedites@bswhealth.org to check status of provider load.  DCannon"]
["Daniel Jeremy Dominguez, APRN-FNP-BC",1720610447,"","TX","PE - Midland Community Healthcare Services","Scott&White (First Care)","In Process","Payor Follow Up","","","","2023-03-08","3/8/2023 Emailed Scott & White at bswhpexpedites@bswhealth.org to check status of provider load.  DCannon"]
["Daniel Jeremy Dominguez, APRN-FNP-BC",1720610447,"","TX","PE - Midland Community Healthcare Services","HealthSmart PPO","Participating","Enrollment Complete","2022-06-01","","","2022-10-10","10/10/2022 Per Healthsmart website provider is PAR and loaded under TIN/location effective 6/1/2022.  DCannon"]
["Daniel Jeremy Dominguez, APRN-FNP-BC",1720610447,"","TX","PE - Midland Community Healthcare Services","HealthSmart PPO","Participating","Enrollment Complete","2022-06-01","","","2022-10-10","10/10/2022 Per Healthsmart website provider is PAR and loaded under TIN/location effective 6/1/2022.  DCannon"]
["Daniel Jeremy Dominguez, APRN-FNP-BC",1720610447,"","TX","PE - Midland Community Healthcare Services","HealthSmart PPO","Participating","Enrollment Complete","2022-06-01","","","2022-10-10","10/10/2022 Per Healthsmart website provider is PAR and loaded under TIN/location effective 6/1/2022.  DCannon"]
["Daniel Jeremy Dominguez, APRN-FNP-BC",1720610447,"","TX","PE - Midland Community Healthcare Services","Omni PPO","Participating","Enrollment Complete","2022-06-01","","","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 6/1/2022.   DCannon"]
["Daniel Jeremy Dominguez, APRN-FNP-BC",1720610447,"","TX","PE - Midland Community Healthcare Services","Boon Chapman","Participating","Enrollment Complete","2022-06-01","","","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 6/1/2022.  DCannon"]
["Daniel Jeremy Dominguez, APRN-FNP-BC",1720610447,"","TX","PE - Midland Community Healthcare Services","Boon Chapman","Participating","Enrollment Complete","2022-06-01","","","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 6/1/2022.  DCannon"]
["Daniel Jeremy Dominguez, APRN-FNP-BC",1720610447,"","TX","PE - Midland Community Healthcare Services","Boon Chapman","Participating","Enrollment Complete","2022-06-01","","","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 6/1/2022.  DCannon"]
["Daniel Jeremy Dominguez, APRN-FNP-BC",1720610447,"","TX","PE - Midland Community Healthcare Services","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"]
["Daniel Jeremy Dominguez, APRN-FNP-BC",1720610447,"","TX","PE - Midland Community Healthcare Services","Aetna","Participating","Enrollment Complete","2022-09-01","6761851","","2022-10-18","10/18/2022 Per email from Priscilla Albertine at MQA provider is PAR and linked to group TIN effective 9/1/2022.  PID # 6761851.  DCannon"]
["Daniel Jeremy Dominguez, APRN-FNP-BC",1720610447,"","TX","PE - Midland Community Healthcare Services","Aetna","Participating","Enrollment Complete","2022-09-01","6761851","","2022-10-18","10/18/2022 Per email from Priscilla Albertine at MQA provider is PAR and linked to group TIN effective 9/1/2022.  PID # 6761851.  DCannon"]
["Daniel Jeremy Dominguez, APRN-FNP-BC",1720610447,"","TX","PE - Midland Community Healthcare Services","Galaxy Health","Participating","Enrollment Complete","2022-06-01","","","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 6/1/2022.  DCannon"]
["Daniel Jeremy Dominguez, APRN-FNP-BC",1720610447,"","TX","PE - Midland Community Healthcare Services","Galaxy Health","Participating","Enrollment Complete","2022-06-01","","","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 6/1/2022.  DCannon"]
["Daniel Jeremy Dominguez, APRN-FNP-BC",1720610447,"","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"]
["Daniel Jeremy Dominguez, APRN-FNP-BC",1720610447,"","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"]
["Daniel Jeremy Dominguez, APRN-FNP-BC",1720610447,"","TX","PE - Midland Community Healthcare Services","USA PPO","In Process","Payor Follow Up","","","","2023-03-08","3/8/2023 Emailed USA PPO at ipa@usamco.com to check status of provider.  DCannon"]
["Daniel Jeremy Dominguez, APRN-FNP-BC",1720610447,"","TX","PE - Midland Community Healthcare Services","USA PPO","In Process","Payor Follow Up","","","","2023-03-08","3/8/2023 Emailed USA PPO at ipa@usamco.com to check status of provider.  DCannon"]
["Daniel Jeremy Dominguez, APRN-FNP-BC",1720610447,"","TX","PE - Midland Community Healthcare Services","Superior","Participating","Enrollment Complete","2022-09-01","","","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 9/1/2022.   DCannon"]
["Daniel Jeremy Dominguez, APRN-FNP-BC",1720610447,"","TX","PE - Midland Community Healthcare Services","Superior","Participating","Enrollment Complete","2022-09-01","","","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 9/1/2022.   DCannon"]
["Daniel Jeremy Dominguez, APRN-FNP-BC",1720610447,"","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"]
["Daniel Jeremy Dominguez, APRN-FNP-BC",1720610447,"","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"]
["Daniel Jeremy Dominguez, APRN-FNP-BC",1720610447,"","TX","PE - Midland Community Healthcare Services","United Health Care","Participating","Enrollment Complete","2022-06-01","","","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 6/1/2022.   MPIN# 007808995.   DCannon"]
["Daniel Jeremy Dominguez, APRN-FNP-BC",1720610447,"","TX","PE - Midland Community Healthcare Services","IMS","Participating","Enrollment Complete","2022-06-01","","","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 6/1/2022.   DCannon"]
["Daniel Jeremy Dominguez, APRN-FNP-BC",1720610447,"","TX","PE - Midland Community Healthcare Services","IMS","Participating","Enrollment Complete","2022-06-01","","","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 6/1/2022.   DCannon"]
["Daniel Jeremy Dominguez, APRN-FNP-BC",1720610447,"","TX","PE - Midland Community Healthcare Services","IMS","Participating","Enrollment Complete","2022-06-01","","","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 6/1/2022.   DCannon"]
["Daniel Jeremy Dominguez, APRN-FNP-BC",1720610447,"","TX","PE - Midland Community Healthcare Services","Amerigroup","Participating","Enrollment Complete","2022-06-01","","","2022-10-11","10/11/2022 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 6/1/2022.  DCannon"]
["Daniel Jeremy Dominguez, APRN-FNP-BC",1720610447,"","TX","PE - Midland Community Healthcare Services","First Health Coventry","In Process","Enrollment Complete","","","","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 10/1/2022. Location is on file. Provider ID is 3546319. Next recredentialing date is every 3 years (10/1/2025) No information for the payer#. -Kim Monique Fabian"]
["Daniel Jeremy Dominguez, APRN-FNP-BC",1720610447,"","TX","PE - Midland Community Healthcare Services","First Health Coventry","In Process","Enrollment Complete","","","","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 10/1/2022. Location is on file. Provider ID is 3546319. Next recredentialing date is every 3 years (10/1/2025) No information for the payer#. -Kim Monique Fabian"]
["Daniel Jeremy Dominguez, APRN-FNP-BC",1720610447,"","TX","PE - Midland Community Healthcare Services","First Health Coventry","In Process","Enrollment Complete","","","","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 10/1/2022. Location is on file. Provider ID is 3546319. Next recredentialing date is every 3 years (10/1/2025) No information for the payer#. -Kim Monique Fabian"]
["Daniel Jeremy Dominguez, APRN-FNP-BC",1720610447,"","TX","PE - Midland Community Healthcare Services","Ambetter","Participating","Enrollment Complete","2014-01-01","","","2022-10-12","10/12/2022 Per email from Priscilla Albertine at MQA she spoke w/ Shakita H. at Ambetter 800-218-7453 and provider is PAR and linked to group TIN and 3 MCHS locations - 801 E. Florida, 401 E. Illinois and 4214 Andrews Hwy effective 1/14/2014.  Ref # I-66177590.  Requested written confirmation of 4th address - 400 Rosalind Redfern Grover Pkwy.  DCannon"]
["Daniel Jeremy Dominguez, APRN-FNP-BC",1720610447,"","TX","PE - Midland Community Healthcare Services","Multiplan","Participating","Enrollment Complete","2022-06-01","","","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 6/1/2022.  DCannon"]
["Daniel Jeremy Dominguez, APRN-FNP-BC",1720610447,"","TX","PE - Midland Community Healthcare Services","Multiplan","Participating","Enrollment Complete","2022-06-01","","","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 6/1/2022.  DCannon"]
["Daniel Jeremy Dominguez, APRN-FNP-BC",1720610447,"","TX","PE - Midland Community Healthcare Services","Multiplan","Participating","Enrollment Complete","2022-06-01","","","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 6/1/2022.  DCannon"]
["Abraham Wai Jyun Leung, PA",1427541085,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Omni PPO","Participating","Enrollment Complete","2021-01-07","","","2021-03-24","3/24/2021 Rcvd email confirmation from German Aviles that provider has been loaded under delegation agrement and is participating and linked to TIN and location effective 1/7/2021.  DCannon"]
["Abraham Wai Jyun Leung, PA",1427541085,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","CAQH","Participating","CAQH Reattested","2023-01-03","","","2022-09-17","9/17/2022 CAQH reviewed and re-attested.  DCannon"]
["Abraham Wai Jyun Leung, PA",1427541085,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","CAQH","Participating","CAQH Reattested","2023-01-03","","","2022-09-17","9/17/2022 CAQH reviewed and re-attested.  DCannon"]
["Abraham Wai Jyun Leung, PA",1427541085,"47-3465832: S","TX","PE - WesTex Urgent Care, PLLC","CAQH","Participating","CAQH Reattested","2023-01-03","","","2023-01-03","1/3/2023 CAQH reviewed and re-attested.  DCannon."]
["Abraham Wai Jyun Leung, PA",1427541085,"47-3465832: T","TX","PE - WesTex Urgent Care, PLLC","CAQH","Participating","CAQH Reattested","2023-01-03","","","2023-01-03","1/3/2023 CAQH reviewed and re-attested.  DCannon."]
["Abraham Wai Jyun Leung, PA",1427541085,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","First Health Coventry","Participating","Enrollment Complete","2022-07-07","","","2022-07-12","7/12/2022 Per email from Priscilla Albertine at MQA she spoke with Diane at First Health Coventry 800-226-5116 and provider is PAR with group TIN/locations effective 7/7/2022.  DCannon"]
["Abraham Wai Jyun Leung, PA",1427541085,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Multiplan","Participating","Enrollment Complete","2022-04-14","","","2022-05-11","5/11/2022 Per email response from Marcie at Multiplan provider is PAR and linked to group TIN/locations effective 4/14/2022.  DCannon"]
["Abraham Wai Jyun Leung, PA",1427541085,"47-3465832: S","TX","PE - WesTex Urgent Care, PLLC","Texas Mutual","Participating","Enrollment Complete","","","","2022-07-18","7/18/2022 Per TX Mutual-Work Well provider portal provider is now PAR and linked to ALL WesTex Urgent Care locations.  DCannon"]
["Abraham Wai Jyun Leung, PA",1427541085,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","IMS","Participating","Enrollment Complete","2021-01-07","","","2021-03-24","3/24/2021 Rcvd email confirmation from German Aviles that provider has been loaded under delegation agrement and is participating and linked to TIN and location effective 1/7/2021.  DCannon"]
["Abraham Wai Jyun Leung, PA",1427541085,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Texas Municipal League","Participating","Enrollment Complete","2021-03-12","","","2021-03-24","3/24/2021 Rcvd email from Michelle Killough at Alliance WC that provider is participating and linked to TIN and location effective 3/12/2021.  DCannon"]
["Abraham Wai Jyun Leung, PA",1427541085,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Liberty Mutual","Participating","Enrollment Complete","2022-06-01","","","2023-02-28","2/28/2023 Per Coventry web portal provider is PAR with Liberty Mutual WC and linked to group effective 6/1/2022.  DCannon"]
["Rami Bonam, MD",1821384058,475554737,"TX","PE - Midland Inpatient Medical Association","Medicaid","Participating","Enrollment Complete","2020-12-05","382274405","","2021-01-26","1/26/2021 - Per follow-up notes provider NPI is on file and participating at location and TIN effective 12/5/2020.  TPI # 382274405.  DCannon"]
["Rami Bonam, MD",1821384058,475554737,"TX","PE - Midland Inpatient Medical Association","Amerigroup","Participating","Enrollment Complete","2020-07-10","","","2021-08-26","8/26/2021 Rcvd full roster from Joe Rodriguez at Amerigroup listing provider as PAR w/ group TIN and location effective 7/10/2020.  DCannon"]
["Rami Bonam, MD",1821384058,475554737,"TX","PE - Midland Inpatient Medical Association","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"]
["Rami Bonam, MD",1821384058,475554737,"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"]
["Paula Kaye Brookings, NP",1295136034,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Cigna","Participating","Enrollment Complete","2021-03-31","2032079","","2021-04-19","4/19/2021 Received email from PDMCOGZ@cign.com with confirmation provider has been loaded under Tax ID with both locations effective 3/31/2021 with assigned provider ID 2032079. KFrazier"]
["Paula Kaye Brookings, NP",1295136034,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Sedgwick","Participating","Enrollment Complete","2021-03-26","","","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 3/26/2021.  DCannon"]
["Paula Kaye Brookings, NP",1295136034,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Caprock (CapStar)","Participating","Enrollment Complete","2021-03-26","","","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 3/26/2021.  DCannon"]
["Paula Kaye Brookings, NP",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, NP",1295136034,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Texas Mutual","Participating","Enrollment Complete","2021-11-18","","","2022-05-20","05/19/2022 Per follow-up note on 2/6/2022 - Received email from wwtxcontracts@texasmutual.com that provider is in network.  DCannon"]
["Paula Kaye Brookings, NP",1295136034,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Texas Mutual","Participating","Enrollment Complete","2021-11-18","","","2022-05-20","05/19/2022 Per follow-up note on 2/6/2022 - Received email from wwtxcontracts@texasmutual.com that provider is in network.  DCannon"]
["Paula Kaye Brookings, NP",1295136034,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Zurich","Pending Other Enrollment","Pending Other Enrollment","","","","2023-02-03","2.3.23 Plan pends enrollment with Coventry WC. ABoles"]
["Paula Kaye Brookings, NP",1295136034,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Zurich","Pending Other Enrollment","Pending Other Enrollment","","","","2023-02-03","2.3.23 Plan pends enrollment with Coventry WC. ABoles"]
["Paula Kaye Brookings, NP",1295136034,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Omni PPO","Participating","Enrollment Complete","2021-03-26","","","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 3/26/2021. DCannon"]
["Paula Kaye Brookings, NP",1295136034,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","USA PPO","Participating","Enrollment Complete","2021-03-26","","","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 3/26/2021.  DCannon"]
["Paula Kaye Brookings, NP",1295136034,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Gallagher","Pending Other Enrollment","Pending Other Enrollment","","","","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"]
["Paula Kaye Brookings, NP",1295136034,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Sedgwick","Participating","Enrollment Complete","2021-03-26","","","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 3/26/2021.  DCannon"]
["Paula Kaye Brookings, NP",1295136034,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Rail Road Medicare","Participating","Enrollment Complete","2021-03-29","Q00082135","DX4335","2021-12-29","12/29/2021 Rcvd RR Medicare approval letter. RR Medicare PTAN #  Q00082135 - effective 3/29/2021.  DCannon"]
["Paula Kaye Brookings, NP",1295136034,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Aetna","Participating","Enrollment Complete","2021-03-26","6518709","","2021-07-01","7/1/2021 Per Aetna roster received from Jamie Roberts provider is PAR and linked to TIN/locations effective 3/26/2021.  DCannon"]
["Paula Kaye Brookings, NP",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, NP",1295136034,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Aetna","Participating","Enrollment Complete","2021-03-26","6518709","","2021-07-01","7/1/2021 Per Aetna roster received from Jamie Roberts provider is PAR and linked to TIN/locations effective 3/26/2021.  DCannon"]
["Paula Kaye Brookings, NP",1295136034,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Gallagher","Pending Other Enrollment","Pending Other Enrollment","","","","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"]
["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","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","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","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","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"]
["Meagan Leighann Cunningham, FNP",1891302931,"75-1997880","TX","PE - Andrews County Hospital District","USA PPO","Participating","Enrollment Complete","2021-01-07","1312391","","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"]
["Meagan Leighann Cunningham, FNP",1891302931,"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"]
["Meagan Leighann Cunningham, FNP",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, FNP",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"]
["Bola O Jaiyeola, NP",1235605064,"47-5554737","TX","PE - Midland Inpatient Medical Association","Medicaid","Participating","Enrollment Complete","2020-11-14","397001403","364596201","2021-03-01","3/1/2021 Upon review of the TMHP portal, provider has been approved and assigned TPI 397001403 under Group and effective date is that of Medicare approval, which is 11/14/2020. KFrazier"]
["Bola O Jaiyeola, NP",1235605064,"47-5554737","TX","PE - Midland Inpatient Medical Association","Scott&White (First Care)","Participating","Enrollment Complete","2021-03-12","","","2021-03-16","3/16/2021 Received an email from BSWHPEXPEDITES@BSWHealth.org confirming approval of participation under group Tax ID and location with an effective date of 3/12/2021. However, they state to allow 3-4 weeks before submitting claims to allow sufficient time for loading into their system. KFrazier"]
["Bola O Jaiyeola, NP",1235605064,"47-5554737","TX","PE - Midland Inpatient Medical Association","Medicare","Participating","Enrollment Complete","2020-11-14","1M2870","519061","2021-02-18","2/18/2021 Received Medicare approval notice with assigned PTAN 1M2870, effective 11/14/2020. KFrazier"]
["Bola O Jaiyeola, NP",1235605064,"47-5554737","TX","PE - Midland Inpatient Medical Association","CAQH","Participating","CAQH Reattested","2022-11-26","","","2022-11-26","11/26/2022 CAQH reviewed and re-attested.  DCannon"]
["Bola O Jaiyeola, NP",1235605064,"47-5554737","TX","PE - Midland Inpatient Medical Association","Aetna","Participating","Enrollment Complete","2021-02-08","","","2021-03-26","3/26/2021 Rcvd confirmation email from Jamie Roberts that February delegation roster adds have been completed.  DCannon"]
["Bola O Jaiyeola, NP",1235605064,"47-5554737","TX","PE - Midland Inpatient Medical Association","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"]
["Loyce Michelle Daniels, NP",1194320465,"75-2656723","TX","PE - Premier Family Care I, Inc","USA PPO","Participating","Enrollment Complete","2021-03-15","","","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 3/15/2021.  DCannon"]
["Loyce Michelle Daniels, NP",1194320465,"75-2656723","TX","PE - Premier Family Care I, Inc","Aetna","Participating","Enrollment Complete","2021-04-01","","","2021-03-24","3/19/21 (kstrickland) Called Atena SW Allen Call ref# 6008145974. Provider will be in network and effective on 4/1/21. However they are still loading the demographics. That should be loaded no later then 4/9/21. You can call back and get provider ID on that date. Tracking # PVB-1256016.  DCannon"]
["Loyce Michelle Daniels, NP",1194320465,"75-2656723","TX","PE - Premier Family Care I, Inc","Galaxy Health","Participating","Enrollment Complete","2021-03-15","","","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 3/15/2021.  DCannon"]
["Loyce Michelle Daniels, NP",1194320465,"75-2656723","TX","PE - Premier Family Care I, Inc","Triwest VA","Facility Enrollment","Application Submitted","","","","2022-11-23","08/19/2022 - Submitted application to TriWest VA (sent to Scarlett Abigail, Scarlett_Abigail@bcbstx.com)"]
["Loyce Michelle Daniels, NP",1194320465,"75-2656723","TX","PE - Premier Family Care I, Inc","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"]
["Loyce Michelle Daniels, NP",1194320465,"75-2656723","TX","PE - Premier Family Care I, Inc","Scott&White (First Care)","Participating","Enrollment Complete","2021-04-01","","","2021-03-18","3/18/2021 Received an email from SWHPEXPEDITES@BSWHealth.org confirming provider will be participating effective 4/1/2021. KFrazier"]
["Victoria Martinez, NP",1831729193,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Boon Chapman","Participating","Enrollment Complete","2022-03-15","","","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"]
["Victoria Martinez, NP",1831729193,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Rail Road Medicare","Participating","Enrollment Complete","2021-01-01","Q00040087","DX4335","","3/31/2021 Rcvd RR Medicaire PTAN approval letter.  PTAN # Q00040087 effective 1/1/2021."]
["Victoria Martinez, NP",1831729193,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Texas Mutual","Enrollment Stopped","Enrollment Denied","","","","2021-12-16","12/15/2021 Received email from Dee Dee Johson, wwtxcontracts@texasmutual.com, This provider was denied by the Credentialing Committee in March 2021 and her network application was withdrawn by Regina Stiger. Cbankston"]
["Victoria Martinez, NP",1831729193,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","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"]
["Victoria Martinez, NP",1831729193,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Alliance WC","Participating","Enrollment Complete","2021-05-21","","","2021-12-02","12/2/21 Received email from michelle.killough@pswca.org, provider eff 05/21/2021 with Tax ID 47-3465832 . Please see primary payor line for detailed notes regarding enrolment. Cbankston"]
["Victoria Martinez, NP",1831729193,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","United Health Care","Participating","Enrollment Complete","2021-03-15","","","2021-11-03","11/3/2021 Per email from Katherine Floyd on 9/7/2021 provider is an urgent care provider and credentialing is not required.  She is linked to group TIN/locations effective 3/15/2021.  DCannon."]
["Victoria Martinez, NP",1831729193,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Galaxy Health","Participating","Enrollment Complete","2021-03-15","","","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 3/15/2021.  DCannon"]
["Victoria Martinez, NP",1831729193,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Boon Chapman","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"]
["Victoria Martinez, NP",1831729193,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","United Health Care","Participating","Enrollment Complete","2021-03-15","","","2021-11-03","11/3/2021 Per email from Katherine Floyd on 9/7/2021 provider is an urgent care provider and credentialing is not required.  She is linked to group TIN/locations effective 3/15/2021.  DCannon."]
["Victoria Martinez, NP",1831729193,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Galaxy Health","Participating","Enrollment Complete","2021-03-15","","","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 3/15/2021.  DCannon"]
["Victoria Martinez, NP",1831729193,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Rail Road Medicare","Participating","Enrollment Complete","2021-01-01","","","2021-03-31","3/31/2021 Rcvd RR Medicaire PTAN approval letter.  PTAN # Q00040087 effective 1/1/2021."]
["Victoria Martinez, NP",1831729193,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Medicare","Participating","In House Enrollment","2021-01-01","1M6875","","2021-02-25","2/25/2021 This enrollment is processed In House. KFrazier"]
["Victoria Martinez, NP",1831729193,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","First Health Coventry","Participating","Enrollment Complete","2022-11-01","3605636","","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 11/01/2022 and link under the Group and TIN. Provider ID 3605636, Payer ID 73159 and Recredentialing date 11/01/2025. Service location is on file. Call ref#:517643. -Danico Gabriel Melendres"]
["Victoria Martinez, NP",1831729193,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","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"]
["Victoria Martinez, NP",1831729193,"47-3465832","TX","PE - WesTex Urgent Care, 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"]
["Victoria Martinez, NP",1831729193,"47-3465832","TX","PE - WesTex Urgent Care, 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"]
["Victoria Martinez, NP",1831729193,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","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"]
["Victoria Martinez, NP",1831729193,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Galaxy Health","Participating","Enrollment Complete","2021-03-15","","","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 3/15/2021.  DCannon"]
["Victoria Martinez, NP",1831729193,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Alliance WC","Participating","Enrollment Complete","2021-05-21","","","2021-12-02","12/2/21 Received email from michelle.killough@pswca.org, provider eff 05/21/2021 with Tax ID 47-3465832 . Cbankston"]
["Rebecca McClay, DNP",1629613070,"47-5554737","TX","PE - Midland Inpatient Medical Association","Rail Road Medicare","Participating","Enrollment Complete","2021-02-08","Q00052513","DW7662","2021-04-07","4/7/2021 Rcvd automatic approval of RR Medicare PTAN via web submittal.  PTAN # Q00052513 effective 2/8/2021.  DCannon"]
["Rebecca McClay, DNP",1629613070,"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"]
["Rebecca McClay, DNP",1629613070,"47-5554737","TX","PE - Midland Inpatient Medical Association","Caprock (CapStar)","Participating","Enrollment Complete","2021-03-15","","","2021-08-05","8/5/2021 Rcvd email from Caprock Provider Services provider_services_shared.t8@90degreebenefits.com  that providers from Mar, April, May and June delegated rosters have been loaded into their systems under requested TINS effective 3/15/2021.  DCannon"]
["Rebecca McClay, DNP",1629613070,"47-5554737","TX","PE - Midland Inpatient Medical Association","Aetna","Participating","Enrollment Complete","2021-03-15","6557282","","2021-07-01","7/1/2021 Per Aetna roster received from Jamie Roberts provider is PAR and linked to TIN/locations 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."]
["Rebecca McClay, DNP",1629613070,"47-5554737","TX","PE - Midland Inpatient Medical Association","Boon Chapman","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","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"]
["Amanda Compton, MD",1679953517,"26-3789190","TX","PE - Permian Physician Services","Superior","Participating","Enrollment Complete","2023-01-01","","","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 1/1/2023.   DCannon"]
["Amanda Compton, MD",1679953517,"26-3789190","TX","PE - Permian Physician Services","Scott&White (First Care)","In Process","Payor Follow Up","","","","2023-03-08","3/8/2023 Emailed Scott & White at bswhpexpedites@bswhealth.org to check status of provider load.  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","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,"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,"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,"75-1997880","TX","PE - Andrews County Hospital District","First Health Coventry","In Process","Enrollment Complete","","","","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 12/01/2022 and link under the Group and TIN. Provider ID 3629097, Payer ID 73159 and Recredentialing date 12/01/2025. Service location is on file. Call ref#:517643. -Danico Gabriel Melendres"]
["Amanda Compton, MD",1679953517,"75-1997880","TX","PE - Andrews County Hospital District","Aetna","Participating","Enrollment Complete","2021-04-15","6529979","","2021-07-01","7/1/2021 Per Aetna roster received from Jamie Roberts provider is PAR and linked to TIN/locations effective 4/15/2021.  DCannon"]
["Amanda Compton, MD",1679953517,"26-3789190","TX","PE - Permian Physician Services","Multiplan","In Process","Application Submitted","","","","2022-12-15","12/15/2022 Emailed monthly delegated roster to Multiplan to add providers to delegated roster.  DCannon"]
["Amanda Compton, MD",1679953517,"26-3789190","TX","PE - Permian Physician Services","CAQH","Participating","CAQH Reattested","2022-12-16","","","2022-12-16","12/16/2022 CAQH profile updated w/ new practice location.  Reviewed all other information and re-attested profile.  DCannon"]
["Amanda Compton, MD",1679953517,"75-1997880","TX","PE - Andrews County Hospital District","TriCare Standard","Participating","Enrollment Complete","2022-12-16","","","2023-03-08","3/8/2023 Per Tricare portal provider is PAR and linked to group TIN/location effective 12/16/2022.  DCannon"]
["Amanda Compton, MD",1679953517,"75-1997880","TX","PE - Andrews County Hospital District","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","2021-05-20","","","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","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"]
["Lisa A. Hernandez, NP",1942766092,"83-0358685","TX","PE - Midland Community Healthcare Services","USA PPO","Participating","Enrollment Complete","2021-05-20","","","2022-04-09","4/09/2022 Per roster from USA MCO provider is PAR and linked to group TIN/location effective 5/20/2021.  DCannon"]
["Lisa A. Hernandez, NP",1942766092,"83-0358685","TX","PE - Midland Community Healthcare Services","Medicaid","In House Enrollment","In House Enrollment","","430776101","","2021-04-15","4/15/2021 Facility processes own provider enrollments. KFrazier"]
["Lisa A. Hernandez, NP",1942766092,"83-0358685","TX","PE - Midland Community Healthcare Services","Multiplan","Participating","Enrollment Complete","2021-04-20","","","2021-07-01","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","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","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","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","Galaxy Health","Participating","Enrollment Complete","2021-05-20","","","2022-04-09","4/9/2022 Per roster received from Galaxy provider is listed as PAR and linked to group TIN/location 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","","2021-08-03","8/3/2021 Medicare enrollment is handled in-house by MCHS.  DCannon"]
["Lisa A. Hernandez, NP",1942766092,"83-0358685","TX","PE - Midland Community Healthcare Services","Superior","Participating","Enrollment Complete","2021-07-01","","","2021-07-08","7/8/2021 Rcvd email from Superior that monthly delegation roster for May is complete and providers are loaded under TIN/locations effective 7/1/2021.  DCannon"]
["Lisa A. Hernandez, NP",1942766092,"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"]
["Lisa A. Hernandez, NP",1942766092,"83-0358685","TX","PE - Midland Community Healthcare Services","Medicaid","In House Enrollment","In House Enrollment","","430776101","","2021-04-15","4/15/2021 Facility processes own provider enrollments. KFrazier"]
["Lisa A. Hernandez, NP",1942766092,"83-0358685","TX","PE - Midland Community Healthcare Services","Amerigroup","Participating","Enrollment Complete","2021-05-20","","","2021-11-11","11/11/2021 Rcvd email from Marco Rodriguez @ Amerigroup confirming that provider is PAR under group TIN/location effective 5/20/2021.  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","TriCare Standard","Participating","Enrollment Complete","2022-02-25","","","2022-03-08","3/8/2022 Provider has been added to this location eff 2.25.2022. Cbankston"]
["Lisa A. Hernandez, NP",1942766092,"83-0358685","TX","PE - Midland Community Healthcare Services","CAQH","In House Enrollment","In House Enrollment","","","","2021-04-15","4/15/2021 Denisse Villa maintains provider CAQH profiles. However, requested via email to confirm provider is current re-attestation and pending response. KFrazier"]
["Lisa A. Hernandez, NP",1942766092,"83-0358685","TX","PE - Midland Community Healthcare Services","Triwest VA","In Process","Application Submitted","","","","","08/19/2022 - Application submitted to Scarlett Abigail (Scarlett_Abigail@bcbstx.com) of TriWest VA"]
["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"]
["Lisa A. Hernandez, NP",1942766092,"83-0358685","TX","PE - Midland Community Healthcare Services","Aetna","Participating","Enrollment Complete","2021-06-15","6626989","","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 6/15/2021.  PID # 6626989  DCannon"]
["Karthik Chakrala, DO",1043633233,"47-5554737","TX","PE - Midland Inpatient Medical Association","Medicaid","Participating","Enrollment Complete","2021-06-08","426493901","364596201","2021-09-09","9/9/2021 Rcvd TMHP Approval letter from Candace Wynne.  TPI # 426493901 - effective 6/8/2021 DCannon"]
["Karthik Chakrala, DO",1043633233,"47-5554737","TX","PE - Midland Inpatient Medical Association","Boon Chapman","Participating","Enrollment Complete","2021-05-10","","","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 5/10/2021.  DCannon"]
["Karthik Chakrala, DO",1043633233,"47-5554737","TX","PE - Midland Inpatient Medical Association","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"]
["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","In Process","Payor Follow Up","","","","2023-02-15","02.15.2023 S/W Teresita of First Health @800-226-5116. Rep advised me to contact Aetna @800-353-1232 to check if the application was received or not since they don't have an access to that. Called Aetna @800-353-1232 and spoke with Joan. Per rep, provider is linked under the TIN however it's not in network with First Health. No application received. Rep advised to submit a first health application online. Go to their website Aetna.com> click working with us>click join our network> select I'm interested in first health> fill out the application and click submit. TAT for the process is 30-45 business days. Call ref# 6133568833. - Mary Rose Acebedo"]
["Orlando Enrique Garner Cruz, MD",1417309105,"75-2656723","TX","PE - Premier Family Care I, 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"]
["Orlando Enrique Garner Cruz, MD",1417309105,"75-2656723","TX","PE - Premier Family Care I, 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 I, Inc","Medicaid","In House Enrollment","In House Enrollment","2021-07-01","1417309105","","2021-09-21","9/21/2021 Per email received from Candace Wynne she has submitted the TMHP application for provider.  DCannon"]
["Orlando Enrique Garner Cruz, MD",1417309105,"75-2656723","TX","PE - Premier Family Care I, 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"]
["Orlando Enrique Garner Cruz, MD",1417309105,"75-2656723","TX","PE - Premier Family Care I, Inc","Multiplan","Participating","Enrollment Complete","2021-05-10","","","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 5/10/2021.  DCannon"]
["Orlando Enrique Garner Cruz, MD",1417309105,"75-2656723","TX","","Triwest VA","Facility 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.\""]
["Orlando Enrique Garner Cruz, MD",1417309105,"75-2656723","TX","PE - Premier Family Care I, Inc","Superior","Participating","Enrollment Complete","2021-05-10","","","2021-06-03","6/3/2021 Rcvd email from Superior that monthly delegation roster for May is complete and providers are loaded under TIN/locations effective 6/1/2021.  DCannon"]
["Kristin M Moose, FNP",1215213970,752182177,"TX","PE - Debbie P. Reese, MD PA","Aetna","Participating","Enrollment Complete","2021-06-15","6246607","","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 6/15/2021.  PID # 6246607 DCannon"]
["Kristin M Moose, FNP",1215213970,752182177,"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",1215213970,752182177,"TX","PE - Debbie P. Reese, MD PA","Scott&White (First Care)","Participating","Enrollment Complete","2021-06-10","","","2021-08-18","8/18/2021 Rcvd complete roster from S & W list provider has PAR and loaded under TIN/location effective 6/10/2021.  DCannon"]
["Kristin M Moose, FNP",1215213970,752182177,"TX","PE - Debbie P. Reese, MD PA","Multiplan","Participating","Enrollment Complete","2021-06-10","","","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 6/10/2021.  DCannon"]
["Kristin M Moose, FNP",1215213970,752182177,"TX","PE - Debbie P. Reese, MD PA","TriCare Standard","Participating","Enrollment Complete","2021-06-15","","","2021-06-16","6/16/2021 Upon review of the Self-Service portal, provider has been loaded effective 6/15/2021 as certified as non-network under group Tax ID. KFrazier"]
["Jeffery Dickson, NP",1851865067,"473465832: S","TX","PE - WesTex Urgent Care, PLLC","HealthSmart PPO","Participating","Enrollment Complete","2021-08-13","","","2021-10-06","10/6/2021 Per Healthsmart website provider is PAR and loaded under TIN/location effective 8/13/2021.  DCannon"]
["Jeffery Dickson, NP",1851865067,"473465832: S","TX","PE - WesTex Urgent Care, PLLC","Caprock (CapStar)","Participating","Enrollment Complete","2021-08-13","","","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"]
["Jeffery Dickson, NP",1851865067,"473465832: S","TX","PE - WesTex Urgent Care, PLLC","Aetna","Participating","Enrollment Complete","2021-09-01","6764944","","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 # 6764944 DCannon"]
["Jeffery Dickson, NP",1851865067,"473465832: S","TX","PE - WesTex Urgent Care, PLLC","United Health Care","Participating","Enrollment Complete","2021-07-19","PR-6183946","","2021-11-01","11/1/2021 Received an email from united_healthcare_provider_operations@uhc.com confirming provider is now participating under group Tax ID effective 7/19/2021 with assigned provider ID 007017728, which was processed under reference number PR-6183946. KFrazier"]
["Jeffery Dickson, NP",1851865067,"473465832: P","TX","PE - WesTex Urgent Care, PLLC","Boon Chapman","Participating","Thru Other Payor","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,"473465832: T","TX","PE - WesTex Urgent Care, PLLC","HealthSmart PPO","Participating","Enrollment Complete","2021-08-13","","","2021-10-06","10/6/2021 Per Healthsmart website provider is PAR and loaded under TIN/location effective 8/13/2021.  DCannon"]
["Jeffery Dickson, NP",1851865067,"473465832: S","TX","PE - WesTex Urgent Care, PLLC","IMS","Participating","Enrollment Complete","2021-08-13","","","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"]
["Jeffery Dickson, NP",1851865067,"473465832: T","TX","PE - WesTex Urgent Care, PLLC","Cigna","Participating","Enrollment Complete","2021-07-19","","","2021-09-08","9/8/2021 Per email received from Rep Karen Deal at karen.deal@cigna.com confirming group is contracted as an ancillary facility and not enrollment is required, and all claims are paid under the group. KFrazier"]
["Jeffery Dickson, NP",1851865067,"473465832: S","TX","PE - WesTex Urgent Care, PLLC","Amerigroup","Participating","Enrollment Complete","2021-08-13","","","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"]
["Jeffery Dickson, NP",1851865067,"473465832: T","TX","PE - WesTex Urgent Care, PLLC","Aetna","Participating","Enrollment Complete","2021-09-01","6764944","","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 # 6764944 DCannon"]
["Jeffery Dickson, NP",1851865067,"473465832: T","TX","PE - WesTex Urgent Care, PLLC","Triwest VA","In House Enrollment","In House Enrollment","","","","2021-07-06","7/6/2021 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, enrollment and approval are required with BCBS of TX before may enroll for VACCN network participation, which are all processed In-House.  KFrazier"]
["Jeffery Dickson, NP",1851865067,"473465832: T","TX","PE - WesTex Urgent Care, PLLC","Texas Mutual","Participating","Enrollment Complete","2021-09-01","","","2021-11-18","11/18/21 Recevied email from MGorman@texasmutual.com, Jeffrey Dickson NP went “live” with the network on 09/01/2021. Cbankston"]
["Jeffery Dickson, NP",1851865067,"473465832: T","TX","PE - WesTex Urgent Care, PLLC","Rail Road Medicare","Participating","Enrollment Complete","2021-07-01","Q00126646","DX4335","2021-09-03","9/3/2021 Upon application submitted, received assigned RR PTAN Q00126646 effective 7/1/2021 under group RR PTAN DX4335. KFrazier"]
["Jeffery Dickson, NP",1851865067,"473465832: S","TX","PE - WesTex Urgent Care, PLLC","Multiplan","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,"473465832: S","TX","PE - WesTex Urgent Care, PLLC","Amerigroup","Participating","Enrollment Complete","2021-08-13","","","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"]
["Jeffery Dickson, NP",1851865067,"473465832: S","TX","PE - WesTex Urgent Care, PLLC","TriCare Standard","Participating","Enrollment Complete","2021-07-10","","","2021-07-13","7/13/2021 Received email confirmation from Rep Angela.Matesevac@wpsic.com confirming provider has now been loaded under group Tax ID and location effective 7/10/2021. KFrazier"]
["Jeffery Dickson, NP",1851865067,"473465832: P","TX","PE - WesTex Urgent Care, PLLC","First Health Coventry","Participating","Enrollment Complete","2021-09-01","","","2023-02-28","2/28/2023 Per First Health web portal provider is PAR and linked to group TIN/location effective 9/1/2021.  DCannon"]
["Sandra Maerzacker, MD",1396190823,542080139,"TX","PE - Sari Nabulsi, MD, LTD, LLP","Caprock (CapStar)","Participating","Enrollment Complete","2021-08-13","","","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",1396190823,542080139,"TX","PE - Sari Nabulsi, MD, LTD, LLP","Multiplan","Participating","Enrollment Complete","2021-08-13","","","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",1396190823,542080139,"TX","PE - Sari Nabulsi, MD, LTD, LLP","Omni PPO","Participating","Enrollment Complete","2021-08-13","","","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",1396190823,542080139,"TX","PE - Sari Nabulsi, MD, LTD, LLP","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"]
["Sandra Maerzacker, MD",1396190823,542080139,"TX","PE - Sari Nabulsi, MD, LTD, LLP","Boon Chapman","Participating","Enrollment Complete","2021-08-13","","","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",1396190823,542080139,"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"]
["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","Triwest VA","Panel Closed","Panel Closed","","","","2021-08-12",""]
["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"]
["William Bracamonte Baran, MD",1487117420,"47-5554737","TX","PE - Midland Inpatient Medical Association","Medicaid","Participating","Enrollment Complete","2021-08-01","429794701","364596201","2021-11-12","11/12/2021 Per TMHP web portal provider's application has been processed/approved.  TPI # 429794701 - effective 8/1/2021 - 11/8/2026.  DCannon."]
["William Bracamonte Baran, MD",1487117420,"47-5554737","TX","PE - Midland Inpatient Medical Association","Scott&White (First Care)","Participating","Enrollment Complete","2021-11-19","","","2022-03-16","3/16/2022 Per email response from BSW provider is PAR effective 11/19/2021.  DCannon"]
["William Bracamonte Baran, MD",1487117420,"47-5554737","TX","PE - Midland Inpatient Medical Association","Triwest VA","Enrollment Stopped","Enrollment Stopped","","","","","Practice is hospital-based; not eligible for TriWest VA enrollment"]
["William Bracamonte Baran, MD",1487117420,475554737,"TX","PE - Midland Inpatient Medical Association","Medicare","Participating","Enrollment Complete","2021-08-01","1U3010","519061","2021-09-22","9/22/2021 Per PECOS provider is PAR and linked to group/locaitons.  PTAN # 1U3010 - effective 8/1/2021.  DCannon"]
["William Bracamonte Baran, MD",1487117420,475554737,"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"]
["William Bracamonte Baran, MD",1487117420,475554737,"TX","PE - Midland Inpatient Medical Association","Boon Chapman","Participating","Enrollment Complete","2022-04-05","","","2022-04-21","4/21/2022 Per email received from Ryan Gardner at Multiplan provider is PAR and linked to group/location effective 4/5/2022.  DCannon"]
["Brenda Campos-Ilesanmi, APRN-NP",1740807304,"","TX","PE - Premier Family Care I, Inc","Triwest VA","Facility Enrollment","Application Submitted","","","","2022-11-23","08/19/2022 - Submitted application to TriWest VA (sent to Scarlett Abigail, Scarlett_Abigail@bcbstx.com)"]
["Brenda Campos-Ilesanmi, APRN-NP",1740807304,"","TX","","Triwest VA","Facility Enrollment","Application Submitted","","","","2022-11-23","08/19/2022 - Submitted application to TriWest VA (sent to Scarlett Abigail, Scarlett_Abigail@bcbstx.com)"]
["Brenda Campos-Ilesanmi, APRN-NP",1740807304,"","TX","PE - Premier Family Care I, Inc","IMS","Participating","Enrollment Complete","2022-08-01","","","2023-01-05","1/5/2023 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 8/1/2022.   DCannon"]
["Brenda Campos-Ilesanmi, APRN-NP",1740807304,475554737,"TX","PE - ADA Adult and Children Family Clinic LLC","CAQH","Participating","CAQH Reattested","2023-02-08","","","2023-02-08","2/8/2023 CAQH reviewed and re-attested.  DCannon"]
["Brenda Campos-Ilesanmi, APRN-NP",1740807304,"","TX","PE - Premier Family Care I, Inc","CAQH","Participating","CAQH Reattested","2023-02-08","","","2023-02-08","2/8/2023 CAQH reviewed and re-attested.  DCannon"]
["Brenda Campos-Ilesanmi, APRN-NP",1740807304,"","TX","PE - ADA Adult and Children Family Clinic LLC","CAQH","Participating","CAQH Reattested","2023-02-08","","","2023-02-08","2/8/2023 CAQH reviewed and re-attested.  DCannon"]
["Brenda Campos-Ilesanmi, APRN-NP",1740807304,475554737,"TX","PE - Midland Inpatient Medical Association","IMS","Participating","Enrollment Complete","2021-11-18","","","2022-02-04","2/4/2022 Rcvd email from G. Aviles @ IMS/Omni that provider is PAR and linked to group TIN/location effective 11/18/2021.  DCannon"]
["Brenda Campos-Ilesanmi, APRN-NP",1740807304,475554737,"TX","PE - Midland Inpatient Medical Association","HealthSmart PPO","Participating","Enrollment Complete","2021-11-18","13799034","","2022-04-23","4/23/2022 Per follow-up note - Providers NPI is on file and participating under the group and TIN# effective 11/18/2021. Physical location is on file.  Provider ID is 13799034.  DCannon"]
["Brenda Campos-Ilesanmi, APRN-NP",1740807304,"84-4724927","TX","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.\""]
["Brenda Campos-Ilesanmi, APRN-NP",1740807304,"84-4724927","TX","","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.\""]
["Brenda Campos-Ilesanmi, APRN-NP",1740807304,"","TX","PE - Premier Family Care I, Inc","United Health Care","Participating","Enrollment Complete","2022-08-01","007514238","","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 8/1/2022.  MPIN # 007514238 DCannon"]
["Brenda Campos-Ilesanmi, APRN-NP",1740807304,475554737,"TX","PE - Midland Inpatient Medical Association","Wellcare","Participating","Enrollment Complete","2022-03-01","","","2022-11-15","11/15/2022 Per roster received from Wellcare provider is PAR and linked to group TIN/location effective 3/1/2022.  DCannon"]
["Brenda Campos-Ilesanmi, APRN-NP",1740807304,475554737,"TX","PE - Midland Inpatient Medical Association","Rail Road Medicare","Participating","Enrollment Complete","2021-11-07","Q00181257","DW7662","2021-12-15","12/15/2021 Rcvd RR Medicare approval letter.  PTAN # Q00181257 - effective 11/7/2021.  DCannon"]
["Brenda Campos-Ilesanmi, APRN-NP",1740807304,"","TX","PE - Premier Family Care I, 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"]
["Brenda Campos-Ilesanmi, APRN-NP",1740807304,"84-4724927","TX","PE - ADA Adult and Children Family Clinic LLC","Medicaid","In House Enrollment","In House Enrollment","","","","2022-07-21","7/21/2022 Per email from Candace Wynne she will be completing the TX Medicaid enrollment for provider to link to ADA Adult and Children Family Clinic LLC.  DCannon"]
["Brenda Campos-Ilesanmi, APRN-NP",1740807304,"84-4724927","TX","PE - ADA Adult and Children Family Clinic LLC","HealthSmart PPO","Participating","Enrollment Complete","2022-02-01","","","2022-03-25","3/25/2022 Per Healthsmart website provider is PAR and loaded under TIN/location effective 2/1/2022.  DCannon"]
["Brenda Campos-Ilesanmi, APRN-NP",1740807304,475554737,"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"]
["Brenda Campos-Ilesanmi, APRN-NP",1740807304,"84-4724927","TX","PE - ADA Adult and Children Family Clinic LLC","USA PPO","Participating","Enrollment Complete","2021-12-15","","","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 12/15/2021.  DCannon"]
["Brenda Campos-Ilesanmi, APRN-NP",1740807304,"","TX","PE - Premier Family Care I, Inc","USA PPO","Participating","Enrollment Complete","2022-08-01","","","2023-03-08","3/8/2023 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 8/1/2022.  DCannon"]
["Brenda Campos-Ilesanmi, APRN-NP",1740807304,475554737,"TX","PE - Midland Inpatient Medical Association","Humana","Participating","Enrollment Complete","2021-11-18","","","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 11/18/2021.  DCannon"]
["Addis Getahun, MD",1548765183,"47-5554737","TX","PE - Midland Inpatient Medical Association","HealthSmart PPO","Participating","Enrollment Complete","2021-11-01","","","2021-12-30","12/30/2021 Per Healthsmart website provider is PAR and loaded under TIN/location effective 11/1/2021.  DCannon"]
["Addis Getahun, MD",1548765183,"47-5554737","TX","PE - Midland Inpatient Medical Association","Multiplan","Participating","Enrollment Complete","2022-04-05","","","2022-04-21","4/21/2022 Per email received from Ryan Gardner at Multiplan provider is PAR and linked to group/location effective 4/5/2022.  DCannon"]
["Addis Getahun, MD",1548765183,"47-5554737","TX","PE - Midland Inpatient Medical Association","CAQH","Participating","CAQH Reattested","2022-12-20","","","2022-09-06","9/6/2022 CAQH reviewed and re-attested.  Updated malpractice information.  DCannon"]
["Addis Getahun, MD",1548765183,"47-5554737","TX","PE - Midland Inpatient Medical Association","Caprock (CapStar)","Participating","Enrollment Complete","2021-11-01","","","2022-03-11","3/11/2022 Rcvd email from Caprock ProviderServices.T8@90degreebenefits.com that monthly delegated roster provider load is complete and provider is loaded under TIN at location effective 11/1/2021.  DCannon"]
["Addis Getahun, MD",1548765183,"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"]
["Addis Getahun, MD",1548765183,"47-5554737","TX","PE - Midland Inpatient Medical Association","Rail Road Medicare","Participating","Enrollment Complete","2021-10-21","Q00162940","DW7662","2021-11-12","11/12/2021 Rcvd RR Medicare PTAN via online RR Medicare portal.  PTAN # Q00162940 - effective 10/21/2021.  DCannon"]
["Martha Denise Mourning, NP",1922552959,"47-5554737","TX","PE - Midland Inpatient Medical Association","IMS","Participating","Enrollment Complete","2021-10-29","","","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 10/29/2021. DCannon"]
["Martha Denise Mourning, NP",1922552959,"47-5554737","TX","PE - Midland Inpatient Medical Association","Triwest VA","Enrollment Stopped","Enrollment Stopped","","","","","Practice is hospital-based; not eligible for TriWest VA enrollment"]
["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","Boon Chapman","Participating","Enrollment Complete","2021-12-22","","","2022-03-10","3/10/2022 Rcvd roster from Multiplan listing provider as PAR and listed under group TIN/location effective 12/22/2021.  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"]
["Martha Denise Mourning, NP",1922552959,"47-5554737","TX","PE - Midland Inpatient Medical Association","United Health Care","Participating","Enrollment Complete","2021-09-27","6663751","","2022-06-22","6/22/2022 Per email received from UHC with a roster attached provider is PAR and linked to group TIN/locations effective 9/27/2021.  MPIN # 6663751.  DCannon"]
["Daniel Gellan, MD",1811315880,"47-5554737","TX","PE - Midland Inpatient Medical Association","IMS","Participating","Enrollment Complete","2021-11-18","","","2022-02-04","2/4/2022 Rcvd email from G. Aviles @ IMS/Omni 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","2023-03-13","","","2023-03-13","3/13/2023 CAQH reviewed and re-attested.  DCannon"]
["Daniel Gellan, MD",1811315880,"47-5554737","TX","PE - Midland Inpatient Medical Association","Scott&White (First Care)","Participating","Enrollment Complete","2021-10-29","","","2021-11-01","11/1/2021 Received welcome letter, provider approved as of 10/29/21. Allow 3-4 weeks before submitting claims in order to ensure provider is fully loaded in all systems. Cbankston"]
["Daniel Gellan, MD",1811315880,"47-5554737","TX","PE - Midland Inpatient Medical Association","Omni PPO","Participating","Enrollment Complete","2021-11-18","","","2022-02-04","2/4/2022 Rcvd email from G. Aviles @ IMS/Omni 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","Caprock (CapStar)","Participating","Enrollment Complete","2021-11-18","","","2022-03-11","03/11/2022  Rcvd email from Caprock ProviderServices.T8@90degreebenefits.com that monthly delegated roster provider load is complete and provider is loaded under TIN at location effective 11/18/2021.  DCannon"]
["Kendra D Alexander, APRN-FNP-BC",1003441460,"473465832: S","TX","PE - WesTex Urgent Care, PLLC","USA PPO","Participating","Enrollment Complete","2021-12-09","","","2022-06-11","6/11/2022 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 12/9/2021.  DCannon"]
["Kendra D Alexander, APRN-FNP-BC",1003441460,"473465832: T","TX","PE - WesTex Urgent Care, PLLC","Cigna","Participating","Enrollment Complete","2021-08-15","","","2021-10-28","10/28/2021 Group is enrolled with payor as ancillary facility and no enrollment is required for providers. KFrazier"]
["Kendra D Alexander, APRN-FNP-BC",1003441460,"473465832: T","TX","PE - WesTex Urgent Care, PLLC","Gallagher","Pending Other Enrollment","Pending Other Enrollment","","","","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"]
["Kendra D Alexander, APRN-FNP-BC",1003441460,"473465832: T","TX","PE - WesTex Urgent Care, PLLC","Gallagher","Pending Other Enrollment","Pending Other Enrollment","","","","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"]
["Kendra D Alexander, APRN-FNP-BC",1003441460,"473465832: P","TX","PE - WesTex Urgent Care, PLLC","Rail Road Medicare","Pending Other Enrollment","Pending Medicare","","","","2021-09-27",""]
["Kendra D Alexander, APRN-FNP-BC",1003441460,"473465832: T","TX","PE - WesTex Urgent Care, PLLC","Humana","Participating","Enrollment Complete","2021-12-09","","","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 12/9/2021.  DCannon"]
["Kendra D Alexander, APRN-FNP-BC",1003441460,"473465832: P","TX","PE - WesTex Urgent Care, PLLC","Galaxy Health","Participating","Enrollment Complete","2021-12-09","","","2022-03-10","3/10/2022 Rcvd email from K. Avalos @ Galaxy that provider is PAR and linked to group TIN/location effective 12/09/2021.  DCannon"]
["Kendra D Alexander, APRN-FNP-BC",1003441460,"473465832: T","TX","PE - WesTex Urgent Care, PLLC","Galaxy Health","Participating","Enrollment Complete","2021-12-09","","","2022-03-10","3/10/2022 Rcvd email from K. Avalos @ Galaxy that provider is PAR and linked to group TIN/location effective 12/09/2021.  DCannon"]
["Kendra D Alexander, APRN-FNP-BC",1003441460,"473465832: P","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"]
["Kendra D Alexander, APRN-FNP-BC",1003441460,"473465832: P","TX","PE - WesTex Urgent Care, PLLC","IMS","Participating","Enrollment Complete","2021-12-09","","","2022-02-24","02/24/2022 Per follow-up note from 2/16/2022 - Provider NPI# is on file for the provider and is participating effective 12/9/21 under the group and TIN#. Provider ID is also the NPI. Physical location is on file. Ref# 2759469. - DCannon"]
["Kendra D Alexander, APRN-FNP-BC",1003441460,"473465832: S","TX","PE - WesTex Urgent Care, PLLC","IMS","Participating","Enrollment Complete","2021-12-09","","","2022-02-24","02/24/2022 Per follow-up note from 2/16/2022 - Provider NPI# is on file for the provider and is participating effective 12/9/21 under the group and TIN#. Provider ID is also the NPI. Physical location is on file. Ref# 2759469. - DCannon"]
["Kendra D Alexander, APRN-FNP-BC",1003441460,"473465832: P","TX","PE - WesTex Urgent Care, PLLC","Caprock (CapStar)","Participating","Enrollment Complete","2021-12-09","","","2022-03-11","03/11/2022  Rcvd email from Caprock ProviderServices.T8@90degreebenefits.com that monthly delegated roster provider load is complete and provider is loaded under TIN at location effective 12/9/2021.  DCannon"]
["Kendra D Alexander, APRN-FNP-BC",1003441460,"473465832: S","TX","PE - WesTex Urgent Care, PLLC","Caprock (CapStar)","Participating","Enrollment Complete","2021-12-09","","","2022-03-11","03/11/2022  Rcvd email from Caprock ProviderServices.T8@90degreebenefits.com that monthly delegated roster provider load is complete and provider is loaded under TIN at location effective 12/9/2021.  DCannon"]
["Kendra D Alexander, APRN-FNP-BC",1003441460,"473465832: S","TX","PE - WesTex Urgent Care, PLLC","Liberty Mutual","Pending Other Enrollment","Pending Other Enrollment","","","","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"]
["Kendra D Alexander, APRN-FNP-BC",1003441460,"473465832: T","TX","PE - WesTex Urgent Care, PLLC","Multiplan","Participating","Enrollment Complete","2022-02-02","13986301","","2022-02-24","2/24/2022 Per f/u note from 2/22/2022 -  NPI# for the provider is on file and shows Linked and Par under group and   TIN# effective 02/02/2022, the physical location is on file and the Provider ID is 13986301.  Case ref#:7922824. DCannon"]
["Kendra D Alexander, APRN-FNP-BC",1003441460,"473465832: T","TX","PE - WesTex Urgent Care, PLLC","Medicare","In Process","Pending Info/Document","","","","2023-01-24","1/24/2023 As of today still do not have surrogacy approval.  Sent email to Priscilla Albertine at MQA to see if she can help.  DCannon"]
["Kendra D Alexander, APRN-FNP-BC",1003441460,"473465832: S","TX","PE - WesTex Urgent Care, PLLC","Medicare","In Process","Pending Info/Document","","","","2023-01-24","1/24/2023 As of today still do not have surrogacy approval.  Sent email to Priscilla Albertine at MQA to see if she can help.  DCannon"]
["Kendra D Alexander, APRN-FNP-BC",1003441460,"473465832: T","TX","PE - WesTex Urgent Care, PLLC","Aetna","Participating","Enrollment Complete","2021-12-15","6888717","","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 12/15/21 under the group and TIN#. PIN 6888717. Physical location is on file. No ref# call disconnected. -DCannon"]
["Kendra D Alexander, APRN-FNP-BC",1003441460,"473465832: T","TX","PE - WesTex Urgent Care, PLLC","Zurich","Pending Other Enrollment","Pending Other Enrollment","","","","2023-02-03","2.3.23 Plan pends enrollment with Coventry WC. ABoles"]
["Kendra D Alexander, APRN-FNP-BC",1003441460,"473465832: T","TX","PE - WesTex Urgent Care, PLLC","Zurich","Pending Other Enrollment","Pending Other Enrollment","","","","2023-02-03","2.3.23 Plan pends enrollment with Coventry WC. ABoles"]
["Kendra D Alexander, APRN-FNP-BC",1003441460,"473465832: T","TX","PE - WesTex Urgent Care, PLLC","Omni PPO","Participating","Enrollment Complete","2021-12-09","","","2022-02-24","2/24/2022 Per follow-up note from 2/16/2022 - Provider NPI# is on file for the provider and is participating effective 12/9/21 under the group and TIN#. Provider ID is also the NPI. Physical location is on file. Ref# 2759469. - DCannon"]
["Kendra D Alexander, APRN-FNP-BC",1003441460,"473465832: P","TX","PE - WesTex Urgent Care, PLLC","Sedgwick","In Process","Sent to Provider For Signature","","","","2022-08-23","Emailed 2 documents to Rebecca Pontaski, Neeraja Ganeshraj, Priscilla Albertine in order to get providers' signature. MStone"]
["Kendra D Alexander, APRN-FNP-BC",1003441460,"473465832: P","TX","PE - WesTex Urgent Care, PLLC","CAQH","Participating","CAQH Reattested","2023-02-12","","","2023-02-12","2/12/2023 CAQH reviewed and re-attested.  DCannon"]
["Kendra D Alexander, APRN-FNP-BC",1003441460,"473465832: P","TX","PE - WesTex Urgent Care, PLLC","CAQH","Participating","CAQH Reattested","2023-02-12","","","2023-02-12","2/12/2023 CAQH reviewed and re-attested.  DCannon"]
["Kendra D Alexander, APRN-FNP-BC",1003441460,"473465832: T","TX","PE - WesTex Urgent Care, PLLC","United Health Care","Participating","Enrollment Complete","2021-12-09","","","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 12/9/2021.  DCannon"]
["Kendra D Alexander, APRN-FNP-BC",1003441460,"473465832: P","TX","PE - WesTex Urgent Care, PLLC","HealthSmart PPO","Participating","Enrollment Complete","2021-12-09","","","2022-04-23","4/23/2022 Per follow-up note - Providers NPI is on file and participating under the group and TIN# effective 12/9/2021.  Physical location is on file."]
["Kendra D Alexander, APRN-FNP-BC",1003441460,"473465832: S","TX","PE - WesTex Urgent Care, PLLC","HealthSmart PPO","Participating","Enrollment Complete","2021-12-09","","","2022-04-23","4/23/2022 Per follow-up note - Providers NPI is on file and participating under the group and TIN# effective 12/9/2021.  Physical location is on file."]
["Kendra D Alexander, APRN-FNP-BC",1003441460,"473465832: P","TX","PE - WesTex Urgent Care, PLLC","TriCare Standard","Participating","Enrollment Complete","2021-10-16","","","2022-02-24","2/24/2022 Per Humana Tricare portal provider is PAR and linked to group TIN/locations .  \nGreenbriar - 12/9/21, Odessa - 10/16/21 and Longview - 12/15/2021.  DCannon"]
["Kendra D Alexander, APRN-FNP-BC",1003441460,"473465832: S","TX","PE - WesTex Urgent Care, PLLC","TriCare Standard","Participating","Enrollment Complete","2021-10-16","","","2022-02-24","2/24/2022 Per Humana Tricare portal provider is PAR and linked to group TIN/locations .  \nGreenbriar - 12/9/21, Odessa - 10/16/21 and Longview - 12/15/2021.  DCannon"]
["Kendra D Alexander, APRN-FNP-BC",1003441460,"473465832: S","TX","PE - WesTex Urgent Care, PLLC","Texas Municipal League","Participating","Enrollment Complete","2022-04-15","","","2022-04-22","4/22/2022 Rcvd approval letter from payor effective 4/15/2022.  DCannon"]
["Kendra D Alexander, APRN-FNP-BC",1003441460,"473465832: T","TX","PE - WesTex Urgent Care, PLLC","Triwest VA","In House Enrollment","In House Enrollment","","","","2021-10-28",""]
["Kendra D Alexander, APRN-FNP-BC",1003441460,"473465832: S","TX","PE - WesTex Urgent Care, PLLC","Triwest VA","In House Enrollment","In House Enrollment","","","","2021-10-28",""]
["Kendra D Alexander, APRN-FNP-BC",1003441460,"473465832: T","TX","PE - WesTex Urgent Care, PLLC","First Health Coventry","Participating","Enrollment Complete","2021-12-09","3456202","","2022-05-11","5/11/2022 Per First Health website provider is PAR and linked to group TIN/location effective 12/9/2021.  PID # 3546202.  DCannon"]
["Venkatasubbaraya Achanta, MD",1780693648,475554737,"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",1780693648,475554737,"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"]
["Venkatasubbaraya Achanta, MD",1780693648,475554737,"TX","PE - Midland Inpatient Medical Association","USA PPO","Participating","Enrollment Complete","2022-01-10","","","2022-03-11","3/11/2022 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"]
["Venkatasubbaraya Achanta, MD",1780693648,475554737,"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"]
["Venkatasubbaraya Achanta, MD",1780693648,475554737,"TX","PE - Midland Inpatient Medical Association","First Health Coventry","In Process","Action Needed","","","","2022-10-10","10.11.2022 S/W Pam of First Health @ 800-226-5116. NPI is on file for the provider but non-participating under the group and TIN. Rep unable to check pending application. For the provider to be participating, rep advised to go to aetna.com>fill out application online>for first health request. No specific TAT. Ref# Kim Monique Fabian."]
["Jarret C Faust, PA-C",1427668250,853162122,"TX","PE - Basin Dermatology","United Health Care","Participating","Enrollment Complete","2022-02-04","9252040","","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 2/4/2022.  DCannon"]
["Jarret C Faust, PA-C",1427668250,853162122,"TX","PE - Basin Dermatology","Humana","Participating","Enrollment Complete","2022-02-04","","","2022-06-21","6/21/2022  Per email received from V. Thomas at Humana provider is PAR and linked to group TIN effective 2/4/2022.  DCannon"]
["Jarret C Faust, PA-C",1427668250,853162122,"TX","PE - Basin Dermatology","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"]
["Jarret C Faust, PA-C",1427668250,853162122,"TX","PE - Basin Dermatology","First Health Coventry","In Process","Payor Follow Up","","","","2023-03-06","03.06.2023 S/W Brenda of First Health @800-226-5116. Per rep, there's no provider under the TIN. Informed rep that our consultant received a confirmation from Aetna that the credentialing process was completed and a network rep will be in contact soon with effective date. Rep doesn't have an access to check pending application and advised me to allow more time for the process. TAT for the process is 180 business days. Call ref# 564186. - Mary Rose Acebedo"]
["Jarret C Faust, PA-C",1427668250,853162122,"TX","PE - Basin Dermatology","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"]
["Jarret C Faust, PA-C",1427668250,853162122,"TX","PE - Basin Dermatology","Cigna","Participating","Enrollment Complete","2022-02-04","9252040","","2022-02-23","2/7/2022 Rcvd email from Cigna stating that provider is PAR and linked to group TIN/location effective 2/4/2022.  PID # 9252040.  DCannon"]
["Ragini Sastry, DO",1942568431,"75-1997880","TX","PE - Andrews County Hospital District","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","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","2023-02-09","","","2022-10-24","10/24/2022 CAQH reviewed and re-attested.  DCannon"]
["Ragini Sastry, DO",1942568431,"26-3789190","TX","PE - Permian Physician Services","CAQH","Participating","CAQH Reattested","2023-02-09","","","2023-02-09","2/9/2023 CAQH reviewed and re-attested.  DCannon"]
["Ragini Sastry, DO",1942568431,"75-1997880","TX","PE - Andrews County Hospital District","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","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,"75-1997880","TX","PE - Andrews County Hospital District","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","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","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"]
["Judy J Jia, MD",1588983134,"75-2656723","TX","PE - Premier Family Care I, Inc","TriCare Standard","Participating","Enrollment Complete","2022-05-06","","","2022-05-19","5/19/2022 Per Tricare portal provider is PAR and linked to group TIN/location effective 5/6/2022.  DCannon"]
["Judy J Jia, MD",1588983134,"75-2656723","TX","PE - Premier Family Care I, 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 I, 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"]
["Judy J Jia, MD",1588983134,"75-2656723","TX","PE - Premier Family Care I, Inc","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"]
["Judy J Jia, MD",1588983134,"75-2656723","TX","PE - Premier Family Care I, 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 I, Inc","Galaxy Health","Participating","Enrollment Complete","2022-04-11","","","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  4/11/2022.  DCannon"]
["Joshuae G Gallardo, MD",1689985962,"75-2656723","TX","PE - Premier Family Care I, Inc","United Health Care","Participating","Enrollment Complete","2022-04-11","005305986","","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 4/11/2022.   MPIN# 005305986.   DCannon"]
["Joshuae G Gallardo, MD",1689985962,"75-2656723","TX","PE - Premier Family Care I, Inc","Omni PPO","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"]
["Joshuae G Gallardo, MD",1689985962,"75-2656723","TX","PE - Premier Family Care I, Inc","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"]
["Joshuae G Gallardo, MD",1689985962,"75-2656723","TX","PE - Premier Family Care I, Inc","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"]
["Joshuae G Gallardo, MD",1689985962,"75-2656723","TX","PE - Premier Family Care I, Inc","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"]
["Joshuae G Gallardo, MD",1689985962,"75-2656723","TX","","Triwest VA","Facility Enrollment","Application Submitted","","","","","08/19/2022 - Submitted application to TriWest VA (sent to Scarlett Abigail, Scarlett_Abigail@bcbstx.com)"]
["Joshuae G Gallardo, MD",1689985962,"75-2656723","TX","PE - Premier Family Care I, Inc","Galaxy Health","Participating","Enrollment Complete","2022-04-11","","","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  4/11/2022.  DCannon"]
["Claude B Nguyen, MD",1619130929,"75-2656723","TX","","Triwest VA","Facility Enrollment","Application Submitted","","","","2022-11-23","08/19/2022 - Submitted application to TriWest VA (sent to Scarlett Abigail, Scarlett_Abigail@bcbstx.com)"]
["Claude B Nguyen, MD",1619130929,"75-2656723","TX","PE - Premier Family Care I, Inc","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.\""]
["Claude B Nguyen, MD",1619130929,"75-2656723","TX","PE - Premier Family Care I, Inc","USA PPO","Participating","Enrollment Complete","2022-04-11","","","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 4/11/2022.  DCannon"]
["Claude B Nguyen, MD",1619130929,"75-2656723","TX","PE - Premier Family Care I, Inc","Amerigroup","Participating","Enrollment Complete","2022-04-11","","","2022-09-24","9/23/2022 Per roster received from Joe Rodriguez at Amerigroup 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 I, Inc","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"]
["Claude B Nguyen, MD",1619130929,"75-2656723","TX","PE - Premier Family Care I, 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"]
["Claude B Nguyen, MD",1619130929,"75-2656723","TX","PE - Premier Family Care I, Inc","First Health Coventry","Participating","Enrollment Complete","2022-07-01","2582285","","2022-08-10","8/10/2022 Per First Health web portal provider is PAR and linked to group TIN/location effective 7/1/2022.  PID # 2582285.  DCannon"]
["John H Ownby, MD",1558343988,"75-2656723","TX","PE - Premier Family Care I, Inc","Multiplan","Participating","Enrollment Complete","2022-04-11","","","2022-08-23","8/23/2022 Per email from Multiplan 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 I, Inc","Galaxy Health","Participating","Enrollment Complete","2022-04-11","","","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  4/11/2022.  DCannon"]
["John H Ownby, MD",1558343988,"75-2656723","TX","PE - Premier Family Care I, Inc","First Health Coventry","Participating","Enrollment Complete","2022-07-01","2359722","","2022-08-10","8/10/2022 Per First Health web portal provider is PAR and linked to group TIN/location effective 7/1/2022.  PID# 2359722  DCannon"]
["John H Ownby, MD",1558343988,"75-2656723","TX","","Triwest VA","Facility Enrollment","Application Submitted","","","","2022-11-23","08/19/2022 - Submitted application to TriWest VA (sent to Scarlett Abigail, Scarlett_Abigail@bcbstx.com)"]
["John H Ownby, MD",1558343988,"75-2656723","TX","PE - Premier Family Care I, Inc","Cigna","Participating","Enrollment Complete","2022-02-21","9403276","","2022-08-19","8/19/2022 Rcvd email from Cigna that provider is PAR and linked to group TIN/location effective 2/21/2022.  PID# 9403276.  DCannon"]
["John H Ownby, MD",1558343988,"75-2656723","TX","PE - Premier Family Care I, Inc","Superior","Participating","Enrollment Complete","2022-05-01","","","2022-05-19","5/19/2022 Rcvd roster from Superior Health Plan confirming provider is PAR and linked to group TIN/location effective 5/1/2022.  DCannon"]
["John H Ownby, MD",1558343988,"75-2656723","TX","PE - Premier Family Care I, Inc","United Health Care","Participating","Enrollment Complete","2022-04-11","002074110","","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 4/11/2022.   MPIN# 002074110.   DCannon"]
["Elena Krendelshchikova, NP",1356714406,"27-4061759","TX","PE - Permian Cardiology Inc.","Amerigroup","In Process","Action Needed","","","","2023-01-19","01.19.2023 S/W Kim of Amerigroup @ 800-454-3730. Per rep, provider is on file but showing out of network. Rep don't have access to check the status of the application. Per rep, to check the status of the application visit their website @ provider.amerigroup.com\\texas-provider\\home and if there's no application submitted just fill out the online application form then submit. TAT of 90 days. Call ref#:I-171689735. Verification request has been emailed to TXProviderRelations@amerigroup.com to verify Provider credentialing status. -Danico Gabriel Melendres"]
["Elena Krendelshchikova, NP",1356714406,"27-4061759","TX","PE - Permian Cardiology Inc.","Multiplan","Participating","Enrollment Complete","2022-02-04","","","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 2/4/2022.  DCannon"]
["Elena Krendelshchikova, NP",1356714406,"27-4061759","TX","PE - Permian Cardiology Inc.","Medicaid","Pending Other Enrollment","Pending Medicare","","","","",""]
["Elena Krendelshchikova, NP",1356714406,"27-4061759","TX","PE - Permian Cardiology Inc.","USA PPO","Participating","Enrollment Complete","2016-12-12","","","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 12/12/2016.  DCannon"]
["Elena Krendelshchikova, NP",1356714406,"27-4061759","TX","PE - Permian Cardiology Inc.","CAQH","Participating","CAQH Reattested","2023-02-14","","","2023-02-14","2/14/2023 CAQH profile reviewed and re-attested by provider.  DCannon"]
["Nidhi G Shah, MD",1093147217,"83-0358685","TX","PE - Midland Community Healthcare Services","IMS","Participating","Enrollment Complete","2022-03-02","","","2022-03-29","3/29/2022 Rcvd email from G. Aviles at IMS/Omni stating that March delegated roster has been completed and provider are now loaded effective 3/2/2022.  DCannon"]
["Nidhi G Shah, MD",1093147217,"83-0358685","TX","PE - Midland Community Healthcare Services","Caprock (CapStar)","Participating","Enrollment Complete","2022-03-02","","","2022-07-15","7/15/2022 Per roster rcvd from Caprock provider is PAR and linked to group effective 3/2/2022.  DCannon"]
["Nidhi G Shah, MD",1093147217,"83-0358685","TX","PE - Midland Community Healthcare Services","Caprock (CapStar)","Participating","Enrollment Complete","2022-03-02","","","2022-07-15","7/15/2022 Per roster rcvd from Caprock provider is PAR and linked to group effective 3/2/2022.  DCannon"]
["Nidhi G Shah, MD",1093147217,"83-0358685","TX","PE - Midland Community Healthcare Services","Caprock (CapStar)","Participating","Enrollment Complete","2022-03-02","","","2022-07-15","7/15/2022 Per roster rcvd from Caprock provider is PAR and linked to group effective 3/2/2022.  DCannon"]
["Nidhi G Shah, MD",1093147217,"83-0358685","TX","PE - Midland Community Healthcare Services","Galaxy Health","Participating","Enrollment Complete","2022-03-02","","","2022-05-03","5/3/2022 Rcvd email from Karen Avalos at Galaxy that March delegation roster has been completed and loaded.  Provider is PAR effective 3/2/2022.  DCannon"]
["Nidhi G Shah, MD",1093147217,"83-0358685","TX","PE - Midland Community Healthcare Services","Aetna","Participating","Enrollment Complete","2022-03-02","4192672","","2022-04-23","4/23/2022 Per follow-up note - provider NPI# is on file for the provider and is participating effective 03/02/2022 under the group and TIN#. Provider ID is 4192672.  DCannon"]
["Nidhi G Shah, MD",1093147217,"83-0358685","TX","PE - Midland Community Healthcare Services","Aetna","Participating","Enrollment Complete","2022-03-02","4192672","","2022-04-23","4/23/2022 Per follow-up note - provider NPI# is on file for the provider and is participating effective 03/02/2022 under the group and TIN#. Provider ID is 4192672.  DCannon"]
["Nidhi G Shah, MD",1093147217,"83-0358685","TX","PE - Midland Community Healthcare Services","Aetna","Participating","Enrollment Complete","2022-03-02","4192672","","2022-04-23","4/23/2022 Per follow-up note - provider NPI# is on file for the provider and is participating effective 03/02/2022 under the group and TIN#. Provider ID is 4192672.  DCannon"]
["Nidhi G Shah, MD",1093147217,"83-0358685","TX","PE - Midland Community Healthcare Services","TriCare Standard","Participating","Enrollment Complete","2022-03-02","","","2022-03-08","3/8/2022 Per Tricare portal, provider is linked to all locations eff 3.2.2022. Cbankston"]
["Nidhi G Shah, MD",1093147217,"83-0358685","TX","PE - Midland Community Healthcare Services","Boon Chapman","Participating","Enrollment Complete","2022-03-02","","","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 3/2/2022.  DCannon"]
["Nidhi G Shah, MD",1093147217,"83-0358685","TX","PE - Midland Community Healthcare Services","Boon Chapman","Participating","Enrollment Complete","2022-03-02","","","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 3/2/2022.  DCannon"]
["Nidhi G Shah, MD",1093147217,"83-0358685","TX","PE - Midland Community Healthcare Services","Boon Chapman","Participating","Enrollment Complete","2022-03-02","","","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 3/2/2022.  DCannon"]
["Nidhi G Shah, MD",1093147217,"83-0358685","TX","PE - Midland Community Healthcare Services","Omni PPO","Participating","Enrollment Complete","2022-03-02","","","2022-03-29","3/29/2022 Rcvd email from G. Aviles at IMS/Omni stating that March delegated roster has been completed and provider are now loaded effective 3/2/2022.  DCannon"]
["Nidhi G Shah, MD",1093147217,"83-0358685","TX","PE - Midland Community Healthcare Services","United Health Care","Participating","Enrollment Complete","2022-03-02","006281881","","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 3/2/2022.   MPIN# 006281881.   DCannon"]
["Nidhi G Shah, MD",1093147217,"83-0358685","TX","PE - Midland Community Healthcare Services","United Health Care","Participating","Enrollment Complete","2022-03-02","006281881","","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 3/2/2022.   MPIN# 006281881.   DCannon"]
["Nidhi G Shah, MD",1093147217,"83-0358685","TX","PE - Midland Community Healthcare Services","United Health Care","Participating","Enrollment Complete","2022-03-02","006281881","","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 3/2/2022.   MPIN# 006281881.   DCannon"]
["Nidhi G Shah, MD",1093147217,"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."]
["Nidhi G Shah, MD",1093147217,"83-0358685","TX","PE - Midland Community Healthcare Services","First Health Coventry","In Process","Enrollment Complete","","","","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 3613141, Payer ID 73159 and Recredentialing date 10/01/2025. Service location is on file. Call ref#:517681. -Danico Gabriel Melendres"]
["Nidhi G Shah, MD",1093147217,"83-0358685","TX","PE - Midland Community Healthcare Services","First Health Coventry","In Process","Enrollment Complete","","","","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 3613141, Payer ID 73159 and Recredentialing date 10/01/2025. Service location is on file. Call ref#:517681. -Danico Gabriel Melendres"]
["Nidhi G Shah, MD",1093147217,"83-0358685","TX","PE - Midland Community Healthcare Services","Superior","Participating","Enrollment Complete","2022-04-01","","","2022-04-01","4/1/2022 Rcvd email from Superior that provider is PAR and linked to group TIN/location effective 4/1/2022.  DCannon"]
["Nidhi G Shah, MD",1093147217,"83-0358685","TX","PE - Midland Community Healthcare Services","Superior","Participating","Enrollment Complete","2022-04-01","","","2022-04-01","4/1/2022 Rcvd email from Superior that provider is PAR and linked to group TIN/location effective 4/1/2022.  DCannon"]
["Nidhi G Shah, MD",1093147217,"83-0358685","TX","PE - Midland Community Healthcare Services","Humana","Participating","Enrollment Complete","2022-03-02","","","2022-04-19","4/19/2022 Per email from VThomas at Humana provider is PAR and linked to group TIN/location effective 3/2/2022.  DCannon"]
["Nidhi G Shah, MD",1093147217,"83-0358685","TX","PE - Midland Community Healthcare Services","Humana","Participating","Enrollment Complete","2022-03-02","","","2022-04-19","4/19/2022 Per email from VThomas at Humana provider is PAR and linked to group TIN/location effective 3/2/2022.  DCannon"]
["Nidhi G Shah, MD",1093147217,"83-0358685","TX","PE - Midland Community Healthcare Services","Multiplan","Participating","Enrollment Complete","2022-03-02","","","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 3/2/2022.  DCannon"]
["Nidhi G Shah, MD",1093147217,"83-0358685","TX","PE - Midland Community Healthcare Services","Multiplan","Participating","Enrollment Complete","2022-03-02","","","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 3/2/2022.  DCannon"]
["Nidhi G Shah, MD",1093147217,"83-0358685","TX","PE - Midland Community Healthcare 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"]
["Nidhi G Shah, MD",1093147217,"83-0358685","TX","PE - Midland Community Healthcare 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"]
["Nidhi G Shah, MD",1093147217,"83-0358685","TX","PE - Midland Community Healthcare Services","HealthSmart PPO","Participating","Enrollment Complete","2022-03-02","","","2022-04-05","4/5/2022 Per Healthsmart website provider is PAR and loaded under TIN/location effective 3/2/2022.  DCannon"]
["Nidhi G Shah, MD",1093147217,"83-0358685","TX","PE - Midland Community Healthcare Services","HealthSmart PPO","Participating","Enrollment Complete","2022-03-02","","","2022-04-05","4/5/2022 Per Healthsmart website provider is PAR and loaded under TIN/location effective 3/2/2022.  DCannon"]
["Nidhi G Shah, MD",1093147217,"83-0358685","TX","PE - Midland Community Healthcare Services","Amerigroup","Participating","Enrollment Complete","2022-03-02","","","2022-09-23","9/23/2022 Per roster received from Joe Rodriguez at Amerigroup provider is PAR and linked to group TIN effective 3/2/2022.  DCannon"]
["Nidhi G Shah, MD",1093147217,"83-0358685","TX","PE - Midland Community Healthcare Services","Amerigroup","Participating","Enrollment Complete","2022-03-02","","","2022-09-23","9/23/2022 Per roster received from Joe Rodriguez at Amerigroup provider is PAR and linked to group TIN effective 3/2/2022.  DCannon"]
["Nidhi G Shah, MD",1093147217,"83-0358685","TX","PE - Midland Community Healthcare Services","Cigna","Participating","Enrollment Complete","2022-07-29","2411707","","2022-08-01","8/1/2022 Rcvd email from Cigna stating that provider is PAR and linked to group effective 7/29/2022.  PID# 2411707.  DCannon"]
["Nidhi G Shah, MD",1093147217,"83-0358685","TX","PE - Midland Community Healthcare Services","Cigna","Participating","Enrollment Complete","2022-07-29","2411707","","2022-08-01","8/1/2022 Rcvd email from Cigna stating that provider is PAR and linked to group effective 7/29/2022.  PID# 2411707.  DCannon"]
["Nidhi G Shah, MD",1093147217,"83-0358685","TX","PE - Midland Community Healthcare Services","Scott&White (First Care)","Participating","Enrollment Complete","2022-03-15","","","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 3/15/2022.  DCannon"]
["Nidhi G Shah, MD",1093147217,"83-0358685","TX","PE - Midland Community Healthcare Services","Scott&White (First Care)","Participating","Enrollment Complete","2022-03-15","","","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 3/15/2022.  DCannon"]
["Shawn Collins Harris, NP",1679236053,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Coventry Workers Comp","In Process","Action Needed","","","","2022-10-11","10.11.2022 S/W Warren of Coventry @ 800-937-6824. Per rep, provider is showing as non in network. No pending application or request. Per rep, application can be done over the phone however, instead of doing the application over the phone rep advised to complete the document request form that was sent to Dcannon@symplr.com from pccdocssub.mitchel.com. TAT of 5 business days. As per rep, if the provider's application is already beyond 90 days rep advised to resubmit the nomination. Call ref#:10714445.-Danico Gabriel Melendres"]
["Shawn Collins Harris, NP",1679236053,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Broadspire Services Inc.","Thru Other Payor","Thru Other Payor","","","","2023-02-03","2.3.23 Tried calling Broadspire WC Support @ 866-830-2383, but was unsuccessful. Sent email to customer_Releations@choosebroadspire.com to verify current enrollment process. ABoles"]
["Shawn Collins Harris, NP",1679236053,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Broadspire Services Inc.","Thru Other Payor","Thru Other Payor","","","","2023-02-03","2.3.23 Tried calling Broadspire WC Support @ 866-830-2383, but was unsuccessful. Sent email to customer_Releations@choosebroadspire.com to verify current enrollment process. ABoles"]
["Shawn Collins Harris, NP",1679236053,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Gallagher","Pending Other Enrollment","Pending Other Enrollment","","","","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"]
["Shawn Collins Harris, NP",1679236053,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Amerigroup","In Process","Action Needed","","","","2022-12-21","12.21.22 Access Team has been following up on provider who was most recently submitted to payor February 2022. ABoles"]
["Shawn Collins Harris, NP",1679236053,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Amerigroup","In Process","Action Needed","","","","2022-12-21","12.21.22 Access Team has been following up on provider who was most recently submitted to payor February 2022. ABoles"]
["Shawn Collins Harris, NP",1679236053,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Sedgwick","In Process","Action Needed","","","","2023-01-31","1.31.23 Per response from SPNEAST@sedgwickcms.com there is no application on file for provider. Advised to submit new application. ABoles"]
["Shawn Collins Harris, NP",1679236053,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Sedgwick","In Process","Action Needed","","","","2023-01-31","1.31.23 Per response from SPNEAST@sedgwickcms.com there is no application on file for provider. Advised to submit new application. ABoles"]
["Shawn Collins Harris, NP",1679236053,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Omni PPO","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","USA PPO","Participating","Enrollment Complete","2022-02-04","","","2022-07-07","7/7/2022 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 2/4/2022.  DCannon"]
["Shawn Collins Harris, NP",1679236053,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Caprock (CapStar)","Participating","Enrollment Complete","2022-02-04","","","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 2/4/2022.  DCannon"]
["Shawn Collins Harris, NP",1679236053,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Caprock (CapStar)","Participating","Enrollment Complete","2022-02-04","","","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 2/4/2022.  DCannon"]
["Shawn Collins Harris, NP",1679236053,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","United Health Care","Participating","Enrollment Complete","2022-04-16","","","2022-04-15","Received email from networkhelp@uhc.com, enrollment is complete and eff 4.16.2022. MPIN 7967451. Cbankston"]
["Shawn Collins Harris, NP",1679236053,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Texas Municipal League","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","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","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","CAQH","Participating","CAQH Reattested","2023-01-13","","","2023-01-13","1/13/2023 CAQH reviewed and re-attested.  Current COI uploaded.  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","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","2022-02-04","","","2022-04-19","4/19/2022 Per email from VThomas at Humana 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","Humana","Participating","Enrollment Complete","2022-02-04","","","2022-04-19","4/19/2022 Per email from VThomas at Humana 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","Cigna","Participating","Enrollment Complete","2022-01-02","","","2022-03-08","3/8/2022 Received email from alec.welke2@cigna.com, this group and Tax ID are already contracted with Cigna via an Ancillary contract agreement.  Therefore, the provider does not require credentialing.  All services rendered by the provider should be billed under the contracted Ancillary Tax ID. Cbankston"]
["Shawn Collins Harris, NP",1679236053,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Scott&White (First Care)","Participating","Enrollment Complete","2022-03-15","","","2022-07-14","7/14/2022 Per email received on 5/5/2022 from Scott & White delegation roster provider load has been completed.  Providers are PAR and linked to group/locations effective 3/15/2022.  DCannon"]
["Shawn Collins Harris, NP",1679236053,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Scott&White (First Care)","Participating","Enrollment Complete","2022-03-15","","","2022-07-14","7/14/2022 Per email received on 5/5/2022 from Scott & White delegation roster provider load has been completed.  Providers are PAR and linked to group/locations effective 3/15/2022.  DCannon"]
["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","Rail Road Medicare","Participating","Enrollment Complete","2022-03-12","Q00315729","DX4335","2022-08-26","8/26/2022 Rcvd Rail Road Medicare  approval letter.  PTAN # Q00315729 - effective 3/12/2022.  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","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","Aetna","Participating","Enrollment Complete","2022-02-15","6299165","","2022-03-23","3/23/2022 Per follow-up note - DM: Called Aetna @ 800-353-1232 to obtain FU status for  the provider and Spoke to Alvin. Per rep, NPI# is on file for the provider and is Participating Effective 02/15/2022 under the group and TIN#. Physical location is on file. Provider ID is 6299165. Call ref#:6080313797. -DCannon"]
["Shawn Collins Harris, NP",1679236053,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Zurich","Pending Other Enrollment","Pending Other Enrollment","","","","2023-02-03","2.3.23 Plan pends enrollment with Coventry WC. ABoles"]
["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","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","Boon Chapman","Participating","Enrollment Complete","2022-02-04","","","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 2/4/2022.  DCannon"]
["Shawn Collins Harris, NP",1679236053,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Boon Chapman","Participating","Enrollment Complete","2022-02-04","","","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 2/4/2022.  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","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","Triwest VA","In House Enrollment","In House Enrollment","","","","2022-02-08",""]
["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","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","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"]
["Shawn Collins Harris, NP",1679236053,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Liberty Mutual","Pending Other Enrollment","Pending Other Enrollment","","","","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"]
["Shawn Collins Harris, NP",1679236053,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Multiplan","Participating","Enrollment Complete","2022-02-04","","","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 2/4/2022.  DCannon"]
["Shawn Collins Harris, NP",1679236053,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Multiplan","Participating","Enrollment Complete","2022-02-04","","","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 2/4/2022.  DCannon"]
["Amanda J Wilson, FNP-BC",1609484419,842617748,"TX","PE - Midland Medicine PA","Caprock (CapStar)","Participating","Enrollment Complete","2022-05-09","","","2022-08-10","8/10/2022 Per email from Priscilla Albertine at MQA provider is PAR and linked to group TIN/location effective 5/9/2022.  DCannon"]
["Amanda J Wilson, FNP-BC",1609484419,842617748,"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",1609484419,842617748,"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 w/ Ambetter and linked to group delegation roster effective 6/1/2022.  DCannon"]
["Amanda J Wilson, FNP-BC",1609484419,842617748,"TX","PE - Midland Medicine PA","Rail Road Medicare","Participating","Enrollment Complete","2022-04-26","Q00295742","EA8735","2022-07-21","7/21/2022 Received RR Medicare approval letter.  PTAN # Q00295742 effective 4/26/2022.  DCannon"]
["Amanda J Wilson, FNP-BC",1609484419,842617748,"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",1609484419,842617748,"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",1609484419,842617748,"TX","PE - Midland Medicine PA","United Health Care","Participating","Enrollment Complete","2022-05-09","008095998","","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# 008095998.   DCannon"]
["Amanda J Wilson, FNP-BC",1609484419,842617748,"TX","PE - Midland Medicine PA","USA PPO","Participating","Enrollment Complete","2022-05-09","","","2022-07-21","7/21/2022 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"]
["Amanda J Wilson, FNP-BC",1609484419,842617748,"TX","PE - Midland Medicine PA","Medicare","Participating","Enrollment Complete","2022-04-26","2F6260","IN5325","2022-07-11","7/11/2022 Rcvd Medicare approval letter.  PTAN # 2F6260 - effective 4/26/2022.  DCannon"]
["Amanda J Wilson, FNP-BC",1609484419,842617748,"TX","PE - Midland Medicine PA","IMS","Participating","Enrollment Complete","2022-05-09","","","2022-07-07","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"]
["Kendra Cooper, FNP-C",1780334193,"","TX","PE - Premier Family Care I, 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, FNP-C",1780334193,475554737,"TX","PE - Midland Inpatient Medical Association","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"]
["Kendra Cooper, FNP-C",1780334193,"","TX","PE - Premier Family Care I, Inc","Rail Road Medicare","Participating","Enrollment Complete","2022-07-01","Q00306927","CE1588","2022-08-11","8/11/2022 Rcvd RR Medicare approval letter.  Provider is PAR and linked to group/locations -   PTAN # Q00306927 - effective 7/1/2022.  DCannon"]
["Kendra Cooper, FNP-C",1780334193,"","TX","PE - Premier Family Care I, Inc","Cigna","Participating","Enrollment Complete","2022-07-01","","","2022-08-18","8/18/2022 Rcvd email from Cigna that provider is PAR and linked to group TIN/locations effective 7/1/2022.  PID# 2017438.  DCannon"]
["Kendra Cooper, FNP-C",1780334193,475554737,"TX","PE - Midland Inpatient Medical Association","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"]
["Kendra Cooper, FNP-C",1780334193,"","TX","PE - Premier Family Care I, 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, FNP-C",1780334193,475554737,"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"]
["Kendra Cooper, FNP-C",1780334193,"","TX","PE - Premier Family Care I, Inc","Ambetter","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"]
["Kendra Cooper, FNP-C",1780334193,475554737,"TX","PE - Midland Inpatient Medical Association","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"]
["Kendra Cooper, FNP-C",1780334193,"","TX","PE - Premier Family Care I, Inc","HealthSmart PPO","In Process","Application Submitted","","","","2022-07-15","7/15/2022 Emailed monthly delegation roster to Healthsmart to add provider to delegated roster.  DCannon"]
["Kendra Cooper, FNP-C",1780334193,"","TX","PE - Premier Family Care I, Inc","Galaxy Health","Participating","Enrollment Complete","2022-07-01","","","2022-08-17","8/17/2022 Per email from Karen Avalos at Galaxy delegated roster for July is complete and provider is loaded effective 7/1/2022.  DCannon"]
["Valarie Ramirez Alcala, PA-C",1790251031,463131679,"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-C",1790251031,463131679,"TX","PE - Midland Texas Orthopedic Group Inc","CAQH","Participating","CAQH Reattested","2023-02-16","","","2023-02-16","2/16/2023 CAQH reviewed and re-attested.  Uploaded COI.  DCannon"]
["Valarie Ramirez Alcala, PA-C",1790251031,463131679,"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-C",1790251031,463131679,"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-C",1790251031,463131679,"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-C",1790251031,463131679,"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-C",1790251031,463131679,"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-C",1790251031,463131679,"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-C",1720698574,463131679,"TX","","Triwest VA","In Process","Application Submitted","","","","2022-11-23","08/19/2022 - Submitted application to TriWest VA (sent to Scarlett Abigail, Scarlett_Abigail@bcbstx.com)"]
["Caroline D Hammond, PA-C",1720698574,463131679,"TX","PE - Midland Texas Orthopedic Group Inc","Liberty Mutual","Pending Other Enrollment","Pending Other Enrollment","","","","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"]
["Caroline D Hammond, PA-C",1720698574,463131679,"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-C",1720698574,463131679,"TX","PE - Midland Texas Orthopedic Group Inc","Travelers WC","Pending Other Enrollment","Pending Other Enrollment","","","","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"]
["Caroline D Hammond, PA-C",1720698574,463131679,"TX","PE - Midland Texas Orthopedic Group Inc","TriCare Standard","In Process","Enrollment Complete","","","","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-C",1720698574,463131679,"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-C",1720698574,463131679,"TX","PE - Midland Texas Orthopedic Group Inc","Sedgwick","In Process","Action Needed","","","","2023-01-31","1.31.23 Per response from SPNEAST@sedgwickcms.com, enrollment does not pend participation with Coventry WC. Advised to submit application. ABoles"]
["Caroline D Hammond, PA-C",1720698574,463131679,"TX","PE - Midland Texas Orthopedic Group Inc","Coventry Workers Comp","In Process","Payor Follow Up","","","","2023-02-16","2.16.2023 S/W Elijah of Coventry WC @ 800-937-6824. NPI is on file for the provider but not link under the group and TIN. Provider is not on file. Application was received on 1/25/2023. However, it was closed due to no douments received. To be credentialed and participating, rep sent a form to Amanda Boles (aboles@symplr.com) using the email pccdocsub@mitchell.com. Rep advised to reply and submit a LOI (word or PDF with company letterhead), name, TIN, address, contract change requesting to link the provider to the TIN, signature from contract owner and W9 form. TAT is 30-90 calendar days. -Kim Monique Fabian"]
["Caroline D Hammond, PA-C",1720698574,463131679,"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"]
["Innocentia Ifunanya Onyemetu, NP",1790457075,830358685,"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",1790457075,830358685,"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",1790457075,830358685,"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",1790457075,830358685,"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",1790457075,830358685,"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",1790457075,830358685,"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",1790457075,830358685,"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",1790457075,830358685,"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",1790457075,830358685,"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",1790457075,830358685,"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",1790457075,830358685,"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",1790457075,830358685,"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",1790457075,830358685,"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",1790457075,830358685,"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",1790457075,830358685,"TX","PE - Midland Community Healthcare Services","Triwest VA","In Process","Application Submitted","","","","2022-11-15"," 08/19/2022 - Application submitted to Scarlett Abigail (Scarlett_Abigail@bcbstx.com) of TriWest VA"]
["Innocentia Ifunanya Onyemetu, NP",1790457075,830358685,"TX","PE - Midland Community Healthcare Services","Triwest VA","In Process","Application Submitted","","","","2022-11-15"," 08/19/2022 - Application submitted to Scarlett Abigail (Scarlett_Abigail@bcbstx.com) of TriWest VA"]
["Innocentia Ifunanya Onyemetu, NP",1790457075,830358685,"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",1790457075,830358685,"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",1790457075,830358685,"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",1790457075,830358685,"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",1790457075,830358685,"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",1790457075,830358685,"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",1790457075,830358685,"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",1790457075,830358685,"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",1790457075,830358685,"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",1790457075,830358685,"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",1790457075,830358685,"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",1790457075,830358685,"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",1790457075,830358685,"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",1790457075,830358685,"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",1790457075,830358685,"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",1790457075,830358685,"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",1790457075,830358685,"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",1790457075,830358685,"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",1790457075,830358685,"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",1790457075,830358685,"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",1790457075,830358685,"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",1790457075,830358685,"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",1790457075,830358685,"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",1790457075,830358685,"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",1790457075,830358685,"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",1790457075,830358685,"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"]
["Sridhar R Allam, MD",1700061819,881668292,"TX","PE - Premier Texas Kidney Care, PLLC","CAQH","Participating","CAQH Reattested","2022-11-21","","","2022-11-21","11/21/2022 CAQH reviewed and re-attested.  DCannon"]
["Sridhar R Allam, MD",1700061819,881668292,"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",1700061819,881668292,"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",1700061819,881668292,"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",1700061819,881668292,"TX","PE - Premier Texas Kidney Care, PLLC","HealthSmart PPO","In Process","Application Submitted","","","","2022-07-15","7/15/2022 Emailed monthly delegated roster to Healthsmart to add provider to delegation roster.  DCannon"]
["Sridhar R Allam, MD",1700061819,881668292,"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",1700061819,881668292,"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",1700061819,881668292,"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",1700061819,881668292,"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"]
["Vishnu S Brahmandam, MD",1548447899,"75-2656723","TX","PE - Premier Family Care I, Inc","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","","Triwest VA","Facility Enrollment","In House Enrollment","","","","2022-08-06",""]
["Vishnu S Brahmandam, MD",1548447899,"75-2656723","TX","","Triwest VA","Facility Enrollment","In House Enrollment","","","","2022-08-06",""]
["Vishnu S Brahmandam, MD",1548447899,"75-2656723","TX","","Triwest VA","Facility 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.\""]
["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 I, Inc","USA PPO","In Process","Payor Follow Up","","","","2023-03-08","3/8/2023 Emailed USA PPO at ipa@usamco.com to check status of provider.  DCannon"]
["Vishnu S Brahmandam, MD",1548447899,"75-2656723","TX","","USA PPO","In Process","Payor Follow Up","","","","2023-03-08","3/8/2023 Emailed USA PPO at ipa@usamco.com to check status of provider.  DCannon"]
["Vishnu S Brahmandam, MD",1548447899,"75-2656723","TX","PE - Premier Family Care I, Inc","Medicare","Participating","Enrollment Complete","2022-08-15","2H6458","0008AH","2022-08-25","8/25/2022 Per PECOS provider is PAR and linked to group/location effective 8/15/2022.  PTAN # 2H6458.  DCannon"]
["Vishnu S Brahmandam, MD",1548447899,"75-2656723","TX","","TriCare Standard","Participating","Enrollment Complete","2022-08-25","","","2022-09-06","9/6/2022 Rcvd certification approval letter from Tricare that provider is approved and certified for the State of Texas effective 8/25/2022.  DCannon"]
["Vishnu S Brahmandam, MD",1548447899,"75-2656723","TX","PE - Premier Family Care I, Inc","Tricare Prime","Participating","Enrollment Complete","2022-08-25","","","2022-09-06","9/6/2022 Per Tricare portal provider is PAR and linked to group TIN/locations effective 8/25/2022.    DCannon"]
["Vishnu S Brahmandam, MD",1548447899,"75-2656723","TX","PE - Premier Family Care I, 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","","Multiplan","In Process","Application Submitted","","","","2022-09-15","9/15/2022 Submitted monthly delegation roster to Multiplan to add provider to delegation roster.  DCannon"]
["Vishnu S Brahmandam, MD",1548447899,"75-2656723","TX","PE - Premier Family Care I, Inc","Cigna","Participating","Enrollment Complete","2022-08-15","6692236","","2022-10-11","10/11/2022 Per email from Cigna provider is PAR and linked to group TIN/location effective 8/15/2022.  PID# 6692236.  DCannon"]
["Vishnu S Brahmandam, MD",1548447899,"75-2656723","TX","","Boon Chapman","Pending Other Enrollment","Pending Other Enrollment","","","","2022-08-11",""]
["Vishnu S Brahmandam, MD",1548447899,"75-2656723","TX","PE - Premier Family Care I, Inc","Amerigroup","Participating","Enrollment Complete","2022-09-12","","","2022-10-11","10.11.2022 Per follow-up note -S/W Qjuana of Amerigroup @ 800-454-3730. Per rep, provider is showing as participating with an Effective date 09/12/2022 and link under the Group and TIN. Provider ID 14402887, Payer ID 26375 and No Recredentialing date. Service location is on file. Call ref#:I-165123663.  DCannon"]
["Christopher A Stack, MD",1568704971,"75-2656723","TX","PE - Premier Family Care I, Inc","CAQH","Participating","CAQH Reattested","2022-11-29","","","2022-11-29","11/29/2022 CAQH reviewed and re-attested.  DCannon"]
["Christopher A Stack, MD",1568704971,"75-2656723","TX","PE - Premier Family Care I, Inc","Cigna","Participating","Enrollment Complete","2022-07-18","9368747","","2022-10-25","10/25/2022 Rcvd approval notification email from Cigna.  Provider is PAR and linked to group TIN/location effective 7/18/2022.  PID # 9368747.  DCannon"]
["Christopher A Stack, MD",1568704971,"75-2656723","TX","PE - Premier Family Care I, Inc","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"]
["Christopher A Stack, MD",1568704971,"75-2656723","TX","PE - Premier Family Care I, 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","","Triwest VA","Facility Enrollment","Application Submitted","","","","","08/19/2022 - Submitted application to TriWest VA (sent to Scarlett Abigail, Scarlett_Abigail@bcbstx.com)"]
["Christopher A Stack, MD",1568704971,"75-2656723","TX","PE - Premier Family Care I, Inc","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"]
["Misty Fortner, NP",1609152776,"","TX","PE - West Texas Allergy, Lubbock, PLLC","HealthSmart PPO","In Process","Application Submitted","","","","2023-02-15","2/15/2023 Emailed monthly delegated roster to Healthsmart to add provider to delegated roster.  DCannon"]
["Misty Fortner, NP",1609152776,"","TX","PE - West Texas Allergy, Lubbock, PLLC","United Health Care","In Process","Application Submitted","","","","2023-02-15","2/15/2023 Emailed monthly delegated roster to UHC to add provider to delegated roster.  DCannon"]
["Misty Fortner, NP",1609152776,"","TX","PE - West Texas Allergy, Lubbock, PLLC","Rail Road Medicare","Pending Other Enrollment","Pending Medicare","","","","2022-12-16",""]
["Misty Fortner, NP",1609152776,"","TX","PE - West Texas Allergy, Lubbock, PLLC","Medicaid","Provider Load","Provider Load","","","","2022-12-16",""]
["Misty Fortner, NP",1609152776,"","TX","PE - West Texas Allergy, Lubbock, PLLC","Medicare","In Process","Pending Info/Document","","","","2023-01-24","1/24/2023 As of today still do not have surrogacy approval.  Sent email to Priscilla Albertine at MQA to see if she can help.  DCannon"]
["Misty Fortner, NP",1609152776,"","TX","PE - West Texas Allergy, Lubbock, PLLC","Amerigroup","In Process","Application Submitted","","","","2023-02-15","2/15/2023 Emailed monthly delegated roster to Joe Rodriguez at Amerigroup to add provider to delegated roster.  DCannon"]
["Misty Fortner, NP",1609152776,"","TX","PE - West Texas Allergy, Lubbock, PLLC","Aetna","Participating","Enrollment Complete","2023-02-06","9723923","","2023-03-06","03.06.2023 Per follow-up note - provider is showing participating with an Effective date of 02/06/2023 and link under the Group and TIN. Provider ID 9723923.  Service location is on file. DCannon"]
["Dorane Leigh Thornton, PA",1831505338,"","TX","PE - West Texas Allergy, Lubbock, PLLC","Galaxy Health","In Process","Pending PSV","","","","2022-12-29",""]
["Dorane Leigh Thornton, PA",1831505338,"","TX","PE - West Texas Allergy, Lubbock, PLLC","First Health Coventry","Pending Other Enrollment","Pending Other Enrollment","","","","2022-12-29","12/29/2022 Pending Aetna enrollment.  DCannon"]
["Dorane Leigh Thornton, PA",1831505338,"","TX","PE - West Texas Allergy, Lubbock, PLLC","Scott&White (First Care)","In Process","Pending PSV","","","","2022-12-29",""]
["Dorane Leigh Thornton, PA",1831505338,"","TX","PE - West Texas Allergy, Lubbock, PLLC","Cigna","Provider Load","Provider Load","","","","2022-12-16",""]
["Dorane Leigh Thornton, PA",1831505338,"","TX","PE - West Texas Allergy, Lubbock, PLLC","USA PPO","In Process","Pending PSV","","","","2022-12-29",""]
["Dorane Leigh Thornton, PA",1831505338,"","TX","PE - West Texas Allergy, Lubbock, PLLC","IMS","In Process","Pending PSV","","","","2022-12-29",""]
["Annabelle Rivera, NP",1871250191,"","TX","PE - Premier Family Care I, 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"]
["Annabelle Rivera, NP",1871250191,"","TX","PE - Premier Family Care I, 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, NP",1871250191,"","TX","PE - Premier Family Care I, Inc","CAQH","Participating","CAQH Reattested","2023-03-13","","","2023-03-13","3/13/2023 CAQH reviewed/re-attested.  DCannon"]
["Annabelle Rivera, NP",1871250191,"","TX","PE - Premier Family Care I, Inc","First Health Coventry","Pending Other Enrollment","Pending Other Enrollment","","","","2022-08-17","8/17/2022 Pending Aetna enrollment."]
["Annabelle Rivera, NP",1871250191,"","TX","PE - Premier Family Care I, Inc","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"]
["Annabelle Rivera, NP",1871250191,"","TX","PE - Premier Family Care I, Inc","TriCare Standard","In Process","Payor Follow Up","","","","2023-03-08","3/8/2023  Per Tricare portal application is still pending.  DCannon"]
["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","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","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","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","CAQH","Participating","CAQH Reattested","2022-10-31","","","2022-10-31","10/31/2022 CAQH re-attested.  DCannon"]
["Hannah Heflin, RD",1366172579,"75-2656723","TX","PE - Premier Family Care I, Inc","Medicaid","In Process","Application Submitted","","","","2023-01-24","1/24/2023 App submitted online via TMHP web portal.  Request ID # 20182532.  DCannon"]
["Hannah Heflin, RD",1366172579,"75-2656723","TX","PE - Premier Family Care I, Inc","Boon Chapman","Pending Other Enrollment","Pending Other Enrollment","","","","2022-07-20","7/20/2022 Pending Multiplan enrollment.  DCannon"]
["Hannah Heflin, RD",1366172579,"75-2656723","TX","PE - Premier Family Care I, 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 I, Inc","Triwest VA","Facility Enrollment","Application Submitted","","","","2022-11-23","08/19/2022 - Submitted application to TriWest VA (sent to Scarlett Abigail, Scarlett_Abigail@bcbstx.com)"]
["Hannah Heflin, RD",1366172579,"75-2656723","TX","PE - Premier Family Care I, Inc","HealthSmart PPO","Participating","Enrollment Complete","2022-08-12","","","2022-10-10","10/10/2022 Per Healthsmart website provider is PAR and loaded under TIN/location effective 8/12/2022.  DCannon"]
["Hannah Heflin, RD",1366172579,"75-2656723","TX","PE - Premier Family Care I, Inc","CAQH","Participating","CAQH Reattested","2023-02-09","","","2023-02-09","2/9/2023 CAQH reviewed and re-attested.  DCannon"]
["Hannah Heflin, RD",1366172579,"75-2656723","TX","PE - Premier Family Care I, Inc","United Health Care","Participating","Enrollment Complete","2022-08-12","","","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# 008166641.   DCannon"]
["Hannah Heflin, RD",1366172579,"75-2656723","TX","PE - Premier Family Care I, Inc","USA PPO","Provider Type Not Enrolled","Provider Type Not Enrolled","","","","2023-03-09","3/9/2023 Per email from LaNetrice Myart at USA PPO provider type - Registered Dietitians are not enrolled by USA PPO.  DCannon"]
["Ramon Lujan, NP",1205572716,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Boon Chapman","Pending Other Enrollment","Pending Other Enrollment","","","","2022-08-17","8/17/2022 Pending Multiplan enrollment.  DCannon"]
["Ramon Lujan, NP",1205572716,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Medicare","Participating","Enrollment Complete","2022-10-01","2J7030","423838","2022-10-10","10/10/2022 Rcvd Medicare approval letter.  PTAN # 2J7030 - effective 10/1/2022.  DCannon"]
["Ramon Lujan, NP",1205572716,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Medicare","Participating","Enrollment Complete","2022-10-01","2J7030","423838","2022-10-10","10/10/2022 Rcvd Medicare approval letter.  PTAN # 2J7030 - effective 10/1/2022.  DCannon"]
["Ramon Lujan, NP",1205572716,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Corvel Healthcare Corp.","Participating","Enrollment Complete","2022-01-10","1330246","","2022-10-30","10/30/2022 Per follow-up note - 10.25.2022 - S/W Shirvonne of Corvel Healthcare Corp @ 8800-872-0820. Per rep, provider is showing participating with an Effective date 01/10/2022 and link under the Group and TIN. Provider ID#:1330246, No Payer ID and Recredentialing date 01/10/2025. Service location is on file. DCannon"]
["Ramon Lujan, NP",1205572716,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","USA PPO","Participating","Enrollment Complete","2022-09-12","","","2022-11-28","11/28/2022 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 9/12/2022.  DCannon"]
["Ramon Lujan, NP",1205572716,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","USA PPO","Participating","Enrollment Complete","2022-09-12","","","2022-11-28","11/28/2022 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 9/12/2022.  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","Gallagher","Pending Other Enrollment","Pending Other Enrollment","","","","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"]
["Ramon Lujan, NP",1205572716,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Galaxy Health","Participating","Enrollment Complete","2022-09-12","","","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"]
["Ramon Lujan, NP",1205572716,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Galaxy Health","Participating","Enrollment Complete","2022-09-12","","","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"]
["Ramon Lujan, NP",1205572716,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Sedgwick","In Process","Action Needed","","","","2023-01-31","1.31.23 Per response from SPNEAST@sedgwickcms.com there is no application on file for provider. Advised to submit new application. ABoles"]
["Ramon Lujan, NP",1205572716,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Liberty Mutual","Pending Other Enrollment","Pending Other Enrollment","","","","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"]
["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","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","PE - WesTex Urgent Care, PLLC","Amerigroup","In Process","Payor Follow Up","","","","2023-02-16","2.16.2023 S/W Qjuana of Amerigroup @ 800-454-3730. Provider is not on file using the NPI and the name search. Rep don't have an access to check pending application and was advised to send an email to TXcredentialing@amerigroup.com. No other information obtained. Verification request has been emailed to TXcredentialing@amerigroup.com and TXProviderRelations@amerigroup.com to verify Provider credentialing status. -Kim Monique Fabian"]
["Ramon Lujan, NP",1205572716,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Amerigroup","In Process","Payor Follow Up","","","","2023-02-16","2.16.2023 S/W Qjuana of Amerigroup @ 800-454-3730. Provider is not on file using the NPI and the name search. Rep don't have an access to check pending application and was advised to send an email to TXcredentialing@amerigroup.com. No other information obtained. Verification request has been emailed to TXcredentialing@amerigroup.com and TXProviderRelations@amerigroup.com to verify Provider credentialing status. -Kim Monique Fabian"]
["Ramon Lujan, NP",1205572716,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Omni PPO","Participating","Enrollment Complete","2022-09-12","","","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 9/12/2022.   DCannon"]
["Ramon Lujan, NP",1205572716,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Omni PPO","Participating","Enrollment Complete","2022-09-12","","","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 9/12/2022.   DCannon"]
["Ramon Lujan, NP",1205572716,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Zurich","Pending Other Enrollment","Pending Other Enrollment","","","","2023-02-03","2.3.23 Plan pends enrollment with Coventry WC. ABoles"]
["Ramon Lujan, NP",1205572716,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","CAQH","Participating","CAQH Reattested","2023-03-03","","","2023-03-03","3/3/2023 Updated TX License, reviewed and re-attested.  DCannon"]
["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 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","First Health Coventry","Participating","Enrollment Complete","2022-11-01","3637702","","2023-01-31","01.31.2023 S/W Brenda of First Health @ 800-226-5116. Per rep, provider is showing participating with an Effective date 11/01/2022 and link under the Group and TIN. Provider ID 3637702, No Payer ID and Recredentialing date 11/01/2025. Service location is on file. Call ref#:530216. -Danico Gabriel Melendres"]
["Ramon Lujan, NP",1205572716,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Alliance WC","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","Cigna","Participating","Enrollment Complete","2023-03-10","6410739","","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# 6410739 DCannon"]
["Ramon Lujan, NP",1205572716,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Cigna","Participating","Enrollment Complete","2023-03-10","6410739","","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# 6410739 DCannon"]
["Ramon Lujan, NP",1205572716,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Texas Mutual","In Process","Application Submitted","","","","2023-03-08","3/8/2023 Emailed app and misc documents to WorkWell Texas at wwtxcontracts.com.  DCannon"]
["Ramon Lujan, NP",1205572716,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","HealthSmart PPO","Participating","Enrollment Complete","2022-09-12","","","2022-11-01","11/1/2022 Per Healthsmart website provider is PAR and loaded under TIN/location effective 9/12/2022.  DCannon"]
["Ramon Lujan, NP",1205572716,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","HealthSmart PPO","Participating","Enrollment Complete","2022-09-12","","","2022-11-01","11/1/2022 Per Healthsmart website provider is PAR and loaded under TIN/location effective 9/12/2022.  DCannon"]
["Ramon Lujan, NP",1205572716,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Triwest VA","In House Enrollment","In House Enrollment","","","","2022-08-02",""]
["Ramon Lujan, NP",1205572716,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Triwest VA","In House Enrollment","In House Enrollment","","","","2022-08-02",""]
["Ramon Lujan, NP",1205572716,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Multiplan","In Process","Application Submitted","","","","2022-09-15","9/15/2022 Submitted monthly delegation roster to Multiplan to add provider to delegation roster.  DCannon"]
["Ramon Lujan, NP",1205572716,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","United Health Care","Participating","Enrollment Complete","2022-09-12","008299480","","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.  MPIN # 008299480.  DCannon"]
["Ramon Lujan, NP",1205572716,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","United Health Care","Participating","Enrollment Complete","2022-09-12","008299480","","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.  MPIN # 008299480.  DCannon"]
["Ramon Lujan, NP",1205572716,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","TriCare Standard","Participating","Enrollment Complete","2022-09-29","","","2022-10-28","10/28/2022 Per Tricare/Humana Military portal provider is PAR and linked to group TIN/location effective 9/29/2022.  DCannon"]
["Ramon Lujan, NP",1205572716,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Coventry Workers Comp","In Process","Payor Follow Up","","","","2023-02-16","2.16.2023 S/W Elijah of Coventry WC @ 800-937-6824. NPI is on file for the provider but not link under the group and TIN. Provider is not on file. Application was received on 1/25/2023. However, it was closed due to no douments received. To be credentialed and participating, rep sent a form to Amanda Boles (aboles@symplr.com) using the email pccdocsub@mitchell.com. Rep advised to reply and submit a LOI (word or PDF with company letterhead), name, TIN, address, contract change requesting to link the provider to the TIN, signature from contract owner and W9 form. TAT is 30-90 calendar days. -Kim Monique Fabian"]
["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","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","IMS","Participating","Enrollment Complete","2022-09-12","","","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 9/12/2022.   DCannon"]
["Ramon Lujan, NP",1205572716,"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"]
["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","Broadspire Services Inc.","Thru Other Payor","Thru Other Payor","","","","2023-02-03","2.3.23 Tried calling Broadspire WC Support @ 866-830-2383, but was unsuccessful. Sent email to customer_Releations@choosebroadspire.com to verify current enrollment process. ABoles"]
["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","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","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","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","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","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","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","United Health Care","Participating","Enrollment Complete","2022-08-29","007265245","","2022-10-24","10/24/2022 Received confirmation email from UHC 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","United Health Care","Participating","Enrollment Complete","2022-08-29","007265245","","2022-10-24","10/24/2022 Received confirmation email from UHC 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","United Health Care","Participating","Enrollment Complete","2022-08-29","007265245","","2022-10-24","10/24/2022 Received confirmation email from UHC 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","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","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","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","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"]
["Mark Stevens Clee, MD",1972946648,"83-0358685","TX","PE - Midland Community Healthcare Services","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"]
["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","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","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","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","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","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","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","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","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","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"]
["Christian A Richardson, APRN-FNP",1184261950,"","TX","PE - Premier Family Care I, Inc","Cigna","Participating","Enrollment Complete","2022-11-01","0914108","","2022-11-15","11/15/2022 Rcvd email from Cigna that provider is PAR and linked to group TIN/location effective 11/1/2022.  PID # 0914108.  DCannon"]
["Christian A Richardson, APRN-FNP",1184261950,"","TX","PE - Premier Family Care I, 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"]
["Christian A Richardson, APRN-FNP",1184261950,"","TX","PE - Premier Family Care I, Inc","Boon Chapman","Pending Other Enrollment","Pending Other Enrollment","","","","2022-09-13","9/13/2022 Pending Multiplan enrollment.  DCannon"]
["Christian A Richardson, APRN-FNP",1184261950,"","TX","PE - Premier Family Care I, Inc","Caprock (CapStar)","Participating","Enrollment Complete","2022-10-10","","","2022-12-29","12/29/2022 Rcvd email  confirmation from Caprock that provider is PAR and linked to group TIN/locations effective 10/10/2022.  DCannon"]
["Christian A Richardson, APRN-FNP",1184261950,"","TX","PE - Premier Family Care I, Inc","Humana","Participating","Enrollment Complete","2022-10-10","","","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 10/10/2022.  DCannon"]
["Christian A Richardson, APRN-FNP",1184261950,"","TX","PE - Premier Family Care I, Inc","Medicaid","Participating","Enrollment Complete","2022-11-01","1184261950","","2023-01-11","1/11/2023 Rcvd TMHP portal provider is PAR and linked to group/ location effective 11/1/2022.  DCannon"]
["Christian A Richardson, APRN-FNP",1184261950,"","TX","PE - Premier Family Care I, 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"]
["Richard Glenn Eby, MD",1598260325,"26-3789190","TX","PE - Permian Physician Services","Travelers WC","Pending Other Enrollment","Pending Other Enrollment","","","","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"]
["Richard Glenn Eby, MD",1598260325,"26-3789190","TX","PE - Permian Physician Services","Texas Mutual","Provider Load","Provider Load","","","","2023-01-14",""]
["Richard Glenn Eby, MD",1598260325,"26-3789190","TX","PE - Permian Physician Services","Multiplan","In Process","Application Submitted","","","","2022-10-14","10/14/2022 Emailed monthly delegated roster to Multiplan to add provider to delegated roster.  DCannon"]
["Richard Glenn Eby, MD",1598260325,"26-3789190","TX","PE - Permian Physician Services","Triwest VA","In Process","Application Submitted","","","","2022-09-28","09/28/2022 - submitted application to TriWest VA (through email, sent to Scarlett Abigail (Scarlett_Abigail@bcbstx.com), including COI;  BCBSTX case# 04838804"]
["Richard Glenn Eby, MD",1598260325,"26-3789190","TX","PE - Permian Physician Services","Corvel Healthcare Corp.","Provider Load","Payor Receipt Validated","","","","2023-01-25","1.25.23 Received conformation from Bre Waynes that the provider was being sent to committee for contracting. ABoles"]
["Richard Glenn Eby, MD",1598260325,"75-1997880","TX","PE - Andrews County Hospital District","Corvel Healthcare Corp.","In Process","Payor Follow Up","","","","2023-03-06","3.6.2023 S/W Lanterice of Corvel @ 800-872-0820. Provider is not on file using the NPI and the name search. No pending application. To be credentialed and participating, rep advised to submit a request to be participating to the email address providermarketinginfo@usamco.com. TAT is 30-90 business days. If provider is under delegated entity, rep advised to contact directly the delegated entity. TAT is 30-90 business days. No call ref#. - Kim Monique Fabian."]
["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,"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,"75-1997880","TX","PE - Andrews County Hospital District","Triwest VA","Enrollment on Hold","In House Enrollment","","","","2022-08-23",""]
["Richard Glenn Eby, MD",1598260325,"75-1997880","TX","PE - Andrews County Hospital District","Texas Municipal League","Pending Other Enrollment","Pending Other Enrollment","","","","2023-01-31","1.31.23 Texas Municipal League pends Alliance WC enrollment. Alliance WC submitted on 1.30.23. ABoles."]
["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","USA PPO","In Process","Payor Follow Up","","","","2023-03-08","3/8/2023 Emailed USA PPO at ipa@usamco.com to check status of provider.  DCannon"]
["Richard Glenn Eby, MD",1598260325,"75-1997880","TX","PE - Andrews County Hospital District","CAQH","Participating","CAQH Reattested","2023-02-08","","","2023-02-08","2/8/2023 CAQH reviewed and re-attested.  DCannon"]
["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","Pending Other Enrollment","Pending Other Enrollment","","","","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"]
["Richard Glenn Eby, MD",1598260325,"75-1997880","TX","PE - Andrews County Hospital District","Hartford","Provider Load","Provider Load","","","","2023-01-14",""]
["Richard Glenn Eby, MD",1598260325,"26-3789190","TX","PE - Permian Physician Services","Gallagher","Pending Other Enrollment","Pending Other Enrollment","","","","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"]
["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"]
["Kathryn A. Lagus, APRN-FNP-BC",1285983155,"75-2656723","TX","PE - Premier Family Care I, Inc","Wellcare","Pending Other Enrollment","Pending Other Enrollment","","","","2022-12-29","12/29/2022 Pending Superior enrollment.  DCannon"]
["Kathryn A. Lagus, APRN-FNP-BC",1285983155,"75-2656723","TX","PE - Premier Family Care I, Inc","Tricare Prime","Panel Closed","Panel Closed","","","","2023-01-05","1/5/2023 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"]
["Kathryn A. Lagus, APRN-FNP-BC",1285983155,"75-2656723","TX","PE - Premier Family Care I, Inc","Scott&White (First Care)","Participating","Enrollment Complete","2023-02-23","","","2023-02-28","2/28/2023 Per email received from Scott & White provider is PAR and linked to group TIN effective 2/23/2023.  DCannon"]
["Kathryn A. Lagus, APRN-FNP-BC",1285983155,"75-2656723","TX","PE - Premier Family Care I, Inc","Aetna","Participating","Enrollment Complete","2023-03-01","826647","","2023-03-06","03.06.2023 Per follow-up note -  provider is showing participating with an Effective date of 03/01/2023 and link under the Group and TIN. Provider ID 826647. Service location is on file.  DCannon"]
["Kathryn A. Lagus, APRN-FNP-BC",1285983155,"75-2656723","TX","PE - Premier Family Care I, Inc","Ambetter","Pending Other Enrollment","Pending Other Enrollment","","","","2022-12-29","12/29/2022 Pending Superior enrollment.  DCannon"]
["Kathryn A. Lagus, APRN-FNP-BC",1285983155,"75-2656723","TX","PE - Premier Family Care I, 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"]
["Marisela Sample, LPC",1396470357,"83-0358685","TX","PE - Midland Community Healthcare Services","Scott&White (First Care)","In Process","Payor Follow Up","","","","2023-02-17","02.17.2023: Called Scott&White (First Care) @1-737-401-9207 however unable to reach a live representative and was routed to voicemail. Per IVR, Paul Cuter is not available at the moment. Leave detailed message including provider's information and consultant's email address and phone number for the call back. Verification request has been emailed to hpdelegation@bswhealth.org to verify provider credentialing status. - Danico Gabriel Melendres"]
["Marisela Sample, LPC",1396470357,"83-0358685","TX","PE - Midland Community Healthcare Services","Omni PPO","Participating","Enrollment Complete","2022-10-31","","","2023-03-08","3/8/2023 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","Omni PPO","Participating","Enrollment Complete","2022-10-31","","","2023-03-08","3/8/2023 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","Cigna","In Process","Action Needed","","","","2023-01-18","01.18.2023 S/W Isaac of Cigna @ 800-882-4462. Provider is out of network. Informed that request was sent however upon checking there was no pending application or request submitted. As per rep, if the provider is a hospital base need to send a Letter to intake_pdm@cigna.com with the following info: tax id, provider name, npi, addresses and W9 form to fax#:888-208-7159 with Attn to Cigna Provider Data Management. TAT of 20-30 business days but if the provider is a office base the application would over the phone. TAT of 45-60 calendar days. Call ref#:Isaac01182022. -Danico Gabriel Melendres"]
["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","","","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","TriCare Standard","In Process","Application Submitted","","","","2023-03-08","3/8/2023 App submitted online via Tricare portal.  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","Humana","Participating","Enrollment Complete","2022-10-31","","","2023-02-25","2/25/2023 Per email received from Vernita Young November delegated roster has been processed and provider is PAR 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","Boon Chapman","Pending Other Enrollment","Pending Other Enrollment","","","","2022-10-04","10/4/2022 Pending Multiplan enrollment.  DCannon"]
["Marisela Sample, LPC",1396470357,"83-0358685","TX","PE - Midland Community Healthcare Services","Tricare Prime","In Process","Confirm Par Status","","","","2022-10-04","10/4/2022 Called Tricare at 800-444-5445 to check provider status and verify which application will be needed to enroll at licensed professional counselor.  Waiting on return call.  DCannon"]
["Marisela Sample, LPC",1396470357,"83-0358685","TX","PE - Midland Community Healthcare Services","Tricare Prime","In Process","Confirm Par Status","","","","2022-10-04","10/4/2022 Called Tricare at 800-444-5445 to check provider status and verify which application will be needed to enroll at licensed professional counselor.  Waiting on return call.  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",""]
["Marisela Sample, LPC",1396470357,"83-0358685","TX","PE - Midland Community Healthcare Services","Medicaid","In House Enrollment","In House Enrollment","","","","2022-10-04",""]
["Marisela Sample, LPC",1396470357,"83-0358685","TX","PE - Midland Community Healthcare Services","United Health Care","In Process","Application Submitted","","","","2022-11-15","11/15/2022 Submitted monthly delegation roster to UHC to add provider to delegation roster.  DCannon"]
["Taylor Allison Arrington",1619603255,"75-2182177","TX","PE - Debbie P. Reese, MD PA","HealthSmart PPO","In Process","Application Submitted","","","","2023-02-15","2/15/2023 Emailed monthly delegated roster to Healthsmart PPO to add provider to delegated roster.  DCannon"]
["Taylor Allison Arrington",1619603255,"75-2182177","TX","PE - Debbie P. Reese, MD PA","Scott&White (First Care)","In Process","Application Submitted","","","","2023-02-15","2/15/2023 Emailed monthly delegated roster to Scott & White to add provider to delegated roster.  DCannon"]
["Taylor Allison Arrington",1619603255,"75-2182177","TX","PE - Debbie P. Reese, MD PA","Galaxy Health","In Process","Application Submitted","","","","2023-02-15","2/15/2023 Emailed monthly delegated roster to Galaxy to add provider to delegated roster.  DCannon"]
["Taylor Allison Arrington",1619603255,"75-2182177","TX","PE - Debbie P. Reese, MD PA","United Health Care","In Process","Application Submitted","","","","2023-02-15","2/15/2023 Emailed monthly delegated roster to UHC to add provider to delegated roster.  DCannon"]
["Nicole Nutter, PA-C",1184258378,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Boon Chapman","Pending Other Enrollment","Pending Other Enrollment","","","","2023-01-05","1/5/2023 Pending Multiplan enrollment.  DCannon"]
["Nicole Nutter, PA-C",1184258378,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Coventry Workers Comp","In Process","Payor Follow Up","","","","2023-03-06","03.06.2023 S/W Warren of Coventry WC @800-937-6824. Per rep, provider is not in network with Coventry. Application was received on 02/16/2023 however it was closed on 02/27/2023 due to no documentation received. Rep sent a documentation request to aboles@symplr.com using pccdocsub@mitchell.com. Rep advised to reply to that email and attach a Letter of Intent and W9 form. Per rep, if we didn't reply within 5 business days, the application will be automatically close. TAT for us to send the documents is 5 business days. Call ref# 11782375."]
["Nicole Nutter, PA-C",1184258378,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Coventry Workers Comp","In Process","Payor Follow Up","","","","2023-03-06","03.06.2023 S/W Warren of Coventry WC @800-937-6824. Per rep, provider is not in network with Coventry. Application was received on 02/16/2023 however it was closed on 02/27/2023 due to no documentation received. Rep sent a documentation request to aboles@symplr.com using pccdocsub@mitchell.com. Rep advised to reply to that email and attach a Letter of Intent and W9 form. Per rep, if we didn't reply within 5 business days, the application will be automatically close. TAT for us to send the documents is 5 business days. Call ref# 11782375."]
["Nicole Nutter, PA-C",1184258378,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Omni PPO","In Process","Application Submitted","","","","2023-02-15","2/15/2023 Emailed monthly delegated roster to IMS/OMNI to add provider to delegated roster.  DCannon"]
["Nicole Nutter, PA-C",1184258378,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Omni PPO","In Process","Application Submitted","","","","2023-02-15","2/15/2023 Emailed monthly delegated roster to IMS/OMNI to add provider to delegated roster.  DCannon"]
["Nicole Nutter, PA-C",1184258378,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Travelers WC","Pending Other Enrollment","Pending Other Enrollment","","","","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"]
["Nicole Nutter, PA-C",1184258378,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Travelers WC","Pending Other Enrollment","Pending Other Enrollment","","","","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"]
["Nicole Nutter, PA-C",1184258378,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Galaxy Health","In Process","Application Submitted","","","","2023-02-15","2/15/2023 Emailed monthly delegated roster to Galaxy to add provider to delegated roster.  DCannon"]
["Nicole Nutter, PA-C",1184258378,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Zurich","Pending Other Enrollment","Pending Other Enrollment","","","","2023-02-03","2.3.23 Plan pends enrollment with Coventry WC. ABoles"]
["Nicole Nutter, PA-C",1184258378,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","United Health Care","In Process","Application Submitted","","","","2023-02-15","2/15/2023 Emailed monthly delegated roster to UHC to add provider to delegated roster.  DCannon"]
["Nicole Nutter, PA-C",1184258378,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","United Health Care","In Process","Application Submitted","","","","2023-02-15","2/15/2023 Emailed monthly delegated roster to UHC to add provider to delegated roster.  DCannon"]
["Nicole Nutter, PA-C",1184258378,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Texas Municipal League","Pending Other Enrollment","Pending Other Enrollment","","","","2022-12-29","12/29/2022 Pending PSWCA - Alliance Workers Comp enrollment.  DCannon"]
["Nicole Nutter, PA-C",1184258378,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Caprock (CapStar)","In Process","Application Submitted","","","","2023-02-15","2/15/2023 Emailed monthly delegated roster to Caprock to add provider to delegated roster.  DCannon"]
["Nicole Nutter, PA-C",1184258378,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Scott&White (First Care)","In Process","Payor Follow Up","","","","2023-03-06","03.06.2023 Called First Health @1-737-401-9207 however unable to reach a live representative and was routed to voicemail. Per IVR, Paul Cuter is not available at the moment. Left detailed message including provider's information and consultant's email address and phone number for the call back. Verification request has been emailed to hpdelegation@bswhealth.org to verify provider credentialing status. - Mary Rose Acebedo"]
["Nicole Nutter, PA-C",1184258378,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Scott&White (First Care)","In Process","Payor Follow Up","","","","2023-03-06","03.06.2023 Called First Health @1-737-401-9207 however unable to reach a live representative and was routed to voicemail. Per IVR, Paul Cuter is not available at the moment. Left detailed message including provider's information and consultant's email address and phone number for the call back. Verification request has been emailed to hpdelegation@bswhealth.org to verify provider credentialing status. - Mary Rose Acebedo"]
["Nicole Nutter, PA-C",1184258378,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Tricare Prime","Panel Closed","Panel Closed","","","","2022-12-29","12/29/2022 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"]
["Nicole Nutter, PA-C",1184258378,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Broadspire Services Inc.","Thru Other Payor","Thru Other Payor","","","","2023-02-03","2.3.23 Tried calling Broadspire WC Support @ 866-830-2383, but was unsuccessful. Sent email to customer_Releations@choosebroadspire.com to verify current enrollment process. ABoles"]
["Nicole Nutter, PA-C",1184258378,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Broadspire Services Inc.","Thru Other Payor","Thru Other Payor","","","","2023-02-03","2.3.23 Tried calling Broadspire WC Support @ 866-830-2383, but was unsuccessful. Sent email to customer_Releations@choosebroadspire.com to verify current enrollment process. ABoles"]
["Nicole Nutter, PA-C",1184258378,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","First Health Coventry","Pending Other Enrollment","Pending Other Enrollment","","","","2023-01-24","1/24/2023 Pending Aetna enrollment.  DCannon"]
["Nicole Nutter, PA-C",1184258378,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","First Health Coventry","Pending Other Enrollment","Pending Other Enrollment","","","","2023-01-24","1/24/2023 Pending Aetna enrollment.  DCannon"]
["Nicole Nutter, PA-C",1184258378,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Multiplan","In Process","Application Submitted","","","","2023-02-15","2/15/2023 Emailed monthly delegated roster to Multiplan to add provider to delegated roster.  DCannon"]
["Nicole Nutter, PA-C",1184258378,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Liberty Mutual","Pending Other Enrollment","Pending Other Enrollment","","","","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"]
["Nicole Nutter, PA-C",1184258378,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Liberty Mutual","Pending Other Enrollment","Pending Other Enrollment","","","","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"]
["Nicole Nutter, PA-C",1184258378,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Hartford","Pending Other Enrollment","Pending Other Enrollment","","","","2022-12-29","12/29/2022 Pending Coventry Workers Comp enrollment.   DCannon"]
["Nicole Nutter, PA-C",1184258378,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","USA PPO","In Process","Application Submitted","","","","2023-02-15","2/15/2023 Emailed monthly delegated roster to USA PPO to add provider to delegated roster.  DCannon"]
["Nicole Nutter, PA-C",1184258378,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","HealthSmart PPO","In Process","Application Submitted","","","","2023-02-15","2/15/2023 Emailed monthly delegated roster to Healthsmart to add provider to delegated roster.  DCannon"]
["Nicole Nutter, PA-C",1184258378,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","HealthSmart PPO","In Process","Application Submitted","","","","2023-02-15","2/15/2023 Emailed monthly delegated roster to Healthsmart to add provider to delegated roster.  DCannon"]
["Nicole Nutter, PA-C",1184258378,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Corvel Healthcare Corp.","In Process","Application Resubmitted","","","","2023-03-08","3/8/2023 Per follow-up note roster submitted to ipa@usamco.com to add provider to Corvel.  DCannon"]
["Nicole Nutter, PA-C",1184258378,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Rail Road Medicare","Pending Other Enrollment","Pending Medicare","","","","2022-12-29","12/29/2022 Pending Medicare enrollment.  DCannon"]
["Nicole Nutter, PA-C",1184258378,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Texas Mutual","Provider Load","Provider Load","","","","2022-12-27",""]
["Nicole Nutter, PA-C",1184258378,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Texas Mutual","Provider Load","Provider Load","","","","2022-12-27",""]
["Nicole Nutter, PA-C",1184258378,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Amerigroup","In Process","Application Submitted","","","","2023-02-15","2/15/2023 Emailed monthly delegated roster to Joe Rodriguez at Amerigroup to add provider to delegated roster.  DCannon"]
["Nicole Nutter, PA-C",1184258378,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Amerigroup","In Process","Application Submitted","","","","2023-02-15","2/15/2023 Emailed monthly delegated roster to Joe Rodriguez at Amerigroup to add provider to delegated roster.  DCannon"]
["Nicole Nutter, PA-C",1184258378,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Medicare","In Process","Application Submitted","","","","2023-02-28","2/28/2023 App submitted online via PECOS to add provider to group/locations.  Tracking ID: T022820230004502.  DCannon"]
["Nicole Nutter, PA-C",1184258378,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Aetna","Participating","Enrollment Complete","2023-01-23","8968718","","2023-03-06","03.06.2023  Per follow-up note, provider is showing participating with an Effective date of 01/23/2023 and link under the Group and TIN. Provider ID 8968718. -DCannon"]
["Nicole Nutter, PA-C",1184258378,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Aetna","Participating","Enrollment Complete","2023-01-23","8968718","","2023-03-06","03.06.2023  Per follow-up note, provider is showing participating with an Effective date of 01/23/2023 and link under the Group and TIN. Provider ID 8968718. -DCannon"]
["Nicole Nutter, PA-C",1184258378,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","IMS","In Process","Application Submitted","","","","2023-02-15","2/15/2023 Emailed monthly delegated roster to IMS/OMNI to add provider to delegated roster.  DCannon"]
["Nicole Nutter, PA-C",1184258378,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","CAQH","Participating","CAQH Reattested","2022-12-29","","","2022-12-29","12/29/2022 CAQH reviewed and re-attested.  Updated practice locations and credentialing contact.  DCannon"]
["Nicole Nutter, PA-C",1184258378,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","CAQH","Participating","CAQH Reattested","2022-12-29","","","2022-12-29","12/29/2022 CAQH reviewed and re-attested.  Updated practice locations and credentialing contact.  DCannon"]
["Nicole Nutter, PA-C",1184258378,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Cigna","Provider Load","Provider Load","","","","2022-12-27",""]
["Nicole Nutter, PA-C",1184258378,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","TriCare Standard","Participating","Enrollment Complete","2023-01-19","","","2023-01-30","1/30/2023 Rcvd Tricare certification approval letter.  Provider is Tricare certified effective 1/19/2023.  DCannon"]
["Nicole Nutter, PA-C",1184258378,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Gallagher","Pending Other Enrollment","Pending Other Enrollment","","","","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"]
["Nicole Nutter, PA-C",1184258378,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Gallagher","Pending Other Enrollment","Pending Other Enrollment","","","","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"]
["Nicole Nutter, PA-C",1184258378,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Alliance WC","In Process","Payor Follow Up","","","","2023-03-06","03.06.2023 Verification request has been emailed to  michelle.killough@pswca.org and phil.hambrick@pswca.org to verify Provider credentialing status. - Danico Gabriel Melendres"]
["Nicole Nutter, PA-C",1184258378,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Sedgwick","Provider Load","Provider Load","","","","2022-12-27",""]
["Nicole Nutter, PA-C",1184258378,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Triwest VA","In House Enrollment","In House Enrollment","","","","2022-12-27",""]
["Nicole Nutter, PA-C",1184258378,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Triwest VA","In House Enrollment","In House Enrollment","","","","2022-12-27",""]
["Nicole Nutter, PA-C",1184258378,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Humana","In Process","Application Submitted","","","","2023-02-15","2/15/2023 Emailed monthly delegated roster to Humana to add provider to delegated roster.  DCannon"]
["Nicole Nutter, PA-C",1184258378,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Humana","In Process","Application Submitted","","","","2023-02-15","2/15/2023 Emailed monthly delegated roster to Humana to add provider to delegated roster.  DCannon"]
["Hilary Cosby, RD",1184341745,"75-2656723","TX","PE - Premier Family Care I, Inc","Galaxy Health","In Process","Pending PSV","","","","2022-12-22",""]
["Hilary Cosby, RD",1184341745,"75-2656723","TX","PE - Premier Family Care I, Inc","TriCare Standard","Participating","Enrollment Complete","2023-01-10","","","2023-03-08","3/8/2023 Received Tricare certification approval letter.  Provider is Tricare certified in the state of Texas effective 1/10/2023.  DCannon"]
["Hilary Cosby, RD",1184341745,"75-2656723","TX","PE - Premier Family Care I, Inc","CAQH","Participating","CAQH Reattested","2022-12-22","","","2022-12-22","12/22/2022 CAQH profile reviewed and re-attested.  Uploaded current copy of COI.  DCannon"]
["Hilary Cosby, RD",1184341745,"75-2656723","TX","PE - Premier Family Care I, Inc","Amerigroup","In Process","Pending PSV","","","","2022-12-22",""]
["Hilary Cosby, RD",1184341745,"75-2656723","TX","PE - Premier Family Care I, Inc","Ambetter","Pending Other Enrollment","Pending Other Enrollment","","","","2022-12-22","12/22/2022 Pending Superior enrollment.  DCannon"]
["KristiAnne Alexis Gore, PA-C",1558971432,"87-1671535","TX","PE - West Texas Allergy, Lubbock, PLLC","Omni PPO","In Process","Application Submitted","","","","2023-02-15","2/15/2023 Emailed monthly delegated roster to IMS/OMNI to add provider to delegated roster.  DCannon"]
["KristiAnne Alexis Gore, PA-C",1558971432,"87-1671535","TX","PE - West Texas Allergy, Lubbock, PLLC","Rail Road Medicare","Pending Other Enrollment","Pending Medicare","","","","2022-12-18",""]
["KristiAnne Alexis Gore, PA-C",1558971432,"75-2781652","TX","PE - West Texas Allergy, PA","Superior","Participating","Enrollment Complete","2023-03-01","","","2023-03-10","3/10/2023 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 3/1/2023.  DCannon"]
["KristiAnne Alexis Gore, PA-C",1558971432,"75-2781652","TX","PE - West Texas Allergy, PA","Humana","In Process","Application Submitted","","","","2023-02-15","2/15/2023 Emailed monthly delegated roster to Humana to add provider to delegated roster.  DCannon"]
["KristiAnne Alexis Gore, PA-C",1558971432,"87-1671535","TX","PE - West Texas Allergy, Lubbock, PLLC","First Health Coventry","Pending Other Enrollment","Pending Other Enrollment","","","","2022-12-18","12/18/2022 Pending Aetna enrollment.  DCannon"]
["KristiAnne Alexis Gore, PA-C",1558971432,"75-2781652","TX","PE - West Texas Allergy, PA","Tricare Prime","Provider Load","Provider Load","","","","2022-12-16",""]
["KristiAnne Alexis Gore, PA-C",1558971432,"75-2781652","TX","PE - West Texas Allergy, PA","Cigna","Provider Load","Provider Load","","","","2022-12-16",""]
["KristiAnne Alexis Gore, PA-C",1558971432,"75-2781652","TX","PE - West Texas Allergy, PA","Aetna","Participating","Enrollment Complete","2023-02-06","8917219","","2023-03-06","03.06.2023 Per follow-up note -  provider is showing participating with an Effective date of 02/06/2023 and link under the Group and TIN. Provider ID 8917219.   Service location is on file. DCannon"]
["KristiAnne Alexis Gore, PA-C",1558971432,"87-1671535","TX","PE - West Texas Allergy, Lubbock, PLLC","Amerigroup","In Process","Application Submitted","","","","2023-02-15","2/15/2023 Emailed monthly delegated roster to Joe Rodriguez at Amerigroup to add provider to delegated roster.  DCannon"]
["KristiAnne Alexis Gore, PA-C",1558971432,"87-1671535","TX","PE - West Texas Allergy, Lubbock, PLLC","Tricare Prime","Provider Load","Provider Load","","","","2022-12-16",""]
["KristiAnne Alexis Gore, PA-C",1558971432,"87-1671535","TX","PE - West Texas Allergy, Lubbock, PLLC","HealthSmart PPO","In Process","Application Submitted","","","","2023-02-15","2/15/2023 Emailed monthly delegated roster to Healthsmart to add provider to delegated roster.  DCannon"]
["KristiAnne Alexis Gore, PA-C",1558971432,"75-2781652","TX","PE - West Texas Allergy, PA","TriCare Standard","In Process","Application Submitted","","","","2023-03-08","3/8/2023 App submitted online via Tricare portal to add provider to group TIN/location.  DCannon"]
["KristiAnne Alexis Gore, PA-C",1558971432,"75-2781652","TX","PE - West Texas Allergy, PA","CAQH","Participating","CAQH Reattested","2023-01-11","","","2023-01-11","01/11/2023 CAQH reviewed/reattested.  DCannon"]
["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.","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","","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","","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.","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","","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","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","","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.","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.","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"]
["\"PK\" Pankaj J Patel, MD",1124009766,"75-2784378","TX","PE - Pankaj N. Patel, MD PA","Triwest VA","Participating","Enrollment Complete","2022-08-01","","","2022-11-14","11/14/22 Per Scarlett Abigail, provider effective 8/1/22"]
["\"PK\" Pankaj J Patel, MD",1124009766,"75-2784378","TX","PE - Pankaj N. Patel, MD PA","Boon Chapman","Participating","Enrollment Complete","2000-07-01","1124009766","","2020-09-30","Enrollment through PHCS"]
["\"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","Superior","Participating","Enrollment Complete","2020-08-01","1124009766","","2020-08-06","8/6/2020 - moved to completed status after receiving email from the payer stating this provider was added to our primed roster from the July 2020 roster - Stacey Hudak"]
["\"PK\" Pankaj J Patel, MD",1124009766,"75-2784378","TX","PE - Pankaj N. Patel, MD PA","Rail Road Medicare","Participating","Enrollment Complete","1997-10-01","110177800","Individual","2020-08-13","8/13/2020 - confirmed this provider is already enrolled through payer site - Stacey Hudak"]
["John M McKenna, MD",1225170103,752656723,"TX","PE - Premier Family Care I, Inc","CAQH","Participating","CAQH Reattested","2023-02-12","","","2023-02-12","2/12/2023 CAQH reviewed and re-attested.  DCannon"]
["John M McKenna, MD",1225170103,752656723,"TX","","CAQH","Participating","CAQH Reattested","2023-02-12","","","2023-02-12","2/12/2023 CAQH reviewed and re-attested.  DCannon"]
["John M McKenna, MD",1225170103,752656723,"TX","","HealthSmart PPO","Participating","Enrollment Complete","2021-12-06","10122396","","2022-02-26","2/26/2022 Per Healthsmart website provider is PAR and loaded under TIN/location effective 12/6/2021.  DCannon"]
["John M McKenna, MD",1225170103,752656723,"TX","PE - Premier Family Care I, Inc","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",1225170103,752656723,"TX","","Superior","Participating","Enrollment Complete","2022-02-01","","","2022-02-07","2/7/2022 Rcvd email from Superior that provider is PAR and linked to group TIN/location effective 2/1/2022.  DCannon"]
["John M McKenna, MD",1225170103,752656723,"TX","","Superior","Participating","Enrollment Complete","2022-02-01","","","2022-02-07","2/7/2022 Rcvd email from Superior that provider is PAR and linked to group TIN/location effective 2/1/2022.  DCannon"]
["John M McKenna, MD",1225170103,752656723,"TX","","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",1225170103,752656723,"TX","PE - Premier Family Care I, Inc","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",1225170103,752656723,"TX","","Galaxy Health","Participating","Enrollment Complete","2021-12-06","","","2022-03-10","3/10/2022 Rcvd email from K. Avalos @ Galaxy that provider is PAR and linked to group TIN/location effective 12/06/2021.  DCannon"]
["John M McKenna, MD",1225170103,752656723,"TX","","Galaxy Health","Participating","Enrollment Complete","2021-12-06","","","2022-03-10","3/10/2022 Rcvd email from K. Avalos @ Galaxy that provider is PAR and linked to group TIN/location effective 12/06/2021.  DCannon"]
["John M McKenna, MD",1225170103,752656723,"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",1225170103,752656723,"TX","PE - Premier Family Care I, 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",1225170103,752656723,"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."]
["John M McKenna, MD",1225170103,752656723,"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",1225170103,752656723,"TX","PE - Premier Family Care I, 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",1225170103,752656723,"TX","","Boon Chapman","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",1225170103,752656723,"TX","","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",1225170103,752656723,"TX","","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",1225170103,752656723,"TX","PE - Premier Family Care I, Inc","Triwest VA","Facility Enrollment","In House Enrollment","","","","2021-12-15",""]
["John M McKenna, MD",1225170103,752656723,"TX","","Triwest VA","Facility Enrollment","Application Submitted","","","","2022-11-23","08/19/2022 - Submitted application to TriWest VA (sent to Scarlett Abigail, Scarlett_Abigail@bcbstx.com)"]
["John M McKenna, MD",1225170103,752656723,"TX","","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.\""]
["John M McKenna, MD",1225170103,752656723,"TX","","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.\""]
["John M McKenna, MD",1225170103,752656723,"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"]
["John M McKenna, MD",1225170103,752656723,"TX","","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"]
["John M McKenna, MD",1225170103,752656723,"TX","","Medicare","Participating","Enrollment Complete","2021-12-01","1X1311","","2021-12-08","12/8/21 Provider approved 12/01/2021. PTAN 1X1311 Cbankston"]
["Ronald W Ingram, M.D.",1609829225,"75-2773462","TX","PE - Ingram Investments LLC","Cigna","Participating","Enrollment Complete","2021-04-01","8162914","","2021-12-03","12/3/2021 Per f/u note:  S/W Camaria of Cigna @ 8008824462, NPI# for the provider is on file, shows LINKED and PAR under the group and TIN# effective 4/1/2021, the physical location is on file, The provider ID is 8162914. NO call ref#.  DCannon"]
["Ronald W Ingram, M.D.",1609829225,"75-2773461","TX","PE - Eye Center of Midland, P.A.","Caprock (CapStar)","Participating","Enrollment Complete","2017-08-30","","","2020-09-14",""]
["Ronald W Ingram, M.D.",1609829225,"75-2773461","TX","PE - Eye Center of Midland, P.A.","Cigna","Participating","Enrollment Complete","2010-11-15","8162914","","2020-06-25","6-25-2020 - Moved to completed status based on info rec'd during follow up complete call - Stacey Hudak"]
["Ronald W Ingram, M.D.",1609829225,"75-2773462","TX","PE - Ingram Investments LLC","Aetna","Participating","Enrollment Complete","2023-02-01","4403072","","2023-03-06","03.06.2023 Per follow-up note -  provider is showing participating with an Effective date of 02/01/2023 and link under the Group and TIN. Provider ID 4403072.   Service location is on file. DCannon"]
["Ronald W Ingram, M.D.",1609829225,"75-2773462","TX","PE - Ingram Investments LLC","Rail Road Medicare","Participating","Enrollment Complete","2004-08-19","Q00217267","DG3997","2022-02-24","2/24/2022 Rcvd RR Medicare approval letter.  PTAN # Q00217267 - effective 8/19/2004.  DCannon"]
["Ronald W Ingram, M.D.",1609829225,"75-2773461","TX","PE - Eye Center of Midland, P.A.","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"]
["Mrunal C Patel, MD",1528000734,"74-2348334","TX","PE - Permian Gastroenterology PA","Multiplan","Participating","Enrollment Complete","2015-06-09","","","2020-02-12","02/12/2020 - rec'd confirmation through payer portal that this provider is EFF through and INDIVIDUAL CONTRACT as of 6-9-2015. Provider is in network with multiplan - Stacey Hudak"]
["Mrunal C Patel, MD",1528000734,"74-2348334","TX","PE - Permian Gastroenterology PA","Boon Chapman","Participating","Enrollment Complete","2015-06-09","","","2020-10-05","Enrolled thru Multiplan"]
["Mrunal C Patel, MD",1528000734,"74-2348334","TX","PE - Permian Gastroenterology PA","Scott&White (First Care)","Participating","Enrollment Complete","2016-02-29","1528000734","","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"]
["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","Application Submitted","","","","","08/19/2022 - Submitted application to TriWest VA (sent to Scarlett Abigail, Scarlett_Abigail@bcbstx.com)"]
["Willie Clyde Watson, III, MD",1659366433,"75-2133441","TX","PE - Midland Pediatric Associates, PLLC","Aetna","Participating","Enrollment Complete","2014-09-29","1659366433","","2020-03-25","3/25/2020--S/W Mary of Aetna @ 8003531232,  provider NPI# is on file for the provider and is participating effective 09/29/2014 under the group and TIN#. Physical location is on file. DIRECT CONTRACT --Call ref#: 5194781237. \nTISHA RADER"]
["Willie Clyde Watson, III, MD",1659366433,"75-2133441","TX","PE - Midland Pediatric Associates, PLLC","HealthSmart PPO","Participating","Enrollment Complete","2011-02-01","1659366433","","2020-06-05","06/05/2020 - Rec'd email from the payer stating this provider is EFF -Stacey Hudak"]
["Willie Clyde Watson, III, MD",1659366433,"75-2133441","TX","PE - Midland Pediatric Associates, PLLC","Galaxy Health","Participating","Enrollment Complete","2014-09-26","1659366433","","2020-07-17","7/17/2020 - Received a spreadsheet from the payer stating this provider is effective as of 9/26/2014. - Jesriel Segovia"]
["Willie Clyde Watson, III, MD",1659366433,"75-2133441","TX","PE - Midland Pediatric Associates, PLLC","First Health Coventry","Participating","Enrollment Complete","2008-09-01","1902473","","2020-03-24","3/24/2020-received email with roster from payor stating provider PAR 9/1/2008 PID # 1902473\ntisha rader"]
["Lawrence A Wilson, MD",1518951342,"75-2656723","TX","PE - Premier Family Care I, 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,"75-6000608","TX","PE - City of Midland Health Department","Scott&White (First Care)","Participating","Enrollment Complete","2021-01-07","","","2021-04-22","4/22/2021 Rcvd roster from S&W and provider is participating and linked to TIN effective 01/07/2021.  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,"75-2656723","TX","PE - Premier Intensive Cardiac Rehabilitation","Boon Chapman","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"]
["Lawrence A Wilson, MD",1518951342,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Triwest VA","In Process","In House Enrollment","","","","2021-09-06",""]
["Lawrence A Wilson, MD",1518951342,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","USA PPO","Participating","Enrollment Complete","2021-07-26","","","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 7/26/2021.  DCannon"]
["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","Multiplan","Participating","Enrollment Complete","2021-08-13","","","2022-02-07","2/7/2022 Rcvd roster from Multi plan listing provider as PAR and linked to group TIN/location effective 8/13/2021.  DCannon"]
["Lawrence A Wilson, MD",1518951342,"75-2656723","TX","","Triwest VA","Facility Enrollment","Application Submitted","","","","2022-11-15"," 08/19/2022 - Application submitted to Scarlett Abigail (Scarlett_Abigail@bcbstx.com) of TriWest VA"]
["Lawrence A Wilson, MD",1518951342,"75-2656723","TX","PE - Premier Family Care I, Inc","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.\""]
["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","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","Caprock (CapStar)","Participating","Enrollment Complete","2021-07-26","","","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 7/26/2021.  DCannon"]
["Lawrence A Wilson, MD",1518951342,"75-2656723","TX","PE - Premier Intensive Cardiac Rehabilitation","First Health Coventry","Participating","Enrollment Complete","2020-12-01","1103233","","2022-05-11","5/11/2022 Per First Health website provider is PAR and linked to group TIN/location effective 12/1/2020.  PID # 1103233.  DCannon"]
["Lawrence A Wilson, MD",1518951342,"75-6000608","TX","PE - City of Midland Health Department","Medicare","Participating","Enrollment Complete","2021-03-01","","","2021-05-24","5/24/2021 Received approval notice from CMS and forwarded to Terri Craig for her records, along with the approved record from PECOS.  KFrazier"]
["Lawrence A Wilson, MD",1518951342,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Aetna","Participating","Enrollment Complete","2021-07-26","7942472","","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 7/26/2021.  PID # 7942472 DCannon"]
["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,"75-2656723","TX","PE - Premier Family Care I, Inc","HealthSmart PPO","Participating","Enrollment Complete","2002-04-01","","","2021-04-09","4/9/2021 4/11/2021 Rcvd email from HealthSmart <mdipsupport@healthsmart.com> confirming participation of provider under TIN and location effective 4/1/2002.  DCannon"]
["Lawrence A Wilson, MD",1518951342,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","TriCare Standard","Participating","Enrollment Complete","2021-11-12","","","2022-02-24","2/24/2022 Per Humana Tricare portal provider is PAR and linked to group TIN/location effective 11/12/2021.  DCannon"]
["Lawrence A Wilson, MD",1518951342,"75-2656723","TX","PE - Premier Family Care I, Inc","CAQH","Participating","CAQH Reattested","2022-11-26","","","2022-11-26","11/26/2022 CAQH reviewed and re-attested.  DCannon"]
["Lawrence A Wilson, MD",1518951342,"75-6000608","TX","PE - WesTex Urgent Care, PLLC","CAQH","Participating","CAQH Reattested","2022-11-26","","","2022-11-26","11/26/2022 CAQH reviewed and re-attested.  DCannon"]
["Lawrence A Wilson, MD",1518951342,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","CAQH","Participating","CAQH Reattested","2022-11-26","","","2022-11-26","11/26/2022 CAQH reviewed and re-attested.  DCannon"]
["Lawrence A Wilson, MD",1518951342,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","CAQH","Participating","CAQH Reattested","2022-11-26","","","2022-11-26","11/26/2022 CAQH reviewed and re-attested.  DCannon"]
["Lawrence A Wilson, MD",1518951342,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Scott&White (First Care)","Participating","Enrollment Complete","2021-07-26","","","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 7/26/2021.  DCannon"]
["Lawrence A Wilson, MD",1518951342,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Multiplan","Participating","Enrollment Complete","2021-08-13","","","2022-02-07","2/7/2022 Rcvd roster from Multi plan listing provider as PAR and linked to group TIN/location effective 8/13/2021.  DCannon"]
["Lawrence A Wilson, MD",1518951342,"75-6000608","TX","","Triwest VA","In Process","Application Submitted","","","","2022-11-15"," 08/19/2022 - Application submitted to Scarlett Abigail (Scarlett_Abigail@bcbstx.com) of TriWest VA"]
["Lawrence A Wilson, MD",1518951342,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Amerigroup","Participating","Enrollment Complete","2021-01-07","","","2021-10-21","10/21/2021  Rcvd full roster from Joe Rodriguez at Amerigroup listing provider as PAR w/ group TIN and location effective 1/7/2021.  DCannon"]
["Lawrence A Wilson, MD",1518951342,"75-2656723","TX","PE - Premier Family Care I, Inc","Alliance WC","Participating","Enrollment Complete","2021-03-19","","","2021-06-28","6/28/2021 Received an email from Rep Michelle Killough at michelle.killough@pswca.org confirming provider is participating effective 3/19/2021 under group Tax ID. KFrazier"]
["Lawrence A Wilson, MD",1518951342,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","USA PPO","Participating","Enrollment Complete","2021-07-26","","","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 7/26/2021.  DCannon"]
["Lawrence A Wilson, MD",1518951342,"75-2656723","TX","PE - Premier Intensive Cardiac Rehabilitation","Omni PPO","Participating","Enrollment Complete","2021-01-07","","","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 1/7/2021. DCannon"]
["Lawrence A Wilson, MD",1518951342,"75-2656723","TX","PE - Premier Intensive Cardiac Rehabilitation","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"]
["Lawrence A Wilson, MD",1518951342,"47-3465832","TX","","Triwest VA","Facility Enrollment","Application Submitted","","","","2022-11-15"," 08/19/2022 - Application submitted to Scarlett Abigail (Scarlett_Abigail@bcbstx.com) of TriWest VA"]
["Lawrence A Wilson, MD",1518951342,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Omni PPO","Participating","Enrollment Complete","2021-07-26","","","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 7/26/2021.  DCannon"]
["Lawrence A Wilson, MD",1518951342,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Omni PPO","Participating","Enrollment Complete","2021-07-26","","","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 7/26/2021.  DCannon"]
["Lawrence A Wilson, MD",1518951342,"75-2656723","TX","PE - Premier Family Care I, 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"]
["Lawrence A Wilson, MD",1518951342,"75-6000608","TX","PE - City of Midland Health Department","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"]
["Lawrence A Wilson, MD",1518951342,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Scott&White (First Care)","Participating","Enrollment Complete","2021-07-26","","","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 7/26/2021.  DCannon"]
["Lawrence A Wilson, MD",1518951342,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Boon Chapman","Participating","Enrollment Complete","2021-08-13","","","2022-02-07","2/7/2022 Rcvd roster from Multi plan listing provider as PAR and linked to group TIN/location effective 8/13/2021.  DCannon"]
["Lawrence A Wilson, MD",1518951342,"75-2656723","TX","PE - Premier Family Care I, 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"]
["Lawrence A Wilson, MD",1518951342,"75-6000608","TX","PE - City of Midland Health Department","Cigna","Participating","Enrollment Complete","2020-12-01","9800227","","2021-11-29","11/29/21 Recevied email from pdmcogz@cigna.com, provider is effective as of 12/01/2020. PID 9800227. Cbankston"]
["Debbie P Reese, MD",1629074984,"75-2133441","TX","PE - Midland Pediatric Associates, PLLC","HealthSmart PPO","Participating","Enrollment Complete","2011-02-01","10120298","","2020-07-21","07/21/2020 - Rec'd email from the payer stating this provider/TIN/service location is EFF under PRIMED DELGATED agreement - stacey Hudak"]
["Debbie P Reese, MD",1629074984,"75-2133441","TX","PE - Midland Pediatric Associates, PLLC","Galaxy Health","Participating","Enrollment Complete","2014-11-04","1629074984","","2020-07-17","7/17/2020- Received a spreadsheet from the payer stating this provider is effective as of  11/4/2014. – Elonah Grace B. Gelig"]
["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","Superior","Participating","Enrollment Complete","2020-08-01","1629074984","","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"]
["Debbie P Reese, MD",1629074984,"75-2133441","TX","PE - Midland Pediatric Associates, PLLC","United Health Care","Participating","Enrollment Complete","2017-10-31"," 466023","","2020-07-30","7/30/2020 - moved to completed status after reviewing follow up complete note - Stacey Hudak"]
["Debbie P Reese, MD",1629074984,"75-2133441","TX","PE - Midland Pediatric Associates, PLLC","Multiplan","Participating","Enrollment Complete","2020-09-09","","","2021-06-29","6/29/2021 Rcvd roster from Multiplan confirming provider is PAR under TIN effective 9/9/2020.  DCannon"]
["Debbie P Reese, MD",1629074984,"75-2133441","TX","PE - Midland Pediatric Associates, PLLC","Superior","Participating","Enrollment Complete","2020-08-01","1629074984","","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"]
["Debbie P Reese, MD",1629074984,"75-2133441","TX","PE - Midland Pediatric Associates, PLLC","First Health Coventry","Participating","Enrollment Complete","2008-09-01","1094380","","2020-03-24","3/24/2020-received email with roster from payor stating provider PAR 9/1/2008  PID # 1094380\ntisha rader"]
["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","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","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"]
["Govind B Patel, MD",1073555249,"74-2348334","TX","PE - Permian Gastroenterology PA","Rail Road Medicare","Participating","Enrollment Complete","2001-08-01","P02417357","CI6074","2020-08-28","08/28/2020 - moved to completed status after finding EFF letter in the payer portal - Stacey Hudak"]
["Govind B Patel, MD",1073555249,"74-2348334","TX","PE - Permian Gastroenterology PA","United Health Care","Participating","Enrollment Complete","2020-03-01","1073555249","","2020-08-31","08/31/2020 - moved to completed status after reviewing follow up complete status - Stacey Hudak"]
["Govind B Patel, MD",1073555249,"74-2348334","TX","PE - Permian Gastroenterology PA","Medicaid","Participating","Enrollment Complete","","096335703","","2020-06-11","06/11/2020 - found TPI thorugh CAQH - but was not able to obtain EFF date - Stacey Hudak"]
["Govind B Patel, MD",1073555249,"74-2348334","TX","","Triwest VA","Facility Enrollment","Application Submitted","","","","","08/19/2022 - Submitted application to TriWest VA (sent to Scarlett Abigail, Scarlett_Abigail@bcbstx.com)"]
["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"]
["Govind B Patel, MD",1073555249,"74-2348334","TX","PE - Permian Gastroenterology PA","Cigna","Participating","Enrollment Complete","2010-10-21","1073555249","","2020-04-22","4/22/2020--SW kanishena of Cigna @ 8008824462, Provider NPI# is on file and participating under the group and TIN# effective 10/21/2010. Location is on file. Call ref# kanishena4212020\ncopied note from spreadsheet-tisha rader"]
["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","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","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","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","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"]
["Sari A Nabulsi, MD",1740289297,"54-2080139","TX","PE - Sari Nabulsi, MD, LTD, LLP","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."]
["Sari A Nabulsi, MD",1740289297,"54-2080139","TX","PE - Sari Nabulsi, MD, LTD, LLP","CAQH","In House Enrollment","In House Enrollment","2020-06-11","10601003","","2020-06-11","06/11/2020 - Provider did not supply CAQH login. Provider will maintain this info in-house - 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","Superior","Participating","Enrollment Complete","2017-01-01","1740289297","","2020-07-14","07/14/2020 - Rec'd email from the payer stating this provider is EFF under PRIMED DELEGATED agreement - Stacey Hudak"]
["Sari A Nabulsi, MD",1740289297,"54-2080139","TX","PE - Sari Nabulsi, MD, LTD, LLP","TriCare Standard","Participating","Enrollment Complete","2003-01-03","1740289297","","2020-05-01","05/01/2020 - Rec'd access to the TIN through the payer portal and was able to confirm that this provider/service location are EFF - Stacey Hudak"]
["John W Foster, Jr, MD",1679568380,"75-2656723","TX","PE - Premier Family Care I, 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","","Triwest VA","Facility Enrollment","Application Submitted","","","","2022-11-23","08/19/2022 - Submitted application to TriWest VA (sent to Scarlett Abigail, Scarlett_Abigail@bcbstx.com)"]
["John W Foster, Jr, MD",1679568380,"75-2656723","TX","PE - Premier Family Care I, Inc","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.\""]
["John W Foster, Jr, MD",1679568380,"75-2656723","TX","PE - Premier Family Care I, 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"]
["John W Foster, Jr, MD",1679568380,"75-2656723","TX","PE - Premier Family Care I, Inc","Superior","Participating","Enrollment Complete","2020-08-01","1679568380","","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"]
["John W Foster, Jr, MD",1679568380,"75-2656723","TX","PE - Premier Family Care I, Inc","Caprock (CapStar)","Participating","Enrollment Complete","2019-09-01","1679568380","","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"]
["John W Foster, Jr, MD",1679568380,"75-2656723","TX","PE - Premier Family Care I, Inc","Boon Chapman","Participating","Enrollment Complete","2020-04-22","","","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 4/22/2020.  DCannon"]
["John W Foster, Jr, MD",1679568380,"75-2656723","TX","PE - Premier Family Care I, Inc","USA PPO","Participating","Enrollment Complete","2021-01-26","514205","","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"]
["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","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","Triwest VA","In Process","Application Submitted","","","","","08/19/2022 - Submitted application to TriWest VA (sent to Scarlett Abigail, Scarlett_Abigail@bcbstx.com)"]
["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","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"]
["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","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"]
["Eric J Venegas, MD",1760485502,"75-2930500","TX","PE - Eric J. Venegas, MD, PA","Omni PPO","Participating","Enrollment Complete","2001-07-01","1760485502","","2020-06-26",""]
["Eric J Venegas, MD",1760485502,"75-2930500","TX","PE - Eric J. Venegas, MD, PA","Aetna","Participating","Enrollment Complete","2006-01-01","7480837","","2020-07-10","07/10/2020 - moved to completed status per notes in Follow Up Complete  - Stacey Hudak"]
["Eric J Venegas, MD",1760485502,"75-2930500","TX","PE - Eric J. Venegas, MD, PA","Amerigroup","Participating","Enrollment Complete","2012-03-01","10016928","","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"]
["Eric J Venegas, MD",1760485502,"75-2930500","TX","PE - Eric J. Venegas, MD, PA","Medicaid","Participating","Enrollment Complete","","144105701","","2020-08-26","8/26/2020 - the clinic only provider an TPI number. I was not given an effective date. - Stacey Hudak"]
["Eric J Venegas, MD",1760485502,"75-2930500","TX","PE - Eric J. Venegas, MD, PA","HealthSmart PPO","Participating","Enrollment Complete","2011-02-01","1760485502","","2020-07-01","07/01/2020 - Rec'd confirmation from the payer that this provider is EFF - Stacey Hudak"]
["Kirit N Patel, MD",1295724698,"75-2656723: S","TX","PE - Premier Family Care I, 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 I, Inc","Medicare","Participating","Enrollment Complete","2011-08-25","TXB134311","0008AH","2020-01-29","01/29/2020 - confirmed EFF through PECOS group enrollment - Stacey Hudak"]
["Kirit N Patel, MD",1295724698,"75-2656723: P","TX","PE - Premier Family Care I, Inc","CAQH","Participating","CAQH Reattested","2023-02-12","10776779","","2023-02-12","2/12/2023 CAQH reviewed and re-attested.  DCannon"]
["Kirit N Patel, MD",1295724698,"75-2656723: S","TX","PE - Premier Family Care I, Inc","Cigna","Terminated","Terminated","2011-09-01","1295724698","","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"]
["Kirit N Patel, MD",1295724698,"75-2656723: P","TX","PE - Premier Family Care I, 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 I, 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 I, Inc","Omni PPO","Participating","Enrollment Complete","2019-09-01","1295724698","","2020-07-27","IMS approved"]
["Kirit N Patel, MD",1295724698,"75-2656723: S","TX","PE - Premier Family Care I, 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."]
["Kirit N Patel, MD",1295724698,"75-2656723: S","TX","PE - Premier Family Care I, 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."]
["Kirit N Patel, MD",1295724698,"75-2656723: S","TX","PE - Premier Family Care I, Inc","Aetna","Participating","Enrollment Complete","2018-08-14","1295724698","","2020-03-24","3/24/2020--S/W Erickof Aetna @ 18003531232, provider NPI# is on file for the provider and is participating effective 08/14/2018 under the group and TIN#. Physical location is on file. DIRECT CONTRACT--Call ref# 5192739438.\ntisha rader"]
["Kirit N Patel, MD",1295724698,"75-2656723: P","TX","PE - Premier Family Care I, Inc","Caprock (CapStar)","Participating","Enrollment Complete","2017-11-01","1295724698","","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"]
["Kirit N Patel, MD",1295724698,"75-2656723: P","TX","PE - Premier Family Care I, 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 I, Inc","TriCare Standard","Participating","Enrollment Complete","2018-11-30","1295724698","","2020-05-01","05/01/2020 - was able to confirm this provider/service location is EFF thorugh payer portal - Stacey Hudak"]
["Kirit N Patel, MD",1295724698,"75-2656723: P","TX","PE - Premier Family Care I, Inc","Amerigroup","Participating","Enrollment Complete","2012-03-01","01350302","","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"]
["Kirit N Patel, MD",1295724698,"75-2656723: P","TX","","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.\""]
["Dario Beltran, MD",1912100850,"75-2656723","TX","PE - Premier Family Care I, Inc","TriCare Standard","Participating","Enrollment Complete","2011-03-03","1912100850","","2021-11-15","11/15/2021 Per confirm par statues note.   S/W Diana of Tricare @ 800-444-5445 Transferred to WPS Dept. S/w Maggie. Provider NPI# is on file for the provider and is participating effective 03/03/2011 under the group and TIN#.  No end date. Physical location is on file. Call ref# 14226448.  DCannon"]
["Dario Beltran, MD",1912100850,"75-2656723","TX","PE - Premier Family Care I, Inc","Cigna","Participating","Enrollment Complete","2021-10-29","3531211","","2022-03-09","3/9/2022 Rcvd email from Cigna that provider is PAR and linked to group TIN/location effective 10/29/2021.  PID # 3531211.  DCannon"]
["Dario Beltran, MD",1912100850,"75-2656723","TX","PE - Premier Family Care I, Inc","First Health Coventry","In Process","Action Needed","","1067924","","2023-03-06","03.06.2023 S/W Brenda of First Health @800-226-5116. Per rep, provider is no longer in the network since 01/31/2021. Since the TIN has delegated group which is PriMed Health Network, rep advised to contact them first because they're the one who terminated the provider with First Health and reinstate the provider back in First Health. Call ref# 564186. - Mary Rose Acebedo"]
["Dario Beltran, MD",1912100850,"75-2656723","TX","PE - Premier Family Care I, Inc","Triwest VA","Facility 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"]
["Dario Beltran, MD",1912100850,"75-2656723","TX","","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.\""]
["Dario Beltran, MD",1912100850,"75-2656723","TX","PE - Premier Family Care I, Inc","IMS","Enrollment Stopped","Enrollment Complete","2019-09-01","1922008234","","2020-07-27","07/27/2020 - enrollment was completed due to being submitted on July 2020 roster to the payer - Stacey Hduak"]
["Dario Beltran, MD",1912100850,"75-2656723","TX","PE - Premier Family Care I, Inc","Galaxy Health","Enrollment Stopped","Enrollment Stopped","2019-05-18","1912100850","","2020-07-15","07/15/2020 - Rec'd email from the clinic stating provider is terming on 6/25/2020.  - Stacey Hudak"]
["Padmaja M Patel, MD",1861408890,"75-2656723","TX","PE - Premier Family Care I, Inc","Caprock (CapStar)","Participating","Enrollment Complete","2021-01-01","","","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 1/1/2021.  DCannon"]
["Padmaja M Patel, MD",1861408890,"20-0256751","TX","PE - Padmaja M. Patel","Medicare","Participating","Enrollment Complete","2004-01-01","8B8466","00681W","2020-04-27","04/27/2020 - was able to confirm this providers EFF info through providers personal PECOS login - Stacey Hudak"]
["Padmaja M Patel, MD",1861408890,"75-2656723","TX","PE - Premier Family Care I, Inc","Caprock (CapStar)","Participating","Enrollment Complete","2020-10-01","","","2021-04-28","4/28/2021 Rcvd roster from payer with all participating providers listed.  Provider is PAR and linked to TIN/locations effective 10/1/2020."]
["Padmaja M Patel, MD",1861408890,"75-2656723","TX","PE - Premier Intensive Cardiac Rehabilitation","Scott&White (First Care)","Participating","Enrollment Complete","2019-06-06","","","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 6/6/2019.  DCannon"]
["Padmaja M Patel, MD",1861408890,"75-2656723","TX","PE - Premier Family Care I, Inc","Amerigroup","Participating","Enrollment Complete","2020-04-03","","","2021-11-11","11/11/2021 Rcvd email from Marco Rodriguez @ Amerigroup confirming that provider is PAR under group TIN/location effective 4/3/2020.  DCannon"]
["Padmaja M Patel, MD",1861408890,"75-2656723","TX","PE - Premier Family Care I, Inc","Scott&White (First Care)","Participating","Enrollment Complete","2019-06-06","","","2021-01-21","1/20/2021 - Rcvd email from BSWHPEXPEDITES@BSWHealth.org that provider is participating and linked to TIN effectivre 6/6/2019"]
["Padmaja M Patel, MD",1861408890,"75-2656723","TX","PE - Premier Family Care I, Inc","Medicare","Participating","Enrollment Complete","2019-04-01","774823","","2020-12-07","12/7/2020 - Verified provider's PTAN # 774823 via the PECOS website.  DCannon"]
["Padmaja M Patel, MD",1861408890,"75-2656723","TX","PE - Premier Intensive Cardiac Rehabilitation","Triwest VA","Facility Enrollment","Facility Enrollment","","","","","10/17/2022 - Received roster from Scarlett; provider status: \"No Action.  TIN is CCN participating under own DCN.\""]
["Padmaja M Patel, MD",1861408890,"75-2656723","TX","PE - Premier Family Care I, Inc","Triwest VA","Facility Enrollment","Application Submitted","","","","","08/19/2022 - Submitted application to TriWest VA (sent to Scarlett Abigail, Scarlett_Abigail@bcbstx.com)"]
["Padmaja M Patel, MD",1861408890,"75-2656723","TX","PE - Premier Family Care I, Inc","First Health Coventry","Participating","Enrollment Complete","2020-09-01","1097226","","2021-01-18","1/18/2021 - Per follow-up notes provider is now on file and participating under group, location and TIN effective 09/1/2020 PID # 1097226.  DCannon"]
["Padmaja M Patel, MD",1861408890,"75-2656723","TX","PE - Premier Family Care I, Inc","Scott&White (First Care)","Participating","Enrollment Complete","2019-06-06","","","2021-01-21","1/20/2021 - Rcvd email from BSWHPEXPEDITES@BSWHealth.org that provider is participating and linked to TIN effectivre 6/6/2019"]
["Padmaja M Patel, MD",1861408890,"75-2656723","TX","PE - Premier Family Care I, 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."]
["Padmaja M Patel, MD",1861408890,"75-2656723","TX","PE - Premier Family Care I, Inc","Medicaid","Enrollment Stopped","Enrollment Denied","","","","2021-08-12","3/24/2021 Upon review of the TMHP portal, application for group and performing provider were denied. KFrazier"]
["Padmaja M Patel, MD",1861408890,"75-2656723","TX","PE - Premier Intensive Cardiac Rehabilitation","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"]
["Padmaja M Patel, MD",1861408890,"75-2656723","TX","PE - Premier Family Care I, 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"]
["Padmaja M Patel, MD",1861408890,"75-2656723","TX","PE - Premier Intensive Cardiac Rehabilitation","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"]
["Padmaja M Patel, MD",1861408890,"75-2656723","TX","PE - Premier Intensive Cardiac Rehabilitation","Aetna","Terminated","Terminated","2021-01-01","5777706","","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"]
["Padmaja M Patel, MD",1861408890,"75-2656723","TX","","Triwest VA","Facility 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.\""]
["Padmaja M Patel, MD",1861408890,"20-0256751","TX","PE - Padmaja M. Patel","USA PPO","Participating","Enrollment Complete","2009-10-23","1861408890","200256751","2020-08-19","Confirmed provider is participating with PPO and H&W networks (list of networks attached). Kimberly Frazier"]
["Padmaja M Patel, MD",1861408890,"75-2656723","TX","PE - Premier Family Care I, Inc","IMS","Participating","Enrollment Complete","2020-10-01","","","2020-11-25","11/25/2020 - Rcvd email confirmation that Nov monthly roster was processed and this provider was made effective with the requested eff date of 10/1/2020.  DCannon"]
["Padmaja M Patel, MD",1861408890,"75-2656723","TX","PE - Premier Family Care I, Inc","HealthSmart PPO","Participating","Enrollment Complete","2019-03-06","","","2021-01-27","1/27/2021 - Rcvd confirmation email that provider is participating and linked to location and TIN effective 3/6/2019.  DCannon"]
["Padmaja M Patel, MD",1861408890,"75-2656723","TX","PE - Premier Family Care I, Inc","TriCare Standard","Participating","Enrollment Complete","2019-04-01","","","2020-10-26","10/26/2020 Confirmed provider is certified as non-network provider under Group with location. Kimberly Frazier"]
["Padmaja M Patel, MD",1861408890,"75-2656723","TX","PE - Premier Family Care I, Inc","Boon Chapman","Participating","Enrollment Complete","2019-03-06","","","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 3/6/2019.  DCannon"]
["Padmaja M Patel, MD",1861408890,"75-2656723","TX","PE - Premier Family Care I, Inc","HealthSmart PPO","Participating","Enrollment Complete","2019-03-06","","","2021-01-27","1/27/2021 - Rcvd confirmation email that provider is participating and linked to location and TIN effective 3/6/2019.  DCannon"]
["Padmaja M Patel, MD",1861408890,"75-2656723","TX","PE - Premier Family Care I, Inc","Cigna","Terminated","Terminated","2019-01-01","","","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"]
["P Douglas Cochran, MD",1316026396,"20-0212181","TX","PE - P. Douglas Cochran, MD PA","HealthSmart PPO","Participating","Enrollment Complete","2011-02-01","1316026396","","2020-06-05","06/05/2020 - Rec'd email from the payer stating this provider is EFF -Stacey Hudak"]
["P Douglas Cochran, MD",1316026396,"20-0212181","TX","PE - P. Douglas Cochran, MD PA","Caprock (CapStar)","Participating","Enrollment Complete","2020-03-01","1316026396","","",""]
["P Douglas Cochran, MD",1316026396,"20-0212181","TX","PE - P. Douglas Cochran, MD PA","Humana","Participating","Enrollment Complete","2006-12-14","","","2021-11-18","11/18/2021 Rcvd full roster from Humana listing provider as PAR and linked to group TIN/location effective 12/14/2006.  DCannon"]
["Terry L Beck, MD",1912991084,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","HealthSmart PPO","Participating","Enrollment Complete","2018-07-31","1912991084","","2020-06-10","06/10/2020 - Rec'd email from the payer stating this provider is EFF - Stacey Hudak"]
["Terry L Beck, MD",1912991084,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","United Health Care","Participating","Enrollment Complete","2020-01-01","1912991084","","2020-07-31","7/31/2020 - emailed UHC to confirm that this provider is NOT part of the PriMed agreement. That informaiton was incorrectly shared by the UHC representative. This provider has a direct contract - Stacey Hudak"]
["Terry L Beck, MD",1912991084,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Medicare","Participating","Enrollment Complete","2015-05-09","318466ZP5M","423838","2020-06-15",""]
["Terry L Beck, MD",1912991084,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Scott&White (First Care)","Participating","Enrollment Complete","2018-10-25","","","2021-01-29","1/29/2021 - Rcvd roster from Scott&White (First Care) confirming participation of provider with TIN and location effective dates.  DCannon"]
["Terry L Beck, MD",1912991084,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Texas Mutual","Participating","Enrollment Complete","2020-03-27","","","2021-01-23","11/25/2020-Confirmed provider is participating under group Tax ID and practice location. Rafael Calixtro"]
["Terry L Beck, MD",1912991084,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Scott&White (First Care)","Participating","Enrollment Complete","2018-10-25","","","2021-01-29","1/29/2021 - Rcvd roster from Scott&White (First Care) confirming participation of provider with TIN and location effective dates.  DCannon"]
["Terry L Beck, MD",1912991084,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Humana","Participating","Enrollment Complete","2015-08-28","1912991084","","2020-07-19","7/19/2020 - Received email spreadsheet from the payor confirming that this provider is EFF ath this service location and PAR with the PRIMED DELEGATED agreement - Pam Porter"]
["Terry L Beck, MD",1912991084,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","IMS","Participating","Enrollment Complete","2015-07-15","1912991084","","2020-06-22","06/22/2020- Rec'd email from the payer confirming this provider is PAR with this group/service location - Stacey Hudak"]
["Terry L Beck, MD",1912991084,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Amerigroup","Participating","Enrollment Complete","2015-08-28","03421119","","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 8/28/2015;  PLUS - eff 8/28/2015, Star_Kids - eff 11/1/2016.  DCannon"]
["Terry L Beck, MD",1912991084,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","First Health Coventry","Delegated - Third Party","Delegated - Third Party","2013-04-01","1912991084","","2020-10-08","10/8/2020 -  Provider is EFF under a delegated group (Prime Health Network.) - Stacey Hudak"]
["Terry L Beck, MD",1912991084,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","CAQH","Participating","CAQH Reattested","2023-01-03","","","2023-01-03","1/3/2023 CAQH reviewed and re-attested.  DCannon"]
["Terry L Beck, MD",1912991084,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Zurich","Participating","Enrollment Complete","2013-04-01","2230880","","2021-08-06","8/6/2021 Moved to enrollment complete per notes from First Health/Coventry. Provider is effective 4/1/2013. KFrazier"]
["Terry L Beck, MD",1912991084,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","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"]
["Terry L Beck, MD",1912991084,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Multiplan","Participating","Enrollment Complete","2016-01-14","1912991084","","2020-07-06","07/06/2020 - Rec'd email from the payer stating \" Here is the following information we have on file for Beck, Terry:\n\nNetwork:  MPI\nTIN: 47-3465832\nNetwork Participation effective: 1/14/16 Contract Source Group contract through: Individual Contract\" - Stacey Hudak"]
["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",""]
["Jose G Delgado, MD",1578557468,"","TX","PE - Premier Family Care I, Inc","Medicaid","Participating","Enrollment Complete","2004-10-01","1578557468","","2022-10-03","10/3/2022 Per TMHP web portal provider is PAR and linked to group effective 10/1/2004.  TPI# 1578557468.  DCannon"]
["Jose G Delgado, MD",1578557468,"","TX","PE - Premier Family Care I, Inc","First Health Coventry","Provider Load","Pending Other Enrollment","","","","2022-09-28","9/28/2022 Pending Aetna enrollment. Hsmith."]
["Jose G Delgado, MD",1578557468,"","TX","PE - Premier Family Care I, Inc","United Health Care","In Process","Application Submitted","","","","2022-10-14","10/14/2022 Emailed monthly delegated roster to UHC to add provider to delegated roster.  DCannon"]
["Jose G Delgado, MD",1578557468,"","TX","PE - Premier Family Care I, Inc","United Health Care","In Process","Application Submitted","","","","2022-10-14","10/14/2022 Emailed monthly delegated roster to UHC to add provider to delegated roster.  DCannon"]
["Jose G Delgado, MD",1578557468,"","TX","PE - Premier Family Care I, Inc","Rail Road Medicare","Participating","Enrollment Complete","2022-09-12","Q00346339","CE1588","2022-10-15","10/15/2022 Rcvd RR Medicare approval letter.  PTAN # Q00346339 - effective 9/12/2022.  DCannon"]
["Jose G Delgado, MD",1578557468,"","TX","PE - Premier Family Care I, Inc","IMS","Participating","Enrollment Complete","2022-09-12","","","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 9/12/2022.   DCannon"]
["Jose G Delgado, MD",1578557468,"","TX","PE - Premier Family Care I, 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,"","TX","PE - Premier Family Care I, 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,"","TX","PE - Premier Family Care I, 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,"","TX","PE - Premier Family Care I, 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,"","TX","PE - Premier Family Care I, Inc","USA PPO","In Process","Payor Follow Up","","","","2023-03-08","3/8/2023 Emailed USA PPO at ipa@usamco.com to check status of provider.  DCannon"]
["Jose G Delgado, MD",1578557468,"","TX","PE - Premier Family Care I, Inc","USA PPO","In Process","Payor Follow Up","","","","2023-03-08","3/8/2023 Emailed USA PPO at ipa@usamco.com to check status of provider.  DCannon"]
["Jose G Delgado, MD",1578557468,"","TX","PE - Premier Family Care I, 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,"","TX","PE - Premier Family Care I, Inc","Multiplan","In Process","Application Submitted","","","","2022-10-14","10/14/2022 Emailed monthly delegated roster to Multiplan to add provider to delegated roster.  DCannon"]
["Jose G Delgado, MD",1578557468,"","TX","PE - Premier Family Care I, 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,"","TX","PE - Premier Family Care I, 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,"","TX","PE - Premier Family Care I, 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,"","TX","PE - Premier Family Care I, 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,"","TX","PE - Premier Family Care I, Inc","CAQH","Participating","CAQH Reattested","2022-12-28","","","2022-12-28","12/28/2022 CAQH reviewed and re-attested.  DCannon"]
["Jose G Delgado, MD",1578557468,"","TX","PE - Premier Family Care I, Inc","CAQH","Participating","CAQH Reattested","2022-12-28","","","2022-12-28","12/28/2022 CAQH reviewed and re-attested.  DCannon"]
["Jose G Delgado, MD",1578557468,"","TX","PE - Premier Family Care I, 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,"","TX","PE - Premier Family Care I, Inc","Omni PPO","Participating","Enrollment Complete","2022-09-12","","","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 9/12/2022.   DCannon"]
["Jose G Delgado, MD",1578557468,"","TX","PE - Premier Family Care I, 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"]
["Jose G Delgado, MD",1578557468,"","TX","PE - Premier Family Care I, 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"]
["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","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: 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: 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","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: 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","Triwest VA","Participating","Enrollment Complete","","","","","11/14/22 Per Scarlett Abigail, provider is effective 8/1/22"]
["Vincent P Rascon, DPM",1346236924,"91-1559006: P","TX","","Triwest VA","Participating","Enrollment Complete","","","","","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","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","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"]
["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,"75-1997880","TX","","Cigna","Participating","Enrollment Complete","2011-03-09","1730181389","","2020-08-26","08/26/2020 - moved to completed status after reviewing foll up complete note - Stacey Hudak"]
["Rand E Waddingham, M.D.",1730181389,"26-3789190","TX","PE - Permian Physician Services","Sedgwick","Participating","Enrollment Complete","2003-02-11","","","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 2/11/2003.  DCannon"]
["Rand E Waddingham, M.D.",1730181389,"75-1997880","TX","","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","","Caprock (CapStar)","Participating","Enrollment Complete","2019-09-01","1730181389","","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"]
["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","","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","CAQH","Participating","CAQH Reattested","2021-05-05","","","2021-12-12","12/12/2021 CAQH reviewed and re-attested.  DCannon"]
["Rand E Waddingham, M.D.",1730181389,"26-3789190","TX","","CAQH","Participating","CAQH Reattested","2021-05-05","","","2021-12-12","12/12/2021 CAQH reviewed and re-attested.  DCannon"]
["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,"75-1997880","TX","","Sedgwick","Participating","Enrollment Complete","2003-02-11","1730181389","751997880","2020-08-19","Confirmed provider is participating with WIN network, which includes this payor (list of networks attached). Kimberly Frazier"]
["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","","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,"26-3789190","TX","PE - Permian Physician Services","Liberty Mutual","Pending Other Enrollment","Pending Other Enrollment","","","","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"]
["Rand E Waddingham, M.D.",1730181389,"75-1997880","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","","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,"75-1997880","TX","PE - Andrews County Hospital District","Liberty Mutual","Participating","Enrollment Complete","2003-02-11","1730181389","751997880","2020-08-19","Confirmed provider is participating with WIN networks which includes this payor (list of networks attached). Kimberly Frazier"]
["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","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"]
["Rajanikant P Pandya, MD",1316965403,"56-2697415","TX","PE - Rajanikant P. Pandya","Triwest VA","Participating","Enrollment Complete","2022-08-01","","","2022-11-14","11/14/22 Per Scarlett Abigail, provider effective 8/1/22"]
["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","2022-12-13","12031991","","2022-12-13","12/13/2022 CAQH reviewed and re-attested.  DCannon"]
["Rajanikant P Pandya, MD",1316965403,"56-2697415","TX","PE - Rajanikant P. Pandya","Cigna","Participating","Enrollment Complete","2010-08-01","1316965403","","2020-04-22","04/22/2020--S/W Jane 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# Jane04202020.\ncopied note from spreadsheet-tisha rader"]
["Rajanikant P Pandya, MD",1316965403,"56-2697415","TX","PE - Rajanikant P. Pandya","Humana","Participating","Enrollment Complete","2011-05-04","1316965403","","2020-08-31","08/31/2020 - moved to completed status after reviewing follow up complete note - Stacey Hudak"]
["Rajanikant P Pandya, MD",1316965403,"56-2697415","TX","PE - Rajanikant P. Pandya","Medicaid","Participating","Enrollment Complete","1900-01-02","136567801","","2020-05-22","05/22/2020 - Rec'd INDIVIDUAL TPI only from the clinic. Was not provided with Medicaid TMHP paperwork or effective date or group TPI. Update payer line with basic info so other enrollments can move forward. - Stacey Hudak"]
["Rajanikant P Pandya, MD",1316965403,"56-2697415","TX","PE - Rajanikant P. Pandya","Amerigroup","Participating","Enrollment Complete","2020-04-15","01449395","","2021-01-01","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"]
["Cheryl J. Vallie, APRN-FNP-BC",1417941410,"20-4063608","TX","","Triwest VA","In Process","Application Submitted","","","","","08/19/2022 - Submitted application to TriWest VA (sent to Scarlett Abigail, Scarlett_Abigail@bcbstx.com)"]
["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","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","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"]
["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","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","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","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"]
["Anand C Reddy, MD",1780892760,"81-3411343: P","TX","","Boon Chapman","Participating","Enrollment Complete","2020-04-01","1780892760","","2020-10-05","Enrollment through PHCS"]
["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","Aetna","Participating","Enrollment Complete","2019-05-01","1780892760","","2020-04-23","04/23/2020--S/W EL of Aetna @ 18003531232, provider NPI# is on file for the provider and is participating effective 05/01/2019 under the group and TIN#. Physical location is on file. Call ref# 5235916733. \ncopied note from spreadsheet-tisha rader"]
["Anand C Reddy, MD",1780892760,"81-3411343: P","TX","","USA PPO","Participating","Enrollment Complete","2021-01-26","1160322","","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"]
["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","","Omni PPO","Participating","Enrollment Complete","2019-05-01","1780892760","","2020-06-26",""]
["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","PE - Permian Basin Kidney Center 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."]
["Anand C Reddy, MD",1780892760,"81-3411343: P","TX","PE - Permian Basin Kidney Center Inc","Medicaid","Participating","Enrollment Complete","2019-05-01","296523803","397597101","2020-05-01","05/01/2020 - Rec'd confirmation of this information from the providers staff - 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"]
["Anand C Reddy, MD",1780892760,"81-3411343: P","TX","","United Health Care","Participating","Enrollment Complete","2019-05-01","3334870","","2020-07-30","7/30/2020 - moved to completed status after reviewing follow up complete note - Stacey Hudak"]
["Anand C Reddy, MD",1780892760,"81-3411343: P","TX","PE - Permian Basin Kidney Center Inc","Rail Road Medicare","Participating","Enrollment Complete","2019-05-01","P02274773","DZ2789","2020-06-11","06/11/2020 - Found EFF info through payer site - Stacey Hudak"]
["Chandan Mazumder, MD",1093928913,"83-0358685","TX","PE - Midland Community Healthcare Services","First Health Coventry","Participating","Enrollment Complete","2020-09-01","1093928913","","2020-10-08","10/8/2020 - moved to completed status after reviewing follow up complete - Stacey Hudak"]
["Chandan Mazumder, MD",1093928913,"83-0358685","TX","PE - Midland Community Healthcare Services","Boon Chapman","Participating","Enrollment Complete","2020-06-30","","","2022-07-01","7/1/2022 Provider is PAR and linked to group TIN/location effective 6/30/2020.  DCannon"]
["Chandan Mazumder, MD",1093928913,"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"]
["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","Caprock (CapStar)","Participating","Enrollment Complete","2012-12-01","","","2020-09-14",""]
["Chandan Mazumder, MD",1093928913,"83-0358685","TX","PE - Midland Community Healthcare Services","Triwest VA","Enrollment Stopped","Enrollment Stopped","","","","2022-11-29","10/17/2022 - Received roster from Scarlett of TriWest VA; provider status: \"No Action.  Pediatrics specialty.\""]
["Chandan Mazumder, MD",1093928913,"83-0358685","TX","","Triwest VA","Enrollment Stopped","Enrollment Stopped","","","","2022-11-29","10/17/2022 - Received roster from Scarlett of TriWest VA; provider status: \"No Action.  Pediatrics specialty.\""]
["Chandan Mazumder, MD",1093928913,"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."]
["Chandan Mazumder, MD",1093928913,"83-0358685","TX","PE - Midland Community Healthcare Services","Aetna","Participating","Enrollment Complete","2012-10-15","","","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"]
["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","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"]
["Chandan Mazumder, MD",1093928913,"83-0358685","TX","PE - Midland Community Healthcare Services","Triwest VA","Enrollment Stopped","Enrollment Stopped","","","","","10/17/2022 - Received roster from Scarlett of TriWest VA; provider status: \"No Action.  Pediatrics specialty.\""]
["Chandan Mazumder, MD",1093928913,"83-0358685","TX","PE - Midland Community Healthcare Services","Galaxy Health","Participating","Enrollment Complete","2020-09-01","","","2022-04-09","4/9/2022 Per roster received from Galaxy provider is listed as PAR and linked to group TIN/location effective 9/1/2020.  DCannon"]
["Chandan Mazumder, MD",1093928913,"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"]
["Chandan Mazumder, MD",1093928913,"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"]
["Chandan Mazumder, MD",1093928913,"83-0358685","TX","PE - Midland Community Healthcare Services","Multiplan","Participating","Enrollment Complete","2020-02-12","","","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 2/12/2020.   DCannon"]
["Chandan Mazumder, MD",1093928913,"83-0358685","TX","PE - Midland Community Healthcare Services","Caprock (CapStar)","Participating","Enrollment Complete","2012-12-01","","","2020-09-14",""]
["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","Aetna","Participating","Enrollment Complete","2020-09-01","","","2021-04-22","4/22/2021 Rcvd email from Kim Brechbiel <KJBrechbiel@aetna.com> that provider is particpating and linked to TIN/location effective 9/1/2020.  DCannon"]
["Chandan Mazumder, MD",1093928913,"83-0358685","TX","PE - Midland Community Healthcare Services","TriCare Standard","Participating","Enrollment Complete","2021-12-13","","","2022-02-10","2/10/2022 Per Tricare portal, provider is added to location as of 12/13/2021. Cbankston"]
["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","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","Superior","Participating","Enrollment Complete","2020-09-01","1093928913","","2020-09-02","09/02/2020 - Rec'd email from the payer stating this provider has been updated to TIN/location - Stacey Hudak"]
["Khadijah A. Abdurrazaq, MD",1336304120,"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"]
["Khadijah A. Abdurrazaq, MD",1336304120,"83-0358685","TX","PE - Midland Community Healthcare Services","Cigna","Participating","Enrollment Complete","2014-06-18","1336304120","","2020-09-24","09/24/2020 - moved to completed status - Stacey Hudak"]
["Khadijah A. Abdurrazaq, MD",1336304120,"83-0358685","TX","PE - Midland Community Healthcare Services","Aetna","Participating","Enrollment Complete","2021-06-01","","","2021-10-06","10/6/2021 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 # 9132703  DCannon"]
["Khadijah A. Abdurrazaq, MD",1336304120,"83-0358685","TX","PE - Midland Community Healthcare Services","Galaxy Health","Participating","Enrollment Complete","2020-09-17","","","2022-03-09","4/9/2022 Per roster received from Galaxy provider is listed as PAR and linked to group TIN/location effective 9/17/2020.  DCannon"]
["Khadijah A. Abdurrazaq, MD",1336304120,"83-0358685","TX","PE - Midland Community Healthcare Services","TriCare Standard","Participating","Enrollment Complete","2021-12-01","","","2021-12-08","12/8/21 Per provider portal, provider is linked to this location. Cbankston"]
["Khadijah A. Abdurrazaq, MD",1336304120,"83-0358685","TX","PE - Midland Community Healthcare Services","Aetna","Participating","Enrollment Complete","2013-09-15","9132703","","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"]
["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","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","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","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"]
["Khadijah A. Abdurrazaq, MD",1336304120,"83-0358685","TX","PE - Midland Community Healthcare Services","Cigna","Participating","Enrollment Complete","2014-06-18","1336304120","","2020-04-22","04/22/2020--S/W Monique of Cigna @ 8008824462, provider NPI is on file for the provider and participating effective 06/18/14 under the group and TIN with direct contract. Physical location is on file. Provider ID#0815933 Call ref# MONIQUE0421.\n-copied note from spreadsheet-tisha rader"]
["Khadijah A. Abdurrazaq, MD",1336304120,"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"]
["Khadijah A. Abdurrazaq, MD",1336304120,"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"]
["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","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","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","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","Humana","Participating","Enrollment Complete","2013-08-29","","","2021-11-18","11/18/2021 Rcvd full roster from Humana listing provider as PAR and linked to group TIN/location effective 8/29/2013.  DCannon"]
["Khadijah A. Abdurrazaq, MD",1336304120,"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"]
["Khadijah A. Abdurrazaq, MD",1336304120,"83-0358685","TX","PE - Midland Community Healthcare Services","First Health Coventry","Participating","Enrollment Complete","2021-06-01","","","2021-10-13","10/13/2021  Per First Health online provider directory provider is PAR and linked to group/locations  effective 6/1/2021  DCannon"]
["Maung K Hlaing, MD",1306167309,"47-5554737","TX","PE - Midland Inpatient Medical Association","Cigna","Participating","Enrollment Complete","2016-08-23","1306167309","","2020-02-20","02/20/2020 - Payer confirmed that this provider is EFF as of 8-26-2016 at this service location under a DIRECT CONTRACT with this payer - Stacey Hudak"]
["Maung K Hlaing, MD",1306167309,"47-5554737","TX","PE - Midland Inpatient Medical Association","Superior","Participating","Enrollment Complete","2020-08-01","1306167309","","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"]
["Maung K Hlaing, MD",1306167309,"47-5554737","TX","PE - Midland Inpatient Medical Association","Caprock (CapStar)","Participating","Enrollment Complete","2020-03-01","1306167309","","",""]
["Maung K Hlaing, MD",1306167309,"47-5554737","TX","PE - Midland Inpatient Medical Association","Galaxy Health","Participating","Enrollment Complete","2019-09-01","1306167309","","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"]
["Maung K Hlaing, MD",1306167309,"47-5554737","TX","PE - Midland Inpatient Medical Association","First Health Coventry","Participating","Enrollment Complete","2020-09-01","1306167309","","2020-09-24","09/24/2020 - moved to completed status after reviewing follow up complete note - Stacey Hudak"]
["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"]
["Leo D Villaroman, MD",1073796330,"26-3413331","TX","PE - Leo Villaroman, MD, PA","CAQH","Participating","CAQH Reattested","2023-02-12","","","2023-02-12","2/12/2023 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","","","","2023-02-16","2.16.2023 S/W Qjuana of Amerigroup @ 800-454-3730. NPI is on file for the provider but not link under the group and TIN.  Rep don't have an access to check pending application and was advised to send an email to TXcredentialing@amerigroup.com. No other information obtained. Verification request has been emailed to TXcredentialing@amerigroup.com and TXProviderRelations@amerigroup.com to verify Provider credentialing status. -Kim Monique Fabian"]
["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","PE - Leo Villaroman, MD, PA","Boon Chapman","Pending Other Enrollment","Pending Other Enrollment","","","","2023-01-14","1/14/2023 Pending Multiplan enrollment.  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","PE - Leo Villaroman, MD, PA","Multiplan","In Process","Application Submitted","","","","2023-01-14","1/14/2023 Emailed monthly delegated roster to Multiplan to add provider to delegated roster.  DCannon"]
["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.","CAQH","Participating","CAQH Reattested","2023-02-12","","","2023-02-12","2/12/2023 CAQH reviewed and re-attested.  DCannon"]
["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.","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.","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"]
["Asif AK Ansari, MD",1528299872,"81-3411343","TX","","USA PPO","Participating","Enrollment Complete","2020-04-03","","","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 04/03/2020.  DCannon"]
["Asif AK Ansari, MD",1528299872,"81-3411343","TX","","Superior","Participating","Delegated - Third Party","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","Boon Chapman","Participating","Enrollment Complete","2020-04-01","1528299872","","2020-10-05","Enrollment thru PHCS"]
["Asif AK Ansari, MD",1528299872,"81-3411343","TX","","United Health Care","Delegated - Third Party","Delegated - Third Party","2019-10-25","1528299872","","2020-06-09","06/09/2020 - Rec'd email from this payer stating \"Delegated for this TIN with Permian Basin Healthcare Network\" - stacey Hudak"]
["Asif AK Ansari, MD",1528299872,"81-3411343","TX","PE - Permian Basin Kidney Center Inc","Multiplan","Participating","Enrollment Complete","2020-04-01","1528299872","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"]
["Asif AK Ansari, MD",1528299872,"81-3411343","TX","","Multiplan","Participating","Enrollment Complete","2020-04-01","1528299872","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"]
["Asif AK Ansari, MD",1528299872,"81-3411343","TX","PE - Permian Basin Kidney Center Inc","Omni PPO","Participating","Enrollment Complete","2019-10-01","1528299872","","2020-06-26",""]
["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","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"]
["Asif AK Ansari, MD",1528299872,"81-3411343","TX","PE - Permian Basin Kidney Center 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"]
["Asif AK Ansari, MD",1528299872,"81-3411343","TX","PE - Permian Basin Kidney Center Inc","Medicaid","Participating","Enrollment Complete","2019-05-01","340590402","397597101","2020-05-01","05/01/2020 - Rec'd email fromt he providers staff with this EFF information - Stacey Hudak"]
["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","","Galaxy Health","Participating","Enrollment Complete","2019-09-01","1528299872","","2020-08-21",""]
["Asif AK Ansari, MD",1528299872,"81-3411343","TX","PE - Permian Basin Kidney Center Inc","Aetna","Participating","Enrollment Complete","2019-10-15","","","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"]
["Venus M Skeen, DNP",1104229293,"75-2656723","TX","PE - Premier Family Care I, Inc","Triwest VA","Facility 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"]
["Venus M Skeen, DNP",1104229293,"75-2656723","TX","","Triwest VA","Facility 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.\""]
["Venus M Skeen, DNP",1104229293,"47-5554737","TX","PE - Midland Inpatient Medical Association","Medicaid","Participating","Enrollment Complete","","357539102","364596201","2020-02-19","02/19/2020 - Per payer portal, this provider is linked to this group TPI 364596201 and affiliated 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"]
["Venus M Skeen, DNP",1104229293,"75-2656723","TX","PE - Premier Family Care I, Inc","Amerigroup","Participating","Enrollment Complete","2020-04-03","","","2021-10-21","10/21/2021  Rcvd full roster from Joe Rodriguez at Amerigroup listing provider as PAR w/ group TIN and location effective 4/3/2020.  DCannon"]
["Venus M Skeen, DNP",1104229293,"75-2656723","TX","PE - Premier Family Care I, Inc","Medicare","Participating","Enrollment Complete","2019-09-01","858626","0008AH","2020-01-29","01/29/2020 - confirmed EFF through PECOS group enrollment - Stacey Hudak"]
["Venus M Skeen, DNP",1104229293,"47-5554737","TX","PE - Midland Inpatient Medical Association","Omni PPO","Participating","Enrollment Complete","2019-09-01","1104229293","","2020-08-13","IMS is complete"]
["Venus M Skeen, DNP",1104229293,"75-2656723","TX","PE - Premier Family Care I, 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"]
["Venus M Skeen, DNP",1104229293,"75-2656723","TX","PE - Premier Family Care I, Inc","Scott&White (First Care)","Participating","Enrollment Complete","2019-09-01","1104229293","","2020-10-02","10/02/2020 - moved to completed status after reviewing follow up complete - Stacey Hudak"]
["Venus M Skeen, DNP",1104229293,"75-2656723","TX","PE - Premier Family Care I, Inc","Superior","Participating","Enrollment Complete","2020-08-01","1104229293","","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"]
["Venus M Skeen, DNP",1104229293,"47-5554737","TX","PE - Midland Inpatient Medical Association","Amerigroup","Participating","Enrollment Complete","2019-09-30","1104229293","","2020-02-12","2/12/2020 – Received Roster from Amerigroup and provider is now PAR- Tisha Rader"]
["Venus M Skeen, DNP",1104229293,"75-2656723","TX","PE - Premier Family Care I, Inc","Rail Road Medicare","Participating","Enrollment Complete","2019-09-01","P02428347","CE1588","2020-08-28","08/28/2020 - moved to completed status after confirming EFF info through payer site - Stacey Hudak"]
["Venus M Skeen, DNP",1104229293,"47-5554737","TX","PE - Midland Inpatient Medical Association","TriCare Standard","Participating","Enrollment Complete","2018-11-06","1104229293","","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"]
["Venus M Skeen, DNP",1104229293,"47-5554737","TX","PE - Midland Inpatient Medical Association","Galaxy Health","Participating","Enrollment Complete","2019-10-02","1104229293","","2020-07-10","07/10/2020 - updated payer line to enrollment complete status instead of \"Delegated status\" for report running purposes - Stacey Hudak"]
["Jason P. Cooper, PA-C",1063591493,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Zurich","Participating","Enrollment Complete","2019-08-30","","","2021-08-06","8/6/2021 Moved to enrollment complete per notes from First Health/Coventry. Provider is effective 8/30/2019. Kfrazier"]
["Jason P. Cooper, PA-C",1063591493,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Gallagher","Participating","Enrollment Complete","2015-09-01","","","2020-08-28","08/28/2020 - S/W Kim of Gallagher @ 800-243-2336, provider NPI is on file and participating effective 09/01/15 as PA and 01/01/15 as Internal Medicine under the group and TIN. Physical location is on file. Call ref#  181602659 - Moises Cipriano"]
["Jason P. Cooper, PA-C",1063591493,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Corvel Healthcare Corp.","Participating","Enrollment Complete","2020-10-29","","","2020-10-30","10/29/2020 Received forwarded approval notice from Regina Stiger confirming provider is participating effective 10/29/2020. Kimberly Frazier"]
["Jason P. Cooper, PA-C",1063591493,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","First Health Coventry","Participating","Enrollment Complete","2018-02-01","","","2020-10-30","10/30/2020 - S/W Robin of Coventry @ 800-937-6824, provider NPI# is on file for the provider and is participating effective 12/01/2018 under the group and TIN#. Physical location is on file. Call ref# 5700862. - El King Moreno"]
["Jason P. Cooper, PA-C",1063591493,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Caprock (CapStar)","Participating","Enrollment Complete","2018-12-21","","","2020-09-14",""]
["Jason P. Cooper, PA-C",1063591493,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Humana","Participating","Enrollment Complete","2018-12-01","","","2021-11-18","11/18/2021 Rcvd full roster from Humana listing provider as PAR and linked to group TIN/location effective 12/1/2018.  DCannon"]
["Jason P. Cooper, PA-C",1063591493,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Multiplan","Facility Enrollment","Facility Enrollment","","","","2020-10-09","10/9/2020 - Rec'd email from the clinic contact (Regina Stieger) stating that this payer is contracted through a facility enrollment - Stacey Hudak"]
["Jason P. Cooper, PA-C",1063591493,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Gallagher","Participating","Enrollment Complete","2015-09-01","","","2020-08-28","08/28/2020 - S/W Kim of Gallagher @ 800-243-2336, provider NPI is on file and participating effective 09/01/15 as PA and 01/01/15 as Internal Medicine under the group and TIN. Physical location is on file. Call ref#  181602659 - Moises Cipriano"]
["Jason P. Cooper, PA-C",1063591493,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","TriCare Standard","Participating","Enrollment Complete","2019-08-17","1063591493","","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"]
["Jason P. Cooper, PA-C",1063591493,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","First Health Coventry","Participating","Enrollment Complete","2018-02-01","","","2020-10-30","10/30/2020 - S/W Robin of Coventry @ 800-937-6824, provider NPI# is on file for the provider and is participating effective 12/01/2018 under the group and TIN#. Physical location is on file. Call ref# 5700862. - El King Moreno"]
["Jason P. Cooper, PA-C",1063591493,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Sedgwick","Participating","Enrollment Complete","2018-12-31","1212945","","2021-01-26","1/26/2021 - Per follow-up notes provider is par with TIN and location effective 12/31/2018.  DCannon"]
["Jason P. Cooper, PA-C",1063591493,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Superior","Participating","Enrollment Complete","2019-02-01","1063591493","","2020-07-14","07/14/2020 - Rec'd emailed spreadsheet from the delegated team stating this provider is enrolled with this TIN under the PRIMED delegated agreement - Stacey Hudak"]
["Jason P. Cooper, PA-C",1063591493,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Texas Mutual","Participating","Enrollment Complete","2018-12-01","1700","","2021-11-23","11/23/21 Received email from wwtxcontracts@texasmutual.com, recredentialing is complete. Cbankston"]
["Jason P. Cooper, PA-C",1063591493,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","IMS","Participating","Enrollment Complete","2019-09-01","1063591493","","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"]
["Jason P. Cooper, PA-C",1063591493,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","HealthSmart PPO","Participating","Enrollment Complete","2018-12-27","1063591493","","2020-06-10","06/10/2020 - Rec'd email from the payer stating this provider is EFF - Stacey Hudak"]
["Jason P. Cooper, PA-C",1063591493,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","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"]
["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","Cigna","Participating","Enrollment Complete","2017-04-14","5715174","","2020-12-30","12/30/2020 - S/W Lee of Cigna @ 800-882-4462, As per rep provider is on file and participating under the tax id effective 04/14/2017 with the provider id: 5715174, location is on file, provider is credentialed in the state of TX and enrolled independently, call ref# LeeP12/29/2020  DCannon"]
["Alaaedin Alhomosh, MD",1063709913,"47-5554737","TX","PE - Midland Inpatient Medical Association","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"]
["Alaaedin Alhomosh, MD",1063709913,"47-5554737","TX","PE - Midland Inpatient Medical Association","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"]
["Alaaedin Alhomosh, MD",1063709913,"47-5554737","TX","PE - Midland Inpatient Medical Association","First Health Coventry","In Process","Enrollment Complete","","","","2023-01-12","1.12.23 Called First Health @800-226-5116 and spoke with Stacey. Provider is participating at service location under Tax ID effective 12/1/22 with recredentialing every 3 years. Reference # 491471. ABoles"]
["Alaaedin Alhomosh, MD",1063709913,"47-5554737","TX","PE - Midland Inpatient Medical Association","Medicaid","Participating","Enrollment Complete","2016-11-27","338869610","364596201","2020-12-31","12/31/2020 Confirmed provider is participating and assigned TPI 338869610 under group. Revalidation due 12/21/2022. KFrazier"]
["Nancy Asamoa, MD",1023135639,475554737,"TX","PE - Midland Inpatient Medical Association","CAQH","Participating","CAQH Reattested","2022-12-29","","","2022-12-29","12/29/2022 CAQH reviewed and re-attested.  DCannon"]
["Nancy Asamoa, MD",1023135639,475554737,"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",1023135639,475554737,"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",1023135639,475554737,"TX","PE - Midland Inpatient Medical Association","Texas Mutual","Enrollment Stopped","Enrollment Stopped","","","","2022-03-25","3/25/2022 Per email from Candace, Dr. Asamoa is a hospitalist and does not see work comp patients.  Cbankston"]
["Nancy Asamoa, MD",1023135639,475554737,"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"]
["Samuel L Baumguardner, PA",1295109510,"75-2656723: S","TX","PE - Premier Family Care I, Inc","Omni PPO","Participating","Enrollment Complete","2019-09-01","1295109510","","2020-07-27","IMS complete"]
["Samuel L Baumguardner, PA",1295109510,"75-2656723: S","TX","PE - Premier Family Care I, 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."]
["Samuel L Baumguardner, PA",1295109510,"75-2656723: S","TX","PE - Premier Family Care I, 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."]
["Samuel L Baumguardner, PA",1295109510,"75-2656723: S","TX","PE - Premier Family Care I, 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 I, 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: P","TX","","Triwest VA","Facility Enrollment","Application Submitted","","","","","08/19/2022 - Submitted application to TriWest VA (sent to Scarlett Abigail, Scarlett_Abigail@bcbstx.com)"]
["Samuel L Baumguardner, PA",1295109510,"75-2656723: P","TX","PE - Premier Family Care I, Inc","Triwest VA","Facility Enrollment","Facility Enrollment","","","","","10/17/2022 - Received roster from Scarlett of TriWest VA; provider status: \"No Action.  TIN is CCN participating under own DCN.\""]
["Samuel L Baumguardner, PA",1295109510,"75-2656723: P","TX","PE - Premier Family Care I, Inc","Cigna","Participating","Enrollment Complete","2021-05-26","2383552","","2021-07-22","7/22/2021 Received an email from PDMCOGZ@cigna.com confirming provider is now participating under group Tax ID effective 5/26/2021 with assigned provider ID 2383552. KFrazier"]
["Samuel L Baumguardner, PA",1295109510,"75-2656723: S","TX","PE - Premier Family Care I, Inc","Triwest VA","Facility 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.\""]
["Samuel L Baumguardner, PA",1295109510,"75-2656723: P","TX","PE - Premier Family Care I, 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: P","TX","PE - Premier Family Care I, Inc","Boon Chapman","Participating","Enrollment Complete","2016-04-26","","","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 4/26/2016.  DCannon"]
["Samuel L Baumguardner, PA",1295109510,"75-2656723: P","TX","PE - Premier Family Care I, Inc","United Health Care","Participating","Enrollment Complete","2017-12-01","1295109510","","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"]
["Samuel L Baumguardner, PA",1295109510,"75-2656723: S","TX","PE - Premier Family Care I, 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"]
["Samuel L Baumguardner, PA",1295109510,"75-2656723: P","TX","PE - Premier Family Care I, Inc","IMS","Participating","Enrollment Complete","2019-09-01","1295109510","","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"]
["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","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","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","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","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","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"]
["Adenike T Esho, MD",1467745240,"75-2656723","TX","PE - Premier Family Care I, Inc","Caprock (CapStar)","Participating","Enrollment Complete","2016-05-01","1467745240","","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"]
["Adenike T Esho, MD",1467745240,"75-2656723","TX","PE - Premier Family Care I, Inc","Superior","Participating","Enrollment Complete","2019-10-01","1467745240","","2020-07-14","07/14/2020 - Rec'd spreadsheet from the delegated team stating this provider has been linked to the PriMed contract since 10-1-2019 **see the other enrollment complete line to see details about when this provider became effective with various specific products** - stacey Hudak"]
["Adenike T Esho, MD",1467745240,"75-2656723","TX","PE - Premier Family Care I, Inc","Multiplan","Participating","Enrollment Complete","2019-08-14","1467745240","","2020-02-13","02/13/2020 - Rec'd roster stating this provider is linked to DIRECT GROUP CONTRACT as of 8-14-2019. Provider is networked with Beechstreet. - Stacey Hudak"]
["Adenike T Esho, MD",1467745240,"75-2656723","TX","PE - Premier Family Care I, Inc","Boon Chapman","Participating","Enrollment Complete","2019-08-14","","","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 8/14/2019.  DCannon"]
["Adenike T Esho, MD",1467745240,"75-2656723","TX","PE - Premier Family Care I, Inc","Medicaid","Participating","Enrollment Complete","","341837801","079837301","2020-01-29","01/29/2020 - Found provider PAR through payer portal. Provider is PAR with the following plans: SUPERIOR - FOSTER CARE, Superior HealthPlan - Lubbock, Superior HealthPlan - Lubbock, TRADITIONAL MEDICAID, 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"]
["Adenike T Esho, MD",1467745240,"75-2656723","TX","PE - Premier Family Care I, Inc","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.\""]
["Christopher Ryan Vela, PA-C",1366728909,"75-2781652","TX","PE - West Texas Allergy, PA","Tricare Prime","Provider Load","Provider Load","","","","2022-12-16",""]
["Christopher Ryan Vela, PA-C",1366728909,"75-2781652","TX","PE - West Texas Allergy, PA","United Health Care","In Process","Application Submitted","","","","2023-02-15","2/15/2023 Emailed monthly delegated roster to UHC to add provider to delegated roster.  DCannon"]
["Christopher Ryan Vela, PA-C",1366728909,"87-1671535","TX","PE - West Texas Allergy, Lubbock, PLLC","Rail Road Medicare","Pending Other Enrollment","Pending Other Enrollment","","","","2022-12-16","12/16/2022 Pending Medicare enrollment.  DCannon"]
["Christopher Ryan Vela, PA-C",1366728909,"87-1671535","TX","PE - West Texas Allergy, Lubbock, PLLC","IMS","In Process","Application Submitted","","","","2023-02-15","2/15/2023 Emailed monthly delegated roster to IMS/OMNI to add provider to delegated roster.  DCannon"]
["Christopher Ryan Vela, PA-C",1366728909,"75-2781652","TX","PE - West Texas Allergy, PA","Wellcare","Participating","Enrollment Complete","2023-03-01","","","2023-03-10","3/10/2023 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 3/1/2023.  DCannon"]
["Christopher Ryan Vela, PA-C",1366728909,"87-1671535","TX","PE - West Texas Allergy, Lubbock, PLLC","Wellcare","Participating","Enrollment Complete","2023-03-01","","","2023-03-10","3/10/2023 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 3/1/2023.  DCannon"]
["Christopher Ryan Vela, PA-C",1366728909,"75-2781652","TX","PE - West Texas Allergy, PA","CAQH","Participating","CAQH Reattested","2023-02-12","","","2023-02-12","2/12/2023 CAQH profile is current and up-to-date.  No changes needed.  Last re-attested on 12/5/2022.  DCannon"]
["Christopher Ryan Vela, PA-C",1366728909,"75-2781652","TX","PE - West Texas Allergy, PA","CAQH","Participating","CAQH Reattested","2023-02-12","","","2023-02-12","2/12/2023 CAQH profile is current and up-to-date.  No changes needed.  Last re-attested on 12/5/2022.  DCannon"]
["Christopher Ryan Vela, PA-C",1366728909,"75-2781652","TX","PE - West Texas Allergy, PA","Aetna","Participating","Enrollment Complete","2023-01-23","8143656","","2023-03-06","03.06.2023  Per follow-up note -  provider is showing participating with an Effective date of 01/23/2023 and link under the Group and TIN. Provider ID 8143656.   Service location is on file. DCannon"]
["Christopher Ryan Vela, PA-C",1366728909,"87-1671535","TX","PE - West Texas Allergy, Lubbock, PLLC","Amerigroup","In Process","Payor Follow Up","","","","2023-03-06","03.06.2023 S/W Rob of Amerigroup @ 1-800-454-3730. Per rep, provider is showing out of network. Ask rep there if there's a pending applicaiton but rep don't have access to check the status of the application. Rep advised to send an email @ TXCredentialing@amerigroup.com. Call ref#:I-174598741. Verification request has been emailed to TXCredentialing@amerigroup.com and TXProviderRelations@amerigroup.com to verify Provider credentialing status. - Danico Gabriel Melendres"]
["Christopher Ryan Vela, PA-C",1366728909,"75-2781652","TX","PE - West Texas Allergy, PA","Omni PPO","In Process","Application Submitted","","","","2023-02-15","2/15/2023 Emailed monthly delegated roster to IMS/OMNI to add provider to delegated roster.  DCannon"]
["Christopher Ryan Vela, PA-C",1366728909,"87-1671535","TX","PE - West Texas Allergy, Lubbock, PLLC","Omni PPO","In Process","Application Submitted","","","","2023-02-15","2/15/2023 Emailed monthly delegated roster to IMS/OMNI to add provider to delegated roster.  DCannon"]
["Haritha Bellam, MD",1770883191,"75-2656723","TX","PE - Premier Family Care I, Inc","Boon Chapman","Participating","Enrollment Complete","2016-07-13","","","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 7/13/2016.  DCannon"]
["Haritha Bellam, MD",1770883191,"75-2656723","TX","","Scott&White (First Care)","Participating","Enrollment Complete","2018-04-13","1770883191","","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"]
["Haritha Bellam, MD",1770883191,"75-2656723","TX","PE - Premier Family Care I, 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","","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","","Cigna","Participating","Enrollment Complete","2019-02-12","1770883191","","2020-02-20","02/20/2020 - Rec'd verification from the payer that this provider is EFF 2-12-2019 and linked to this service location under a DIRECT CONTRACT with this payer - Stacey Hudak"]
["Haritha Bellam, MD",1770883191,"75-2656723","TX","PE - Premier Family Care I, Inc","Wellcare","Participating","Enrollment Complete","2022-09-01","","","2022-11-15","11/15/2022 Per roster received from Wellcare provider is PAR and linked to group TIN/location effective 9/1/2022.  DCannon"]
["Haritha Bellam, MD",1770883191,"75-2656723","TX","","IMS","Participating","Enrollment Complete","2015-10-26","1770883191","","2020-06-22","06/22/2020- Rec'd email from the payer confirming this provider is PAR with this group/service location - Stacey Hudak"]
["Haritha Bellam, MD",1770883191,"75-2656723","TX","PE - Premier Family Care I, 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","","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.\""]
["Haritha Bellam, MD",1770883191,"75-2656723","TX","PE - Premier Family Care I, 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"]
["Haritha Bellam, MD",1770883191,"75-2656723","TX","PE - Premier Family Care I, Inc","Multiplan","Participating","Enrollment Complete","2016-07-13","1770883191","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 7-13-2016. Provider is networked with Beechstreet. - Stacey Hudak"]
["Haritha Bellam, MD",1770883191,"75-2656723","TX","","United Health Care","Participating","Enrollment Complete","2020-01-01","1770883191","","2020-08-31","08/31/2020 - moved to completed status after reviewing follow up completed note - Stacey Hudak"]
["Michael J Hester, APRN-AGACNP",1275044422,"75-2656723: S","TX","PE - Premier Family Care I, Inc","Caprock (CapStar)","Participating","Enrollment Complete","2018-07-24","1275044422","","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 J Hester, APRN-AGACNP",1275044422,"75-2656723: P","TX","PE - Premier Family Care I, 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: S","TX","PE - Premier Family Care I, Inc","Medicaid","Participating","Enrollment Complete","","384181902","079837301","2020-01-29","01/29/2020 - moved to completed status after confirming provider is linked in payer portal. Provider is participating with the following plans: TRADITIONAL MEDICAID, Amerigroup - MRSA West, Amerigroup - MRSA West, Amerigroup Texas, Inc. - MRSA West - Stacey Hudak"]
["Michael J Hester, APRN-AGACNP",1275044422,"75-2656723: P","TX","PE - Premier Family Care I, Inc","United Health Care","Participating","Enrollment Complete","2019-09-01","1275044422","","2020-09-14","09/14/2020 - Rec'd email from the payer stating \"Good news! We’ve completed the provider/group updates you requested on Sep 9, 2020 9:21:18 AM. Your request was assigned reference number PR-5483455 .\" - Stacey Hudak"]
["Michael J Hester, APRN-AGACNP",1275044422,"75-2656723: P","TX","PE - Premier Family Care I, 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","","Triwest VA","Facility Enrollment","Application Submitted","","","","2022-11-23","08/19/2022 - Submitted application to TriWest VA (sent to Scarlett Abigail, Scarlett_Abigail@bcbstx.com)"]
["Michael J Hester, APRN-AGACNP",1275044422,"75-2656723: P","TX","PE - Premier Family Care I, Inc","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.\""]
["Michael J Hester, APRN-AGACNP",1275044422,"75-2656723: P","TX","PE - Premier Family Care I, Inc","Tricare Prime","Participating","Enrollment Complete","2022-05-06","","","2022-06-21","6/21/2022  Per Tricare portal, provider has been added to group TIN and location effective 5/6/2022.  DCannon"]
["Michael J Hester, APRN-AGACNP",1275044422,"75-2656723: S","TX","PE - Premier Family Care I, Inc","First Health Coventry","Participating","Enrollment Complete","2018-08-01","3159807","","2020-03-20","3/20/2020-receieved email with roster stating provider PAR 8/1/2018 PID # 3159807-tisha rader"]
["Michael J Hester, APRN-AGACNP",1275044422,"75-2656723: P","TX","PE - Premier Family Care I, Inc","Aetna","Participating","Enrollment Complete","2018-07-24","1275044422","","2020-02-03","02/03/2020 - Rec'd confirmation from the payer stating this provider is EFF 7-24-2018 under a DIRECT CONTRACT. Next reval in in 2021. - Stacey Hudak"]
["Michael J Hester, APRN-AGACNP",1275044422,"75-2656723: S","TX","PE - Premier Family Care I, Inc","Cigna","Participating","Enrollment Complete","2021-03-31","5803477","","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 \t\n5803477. KFrazier"]
["Michael J Hester, APRN-AGACNP",1275044422,"75-2656723: S","TX","PE - Premier Family Care I, Inc","Cigna","Terminated","Terminated","2019-09-01","5803477","","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"]
["Michael J Hester, APRN-AGACNP",1275044422,"75-2656723: S","TX","PE - Premier Family Care I, Inc","USA PPO","Participating","Enrollment Complete","2018-07-31","1263679","","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"]
["Mini Gopalan, MD",1720060932,"75-2656723","TX","PE - Premier Family Care I, 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"]
["Mini Gopalan, MD",1720060932,"75-2656723","TX","PE - Premier Family Care I, Inc","Caprock (CapStar)","Participating","Enrollment Complete","2016-09-07","1720060932","","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"]
["Mini Gopalan, MD",1720060932,"75-2656723","TX","PE - Premier Family Care I, Inc","Triwest VA","Facility Enrollment","Application Submitted","","","","2022-11-25","08/19/2022 - Submitted application to TriWest VA (sent to Scarlett Abigail, Scarlett_Abigail@bcbstx.com)"]
["Mini Gopalan, MD",1720060932,"75-2656723","TX","PE - Premier Family Care I, Inc","Medicare","Participating","Enrollment Complete","2014-02-01","338891YPVD","0008AH","2020-01-29","01/29/2020 - confirmed EFF through PECOS group enrollment - Stacey Hudak"]
["Mini Gopalan, MD",1720060932,"75-2656723","TX","PE - Premier Family Care I, Inc","Cigna","Participating","Enrollment Complete","2021-04-01","9048323","","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 4/1/2021 and assigned provider ID 9048323. KFrazier"]
["Mini Gopalan, MD",1720060932,"75-2656723","TX","PE - Premier Family Care I, Inc","United Health Care","Participating","Enrollment Complete","2017-10-31","1720060932","","2020-07-30","7/30/2020 - moved to completed status after reviewing follow up complete note - Stacey Hudak"]
["Mini Gopalan, MD",1720060932,"75-2656723","TX","PE - Premier Family Care I, Inc","Cigna","Terminated","Terminated","2013-03-01","1720060932","","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"]
["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 note - Stacey Hudak"]
["Eliseo Rivera, MD",1013990761,"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"]
["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","Scott&White (First Care)","Participating","Enrollment Complete","2018-06-12","1013990761","","2020-08-19","08/19/2020 - Rec'd spreadsheet from the payer confirming this provider is part of the DELEGATED PRIMED AGREEMENT and linked to this TIN/Service Location. This provider is networked with the following: \nFirstCare MyChoice PPO\nCHIP\nFirstCare Select Benefit Network\nHMO Enhanced Benefit Network\nMedicaid (FC)\nMedicare (FC)\nPPO Limited Benefit Network\n- Stacey Hudak"]
["Eliseo Rivera, MD",1013990761,"83-0358685","TX","PE - Midland Community Healthcare Services","Aetna","Participating","Enrollment Complete","2021-06-01","7402267","","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 # 7402267 DCannon"]
["Eliseo Rivera, MD",1013990761,"83-0358685","TX","PE - Midland Community Healthcare Services","Superior","Participating","Enrollment Complete","2017-01-01","1013990761","","2020-07-14","07/14/2020 - Rec'd email from the payer stating this provider is EFF under PRIMED DELEGATED agreement - Stacey Hudak"]
["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","Rail Road Medicare","Participating","Enrollment Complete","2003-12-15","P02452801","DC8592","2020-07-20","07/20/2020 - moved to completed status and uploaded effective info from payer site - 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","Caprock (CapStar)","Participating","Enrollment Complete","2012-03-01","1013990761","","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"]
["Eliseo Rivera, MD",1013990761,"83-0358685","TX","PE - Midland Community Healthcare Services","HealthSmart PPO","Participating","Enrollment Complete","2011-02-01","1013990761","","2020-06-05","06/05/2020 - Rec'd email from the payer stating this provider is EFF - Stacey Hudak"]
["Eliseo Rivera, MD",1013990761,"83-0358685","TX","PE - Midland Community Healthcare Services","Amerigroup","Participating","Enrollment Complete","2014-10-14","","","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 10/14/2014.   DCannon"]
["Eliseo Rivera, MD",1013990761,"83-0358685","TX","PE - Midland Community Healthcare Services","Caprock (CapStar)","Participating","Enrollment Complete","2021-06-01","","","2021-08-06","8/6/2021 Rcvd email from Caprock ProviderServices.T8@90degreebenefits.com that monthly delegated roster provider load is complete and provider is loaded under TIN at location effective 6/1/2021.  DCannon"]
["Eliseo Rivera, MD",1013990761,"83-0358685","TX","PE - Midland Community Healthcare Services","Molina","Participating","Enrollment Complete","2020-07-12","","","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 7/12/2020.  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","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","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","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"]
["Elisa L Brown, MD",1811086986,"83-0358685","TX","PE - Midland Community Healthcare Services","Humana","Participating","Enrollment Complete","2019-08-26","1811086986","","2020-06-30","6/30/2020 - 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"]
["Elisa L Brown, MD",1811086986,"83-0358685","TX","PE - Midland Community Healthcare Services","Humana","Participating","Enrollment Complete","2019-08-26","","","2021-11-18","11/18/2021 Rcvd full roster from Humana listing provider as PAR and linked to group TIN/location effective 8/26/2019.  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","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"]
["Elisa L Brown, MD",1811086986,"83-0358685","TX","PE - Midland Community Healthcare Services","First Health Coventry","Participating","Enrollment Complete","2021-08-28","1110534","","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"]
["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","Cigna","Participating","Enrollment Complete","2019-09-01","7615552","","2020-05-14","05/14/2020 - Rec'd email from the payer stating EFF - Stacey Hudak"]
["Elisa L Brown, MD",1811086986,"83-0358685","TX","PE - Midland Community Healthcare Services","Medicaid","In House Enrollment","In House Enrollment","","","","2021-08-04","8/4/2021 Medicaid enrollment done in-house by MCHS.  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","Caprock (CapStar)","Participating","Enrollment Complete","2021-06-01","","","2021-08-06","8/6/2021 Rcvd email from Caprock ProviderServices.T8@90degreebenefits.com that monthly delegated roster provider load is complete and provider is loaded under TIN at location effective 6/1/2021.  DCannon"]
["Elisa L Brown, MD",1811086986,"83-0358685","TX","PE - Midland Community Healthcare Services","Cigna","Participating","Enrollment Complete","2021-06-01","7615552","","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 7615552. KFrazier"]
["Elisa L Brown, MD",1811086986,"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"]
["Elisa L Brown, MD",1811086986,"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"]
["Elisa L Brown, MD",1811086986,"83-0358685","TX","PE - Midland Community Healthcare Services","TriCare Standard","Participating","Enrollment Complete","2021-12-13","","","2022-02-11","2/11/2022 Per Tricare portal provider is linked to location eff 12.13.2021. Cbankston"]
["Elisa L Brown, MD",1811086986,"83-0358685","TX","PE - Midland Community Healthcare Services","Triwest VA","Participating","In House Enrollment","2022-10-15","","","2021-08-07","7/31/2021 This will be processed by group. KFrazier"]
["Elisa L Brown, MD",1811086986,"83-0358685","TX","PE - Midland Community Healthcare Services","Triwest VA","Participating","Enrollment Complete","2022-10-15","","","2022-10-12","10/12/2022 Per email from Priscilla Albertine at MQA provider is PAR and linked to group TIN/location effective 10/15/2022.  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","Aetna","Participating","Enrollment Complete","2019-10-01","1811086986","","2020-04-23","04/23/2020--S/W Bella of Aetna @ 8003531232, provider NPI is on file for the provider and participating effective 10/01/19 under the group and TIN. Delegated with Midland Community Healthcare Services. Physical location is on file. Provider ID# 7208739. Call ref# 5235911662.\ncopied note from spreadsheet-tisha rader"]
["Elisa L Brown, MD",1811086986,"83-0358685","TX","PE - Midland Community Healthcare Services","Aetna","Participating","Enrollment Complete","2021-06-01","7208739","","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 # 7208739 DCannon"]
["Elisa L Brown, MD",1811086986,"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"]
["Karen Ward, NP-C, CNOR, RNFA",1790831493,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Corvel Healthcare Corp.","Participating","Enrollment Complete","2022-10-31","","","2022-10-31","10/31/2022 Rcvd Corvel approval letter.  Provider is PAR and linked to group TIN/locations effective 10/31/2022.  DCannon"]
["Karen Ward, NP-C, CNOR, RNFA",1790831493,"47-5554737","TX","PE - Midland Inpatient Medical Association","First Health Coventry","Participating","Enrollment Complete","2021-04-01","","","2022-05-24","5/24/2022 Rcvd email from First Health confirming provider is PAR and linked to group TIN/location effective 4/1/2021.  DCannon"]
["Karen Ward, NP-C, CNOR, RNFA",1790831493,"47-5554737","TX","PE - Midland Inpatient Medical Association","Omni PPO","Participating","Enrollment Complete","2021-04-13","","","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 4/13/2021. DCannon"]
["Karen Ward, NP-C, CNOR, RNFA",1790831493,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Alliance WC","Participating","Enrollment Complete","2022-08-26","","","2022-09-07","Received confirmation email with approval letter (attached). MStone"]
["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","Coventry Workers Comp","Participating","Enrollment Complete","2022-08-15","3560602","","2022-11-30","11/30/2022 Per follow-up note - 11.21.2022 S/W Lance of Coventry Workers Comp @ 800-937-6824. Per rep, provider is showing participating with an Effective date 08/15/2022 and link under the Group and TIN. Provider ID 3560602.   Service location is on file. DCannon"]
["Karen Ward, NP-C, CNOR, RNFA",1790831493,"47-5554737","TX","PE - Midland Inpatient Medical Association","Cigna","Participating","Enrollment Complete","2021-05-06","8228233","","2021-05-07","5/7/2021 Received email from discovercigna@information.cigna.com confirming provider has been approved effective 5/6/2021 with assigned provider ID number 8228233. KFrazier"]
["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","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","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","Scott&White (First Care)","Participating","Enrollment Complete","2022-05-01","","","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 5/1/2022.  DCannon"]
["Karen Ward, NP-C, CNOR, RNFA",1790831493,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Scott&White (First Care)","Participating","Enrollment Complete","2022-05-01","","","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 5/1/2022.  DCannon"]
["Karen Ward, NP-C, CNOR, RNFA",1790831493,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Liberty Mutual","Participating","Enrollment Complete","2022-08-15","","","2022-12-15","12/15/2022 Per Coventry WC website provider is PAR in Sedgwick and linked to TIN/locations effective 8/15/2022.  DCannon"]
["Karen Ward, NP-C, CNOR, RNFA",1790831493,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Texas Municipal League","Participating","Enrollment Complete","2022-08-26","","","2022-09-16","9/16/2022 Enrolled through PSWCA provider is PAR and linked to group TIN/locations effective 8/26/2022.  DCannon"]
["Karen Ward, NP-C, CNOR, RNFA",1790831493,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Texas Municipal League","Participating","Enrollment Complete","2022-08-26","","","2022-09-16","9/16/2022 Enrolled through PSWCA provider is PAR and linked to group TIN/locations effective 8/26/2022.  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","","2022-08-10","8/10/2022 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","Triwest VA","In House Enrollment","In House Enrollment","","","","2022-06-13",""]
["Karen Ward, NP-C, CNOR, RNFA",1790831493,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Triwest VA","In House Enrollment","In House Enrollment","","","","2022-06-13",""]
["Karen Ward, NP-C, CNOR, RNFA",1790831493,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Medicare","Participating","Enrollment Complete","2022-05-01","2F3553","423838","2022-08-11","8/11/2022 Per PECOS provider is PAR and linked to group.  PTAN # 2F3553 - effective 5/1/2022.  DCannon"]
["Karen Ward, NP-C, CNOR, RNFA",1790831493,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","United Health Care","Participating","Enrollment Complete","2022-06-01","","","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 6/1/2022.   MPIN# 001163117.   DCannon"]
["Karen Ward, NP-C, CNOR, RNFA",1790831493,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","United Health Care","Participating","Enrollment Complete","2022-06-01","","","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 6/1/2022.   MPIN# 001163117.   DCannon"]
["Karen Ward, NP-C, CNOR, RNFA",1790831493,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Sedgwick","Participating","Enrollment Complete","2022-08-15","","","2022-12-15","12/15/2022 Per Coventry WC website provider is PAR in Sedgwick and linked to TIN/locations effective 8/15/2022.  DCannon"]
["Karen Ward, NP-C, CNOR, RNFA",1790831493,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Sedgwick","Participating","Enrollment Complete","2022-08-15","","","2022-12-15","12/15/2022 Per Coventry WC website provider is PAR in Sedgwick and linked to TIN/locations effective 8/15/2022.  DCannon"]
["Karen Ward, NP-C, CNOR, RNFA",1790831493,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Galaxy Health","Participating","Enrollment Complete","2022-05-01","","","2022-08-17","8/17/2022 Per email from Karen Avalos at Galaxy delegated roster for June is complete and provider is loaded effective 5/1/2022.  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,"47-5554737","TX","PE - Midland Inpatient Medical Association","CAQH","Participating","CAQH Reattested","2023-01-18","","","2023-01-18","1/18/2023 CAQH re-attested.  DCannon"]
["Karen Ward, NP-C, CNOR, RNFA",1790831493,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","USA PPO","Participating","Enrollment Complete","2022-07-01","","","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 7/1/2022.  DCannon"]
["Karen Ward, NP-C, CNOR, RNFA",1790831493,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","USA PPO","Participating","Enrollment Complete","2022-07-01","","","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 7/1/2022.  DCannon"]
["Karen Ward, NP-C, CNOR, RNFA",1790831493,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Aetna","Participating","Enrollment Complete","2022-07-01","5951375","","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 5951375. Physical location is on file. Ref# 6100299498 - Ria Dee Bieren\nDCannon"]
["Karen Ward, NP-C, CNOR, RNFA",1790831493,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Zurich","Participating","Enrollment Complete","2022-08-15","","","2022-12-15","12/15/2022 Per Coventry WC website provider is PAR in Zurich and linked to TIN/locations effective 8/15/2022.  DCannon"]
["Karen Ward, NP-C, CNOR, RNFA",1790831493,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Zurich","Participating","Enrollment Complete","2022-08-15","","","2022-12-15","12/15/2022 Per Coventry WC website provider is PAR in Zurich and linked to TIN/locations effective 8/15/2022.  DCannon"]
["Karen Ward, NP-C, CNOR, RNFA",1790831493,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Multiplan","Participating","Enrollment Complete","2022-05-01","","","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 5/1/2022.  DCannon"]
["Karen Ward, NP-C, CNOR, RNFA",1790831493,"47-5554737","TX","PE - Midland Inpatient Medical Association","Galaxy Health","Participating","Enrollment Complete","2021-04-06","","","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 4/6/2021.  DCannon"]
["Karen Ward, NP-C, CNOR, RNFA",1790831493,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Travelers WC","Participating","Enrollment Complete","2022-08-15","","","2022-12-15","12/15/2022 Per Coventry WC website provider is PAR in Travelers WC and linked to TIN/locations effective 8/15/2022.  DCannon"]
["Karen Ward, NP-C, CNOR, RNFA",1790831493,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Travelers WC","Participating","Enrollment Complete","2022-08-15","","","2022-12-15","12/15/2022 Per Coventry WC website provider is PAR in Travelers WC and linked to TIN/locations effective 8/15/2022.  DCannon"]
["Karen Ward, NP-C, CNOR, RNFA",1790831493,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Gallagher","Participating","Enrollment Complete","2022-08-15","","","2022-12-15","12/15/2022 Per Coventry WC website provider is PAR in Gallagher and linked to TIN/locations effective 8/15/2022.  DCannon"]
["Karen Ward, NP-C, CNOR, RNFA",1790831493,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Boon Chapman","Participating","Enrollment Complete","2022-05-01","","","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 5/1/2022.  DCannon"]
["Karen Ward, NP-C, CNOR, RNFA",1790831493,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Omni PPO","Participating","Enrollment Complete","2022-05-01","","","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 5/1/2022.  DCannon"]
["Karen Ward, NP-C, CNOR, RNFA",1790831493,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Omni PPO","Participating","Enrollment Complete","2022-05-01","","","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 5/1/2022.  DCannon"]
["Karen Ward, NP-C, CNOR, RNFA",1790831493,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","HealthSmart PPO","Participating","Enrollment Complete","2022-07-01","","","2022-08-10","8/10/2022 Per Healthsmart website provider is PAR and loaded under TIN/location effective 7/1/2022.  DCannon"]
["Karen Ward, NP-C, CNOR, RNFA",1790831493,"47-5554737","TX","PE - Midland Inpatient Medical Association","Aetna","Participating","Enrollment Complete","2021-04-15","5951375","","2021-07-01","7/1/2021 Per Aetna roster received from Jamie Roberts provider is PAR and linked to TIN/locations effective 4/15/2021.  DCannon"]
["Karen Ward, NP-C, CNOR, RNFA",1790831493,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","TriCare Standard","Participating","Enrollment Complete","2022-06-23","","","2022-08-10","8/10/2022 Per Tricare portal provider is PAR and linked to group TIN/locations effective 6/23/2022.  DCannon"]
["Karen Ward, NP-C, CNOR, RNFA",1790831493,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","TriCare Standard","Participating","Enrollment Complete","2022-06-23","","","2022-08-10","8/10/2022 Per Tricare portal provider is PAR and linked to group TIN/locations effective 6/23/2022.  DCannon"]
["Karen Ward, NP-C, CNOR, RNFA",1790831493,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","IMS","Participating","Enrollment Complete","2022-05-01","","","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 5/1/2022.  DCannon"]
["Karen Ward, NP-C, CNOR, RNFA",1790831493,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Cigna","Participating","Enrollment Complete","2022-09-01","","","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 09/01/2022 under the group and TIN. Provider ID# 8228233. Physical location is on file.  DCannon"]
["Karen Ward, NP-C, CNOR, RNFA",1790831493,"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"]
["Karen Ward, NP-C, CNOR, RNFA",1790831493,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Tricare Prime","Participating","Enrollment Complete","2022-06-23","","","2022-08-10","8/10/2022 Per Tricare portal provider is PAR and linked to group TIN/locations effective 6/23/2022.  DCannon"]
["Karen Ward, NP-C, CNOR, RNFA",1790831493,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Tricare Prime","Participating","Enrollment Complete","2022-06-23","","","2022-08-10","8/10/2022 Per Tricare portal provider is PAR and linked to group TIN/locations effective 6/23/2022.  DCannon"]
["Karen Ward, NP-C, CNOR, RNFA",1790831493,"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"]
["Karen Ward, NP-C, CNOR, RNFA",1790831493,"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"]
["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","Triwest VA","In Process","Application Submitted","","","","","08/19/2022 - Submitted application to TriWest VA (sent to Scarlett Abigail, Scarlett_Abigail@bcbstx.com)"]
["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","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","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"]
["Nanette R Paredes, PA-C",1437175163,"75-2656723","TX","PE - Premier Family Care I, Inc","HealthSmart PPO","Participating","Enrollment Complete","2018-11-27","1437175163","","2020-06-05","06/05/2020 - Rec'd email from the payer stating this provider is EFF - Stacey Hudak"]
["Nanette R Paredes, PA-C",1437175163,"75-2656723","TX","","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"]
["Nanette R Paredes, PA-C",1437175163,"75-2656723","TX","PE - Premier Family Care I, Inc","Triwest VA","Facility Enrollment","Application Submitted","","","","2022-11-28","08/19/2022 - Submitted application to TriWest VA (sent to Scarlett Abigail, Scarlett_Abigail@bcbstx.com)"]
["Nanette R Paredes, PA-C",1437175163,"75-2656723","TX","PE - Premier Family Care I, Inc","CAQH","Participating","CAQH Reattested","2023-02-12","12235547","","2023-02-12","2/12/2023 CAQH reviewed and re-attested.  DCannon"]
["Nanette R Paredes, PA-C",1437175163,"75-2656723","TX","PE - Premier Family Care I, Inc","Scott&White (First Care)","Participating","Enrollment Complete","2019-01-17","","","2021-01-29","1/29/2021 - Rcvd roster from Scott&White (First Care) confirming participation of provider with TIN and location effective dates.  DCannon"]
["Nanette R Paredes, PA-C",1437175163,"75-2656723","TX","PE - Premier Family Care I, Inc","IMS","Participating","Enrollment Complete","2018-11-30","1437175163","","2020-06-22","06/22/2020- Rec'd email from the payer confirming this provider is PAR with this group/service location - Stacey Hudak"]
["Nanette R Paredes, PA-C",1437175163,"75-2656723","TX","PE - Premier Family Care I, Inc","Medicare","Participating","Enrollment Complete","2018-09-01","716134","0008AH","2020-03-10","03/10/2020 - Signed into PECOS and confirmed that this provider is linked to Premier Family Care as an employee EFF 9-1-2018 - Stacey Hudak"]
["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","","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","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","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"]
["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","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","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","","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","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","","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","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"]
["Johnny L Flitton, PA-C",1437356730,"75-2656723","TX","PE - Premier Family Care I, Inc","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"]
["Johnny L Flitton, PA-C",1437356730,"75-2656723","TX","PE - Premier Family Care I, 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 I, Inc","Rail Road Medicare","Participating","Enrollment Complete","2008-11-10","P02124313","CE1588","2021-11-18","11/18/2021 Received RR Medicare PTAN approval letter instantly.  PTAN # P02124313 - effective 11/10/2008.  DCannon"]
["Johnny L Flitton, PA-C",1437356730,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Zurich","Participating","Enrollment Complete","2019-09-01","","","2021-08-06","8/6/2021 Moved to enrollment complete per notes from First Health/Coventry. Provider is effective 9/1/2019. KFrazier"]
["Johnny L Flitton, PA-C",1437356730,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Galaxy Health","Participating","Enrollment Complete","2019-09-01","1437356730","","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"]
["Johnny L Flitton, PA-C",1437356730,"75-2656723","TX","PE - Premier Family Care I, Inc","Aetna","Participating","Enrollment Complete","2014-02-15"," 9326179","","2021-12-03","12/3/2021 Per f/u note:  S/W Mark of Aetna @ 800-353-1232. advised app sent on 11/15/2021 with Request ID is 00072104. Rep stated, Provider NPI# is on file for the provider and is participating effective 02/15/2014 under the group and TIN#. PIN: 9326179. Physical location is on file. Call ref# 6060911105.  DCannon"]
["Johnny L Flitton, PA-C",1437356730,"75-2656723","TX","PE - Premier Family Care I, Inc","USA PPO","Participating","Enrollment Complete","2015-09-03","1098037","","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"]
["Johnny L Flitton, PA-C",1437356730,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","HealthSmart PPO","Participating","Enrollment Complete","2019-07-18","","","2021-01-27","1/27/2021 - Rcvd confirmation email that provider is participating and linked to location and TIN effective 7/18/2019.  DCannon"]
["Johnny L Flitton, PA-C",1437356730,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Cigna","Participating","Enrollment Complete","2016-06-01","1437356730","47-3465832","2020-06-16","06/16/2020 - CIGNA has an ancillary contract in place for this WesTex Urgent Care (as an urgent care center) that's EFF 6-1-2016.\nPer payer, each provider does not need to be credentialed as long as the facility and service location is on file. I confirmed that all service locations are linked to group contract (1941 E 37th St, 210 W Longview Ave & 3401 Gerenbriar Ste 200) - Stacey Hudak"]
["Johnny L Flitton, PA-C",1437356730,"75-2656723","TX","PE - Premier Family Care I, Inc","HealthSmart PPO","Participating","Enrollment Complete","2021-11-01","","","2021-12-30","12/30/2021 Per Healthsmart website provider is PAR and loaded under TIN/location effective 11/1/2021.  DCannon"]
["Johnny L Flitton, PA-C",1437356730,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","USA PPO","Participating","Enrollment Complete","2015-09-03","1098037","","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"]
["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,"75-2656723","TX","PE - Premier Family Care I, Inc","Medicare","Participating","Enrollment Complete","2008-11-10","8L9009","0008AH","2021-11-18","11/18/2021 Per PECOS provider is PAR and linked to group/location.  PTAN # 8L9009 - effective 11/10/2008.  DCannon"]
["Johnny L Flitton, PA-C",1437356730,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Galaxy Health","Participating","Enrollment Complete","2019-09-01","1437356730","","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"]
["Johnny L Flitton, PA-C",1437356730,"75-2656723","TX","PE - Premier Family Care I, 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"]
["Johnny L Flitton, PA-C",1437356730,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","TriCare Standard","Participating","Enrollment Complete","2018-06-29","1437356730","","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"]
["Johnny L Flitton, PA-C",1437356730,"75-2656723","TX","PE - Premier Family Care I, Inc","Amerigroup","Participating","Enrollment Complete","2020-04-03","","","2021-03-15","3/15/2021 - Per online verification of Amerigroup provider directory provider is participating at location.  Sending email to payor to obtain effective date.  DCannon"]
["Johnny L Flitton, PA-C",1437356730,"75-2656723","TX","PE - Premier Family Care I, 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"]
["Johnny L Flitton, PA-C",1437356730,"75-2656723","TX","PE - Premier Family Care I, Inc","TriCare Standard","Participating","Enrollment Complete","","","","2022-02-13","2/13/2022 Per Tricare portal, provider is linked to location as of 12.14.2022. Cbankston"]
["Johnny L Flitton, PA-C",1437356730,"75-2656723","TX","PE - Premier Family Care I, Inc","Galaxy Health","Participating","Enrollment Complete","2015-02-16","1437356730","","2020-07-10","07/10/2020 - updated payer line to enrollment complete status instead of \"Delegated status\" for report running purposes - Stacey Hudak"]
["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","First Health Coventry","Participating","Enrollment Complete","2015-09-01","","","2020-10-30","\"10/30/2020-S/W Amanda of First Health/Coventry @ 800-937-6824, As per rep provider is in network and participating to the group and TIN# effective 09/01/2015, Physical location is on file,\ncall ref# 5701278- Rafael Calixtro\""]
["Johnny L Flitton, PA-C",1437356730,"75-2656723","TX","PE - Premier Family Care I, Inc","Omni PPO","Participating","Enrollment Complete","2015-02-16","1437356730","","2020-06-25",""]
["Johnny L Flitton, PA-C",1437356730,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","United Health Care","Participating","Enrollment Complete","2020-06-02","2854139","","2020-06-09","06/09/2020 - Rec'd email from the payer stating this provider/service location are EFF - Stacey Hudak"]
["Johnny L Flitton, PA-C",1437356730,"75-2656723","TX","","Triwest VA","Facility Enrollment","Application Submitted","","","","2022-11-23","08/19/2022 - Submitted application to TriWest VA (sent to Scarlett Abigail, Scarlett_Abigail@bcbstx.com)"]
["Johnny L Flitton, PA-C",1437356730,"75-2656723","TX","PE - Premier Family Care I, 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"]
["Johnny L Flitton, PA-C",1437356730,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Galaxy Health","Participating","Enrollment Complete","2019-09-01","1437356730","","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"]
["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","Medicaid","Participating","Enrollment Complete","2020-10-11","189374504","364596201","2021-05-20","5/20/2021 Confirmed via TMHP portal, provider is participating with a new revalidation due date of 3/1/2022. KFrazier"]
["Allen E Gibson, MD",1912068446,"47-5554737","TX","PE - Midland Inpatient Medical Association","Galaxy Health","Participating","Enrollment Complete","2019-09-01","1912068446","","2020-08-21",""]
["Allen E Gibson, MD",1912068446,"47-5554737","TX","PE - Midland Inpatient Medical Association","USA PPO","Participating","Enrollment Complete","2021-01-26","1087929","","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"]
["Allen E Gibson, MD",1912068446,"47-5554737","TX","PE - Midland Inpatient Medical Association","United Health Care","Participating","Enrollment Complete","2010-09-30","1912068446","","2020-07-30","7/30/2020 - moved to completed status after reviewing follow up complete note - Stacey Hudak"]
["Allen E Gibson, MD",1912068446,"47-5554737","TX","PE - Midland Inpatient Medical Association","Medicare","Participating","Enrollment Complete","2016-08-02","334655ZV0W","519061","2020-04-20","04/20/2020 - confirmed provider is EFF and linked through group PECOS enrollment - Stacey Hudak"]
["Gerardo M Catalasan, MD",1760501720,"75-2656723","TX","","CAQH","Participating","CAQH Reattested","2023-03-10","13752595","","2023-03-10","3/10/2023 CAQH reviewed and re-attested.  DCannon"]
["Gerardo M Catalasan, MD",1760501720,"75-2656723","TX","PE - Premier Family Care I, Inc","Aetna","Participating","Enrollment Complete","2020-12-01","","","2020-11-07","11/6/2020 Received email from ProviderCommunications@aetna.cpe.messages2.com confirming provider is participating under group Tax ID effective 12/1/2020 and assigned PIN number 9631791. Kimberly Frazier"]
["Gerardo M Catalasan, MD",1760501720,"75-2656723","TX","","Aetna","Participating","Enrollment Complete","2020-12-01","","","2020-11-07","11/6/2020 Received email from ProviderCommunications@aetna.cpe.messages2.com confirming provider is participating under group Tax ID effective 12/1/2020 and assigned PIN number 9631791. Kimberly Frazier"]
["Gerardo M Catalasan, MD",1760501720,"75-2656723","TX","PE - Premier Family Care I, Inc","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","","Medicaid","Participating","Enrollment Complete","2020-03-29","194527101","079837301","2020-08-13","8/13/2020 - confirmed that this provider is now affiliated with the proper service location through TMHP portal - Stacey Hudak"]
["Gerardo M Catalasan, MD",1760501720,"75-2656723","TX","","Omni PPO","Participating","Enrollment Complete","2008-05-13","1760501720","","2020-06-25",""]
["Gerardo M Catalasan, MD",1760501720,"75-2656723","TX","PE - Premier Family Care I, 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"]
["Gerardo M Catalasan, MD",1760501720,"75-2656723","TX","","Amerigroup","Participating","Enrollment Complete","2012-03-01","1760501720","","2020-02-11","2/11/2020 – Received Roster from Amerigroup and provider is now PAR- Additional effective dates on roster are:\n11/1/16,  8/1/12,  1/1/20, and 1/1/17---Tisha Rader"]
["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","PE - Premier Family Care I, Inc","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.\""]
["Gerardo M Catalasan, MD",1760501720,"75-2656723","TX","","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.\""]
["Gerardo M Catalasan, MD",1760501720,"75-2656723","TX","PE - Premier Family Care I, Inc","First Health Coventry","Participating","Enrollment Complete","2008-09-01","1901802","","2020-03-20","3/20/2020-receieved email with roster stating provider PAR 9/1/2008 PID # 1901802\ntisha rader"]
["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","","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","","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","","Galaxy Health","Participating","Enrollment Complete","2014-05-12","1760501720","","2020-07-10","07/10/2020 - updated payer line to enrollment complete status instead of \"Delegated status\" for report running purposes - Stacey Hudak"]
["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"]
["Nikolay A Azarov, MD",1093937948,"75-2656723: P","TX","PE - Premier Family Care I, Inc","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: P","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","PE - Premier Family Care I, Inc","Rail Road Medicare","Participating","Enrollment Complete","2008-11-01","P00716501","","","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: S","TX","","Galaxy Health","Participating","Enrollment Complete","2019-09-01","1093937948","","2020-08-21",""]
["Nikolay A Azarov, MD",1093937948,"75-2656723: S","TX","PE - Premier Family Care I, 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","","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: P","TX","PE - Premier Family Care I, Inc","Aetna","Participating","Enrollment Complete","2010-01-01","1093937948","","2020-01-28","01/28/2020 - called aetna at 800-353-1232 and spoke with Ali who confirmed that this provider has a direct contract with Aetna EFF 1-1-2010.  (REF# 5062575195) - Stacey Hudak"]
["Nikolay A Azarov, MD",1093937948,"75-2656723: S","TX","","Scott&White (First Care)","Participating","Enrollment Complete","2018-12-01","1093937948","","2020-10-02","10/2/2020 - moved to completed status after reviewing follow up complete note - Stacey Hudak"]
["Nikolay A Azarov, MD",1093937948,"75-2656723: S","TX","PE - Premier Family Care I, Inc","TriCare Standard","Participating","Enrollment Complete","2020-10-22","","","2020-11-17","11/17/2020 - Checked the Humana-Military website provider credentialing is completed effective 10/22/20.  DCannon"]
["Nikolay A Azarov, MD",1093937948,"75-2656723: S","TX","","TriCare Standard","Participating","Enrollment Complete","2020-10-22","","","2020-11-17","11/17/2020 - Checked the Humana-Military website provider credentialing is completed effective 10/22/20.  DCannon"]
["Nikolay A Azarov, MD",1093937948,"75-2656723: S","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"]
["Nikolay A Azarov, MD",1093937948,"75-2656723: S","TX","PE - Premier Family Care I, Inc","Multiplan","Delegated - Third Party","Delegated - Third Party","2018-06-07","1093937948","Permian Basin Healthcare Network","2020-09-24","09/24/2020 - moved to enrollment complete. Networked with: Multiplan/PHCS/BeechStreet\nunder  delegated group, Permian Basin Health.   - Stacey Hudak"]
["Nikolay A Azarov, MD",1093937948,"75-2656723: P","TX","","Triwest VA","Facility Enrollment","Application Submitted","","","","2022-11-28","08/19/2022 - Submitted application to TriWest VA (sent to Scarlett Abigail, Scarlett_Abigail@bcbstx.com)"]
["Nikolay A Azarov, MD",1093937948,"75-2656723: P","TX","PE - Premier Family Care I, Inc","Triwest VA","Facility 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.\""]
["Nikolay A Azarov, MD",1093937948,"75-2656723: S","TX","PE - Premier Family Care I, Inc","Triwest VA","Facility Enrollment","Facility Enrollment","","","","","10/17/2022 - Received roster from Scarlett; provider status: \"No Action.  TIN is CCN participating under own DCN.\""]
["Nikolay A Azarov, MD",1093937948,"75-2656723: S","TX","","Triwest VA","Facility Enrollment","Application Submitted","","","","","08/19/2022 - Submitted application to TriWest VA (sent to Scarlett Abigail, Scarlett_Abigail@bcbstx.com)"]
["Nikolay A Azarov, MD",1093937948,"75-2656723: P","TX","PE - Premier Family Care I, Inc","Sedgwick","Participating","Enrollment Complete","2009-10-23","","","2020-09-09","Confirmed provider is participating with WIN networks, which includes this payor (list of networks attached). Kimberly Frazier"]
["Nikolay A Azarov, MD",1093937948,"75-2656723: P","TX","","Sedgwick","Participating","Enrollment Complete","2009-10-23","","","2020-09-09","Confirmed provider is participating with WIN networks, which includes this payor (list of networks attached). Kimberly Frazier"]
["Nikolay A Azarov, MD",1093937948,"75-2656723: S","TX","PE - Premier Family Care I, Inc","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: P","TX","","Medicare","Participating","Enrollment Complete","2008-11-01","8L6420","0008AH","2020-01-29","01/29/2020 - confirmed EFF through PECOS group enrollment - Stacey Hudak"]
["Nikolay A Azarov, MD",1093937948,"75-2656723: S","TX","PE - Premier Family Care I, 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","","TriCare Standard","Participating","Enrollment Complete","2020-10-22","","","2020-11-17","11/17/2020 - Checked the Humana-Military website provider credentialing is completed effective 10/22/20.  DCannon"]
["Nikolay A Azarov, MD",1093937948,"75-2656723: P","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."]
["Nikolay A Azarov, MD",1093937948,"75-2656723: S","TX","PE - Premier Family Care I, Inc","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"]
["Nikolay A Azarov, MD",1093937948,"75-2656723: S","TX","","Liberty Mutual","Participating","Enrollment Complete","2009-10-23","","","2020-09-09","Confirmed provider is participating with WIN networks, which includes this payor (list of networks attached). Kimberly Frazier"]
["Nikolay A Azarov, MD",1093937948,"75-2656723: S","TX","PE - Premier Family Care I, Inc","Sedgwick","Participating","Enrollment Complete","2009-10-23","","","2020-09-09","Confirmed provider is participating with WIN networks, which includes this payor (list of networks attached). Kimberly Frazier"]
["Nikolay A Azarov, MD",1093937948,"75-2656723: P","TX","","Medicaid","Participating","Enrollment Complete","2008-11-01","194906703","079837301","2021-02-08","2/8/2021 - Per f/u notes provider is participating at location  and under TIN effective 11/1/2008 TIP # 194906703.  DCannon"]
["Jeffrey Limbacher, PA-C",1376723361,"75-2656723","TX","PE - Premier Family Care I, 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","","Humana","Participating","Enrollment Complete","2020-01-01","1376723361","","2020-07-17","7/17/2020 - 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"]
["Jeffrey Limbacher, PA-C",1376723361,"75-2656723","TX","PE - Premier Family Care I, 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"]
["Jeffrey Limbacher, PA-C",1376723361,"75-2656723","TX","","Triwest VA","Facility Enrollment","Application Submitted","","","","2022-11-23","08/19/2022 - Submitted application to TriWest VA (sent to Scarlett Abigail, Scarlett_Abigail@bcbstx.com)"]
["Jeffrey Limbacher, PA-C",1376723361,"75-2656723","TX","PE - Premier Family Care I, 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","","TriCare Standard","Participating","Enrollment Complete","2018-11-30","1376723361","","2020-03-03","03/03/2020 - Rec'd confirmation of provider enrollment through payer portal.  - Stacey Hudak"]
["Jeffrey Limbacher, PA-C",1376723361,"75-2656723","TX","PE - Premier Family Care I, Inc","CAQH","Participating","CAQH Reattested","2022-08-24","13780299","","2022-11-26","11/26/2022 CAQH reviewed and re-attested.  DCannon"]
["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","PE - Premier Family Care I, Inc","Medicaid","Participating","Enrollment Complete","2017-02-01","190978001","079837301","2021-02-08","2/8/2021 - Per f/u notes provider is participating at location  and under TIN effective 2/1/2017 TIP # 190978001.  DCannon"]
["Jeffrey Limbacher, PA-C",1376723361,"75-2656723","TX","","Ambetter","Participating","Enrollment Complete","2022-04-01","","","2022-06-13","6/13/2022 Per roster received from Superior provider is PAR for Ambetter product and linked to group delegation roster effective 4/1/2022."]
["Jeffrey Limbacher, PA-C",1376723361,"75-2656723","TX","PE - Premier Family Care I, Inc","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","","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"]
["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","","Triwest VA","In Process","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","Triwest VA","In Process","Application Submitted","","","","","08/19/2022 - Submitted application to TriWest VA (sent to Scarlett Abigail, Scarlett_Abigail@bcbstx.com)"]
["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","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","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"]
["Ajay K Vaikuntam, MD",1447415476,"47-5554737","TX","PE - Midland Inpatient Medical Association","HealthSmart PPO","Participating","Enrollment Complete","2020-04-15","","","2021-12-03","12/3/2021 Per Healthsmart website provider is PAR and loaded under TIN/location effective 4/15/2020.  DCannon"]
["Ajay K Vaikuntam, MD",1447415476,"47-5554737","TX","PE - Midland Inpatient Medical Association","Triwest VA","Enrollment Stopped","Enrollment Stopped","","","","2022-12-05","Practice is hospital-based; not eligible for TriWest VA enrollment"]
["Ajay K Vaikuntam, MD",1447415476,"47-5554737","TX","PE - Midland Inpatient Medical Association","Multiplan","Participating","Enrollment Complete","2020-04-15","","","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 4/15/2020.   DCannon"]
["Ajay K Vaikuntam, MD",1447415476,"47-5554737","TX","PE - Midland Inpatient Medical Association","IMS","Participating","Enrollment Complete","2019-09-01","1447415476","","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"]
["Ajay K Vaikuntam, MD",1447415476,"47-5554737","TX","PE - Midland Inpatient Medical Association","Amerigroup","Participating","Enrollment Complete","2018-05-01","1447415476","","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"]
["Wayne L Sager, MD",1225182314,"75-2133441","TX","PE - Midland Pediatric Associates, PLLC","Caprock (CapStar)","Participating","Enrollment Complete","2012-04-01","1225182314","","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"]
["Wayne L Sager, MD",1225182314,"75-2133441","TX","PE - Midland Pediatric Associates, PLLC","CAQH","Participating","CAQH Reattested","2022-12-29","11035862","","2022-12-29","12/29/2022 CAQH re-attested.  DCannon"]
["Wayne L Sager, MD",1225182314,"75-2133441","TX","PE - Midland Pediatric Associates, PLLC","Galaxy Health","Participating","Enrollment Complete","2014-11-04","1225182314","","2020-07-17","7/17/2020 - Received a spreadsheet from the payer stating this provider is effective as of 11/4/2014. - Jesriel Segovia"]
["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"]
["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","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","Omni PPO","Participating","Enrollment Complete","2019-01-21","1194813709","","2020-06-25",""]
["Adriana E Nur, MD",1619982584,752656723,"TX","PE - Premier Family Care I, 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","PE - Premier Family Care I, Inc","Medicaid","Participating","Enrollment Complete","2020-08-09","1877169102","079837301","2020-11-23","11/23/2020 Received email confirmation revalidation is complete for provider and confirmed next revalidation date for this TPI is 8/9/2025. Kimberly Frazier"]
["Adriana E Nur, MD",1619982584,"75-2656723","TX","PE - Premier Family Care I, 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."]
["Adriana E Nur, MD",1619982584,"47-5554737","TX","PE - Midland Inpatient Medical Association","Caprock (CapStar)","Participating","Enrollment Complete","2020-03-01","1619982584","","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"]
["Adriana E Nur, MD",1619982584,"47-5554737","TX","PE - Midland Inpatient Medical Association","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,"47-5554737","TX","PE - Midland Inpatient Medical Association","Galaxy Health","Participating","Enrollment Complete","2019-09-01","1619982584","","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"]
["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,"75-2656723","TX","PE - Premier Family Care I, Inc","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","PE - Premier Family Care I, Inc","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,"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"]
["Adriana E Nur, MD",1619982584,"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."]
["Staton Awtrey, MD",1376556019,"75-2656723 : P","TX","PE - Premier Family Care I, 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: S","TX","PE - Premier Family Care I, Inc","Omni PPO","Participating","Enrollment Complete","2019-09-01","1376556019","","2020-07-27","IMS completed"]
["Staton Awtrey, MD",1376556019,"75-2656723: S","TX","PE - Premier Family Care I, Inc","Medicaid","Participating","Enrollment Complete","2009-12-07","147713503","079837301","2020-01-20","01/20/2020 - Logged into TMHP and verified this provider to be currently EFF and linked to: SUPERIOR - FOSTER CARE, Superior HealthPlan - Lubbock, Superior HealthPlan - Lubbock, TRADITIONAL MEDICAID, Superior Health Plan - Lubbock, Superior Health Plan - MRSA West, Superior HealthPlan - MRSA West, Superior Health Plan - MRSA West under our group.  - Stacey Hudak"]
["Staton Awtrey, MD",1376556019,"75-2656723 : P","TX","PE - Premier Family Care I, Inc","Caprock (CapStar)","Participating","Enrollment Complete","2012-03-01","1376556019","","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"]
["Staton Awtrey, MD",1376556019,"75-2656723 : P","TX","PE - Premier Family Care I, 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: S","TX","PE - Premier Family Care I, Inc","Aetna","Participating","Enrollment Complete","2011-09-01","1376556019","","2020-06-09","06/09/2020 - SW Ally of Aetna @ 8003531232. Provider NPI# is on file and in-network participating under the group and TIN#  9/1/2011. Location is on file. Call ref# 5309993264. - Stacey Hudak\n\n**DIRECT CONTRACTED"]
["Staton Awtrey, MD",1376556019,"75-2656723 : P","TX","PE - Premier Family Care I, Inc","Galaxy Health","Participating","Enrollment Complete","2011-09-01","1376556019","","2020-07-10","07/10/2020 - updated payer line to enrollment complete status instead of \"Delegated status\" for report running purposes - Stacey Hudak"]
["Staton Awtrey, MD",1376556019,"75-2656723: S","TX","PE - Premier Family Care I, 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"]
["Staton Awtrey, MD",1376556019,"75-2656723: S","TX","PE - Premier Family Care I, Inc","BCBSTX","Participating","In House Enrollment","","","","2020-06-22","06/22/2020 - this enrollment is not performed by Symplr. Midland performs this in-house - Stacey Hudak"]
["Staton Awtrey, MD",1376556019,"75-2656723: S","TX","PE - Premier Family Care I, Inc","Multiplan","Delegated - Third Party","Enrollment Complete","2016-05-05","1376556019","West Texas Physicians Alliance","2020-09-28","09/28/2020 - Rec'd roster stating this provider is linked to West Texas Physicians Alliance\n as of 5-10-2016. Provider is networked with Multiplan/PHCS/BeechStreet  - Stacey Hudak"]
["Staton Awtrey, MD",1376556019,"75-2656723 : P","TX","PE - Premier Family Care I, Inc","Multiplan","Delegated - Third Party","Delegated - Third Party","2016-05-10","1376556019","52669: West Texas Physicians Alliance Group Cntrct","2020-02-13","02/13/2020 - Rec'd roster stating this provider is linked to West Texas Physicians Alliance\n as of 5-10-2016. Provider is networked with Multiplan/PHCS/BeechStreet  - Stacey Hudak"]
["Staton Awtrey, MD",1376556019,"75-2656723 : P","TX","PE - Premier Family Care I, 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"]
["Juan C Gil, MD",1558392779,"47-5554737","TX","PE - Midland Inpatient Medical Association","Aetna","Participating","Enrollment Complete","2020-09-01","9872306","","2021-01-27","1/27/2021 - Per follow-up notes provider's NPI is online and is participating at location and TIN.   PID 9872306 effective 9/1/2020.  DCannon"]
["Juan C Gil, MD",1558392779,"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"]
["Juan C Gil, MD",1558392779,"75-2656723","TX","PE - Premier Family Care I, Inc","Amerigroup","Participating","Enrollment Complete","2020-06-29","1558392779","","2020-07-09","07/09/2020 - Rec'd welcome letter stating this provider is EFF with amerigroup STAR, STAR PLUS, Star Kids products through Texas True Choice - Stacey Hudak"]
["Juan C Gil, MD",1558392779,"75-2656723","TX","PE - Premier Family Care I, Inc","TriCare Standard","Participating","Enrollment Complete","2018-11-30","1558392779","","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"]
["Juan C Gil, MD",1558392779,"75-2656723","TX","PE - Premier Family Care I, Inc","Caprock (CapStar)","Participating","Enrollment Complete","2012-01-01","1558392779","","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"]
["Juan C Gil, MD",1558392779,"75-2656723","TX","PE - Premier Family Care I, Inc","Triwest VA","Facility Enrollment","Application Submitted","","","","2022-11-23","08/19/2022 - Submitted application to TriWest VA (sent to Scarlett Abigail, Scarlett_Abigail@bcbstx.com)"]
["Juan C Gil, MD",1558392779,"75-2656723","TX","","Triwest VA","Facility Enrollment","Application Submitted","","","","2022-11-23","08/19/2022 - Submitted application to TriWest VA (sent to Scarlett Abigail, Scarlett_Abigail@bcbstx.com)"]
["Juan C Gil, MD",1558392779,"75-2656723","TX","PE - Premier Family Care I, Inc","Omni PPO","Participating","Enrollment Complete","2010-02-26","1558392779","","2020-08-13","IMS Complete"]
["Juan C Gil, MD",1558392779,"47-5554737","TX","PE - Midland Inpatient Medical Association","Omni PPO","Participating","Enrollment Complete","2020-07-20","","","2020-08-25","Confirmed provider is participating under delegation effective 7/20/2020. Kimberly Frazier"]
["Juan C Gil, MD",1558392779,"47-5554737","TX","PE - Midland Inpatient Medical Association","TriCare Standard","In Process","Payor Follow Up","","","","2022-12-28","12/28/2022 Per Tricare portal, provider is not yet linked to location. Submitted another request to link provider to group TIN. DCannon"]
["Juan C Gil, MD",1558392779,"47-5554737","TX","PE - Midland Inpatient Medical Association","United Health Care","Participating","Enrollment Complete","2020-07-31","1558392779","","2020-08-19","8/19/2020 - Rec'd email from the payer stating this provider is EFF \"Good news! We’ve completed the provider/group updates you requested on Jul 31, 2020 8:19:00 AM. Your request was assigned reference number PR-5414535\" - Stacey Hudak"]
["Juan C Gil, MD",1558392779,"75-2656723","TX","PE - Premier Family Care I, Inc","Superior","Participating","Enrollment Complete","2017-01-01","1558392779","","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"]
["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","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","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","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","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","","Triwest VA","In Process","Application Submitted","","","","","08/19/2022 - Submitted application to TriWest VA (sent to Scarlett Abigail, Scarlett_Abigail@bcbstx.com)"]
["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","Omni PPO","Participating","Enrollment Complete","2019-09-01","1174846364","","2020-07-27","IMS complete"]
["Franklin J Dzida, MD",1043270085,"46-3131679","TX","PE - Midland Texas Orthopedic Group Inc","Humana","Participating","Enrollment Complete","2020-01-01","1043270085","","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"]
["Franklin J Dzida, MD",1043270085,"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"]
["Franklin J Dzida, MD",1043270085,"46-3131679","TX","PE - Midland Texas Orthopedic Group Inc","Superior","Participating","Enrollment Complete","2019-10-01","","","2021-02-02","2/2/2021 - Rcvd confirmation from payer that provider is participating and linked to TIN effective 12/1/2020.  DCannon"]
["Franklin J Dzida, MD",1043270085,"46-3131679","TX","PE - Midland Texas Orthopedic Group Inc","Cigna","Participating","Enrollment Complete","2017-01-01","1043270085","","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 1-1-2017 under a DIRECT CONTRACT at this service location. - Stacey Hudak"]
["Franklin J Dzida, MD",1043270085,"46-3131679","TX","PE - Midland Texas Orthopedic Group Inc","Medicaid","Participating","Enrollment Complete","2017-01-01","040735505","3310906-01","2020-02-18","02/18/2020 - Rec'd letter from the payer denying my app submission stating \"Our records indicate your already enrolled into the enrolling group's TPI XXXX906-01 with the same\nphysical address and Medicare ID. Your TPI XXXX355-05 is not due for a Re-Validation until March\n30, 2021.\"\n\nThis provider is already enrolled with Medicaid. - Stacey Hudak"]
["Franklin J Dzida, MD",1043270085,"46-3131679","TX","PE - Midland Texas Orthopedic Group Inc","CAQH","Participating","CAQH Reattested","2023-02-12","","","2023-02-12","2/12/2023 CAQH reviewed and re-attested.  DCannon"]
["Franklin J Dzida, MD",1043270085,"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"]
["Michael P Wolbert, MD",1881711778,"75-2781652","TX","","TriCare Standard","Participating","Enrollment Complete","2022-12-13","","","2022-12-28","12/28/2022 Per Humana Military/Tricare portal provider is PAR and linked to group TIN effective 12/13/2022.  DCannon"]
["Michael P Wolbert, MD",1881711778,"75-2781652","TX","PE - West Texas Allergy, PA","Humana","Participating","Enrollment Complete","2017-05-01","1881711778","","2020-09-24","09/24/2020 - moved to completed status after reviewing follow up complete note - Stacey Hudak"]
["Michael P Wolbert, MD",1881711778,"87-1671535","TX","","Scott&White (First Care)","Participating","Enrollment Complete","2022-08-01","","","2022-08-01","8/1/2022 Received email from Scott & White HPDELEGATION@BSWHealth.org that provider load from August has been completed and provider is PAR effective 8/1/2022.  DCannon"]
["Michael P Wolbert, MD",1881711778,"","TX","PE - West Texas Allergy, Lubbock, PLLC","Ambetter","Participating","Enrollment Complete","2022-07-01","","","2022-07-07","7/7/2022 Received July Monthly Validation roster from Superior and provider is PAR and linked effective 7/1/2022.  DCannon"]
["Michael P Wolbert, MD",1881711778,"","TX","","Humana","Participating","Enrollment Complete","2021-08-01","","","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","HealthSmart PPO","Participating","Enrollment Complete","2021-08-02","","","2021-10-06","10/6/2021 Per Healthsmart website provider is PAR and loaded under TIN/location effective 8/2/2021.  DCannon"]
["Michael P Wolbert, MD",1881711778,"75-2781652","TX","","IMS","Participating","Enrollment Complete","2010-07-14","1881711778","","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 P Wolbert, MD",1881711778,"75-2781652","TX","","Amerigroup","Participating","Enrollment Complete","2020-04-15","","","2021-10-21","10/21/2021  Rcvd full roster from Joe Rodriguez at Amerigroup listing provider as PAR w/ group TIN and location effective 4/15/2020.  DCannon"]
["Michael P Wolbert, MD",1881711778,"75-2781652","TX","PE - West Texas Allergy, PA","Medicaid","Participating","In House Enrollment","2010-07-25","284181901","","2020-10-30","10/30/2020 - Rec'd screenshot of this providers approved TMHP infomation. Updated this payer line to store information for use with other enrollments, but the clinic will maintain this providers Medicaid. - Stacey Hudak"]
["Michael P Wolbert, MD",1881711778,"75-2781652","TX","","TriCare Standard","Participating","Enrollment Complete","2015-07-18","","","2020-12-01","12/1/2020 - Per f/u report Provider is on file and Par under the group and TIN# effective 07/18/2015.  DCannon"]
["Michael P Wolbert, MD",1881711778,"75-2781652","TX","PE - West Texas Allergy, 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."]
["Michael P Wolbert, MD",1881711778,"75-2781652","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."]
["Michael P Wolbert, MD",1881711778,"75-2781652","TX","PE - West Texas Allergy, PA","Multiplan","Participating","Enrollment Complete","2021-08-13","","","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,"","TX","","Boon Chapman","Participating","Enrollment Complete","2021-08-13","","","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 8/13/2021.  DCannon"]
["Michael P Wolbert, MD",1881711778,"87-1671535","TX","PE - West Texas Allergy, Lubbock, PLLC","Superior","Participating","Enrollment Complete","2022-07-01","","","2022-07-07","7/7/2022 Rcvd email from Superior confirming that the providers are PAR and loaded under TIN/locations effective 7/1/2022.  DCannon"]
["Michael P Wolbert, MD",1881711778,"87-1671535","TX","","Superior","Participating","Enrollment Complete","2022-07-01","","","2022-07-07","7/7/2022 Rcvd email from Superior confirming that the providers are PAR and loaded under TIN/locations effective 7/1/2022.  DCannon"]
["Michael P Wolbert, MD",1881711778,"75-2781652","TX","PE - West Texas Allergy, PA","BCBSTX","Participating","Enrollment Complete","2021-08-02","8CH649","","2021-11-19","11/19/21 Updated record from note made on 9/7/21. Michael Wolbert, MD is in network for the following HMO products, Blue Essentials HMO, Health Select, and Blue Advantage HMO. Provider ID, 8CH649, tied to TIN ending in 7379. The Lubbock satellite location has been added. Cbankston"]
["Michael P Wolbert, MD",1881711778,"75-2781652","TX","","Superior","Participating","Enrollment Complete","2017-01-01","1881711778","","2020-07-14","07/14/2020 - Rec'd email from the payer stating this provider is EFF under PRIMED DELEGATED agreement - Stacey Hudak"]
["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,"87-1671535","TX","PE - West Texas Allergy, Lubbock, PLLC","Omni PPO","Participating","Enrollment Complete","2021-08-02","","","2021-07-05","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 8/2/2021.  DCannon"]
["Michael P Wolbert, MD",1881711778,"","TX","","Amerigroup","Participating","Enrollment Complete","2021-08-02","","","2022-11-28","10/11/2022 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 8/2/2021.  DCannon"]
["Michael P Wolbert, MD",1881711778,"75-2781652","TX","PE - West Texas Allergy, PA","Multiplan","Participating","Enrollment Complete","2020-07-02","","","2021-06-29","6/29/2021 Rcvd roster from Multiplan confirming provider is PAR under TIN effective 7/2/2020.  DCannon"]
["Michael P Wolbert, MD",1881711778,"75-2781652","TX","","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","PE - West Texas Allergy, PA","Superior","Participating","Enrollment Complete","2021-09-01","","","2021-09-07","9/7/2021 Rcvd email from Superior that monthly delegation roster for May is complete and providers are loaded under TIN/locations effective 9/1/2021.  DCannon"]
["Michael P Wolbert, MD",1881711778,"75-2781652","TX","","Rail Road Medicare","Participating","Enrollment Complete","2010-07-25","P01233942","CF8499","2020-05-04","05/04/2020 - Was able to confirm this provider is EFF through payer portal - Stacey Hudak"]
["Michael P Wolbert, MD",1881711778,"75-2781652","TX","","Triwest VA","Facility Enrollment","Application Submitted","","","","","08/19/2022 - Submitted application to TriWest VA (sent to Scarlett Abigail, Scarlett_Abigail@bcbstx.com)"]
["Michael P Wolbert, MD",1881711778,"75-2781652","TX","PE - West Texas Allergy, PA","Cigna","Participating","Enrollment Complete","2021-08-01","9097673","","2021-09-01","9/1/2021 Received an email from pdmcogz@cigna.com confirming additional location has been updated for group with an effective date of 8/1/2021, and assigned provider ID 9097673. KFrazier"]
["Michael P Wolbert, MD",1881711778,"75-2781652","TX","","Cigna","Participating","Enrollment Complete","2021-08-01","9097673","","2021-09-01","9/1/2021 Received an email from pdmcogz@cigna.com confirming additional location has been updated for group with an effective date of 8/1/2021, and assigned provider ID 9097673. KFrazier"]
["Michael P Wolbert, MD",1881711778,"75-2781652","TX","PE - West Texas Allergy, PA","Scott&White (First Care)","Participating","Enrollment Complete","2021-08-02","","","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 8/2/2021.  DCannon"]
["Michael P Wolbert, MD",1881711778,"75-2781652","TX","PE - West Texas Allergy, PA","Triwest VA","Enrollment on Hold","Payor Follow Up","","","","","10/17/2022 - Received roster from Scarlett; provider status: \"No Action.  TIN does not exist in BCBSTX system.  Group will need to complete BCBSTX onboarding process for group record and provider records under TIN.\""]
["Michael P Wolbert, MD",1881711778,"","TX","PE - West Texas Allergy, Lubbock, PLLC","Galaxy Health","Participating","Enrollment Complete","2021-08-02","","","2022-08-17","8/17/2022 Per email from Karen Avalos at Galaxy delegated roster for July is complete and provider is loaded effective 8/2/2021.  DCannon"]
["Michael P Wolbert, MD",1881711778,"","TX","","Galaxy Health","Participating","Enrollment Complete","2021-08-02","","","2022-08-17","8/17/2022 Per email from Karen Avalos at Galaxy delegated roster for July is complete and provider is loaded effective 8/2/2021.  DCannon"]
["Ayodele Olowookere, MD",1124350442,"49-4110931","TX","PE - Ayodele O Olowookere MD, PA","Superior","Participating","Enrollment Complete","2016-11-01","1124350442","","2020-07-14","07/14/2020 - Rec'd email from the payer stating this provider is EFF under PRIMED DELEGATED agreement - Stacey Hudak"]
["Ayodele Olowookere, MD",1124350442,"49-4110931","TX","PE - Ayodele O Olowookere MD, PA","Amerigroup","Participating","Enrollment Complete","2020-07-02","1124350442","","2020-07-15","07/15/2020 - Rec'd welcome letter stating this provider is EFF 7-2-2020 with STAR, STAR+PLUS & Star Kids products - Stacey Hudak"]
["Ayodele Olowookere, MD",1124350442,"49-4110931","TX","PE - Ayodele O Olowookere MD, PA","Boon Chapman","Participating","Enrollment Complete","2016-05-16","1124350442","","2020-10-05","Enrollment thru PHCS"]
["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","","CAQH","Participating","No Value Specified","2023-03-20","12067517","","",""]
["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"]
["Rosanna Y Catalasan, MD",1487837712,"75-2656723","TX","PE - Premier Family Care I, Inc","CAQH","Participating","CAQH Reattested","2023-02-12","12038216","","2023-02-12","2/12/2023 CAQH reviewed and re-attested.  DCannon"]
["Rosanna Y Catalasan, MD",1487837712,"75-2656723","TX","PE - Premier Family Care I, Inc","United Health Care","Participating","Enrollment Complete","2020-01-01","1487837712","","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"]
["Rosanna Y Catalasan, MD",1487837712,"75-2656723","TX","PE - Premier Family Care I, 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."]
["Rosanna Y Catalasan, MD",1487837712,"75-2656723","TX","PE - Premier Family Care I, Inc","Triwest VA","Facility Enrollment","Application Submitted","","","","2022-11-28","08/19/2022 - Submitted application to TriWest VA (sent to Scarlett Abigail, Scarlett_Abigail@bcbstx.com)"]
["Rosanna Y Catalasan, MD",1487837712,"75-2656723","TX","PE - Premier Family Care I, Inc","USA PPO","Participating","Enrollment Complete","2010-06-25","","","2020-09-09","Confirmed provider is participating with PPO and H&W networks (list of networks attached). Kimberly Frazier"]
["Rosanna Y Catalasan, MD",1487837712,"75-2656723","TX","PE - Premier Family Care I, Inc","HealthSmart PPO","Participating","Enrollment Complete","2019-07-18","1487837712","","2020-06-10","06/10/2020 - Rec'd a spreadsheet from the payer stating this provider is EFF - Stacey Hudak"]
["Matthew A Sanchez, NP-C",1437402278,"","TX","PE - Premier Family Care I, Inc","Galaxy Health","Participating","Enrollment Complete","2022-07-01","","","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 7/1/2022.  DCannon"]
["Matthew A Sanchez, NP-C",1437402278,"75-2656723","TX","PE - Premier Family Care I, Inc","Omni PPO","Participating","Enrollment Complete","2016-07-08","1437402278","","2020-06-25",""]
["Matthew A Sanchez, NP-C",1437402278,752656723,"TX","PE - Premier Family Care I, 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, NP-C",1437402278,"","TX","PE - Premier Family Care I, Inc","Omni PPO","Participating","Enrollment Complete","2022-07-01","","","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 7/1/2022.   DCannon"]
["Matthew A Sanchez, NP-C",1437402278,752656723,"TX","PE - Premier Family Care I, Inc","Caprock (CapStar)","Participating","Enrollment Complete","2021-11-15","","","2022-03-11","3/11/2022 Rcvd email from Caprock ProviderServices.T8@90degreebenefits.com that monthly delegated roster provider load is complete and provider is loaded under TIN at location effective 11/15/2021.  DCannon"]
["Matthew A Sanchez, NP-C",1437402278,"","TX","PE - Premier Family Care I, Inc","Amerigroup","Participating","Enrollment Complete","2022-11-16","","","2022-12-28","12/28/2022 Per email received from Priscilla Albertine at MQA  she received updated from Joe Rodriguez provider is PAR and linked to group TIN/location effective 11/16/2022.  DCannon"]
["Matthew A Sanchez, NP-C",1437402278,752656723,"TX","PE - Premier Family Care I, Inc","Tricare Prime","Thru Other Payor","See Other Payor Line","","","","2022-02-14","2/14/2022 Provider will be added to location through standard app.  Cbankston"]
["Matthew A Sanchez, NP-C",1437402278,"75-2656723","TX","PE - Premier Family Care I, Inc","Aetna","Participating","Enrollment Complete","2015-12-15","4689558","","2020-02-03","02/03/2020 - Confirmed with the payer that this provider is EFF 12-15-2015 under a DIRECT CONTRACT. Midlevels dont require recred. This service location is linked to the provider profile - Stacey Hudak"]
["Matthew A Sanchez, NP-C",1437402278,"75-2656723","TX","PE - Premier Family Care I, 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."]
["Matthew A Sanchez, NP-C",1437402278,"","TX","PE - Premier Family Care I, Inc","First Health Coventry","Provider Load","Application Submitted","","","","2022-09-21","9/21/2022 Submitted first health application online at aetna.com. TAT 60 business days. Hsmith."]
["Matthew A Sanchez, NP-C",1437402278,752656723,"TX","PE - Premier Family Care I, Inc","United Health Care","Participating","Enrollment Complete","2017-04-19","003639846","","2022-04-18","Received email networkhelp@uhc.com, Matthew Sanchez is effective with the group contract 4/19/17. Cbankston"]
["Matthew A Sanchez, NP-C",1437402278,"","TX","PE - Premier Family Care I, Inc","Boon Chapman","Pending Other Enrollment","Pending Other Enrollment","","","","2022-07-21","7/21/2022 Pending Multiplan enrollment.  DCannon"]
["Matthew A Sanchez, NP-C",1437402278,752656723,"TX","PE - Premier Family Care I, Inc","Rail Road Medicare","Participating","Enrollment Complete","2016-03-21","","","2022-02-14","2/14/2022 Verified provider information on Palmento Website. PID P02179476 eff3/21/2016. Cbankston"]
["Matthew A Sanchez, NP-C",1437402278,752656723,"TX","PE - Premier Family Care I, Inc","Triwest VA","Facility Enrollment","In House Enrollment","","","","2021-11-18",""]
["Matthew A Sanchez, NP-C",1437402278,752656723,"TX","PE - Premier Family Care I, 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"]
["Matthew A Sanchez, NP-C",1437402278,752656723,"TX","PE - Premier Family Care I, Inc","Aetna","Participating","Enrollment Complete","2021-11-01","4689558","","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 9469407. Physical location is on file. Ref# 6075307553.  DCannon"]
["Matthew A Sanchez, NP-C",1437402278,"75-2656723","TX","","Triwest VA","Facility Enrollment","Application Submitted","","","","2022-11-23","08/19/2022 - Submitted application to TriWest VA (sent to Scarlett Abigail, Scarlett_Abigail@bcbstx.com)"]
["Mohammed H Aljarwi, MD",1013320050,"","TX","PE - Premier Family Care I, Inc","HealthSmart PPO","Participating","Enrollment Complete","2022-10-10","","","2022-11-01","11/1/2022 Per Healthsmart website provider is PAR and loaded under TIN/location effective 10/10/2022.  DCannon"]
["Mohammed H Aljarwi, MD",1013320050,"","TX","PE - Premier Family Care I, Inc","Cigna","Participating","Enrollment Complete","2022-12-01","","","2022-11-28","11/28/2022 Received email confirmation from Cigna that provider is PAR and linked to group TIN/location effective 12/1/2022.  PID # 9884987.  DCannon"]
["Mohammed H Aljarwi, MD",1013320050,"","TX","PE - Premier Family Care I, Inc","Multiplan","In Process","Application Submitted","","","","2022-10-14","10/14/2022 Emailed monthly delegated roster to Multiplan to add provider to delegated roster.  DCannon"]
["Mohammed H Aljarwi, MD",1013320050,"","TX","PE - Premier Family Care I, Inc","United Health Care","In Process","Application Submitted","","","","2022-10-14","10/14/2022 Emailed monthly delegated roster to UHC to add provider to delegated roster.  DCannon"]
["Mohammed H Aljarwi, MD",1013320050,"","TX","PE - Premier Family Care I, Inc","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,"","TX","PE - Premier Family Care I, 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# 14615150.  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","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","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","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"]
["Joan S R Petalcorin, MD",1619008141,"75-2656723","TX","PE - Premier Family Care I, Inc","Multiplan","Participating","Enrollment Complete","2016-10-12","1619008141","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 10-12-2016. Provider is networked with Beechstreet. - Stacey Hudak"]
["Joan S R Petalcorin, MD",1619008141,"75-2656723","TX","PE - Premier Family Care I, Inc","Galaxy Health","Participating","Enrollment Complete","2016-10-05","1619008141","","2020-07-10","07/10/2020 - updated payer line to enrollment complete status instead of \"Delegated status\" for report running purposes - Stacey Hudak"]
["Joan S R Petalcorin, MD",1619008141,"75-2656723","TX","PE - Premier Family Care I, Inc","Cigna","Participating","Enrollment Complete","2021-03-31","9223693","","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 9223693. KFrazier"]
["Joan S R Petalcorin, MD",1619008141,"75-2656723","TX","PE - Premier Family Care I, Inc","TriCare Standard","Participating","Enrollment Complete","2016-09-24","1619008141","","2020-09-09","09/09/2020 - moved to completed status after reviewing last note - Stacey Hudak"]
["Joan S R Petalcorin, MD",1619008141,"75-2656723","TX","PE - Premier Family Care I, Inc","Aetna","Participating","Enrollment Complete","2019-05-10","1619008141","","2020-02-03","02/03/2020 - Confirmed with the payer that this provider is EFF 5-10-2019 under a DIRECT CONTRACT. This service location is on file and recred will be \" On or before 05/10/2022 (reval/recred every 3 years)\" - Stacey Hudak"]
["Joan S R Petalcorin, MD",1619008141,"75-2656723","TX","PE - Premier Family Care I, 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"]
["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","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","Caprock (CapStar)","Participating","Enrollment Complete","2020-03-01","1093935975","","",""]
["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"]
["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 Process","Application Submitted","","","","2022-11-15","08/19/2022 - Application submitted to Scarlett Abigail (Scarlett_Abigail@bcbstx.com) of TriWest VA"]
["Leela S Pillarisetty, MD",1235484114,863825791,"TX","PE - West Texas Ob/Gyn","CAQH","Participating","CAQH Reattested","2023-03-03","","","2023-03-03","3/3/2023 CAQH reviewed and re-attested.  DCannon"]
["Leela S Pillarisetty, MD",1235484114,863825791,"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",1235484114,863825791,"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",1235484114,863825791,"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",1235484114,863825791,"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",1235484114,863825791,"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",1235484114,863825791,"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",1235484114,863825791,"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",1235484114,863825791,"TX","PE - West Texas Ob/Gyn","Medicaid","Pending Other Enrollment","Pending Other Enrollment","","","","2022-03-07","3/7/2022 Pending Medicare enrollment.  Once enrolled in Medicare will move forward w/ TX Medicaid enrollment.  DCannon"]
["Leela S Pillarisetty, MD",1235484114,"86-3825791","TX","PE - West Texas Ob/Gyn","Medicaid","Pending Other Enrollment","Pending Other Enrollment","","","","2022-03-07","3/7/2022 Pending Medicare enrollment.  Once enrolled in Medicare will move forward w/ TX Medicaid enrollment.  DCannon"]
["Leela S Pillarisetty, MD",1235484114,863825791,"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",1235484114,863825791,"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",1235484114,863825791,"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"]
["Kavitha Bagadi, MD",1871782961,"47-5554737","TX","PE - Midland Inpatient Medical Association","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"]
["Kavitha Bagadi, MD",1871782961,"47-5554737","TX","PE - Midland Inpatient Medical Association","Rail Road Medicare","Participating","Enrollment Complete","2016-07-27","P01732056","DW7662","2021-08-06","8/6/2021 RR Medicare PTAN received instantly via RR Medicare online portal.  PTAN # P01732056 - effective 7/27/2016.  DCannon"]
["Kavitha Bagadi, MD",1871782961,"47-5554737","TX","PE - Midland Inpatient Medical Association","United Health Care","Participating","Enrollment Complete","2017-08-15","1871782961","","2020-08-31","08/31/2020 - moved to the completed status after reviewing follow up complete note  - Stacey Hudak"]
["Kavitha Bagadi, MD",1871782961,"47-5554737","TX","PE - Midland Inpatient Medical Association","Caprock (CapStar)","Participating","Enrollment Complete","2020-03-01","1871782961","","",""]
["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"]
["Tiffany D Cossey, MD",1053601344,"75-2656723","TX","PE - Premier Family Care I, Inc","TriCare Standard","Participating","Enrollment Complete","2020-05-01","","","2020-09-21","Confirmed via self-service portal provider is participating under group at this location as of 5/1/2020. Kimberly Frazier"]
["Tiffany D Cossey, MD",1053601344,"75-2656723","TX","PE - Premier Family Care I, 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 I, Inc","United Health Care","Delegated","Delegated - Third Party","2019-03-03","1053601344","","2020-09-24","Delegated Entity Name: UT PHYSICIANS (PREV. UCP)\n\n*Primed Delegation termed with UHC on 1/1/2020"]
["Tiffany D Cossey, MD",1053601344,"75-2656723","TX","","Triwest VA","Facility Enrollment","Application Submitted","","","","2022-11-28","08/19/2022 - Submitted application to TriWest VA (sent to Scarlett Abigail, Scarlett_Abigail@bcbstx.com)"]
["Tiffany D Cossey, MD",1053601344,"75-2656723","TX","PE - Premier Family Care I, Inc","Triwest VA","Facility 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.\""]
["Tiffany D Cossey, MD",1053601344,"75-2656723","TX","PE - Premier Family Care I, Inc","Boon Chapman","Participating","Enrollment Complete","2019-04-04","","","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 4/4/2019.  DCannon"]
["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","","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","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","","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","","Triwest VA","Facility Enrollment","Facility Enrollment","","","","","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","","","","","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","","Caprock (CapStar)","Participating","Enrollment Complete","2020-03-01","1972816189","","",""]
["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","","CAQH","Participating","CAQH Reattested","2023-03-06","14113335","","2023-03-06","3/6/2023 Rcvd email from Jack Waters that CAQH profile had been reviewed and re-attested.  DCannon"]
["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","","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.","First Health Coventry","In Process","Action Needed","","","","2023-01-31","01.31.2023 S/W Brenda of First Health @ 800-226-5116. Provider is out of network. No pending application. As per rep, they provider would need to become credentialed with aetna first before submitting an application to first health. Rep advised to visit their website Aetna.com > Join Our Network > go to first health network > fill out the online application form then submit. TAT of 180 business days. Call ref#:530288.-Danico Gabriel Melendres"]
["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","Pending Other Enrollment","Pending Other Enrollment","","","","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"]
["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","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","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","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"]
["Jeffrey Hunter Atkins, MD",1760860720,842617748,"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",1760860720,842617748,"TX","PE - Midland Medicine PA","Medicaid","Participating","Enrollment Complete","2021-04-01","386494405","422293701","2021-06-09","6/9/2021 Upon review of the TMHP portal, provider and group have been approved and assigned provider TPI 386494405 and group TPI 422293701 effective 4/1/2021 with a revalidation date of 5/12/2026. KFrazier"]
["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",1760860720,842617748,"TX","PE - Midland Medicine PA","Aetna","Participating","Enrollment Complete","2021-04-01","6107649","","2021-07-01","7/1/2021 Per Aetna roster received from Jamie Roberts provider is PAR and linked to TIN/locations effective 4/1/2021.  DCannon"]
["Jeffrey Hunter Atkins, MD",1760860720,842617748,"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",1760860720,842617748,"TX","PE - Midland Medicine PA","Rail Road Medicare","Participating","Enrollment Complete","2021-04-01","P02614743","EA8735","2021-08-05","8/5/2021 Submitted new application and was immediately provided provider RR PTAN P02614743, and group RR PTAN EA8735, effective 4/1/2021. KFrazier"]
["Jeffrey Hunter Atkins, MD",1760860720,"47-5554737","TX","PE - Midland Inpatient Medical Association","Ambetter","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"]
["Jeffrey Hunter Atkins, MD",1760860720,842617748,"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",1760860720,842617748,"TX","PE - Midland Medicine PA","Amerigroup","Participating","Enrollment Complete","2021-06-03","","","2021-12-03","12/3/2021 Per Amerigroup roster received Joe Rodriguez provider is PAR under group TIN/location effective 6/3/2021.   DCannon"]
["Jeffrey Hunter Atkins, MD",1760860720,"47-5554737","TX","PE - Midland Inpatient Medical Association","Humana","Participating","Enrollment Complete","2020-01-01","1760860720","","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"]
["Jeffrey Hunter Atkins, MD",1760860720,842617748,"TX","PE - Midland Medicine PA","Superior","Participating","Enrollment Complete","2021-05-01","","","2021-06-03","6/3/2021 Rcvd email from Superior that monthly delegation roster for May is complete and providers are loaded under TIN/locations effective 6/1/2021.  DCannon"]
["Jeffrey Hunter Atkins, MD",1760860720,842617748,"TX","PE - Midland Medicine PA","Triwest VA","In Process","Application Submitted","","","","","08/19/2022 - Submitted application to TriWest VA (sent to Scarlett Abigail, Scarlett_Abigail@bcbstx.com)"]
["Jeffrey Hunter Atkins, MD",1760860720,842617748,"TX","PE - Midland Medicine PA","Galaxy Health","Participating","Enrollment Complete","2021-04-01","","","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 4/1/2021.  DCannon"]
["Jeffrey Hunter Atkins, MD",1760860720,842617748,"TX","PE - Midland Medicine PA","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"]
["Jeffrey Hunter Atkins, MD",1760860720,842617748,"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,"47-5554737","TX","PE - Midland Inpatient Medical Association","Multiplan","Participating","Enrollment Complete","2020-03-20","","","2022-08-23","8/23/2022 Per email from Multiplan provider is PAR and linked to group TIN/location effective 3/20/2020.  DCannon"]
["Jeffrey Hunter Atkins, MD",1760860720,842617748,"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",1760860720,842617748,"TX","PE - Midland Medicine PA","Boon Chapman","Participating","Thru Other Payor","2021-05-24","","","2021-09-15","9/15/2021 Received roster from Multiplan listing provider as PAR under group TIN/location effective 5/24/2021.  DCannon"]
["Jeffrey Hunter Atkins, MD",1760860720,842617748,"TX","PE - Midland Medicine PA","Omni PPO","Participating","Enrollment Complete","2021-04-01","","","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 4/1/2021. DCannon"]
["Jeffrey Hunter Atkins, MD",1760860720,842617748,"TX","PE - Midland Medicine PA","Superior","Participating","Enrollment Complete","2021-06-01","","","2021-06-03","6/3/2021 Rcvd email from Superior that monthly delegation roster for May is complete and providers are loaded under TIN/locations effective 6/1/2021.  DCannon"]
["Jeffrey Hunter Atkins, MD",1760860720,842617748,"TX","PE - Midland Medicine PA","United Health Care","Participating","Enrollment Complete","2021-05-22","","","2021-05-07","5/7/2021 Received email from uhc_provider_contracting_cen@uhc.com with receipt of executed agreement, which is effective 5/22/2021 for both group and provider. KFrazier"]
["Jeffrey Hunter Atkins, MD",1760860720,842617748,"TX","PE - Midland Medicine PA","Wellcare","Participating","Enrollment Complete","2022-07-01","","","2022-11-15","11/15/2022 Per roster received from Wellcare provider is PAR and linked to group TIN/location effective 7/1/2022.  DCannon"]
["Jeffrey Hunter Atkins, MD",1760860720,842617748,"TX","PE - Midland Medicine PA","Wellcare","Participating","Enrollment Complete","2022-07-01","","","2022-11-15","11/15/2022 Per roster received from Wellcare provider is PAR and linked to group TIN/location effective 7/1/2022.  DCannon"]
["Amber J White, PA",1255614970,"47-5554737","TX","PE - Midland Inpatient Medical Association","Medicaid","Participating","Enrollment Complete","","1255614970","364596201","2020-02-19","02/19/2020 - Per payer portal, this provider is effective with this group TPI 364596201 and linked with the following plans: FirstCare - Lubbock, TRADITIONAL MEDICAID, Amerigroup - MRSA West, Amerigroup - MRSA West, FirstCare - MRSA West, Amerigroup Texas, Inc. - MRSA West - Stacey Hudak"]
["Amber J White, PA",1255614970,"47-5554737","TX","PE - Midland Inpatient Medical Association","Scott&White (First Care)","Participating","Enrollment Complete","2018-01-01","1255614970","","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"]
["Amber J White, PA",1255614970,"47-5554737","TX","PE - Midland Inpatient Medical Association","Omni PPO","Participating","Enrollment Complete","2019-09-01","1255614970","","2020-07-27","IMS complete"]
["Amber J White, PA",1255614970,"47-5554737","TX","PE - Midland Inpatient Medical Association","IMS","Participating","Enrollment Complete","2019-09-01","1255614970","","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"]
["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","Cigna","Participating","Enrollment Complete","2021-07-08","6703681","","2021-07-09","7/9/2021 Received an email from discovercigna@information.cigna.com confirming provider is now participating under group Tax ID effective 7/8/2021 with assigned provider ID 6703681. KFrazier"]
["Luis F Hernandez, DO",1447412895,"47-5554737","TX","PE - Midland Inpatient Medical Association","Aetna","Participating","Enrollment Complete","2020-10-01","9699508","5708963","2020-11-24","11/24/2020 - Per F/U Report provider is linked and participating in Network effective 10/01/2020 under the group and TIN#. Provider ID 9699508. Group ID 5708963.  DCannon"]
["Luis F Hernandez, DO",1447412895,"47-5554737","TX","PE - Midland Inpatient Medical Association","Medicaid","Participating","Enrollment Complete","","202275811","","2020-05-07","05/07/2020 - signed onto MIMA TMHP and was able to verify that this provider is effective with the following networks: \nCommunity Health Choice - Harris, Community Health Choice - Jefferson, TRADITIONAL MEDICAID  - Stacey Hudak"]
["Luis F Hernandez, DO",1447412895,"47-5554737","TX","PE - Midland Inpatient Medical Association","IMS","Participating","Enrollment Complete","2019-09-01","1447412895","","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"]
["Luis F Hernandez, DO",1447412895,"47-5554737","TX","PE - Midland Inpatient Medical Association","United Health Care","Participating","Enrollment Complete","2019-09-16","1447412895","","2020-07-30","7/30/2020 - moved to completed status after reviewing follow up complete note - Stacey Hudak"]
["Luis F Hernandez, DO",1447412895,"47-5554737","TX","PE - Midland Inpatient Medical Association","TriCare Standard","Participating","Enrollment Complete","2020-06-09","1447412895","","2020-09-09","09/09/2020 - moved to completed status after reviewing previous note - Stacey Hudak"]
["Luis F Hernandez, DO",1447412895,"47-5554737","TX","PE - Midland Inpatient Medical Association","Medicare","Participating","Enrollment Complete","2016-10-18","319012ZV0W","519061","2020-04-27","04/27/2020 - Confirmed EFF information through Group PECOS enrollment - Stacey Hudak"]
["Raceli L Gibson, APRN-FNP-BC",1518388313,"75-2656723","TX","PE - Premier Family Care I, Inc","USA PPO","Participating","Enrollment Complete","2021-01-26","","","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"]
["Raceli L Gibson, APRN-FNP-BC",1518388313,"75-2656723","TX","PE - Premier Family Care I, Inc","Medicaid","Participating","Enrollment Complete","2020-10-01","349962604","079837301","2020-12-07","12/7/2020 Upon review of TMHP portal, provider has been approved with assigned TPI 349962604. KFrazier"]
["Raceli L Gibson, APRN-FNP-BC",1518388313,"75-2656723","TX","PE - Premier Family Care I, Inc","United Health Care","Participating","Enrollment Complete","2020-11-18","5256394","","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 11/18/2020 and assigned provider ID 5256394. KFrazier"]
["Raceli L Gibson, APRN-FNP-BC",1518388313,"75-2656723","TX","PE - Premier Family Care I, Inc","Humana","In Process","Payor Follow Up","","","","2022-04-01","4/1/2022 Sent email to VThomas at Humana to check status of January delegated roster provider load.  DCannon"]
["Raceli L Gibson, APRN-FNP-BC",1518388313,"75-2656723","TX","","Triwest VA","Facility Enrollment","Application Submitted","","","","2022-11-28","08/19/2022 - Submitted application to TriWest VA (sent to Scarlett Abigail, Scarlett_Abigail@bcbstx.com)"]
["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","PE - Permian Digestive Disease Center PA","Aetna","Participating","Enrollment Complete","2016-04-01","1447406137","","2020-03-24","3/24/2020--S/W Ian of Aetna @ 800-872-3862, rep advised to call 8003531232. Called 8003531232 and S/W Vanessa, provider NPI is on file for the provider and participating effective 4/1/16 under the group and TIN. Physical location is on file. Delegated with Primed Health network. Provider ID# 9536191. Call ref# 5192468082.\ntisha rader"]
["Indira Donepudi, MD",1447406137,"81-1031742: P","TX","","Aetna","Participating","Enrollment Complete","2016-04-01","1447406137","","2020-03-24","3/24/2020--S/W Ian of Aetna @ 800-872-3862, rep advised to call 8003531232. Called 8003531232 and S/W Vanessa, provider NPI is on file for the provider and participating effective 4/1/16 under the group and TIN. Physical location is on file. Delegated with Primed Health network. Provider ID# 9536191. Call ref# 5192468082.\ntisha rader"]
["Indira Donepudi, MD",1447406137,"81-1031742: P","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","","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: P","TX","PE - Permian Digestive Disease Center PA","United Health Care","Participating","Enrollment Complete","2020-01-01","1447406137","","2020-08-31","08/31/2020  - moved to completed status after reviewing follow up complete note - Stacey Hudak"]
["Indira Donepudi, MD",1447406137,"81-1031742: S","TX","","USA PPO","Participating","Enrollment Complete","2016-03-31","1210786","","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"]
["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","","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: P","TX","PE - Permian Digestive Disease Center PA","Boon Chapman","Participating","Enrollment Complete","2018-09-11","1447406137","","2020-10-05","Enrollment thru PHCS"]
["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: S","TX","PE - Permian Digestive Disease Center PA","Cigna","Participating","Enrollment Complete","2019-09-01","8628903","","2020-07-16","7/16/2020 - Rec'd email from the payer stating \"Thank you for your submission. This is to confirm that your request has been completed.\" - Stacey Hudak"]
["Indira Donepudi, MD",1447406137,"81-1031742: S","TX","","Cigna","Participating","Enrollment Complete","2019-09-01","8628903","","2020-07-16","7/16/2020 - Rec'd email from the payer stating \"Thank you for your submission. This is to confirm that your request has been completed.\" - Stacey Hudak"]
["Indira Donepudi, MD",1447406137,"81-1031742: P","TX","PE - Permian Digestive Disease Center PA","USA PPO","Participating","Enrollment Complete","2016-03-31","","","2020-09-09","Confirmed provider is participating with PPO and H&W networks (list of networks attached). Kimberly Frazier"]
["Indira Donepudi, MD",1447406137,"81-1031742: P","TX","","USA PPO","Participating","Enrollment Complete","2016-03-31","","","2020-09-09","Confirmed provider is participating with PPO and H&W networks (list of networks attached). Kimberly Frazier"]
["Indira Donepudi, MD",1447406137,"81-1031742: P","TX","PE - Permian Digestive Disease Center PA","Rail Road Medicare","Participating","Enrollment Complete","2016-01-09"," P01708900","DW5495","2020-05-04","05/04/2020 - confirmed EFF info through payer portal - Stacey Hduak"]
["Indira Donepudi, MD",1447406137,"81-1031742: P","TX","","Rail Road Medicare","Participating","Enrollment Complete","2016-01-09"," P01708900","DW5495","2020-05-04","05/04/2020 - confirmed EFF info through payer portal - Stacey Hduak"]
["Indira Donepudi, MD",1447406137,"81-1031742: S","TX","PE - Permian Digestive Disease Center PA","Medicaid","In House Enrollment","In House Enrollment","2016-01-09","","","2021-08-06","8/6/2021 Group processes enrollment In-House; however, confirmed provider is participating with group effective 9/1/2016. KFrazier"]
["Indira Donepudi, MD",1447406137,"81-1031742: S","TX","","Medicaid","In House Enrollment","In House Enrollment","2016-01-09","","","2021-08-06","8/6/2021 Group processes enrollment In-House; however, confirmed provider is participating with group effective 9/1/2016. KFrazier"]
["Indira Donepudi, MD",1447406137,"81-1031742: P","TX","PE - Permian Digestive Disease Center PA","Caprock (CapStar)","Participating","Enrollment Complete","2016-05-01","1447406137","","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"]
["Indira Donepudi, MD",1447406137,"81-1031742: P","TX","","Caprock (CapStar)","Participating","Enrollment Complete","2016-05-01","1447406137","","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"]
["Indira Donepudi, MD",1447406137,"81-1031742: P","TX","PE - Permian Digestive Disease Center PA","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","","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","Cigna","Participating","Enrollment Complete","2016-02-05","1447406137","","2020-04-22","04/22/2020--SW Sharon of Cigna @ 8008824462, Provider NPI# is on file and participating under the group and TIN# effective 2/5/2016. Location is on file. Call ref# Sharon4202020.\ncopied note from spreadsheet-tisha rader"]
["Indira Donepudi, MD",1447406137,"81-1031742: P","TX","","Cigna","Participating","Enrollment Complete","2016-02-05","1447406137","","2020-04-22","04/22/2020--SW Sharon of Cigna @ 8008824462, Provider NPI# is on file and participating under the group and TIN# effective 2/5/2016. Location is on file. Call ref# Sharon4202020.\ncopied note from spreadsheet-tisha rader"]
["Indira Donepudi, MD",1447406137,"81-1031742: S","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 7/1/2016 PID # 1912442\ntisha rader"]
["Indira Donepudi, MD",1447406137,"81-1031742: S","TX","","First Health Coventry","Participating","Enrollment Complete","2016-07-01","1912442","","2020-03-20","3/20/2020-receieved email with roster stating provider PAR 7/1/2016 PID # 1912442\ntisha rader"]
["Indira Donepudi, MD",1447406137,"81-1031742: S","TX","PE - Permian Digestive Disease Center PA","Triwest VA","Participating","Enrollment Complete","2022-08-01","","","2022-11-14","11/14/22 Per Scarlett Abigail, provider effective 8/1/22"]
["Indira Donepudi, MD",1447406137,"81-1031742: S","TX","","Triwest VA","Participating","Enrollment Complete","2022-08-01","","","2022-11-14","11/14/22 Per Scarlett Abigail, provider effective 8/1/22"]
["Indira Donepudi, MD",1447406137,"81-1031742: P","TX","PE - Permian Digestive Disease Center PA","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"]
["Indira Donepudi, MD",1447406137,"81-1031742: P","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"]
["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","","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: S","TX","PE - Permian Digestive Disease Center PA","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: S","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: 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","","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","","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","Aetna","Participating","Enrollment Complete","2019-09-01","1447406137","","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"]
["Indira Donepudi, MD",1447406137,"81-1031742: S","TX","","Aetna","Participating","Enrollment Complete","2019-09-01","1447406137","","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"]
["Indira Donepudi, MD",1447406137,"81-1031742: P","TX","PE - Permian Digestive Disease Center PA","Humana","Participating","Enrollment Complete","2016-03-10","1447406137","","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"]
["Indira Donepudi, MD",1447406137,"81-1031742: P","TX","","Humana","Participating","Enrollment Complete","2016-03-10","1447406137","","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"]
["Indira Donepudi, MD",1447406137,"81-1031742: P","TX","PE - Permian Digestive Disease Center PA","Amerigroup","Participating","Enrollment Complete","2016-03-30","1447406137","","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"]
["Indira Donepudi, MD",1447406137,"81-1031742: P","TX","","Amerigroup","Participating","Enrollment Complete","2016-03-30","1447406137","","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"]
["Indira Donepudi, MD",1447406137,"81-1031742: S","TX","PE - Permian Digestive Disease Center PA","Boon Chapman","Participating","Enrollment Complete","2018-09-11","1447406137","","2020-10-05","Enrollment thru PHCS"]
["Indira Donepudi, MD",1447406137,"81-1031742: S","TX","","Boon Chapman","Participating","Enrollment Complete","2018-09-11","1447406137","","2020-10-05","Enrollment thru PHCS"]
["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"]
["Indira Donepudi, MD",1447406137,"81-1031742: S","TX","","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"]
["Indira Donepudi, MD",1447406137,"81-1031742: P","TX","PE - Permian Digestive Disease Center PA","Galaxy Health","Participating","Enrollment Complete","2016-03-30","1447406137","","2020-07-17","7/17/2020- Received a spreadsheet from the payer stating this provider is effective as of 3/30/2016. – Jerha Gayorgor"]
["Indira Donepudi, MD",1447406137,"81-1031742: P","TX","","Galaxy Health","Participating","Enrollment Complete","2016-03-30","1447406137","","2020-07-17","7/17/2020- Received a spreadsheet from the payer stating this provider is effective as of 3/30/2016. – Jerha Gayorgor"]
["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: P","TX","","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","PE - Permian Digestive Disease Center PA","Amerigroup","Participating","Enrollment Complete","2018-05-03","","","2021-08-26","8/26/2021 Rcvd full roster from Joe Rodriguez at Amerigroup listing provider as PAR w/ group TIN and location effective 5/3/2018.  DCannon"]
["Indira Donepudi, MD",1447406137,"81-1031742: S","TX","","Amerigroup","Participating","Enrollment Complete","2018-05-03","","","2021-08-26","8/26/2021 Rcvd full roster from Joe Rodriguez at Amerigroup listing provider as PAR w/ group TIN and location effective 5/3/2018.  DCannon"]
["Indira Donepudi, MD",1447406137,"81-1031742: S","TX","PE - Permian Digestive Disease Center PA","United Health Care","Participating","Enrollment Complete","2019-09-01","","","2020-11-10","11/10/20 - Rcvd confirmation email Ref # PR5483501 that provider has been linked and loaded effective 9/1/2019.  MPIN # 002945847"]
["Indira Donepudi, MD",1447406137,"81-1031742: S","TX","","United Health Care","Participating","Enrollment Complete","2019-09-01","","","2020-11-10","11/10/20 - Rcvd confirmation email Ref # PR5483501 that provider has been linked and loaded effective 9/1/2019.  MPIN # 002945847"]
["Indira Donepudi, MD",1447406137,"81-1031742: P","TX","PE - Permian Digestive Disease Center PA","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: P","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","Caprock (CapStar)","Participating","Enrollment Complete","2016-05-01","1447406137","","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"]
["Indira Donepudi, MD",1447406137,"81-1031742: S","TX","","Caprock (CapStar)","Participating","Enrollment Complete","2016-05-01","1447406137","","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"]
["Indira Donepudi, MD",1447406137,"81-1031742: P","TX","PE - Permian Digestive Disease Center PA","Scott&White (First Care)","Participating","Enrollment Complete","2016-03-30","1447406137","","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 with this TIN/Service Location- Stacey Hudak"]
["Indira Donepudi, MD",1447406137,"81-1031742: P","TX","","Scott&White (First Care)","Participating","Enrollment Complete","2016-03-30","1447406137","","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 with this TIN/Service Location- Stacey Hudak"]
["Indira Donepudi, MD",1447406137,"81-1031742: S","TX","PE - Permian Digestive Disease Center PA","Galaxy Health","Participating","Enrollment Complete","2019-09-01","1447406137","","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"]
["Indira Donepudi, MD",1447406137,"81-1031742: S","TX","","Galaxy Health","Participating","Enrollment Complete","2019-09-01","1447406137","","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"]
["Indira Donepudi, MD",1447406137,"81-1031742: P","TX","PE - Permian Digestive Disease Center PA","Omni PPO","Participating","Enrollment Complete","2019-09-01","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: P","TX","","Omni PPO","Participating","Enrollment Complete","2019-09-01","1447406137","","2020-09-04","09/04/2020 - IMS is effective, therefore this payer line is also effective - Stacey Hudak"]
["Tiffany B Hansen, FNP-C",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, FNP-C",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, FNP-C",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, FNP-C",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, FNP-C",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, FNP-C",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, FNP-C",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, FNP-C",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, FNP-C",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, FNP-C",1750794749,"20-8658501","TX","PE - Shylesh Ganta, MD, PA","Triwest VA","In Process","Payor Follow Up","","","","","10/17/2022 - Received roster from Scarlett; provider status: \"The provider is in CCN activation process with a target effective date of 10/15/2022. Please allow 7 days to be finalized.\""]
["Tiffany B Hansen, FNP-C",1750794749,"20-8658501","TX","","Triwest VA","In Process","Payor Follow Up","","","","","10/17/2022 - Received roster from Scarlett; provider status: \"The provider is in CCN activation process with a target effective date of 10/15/2022. Please allow 7 days to be finalized.\""]
["Tiffany B Hansen, FNP-C",1750794749,"20-8658501","TX","PE - Shylesh Ganta, MD, PA","Triwest VA","In Process","Application Submitted","","","","","08/19/2022 - Submitted application to TriWest VA (sent to Scarlett Abigail, Scarlett_Abigail@bcbstx.com)"]
["Tiffany B Hansen, FNP-C",1750794749,"20-8658501","TX","","Triwest VA","In Process","Application Submitted","","","","","08/19/2022 - Submitted application to TriWest VA (sent to Scarlett Abigail, Scarlett_Abigail@bcbstx.com)"]
["Tiffany B Hansen, FNP-C",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, FNP-C",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, FNP-C",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, FNP-C",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, FNP-C",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, FNP-C",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, FNP-C",1750794749,"20-8658501","TX","PE - Shylesh Ganta, MD, PA","CAQH","Participating","CAQH Reattested","2023-01-25","12740460","","2023-01-25","1/25/2023 CAQH reviewed and re-attested.  DCannon"]
["Tiffany B Hansen, FNP-C",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"]
["Jaya Krishna Chadalavada, MD",1710180666,"47-5554737","TX","PE - Midland Inpatient Medical Association","Multiplan","Participating","Enrollment Complete","2020-05-15","","","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 5/15/2020.   DCannon"]
["Jaya Krishna Chadalavada, MD",1710180666,"47-5554737","TX","PE - Midland Inpatient Medical Association","Boon Chapman","Participating","Enrollment Complete","2020-05-15","","","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 5/15/2020.   DCannon"]
["Jaya Krishna Chadalavada, MD",1710180666,"47-5554737","TX","PE - Midland Inpatient Medical Association","Galaxy Health","Participating","Enrollment Complete","2019-09-01","1710180666","","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"]
["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","Omni PPO","Participating","Enrollment Complete","2019-09-01","1710180666","","2020-07-27","IMS complete"]
["Jaya Krishna Chadalavada, MD",1710180666,"47-5554737","TX","PE - Midland Inpatient Medical Association","IMS","Participating","Enrollment Complete","2019-09-01","1710180666","","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"]
["Jaya Krishna Chadalavada, MD",1710180666,"47-5554737","TX","PE - Midland Inpatient Medical Association","United Health Care","Participating","Enrollment Complete","2020-05-01","1447406137","","2020-08-31","08/31/2020 - moved to completed status after reviewing follow up completed note - Stacey Hudak"]
["Jaya Krishna Chadalavada, MD",1710180666,"47-5554737","TX","PE - Midland Inpatient Medical Association","Medicare","Participating","Enrollment Complete","2016-08-24","372879ZV0W","519061","2020-04-20","04/20/2020 - Group PECOS enrollment confirrmed this group is listed as provider employer - Stacey Hudak"]
["Jaya Krishna Chadalavada, MD",1710180666,"47-5554737","TX","PE - Midland Inpatient Medical Association","First Health Coventry","Participating","Enrollment Complete","2020-12-01","2550759","","2021-01-26","1/26/2021 - Per follow-up notes provider is par with TIN and location effective 12/1/2020.  DCannon"]
["Jaya Krishna Chadalavada, MD",1710180666,"47-5554737","TX","PE - Midland Inpatient Medical Association","CAQH","Participating","CAQH Reattested","2023-03-13","11714128","","2023-03-13","3/13/2023 CAQH reviewed and re-attested.  DCannon"]
["Jaya Krishna Chadalavada, MD",1710180666,"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"]
["Jaya Krishna Chadalavada, MD",1710180666,"47-5554737","TX","PE - Midland Inpatient Medical Association","Medicaid","Participating","Enrollment Complete","","341080503","364596201","2020-02-19","02/19/2020 - Per payer portal, this provider is linked to group TPI 364596201 and this provider is affiliated with the following plans: FirstCare - Lubbock, TRADITIONAL MEDICAID, Amerigroup - MRSA West, Amerigroup - MRSA West, FirstCare - MRSA West, Amerigroup Texas, Inc. - MRSA West - stacey Hudak"]
["Jaya Krishna Chadalavada, MD",1710180666,"47-5554737","TX","PE - Midland Inpatient Medical Association","Humana","Participating","Enrollment Complete","2020-01-01","1710180666","","2020-07-02","7/2/2020 - Received email spreadsheet from the payor confirming that this provider is EFF ath this service location and PAR with the PRIMED DELEGATED agreement - Pam Porter"]
["Jaya Krishna Chadalavada, MD",1710180666,"47-5554737","TX","PE - Midland Inpatient Medical Association","Ambetter","Participating","Enrollment Complete","2022-04-01","","","2022-06-13",""]
["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","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","Rail Road Medicare","Participating","Enrollment Complete","2016-08-24","P01732063","DW7662","2020-10-09","10/9/2020 - Was able to confirm RR Medicare enrollment thorugh payer site - Stacey Hudak"]
["Jaya Krishna Chadalavada, MD",1710180666,"47-5554737","TX","PE - Midland Inpatient Medical Association","Aetna","Participating","Enrollment Complete","2017-02-06","1710180666","","2020-08-31","08/31/2020 -moved to completed status after reviewing follow up complete note - 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"]
["Jaya Krishna Chadalavada, MD",1710180666,"47-5554737","TX","PE - Midland Inpatient Medical Association","Amerigroup","Participating","Enrollment Complete","2016-12-16","1710180666","","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"]
["Jaya Krishna Chadalavada, MD",1710180666,"47-5554737","TX","PE - Midland Inpatient Medical Association","Caprock (CapStar)","Participating","Enrollment Complete","2020-03-01","1710180666","","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"]
["Jaya Krishna Chadalavada, MD",1710180666,"47-5554737","TX","PE - Midland Inpatient Medical Association","Scott&White (First Care)","Participating","Enrollment Complete","2016-12-15","1710180666","","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"]
["Jaya Krishna Chadalavada, MD",1710180666,"47-5554737","TX","PE - Midland Inpatient Medical Association","Cigna","Participating","Enrollment Complete","2016-09-15","1710180666","","2020-02-20","02/20/2020 - Payer confirmed that this provider is EFF as of 9-15-2016 at this service location under a DELEGATED ENTITY - but the payer couldnt identify who - Stacey Hudak"]
["Irina Remsburg, MD",1639439185,"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"]
["Irina Remsburg, MD",1639439185,"83-0358685","TX","PE - Midland Community Healthcare Services","Triwest VA","Enrollment Stopped","In House Enrollment","","","","2021-08-07","7/31/2021 This will be processed by group. KFrazier"]
["Irina Remsburg, MD",1639439185,"83-0358685","TX","","Triwest VA","Enrollment Stopped","In House Enrollment","","","","2021-08-07","7/31/2021 This will be processed by group. KFrazier"]
["Irina Remsburg, MD",1639439185,"83-0358685","TX","PE - Midland Community Healthcare Services","Triwest VA","Enrollment Stopped","Application Submitted","","","","2022-11-29","08/19/2022 - Submitted application to TriWest VA (sent to Scarlett Abigail, Scarlett_Abigail@bcbstx.com)"]
["Irina Remsburg, MD",1639439185,"83-0358685","TX","","Triwest VA","Enrollment Stopped","Application Submitted","","","","2022-11-29","08/19/2022 - Submitted application to TriWest VA (sent to Scarlett Abigail, Scarlett_Abigail@bcbstx.com)"]
["Irina Remsburg, MD",1639439185,"83-0358685","TX","PE - Midland Community Healthcare Services","Triwest VA","Enrollment Stopped","Enrollment Stopped","","","","2022-11-29","10/17/2022 - Received roster from Scarlett of TriWest VA; provider status: \"No Action.  Pediatrics specialty.\""]
["Irina Remsburg, MD",1639439185,"83-0358685","TX","","Triwest VA","Enrollment Stopped","Enrollment Stopped","","","","2022-11-29","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","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"]
["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","Medicare","In House Enrollment","In House Enrollment","","","","2021-08-04","8/4/2021 Medicare enrollment completed in-house by MCHS.  DCannon"]
["Irina Remsburg, MD",1639439185,"83-0358685","TX","PE - Midland Community Healthcare Services","Boon Chapman","Participating","Enrollment Complete","2020-06-30","","","2022-06-01","6/1/2022 Provider is PAR w/ Multiplan effective 6/20/2020.  DCannon"]
["Irina Remsburg, MD",1639439185,"83-0358685","TX","PE - Midland Community Healthcare Services","Multiplan","Participating","Enrollment Complete","2020-06-30","13484074","","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","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","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 06/01/2021.  DCannon"]
["Irina Remsburg, MD",1639439185,"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"]
["Irina Remsburg, MD",1639439185,"83-0358685","TX","PE - Midland Community Healthcare Services","Caprock (CapStar)","Participating","Enrollment Complete","2015-11-01","","","2020-09-14",""]
["Irina Remsburg, MD",1639439185,"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"]
["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","Caprock (CapStar)","Participating","Enrollment Complete","2015-11-01","","","2020-09-14",""]
["Irina Remsburg, MD",1639439185,"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"]
["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","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"]
["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","First Health Coventry","Participating","Enrollment Complete","2020-09-01","1639439185","","2020-09-24","09/24/2020 - moved to completed status - PRIMED DELEGATION - Stacey Hudak"]
["Irina Remsburg, MD",1639439185,"83-0358685","TX","PE - Midland Community Healthcare Services","Cigna","Participating","Enrollment Complete","2019-09-01","7132451","","2020-08-04","8/4/2020 - moved to the completed status after getting an email from the payer stating this demo update has been completed - Stacey Hudak"]
["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","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"]
["Irina Remsburg, MD",1639439185,"83-0358685","TX","PE - Midland Community Healthcare Services","Boon Chapman","Participating","Enrollment Complete","2022-03-01","","","2022-09-13","9/13/2022 Per roster received from Multiplan provider is PAR and linked to group TIN/location effective 3/1/2022.  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","Cigna","Participating","Enrollment Complete","2021-06-01","7132451","","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 7132451. KFrazier"]
["Irina Remsburg, MD",1639439185,"83-0358685","TX","PE - Midland Community Healthcare Services","Galaxy Health","Participating","Enrollment Complete","2020-02-12","","","2022-06-01","6/1/2022 Per Galaxy Health provider is PAR and linked to group TIN/location effective 2/12/2020.  DCannon"]
["Irina Remsburg, MD",1639439185,"83-0358685","TX","PE - Midland Community Healthcare Services","Aetna","Participating","Enrollment Complete","2020-11-15","5435845","7496529","2020-11-24","11/24/2020 - Per F/U report provider is linked and participating in Network effective 11/15/2015 under the group and TIN#. Provider ID 5435845. Group ID 7496529.  DCannon"]
["Irina Remsburg, MD",1639439185,"83-0358685","TX","PE - Midland Community Healthcare Services","Superior","Participating","Enrollment Complete","2020-09-01","1639439185","","2020-09-02","09/02/2020 - Rec'd email from the payer stating this provider has been added to the delegation at this TIN/service location - Stacey Hudak"]
["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","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"]
["Irina Remsburg, MD",1639439185,"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"]
["Irina Remsburg, MD",1639439185,"83-0358685","TX","PE - Midland Community Healthcare Services","First Health Coventry","Participating","Enrollment Complete","2021-06-01","","","2021-11-03","11/3/2021  Per First Health online provider directory provider is PAR and linked to group/locations  effective 6/1/2021.  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","Aetna","Participating","Enrollment Complete","2020-11-15","5435845","7496529","2020-11-24","11/24/2020 - Per F/U report provider is linked and participating in Network effective 11/15/2015 under the group and TIN#. Provider ID 5435845. Group ID 7496529.  DCannon"]
["Irina Remsburg, MD",1639439185,"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"]
["Irina Remsburg, MD",1639439185,"83-0358685","TX","PE - Midland Community Healthcare Services","Caprock (CapStar)","Participating","Enrollment Complete","2021-06-01","","","2021-08-06","8/6/2021 Rcvd email from Caprock ProviderServices.T8@90degreebenefits.com that monthly delegated roster provider load is complete and provider is loaded under TIN at location effective 6/1/2021.  DCannon"]
["Irina Remsburg, MD",1639439185,"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"]
["Irina Remsburg, MD",1639439185,"83-0358685","TX","PE - Midland Community Healthcare Services","Medicaid","Participating","Enrollment Complete","2020-09-01","349777802","165581301","2020-10-01","10/01/2020 - Rec'd emailed confirmation of enrollment from the clinic - Stacey Hudak"]
["Irina Remsburg, MD",1639439185,"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"]
["Irina Remsburg, MD",1639439185,"83-0358685","TX","PE - Midland Community Healthcare Services","IMS","Participating","Enrollment Complete","2020-08-01","","","2020-08-25","Confirmed provider is participating at this location as of 8/1/2020. Kimberly Frazier"]
["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","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"]
["Irina Remsburg, MD",1639439185,"83-0358685","TX","PE - Midland Community Healthcare Services","Superior","Participating","Enrollment Complete","2020-09-01","1639439185","","2020-09-02","09/02/2020 - Rec'd email from the payer stating this provider has been added to the delegation at this TIN/service location - Stacey Hudak"]
["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","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","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","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","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","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","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","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","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"]
["Irina Remsburg, MD",1639439185,"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 06/01/2021.  DCannon"]
["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","Galaxy Health","Participating","Enrollment Complete","2020-02-12","","","2022-06-01","6/1/2022 Per Galaxy Health provider is PAR and linked to group TIN/location effective 2/12/2020.  DCannon"]
["Irina Remsburg, MD",1639439185,"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"]
["Irina Remsburg, MD",1639439185,"83-0358685","TX","PE - Midland Community Healthcare Services","Medicare","Participating","Enrollment Complete","2020-09-01","1F3577","00304W","2020-10-14","10/14/2020 - Rec'd requested payer welcome letter from the clinic to update this payer line - Stacey Hudak"]
["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","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","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","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","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","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","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","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","In House Enrollment","","","","2021-08-07","7/31/2021 This will be processed by group. KFrazier"]
["Irina Remsburg, MD",1639439185,"83-0358685","TX","","Triwest VA","Enrollment Stopped","In House Enrollment","","","","2021-08-07","7/31/2021 This will be processed by group. KFrazier"]
["Irina Remsburg, MD",1639439185,"83-0358685","TX","PE - Midland Community Healthcare Services","Triwest VA","Enrollment Stopped","Application Submitted","","","","","08/19/2022 - Submitted application to TriWest VA (sent to Scarlett Abigail, Scarlett_Abigail@bcbstx.com)"]
["Irina Remsburg, MD",1639439185,"83-0358685","TX","","Triwest VA","Enrollment Stopped","Application Submitted","","","","","08/19/2022 - Submitted application to TriWest VA (sent to Scarlett Abigail, Scarlett_Abigail@bcbstx.com)"]
["Irina Remsburg, MD",1639439185,"83-0358685","TX","PE - Midland Community Healthcare Services","Triwest VA","Enrollment Stopped","Enrollment Stopped","","","","","10/17/2022 - Received roster from Scarlett of TriWest VA; provider status: \"No Action.  Pediatrics specialty.\""]
["Irina Remsburg, MD",1639439185,"83-0358685","TX","","Triwest VA","Enrollment Stopped","Enrollment Stopped","","","","","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","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","Medicare","In House Enrollment","In House Enrollment","","","","2021-08-04","8/4/2021 Medicare enrollment completed in-house by MCHS.  DCannon"]
["Irina Remsburg, MD",1639439185,"83-0358685","TX","PE - Midland Community Healthcare Services","TriCare Standard","Participating","Enrollment Complete","2020-09-29","","","2020-10-23","10/23/2020 Upon review of the self-service portal provider is certified as a non-network provider under Group Tax ID and location is confirmed, effective 9/29/2020. Kimberly Frazier"]
["Irina Remsburg, MD",1639439185,"83-0358685","TX","PE - Midland Community Healthcare Services","Caprock (CapStar)","Participating","Enrollment Complete","2021-06-01","","","2021-08-06","8/6/2021 Rcvd email from Caprock ProviderServices.T8@90degreebenefits.com that monthly delegated roster provider load is complete and provider is loaded under TIN at location effective 6/1/2021.  DCannon"]
["Irina Remsburg, MD",1639439185,"83-0358685","TX","PE - Midland Community Healthcare Services","TriCare Standard","Participating","Enrollment Complete","2021-12-14","","","2022-02-11","2/10/2022 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","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"]
["Irina Remsburg, MD",1639439185,"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"]
["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","Cigna","Participating","Enrollment Complete","2021-06-01","7132451","","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 7132451. KFrazier"]
["Irina Remsburg, MD",1639439185,"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"]
["Irina Remsburg, MD",1639439185,"83-0358685","TX","PE - Midland Community Healthcare Services","First Health Coventry","Participating","Enrollment Complete","2021-06-01","","","2021-11-03","11/3/2021  Per First Health online provider directory provider is PAR and linked to group/locations  effective 6/1/2021.  DCannon"]
["Irina Remsburg, MD",1639439185,"83-0358685","TX","PE - Midland Community Healthcare Services","Cigna","Participating","Enrollment Complete","2019-09-01","7132451","","2020-08-04","8/4/2020 - rec'd email from the payer stating that this demo update has been completed.\" - Stacey Hudak"]
["Irina Remsburg, MD",1639439185,"83-0358685","TX","PE - Midland Community Healthcare Services","Medicaid","In House Enrollment","In House Enrollment","","","","2021-08-04",""]
["Irina Remsburg, MD",1639439185,"83-0358685","TX","PE - Midland Community Healthcare Services","Medicare","Participating","Enrollment Complete","2020-09-01","1F3577","00304W","2020-10-14","10/14/2020 - Rec'd requested payer welcome letter from the clinic to update this payer line - Stacey Hudak"]
["Irina Remsburg, MD",1639439185,"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"]
["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"]
["Casey Mraz, MD",1659728855,"75-2656723","TX","PE - Premier Family Care I, Inc","Superior","Participating","Enrollment Complete","2019-08-01","1659728855","","2020-07-14","07/14/2020 - Rec'd spreadsheet from the delegated team stating this provider has been linked to the PriMed contract since 8-1-2019 **see the other enrollment complete line to see details about when this provider became effective with various specific products** - stacey Hudak"]
["Casey Mraz, MD",1659728855,"75-2656723","TX","PE - Premier Family Care I, Inc","Multiplan","Participating","Enrollment Complete","2019-08-07","1659728855","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 8-7-2019. Provider is networked with Beechstreet. - Stacey Hudak"]
["Casey Mraz, MD",1659728855,"75-2656723","TX","PE - Premier Family Care I, Inc","HealthSmart PPO","Participating","Enrollment Complete","2019-06-12","13681723","","2020-07-21","07/21/2020 - rec'd spreadsheet from the payer stating this provider is EFF with this TIN/service location as of 6-12-2019 under the WEST TEXAS PHYSICIANS ALLIANCE MDDO delegation - Stacey Hudak"]
["Casey Mraz, MD",1659728855,"75-2656723","TX","PE - Premier Family Care I, 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"]
["Casey Mraz, MD",1659728855,"75-2656723","TX","PE - Premier Family Care I, Inc","IMS","Participating","Enrollment Complete","2019-06-14","1659728855","","2020-06-22","06/22/2020- Rec'd email from the payer confirming this provider is PAR with this group/service location - Stacey Hudak"]
["Casey Mraz, MD",1659728855,"75-2656723","TX","PE - Premier Family Care I, Inc","Aetna","Participating","Enrollment Complete","2019-10-04","1659728855","","2020-02-03","02/03/2020 - Confirmed with the payer that this provider is EFF 10-4-2019 under a DIRECT CONTRACT. Next recred is 10-4-2022 and service location is on file and linked to provider - Stacey  Hudak"]
["Casey Mraz, MD",1659728855,"75-2656723","TX","PE - Premier Family Care I, 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 I, Inc","USA PPO","Participating","Enrollment Complete","2019-06-16","","","2020-09-09","Confirmed provider is participating with PPO and H&W networks (list of networks attached). Kimberly Frazier"]
["Casey Mraz, MD",1659728855,"75-2656723","TX","PE - Premier Family Care I, Inc","Medicaid","Participating","Enrollment Complete","","396567501","079837301","2020-01-29","01/29/2020 - Provider is linked to group. Provider is only PAR with traditional medicaid - stacey Hudak"]
["Casey Mraz, MD",1659728855,"75-2656723","TX","PE - Premier Family Care I, Inc","Amerigroup","Participating","Enrollment Complete","2019-10-21","1659728855","","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 the payer (Multiplan/Texas True Choice) confirming that this EFF info is true - Stacey Hudak"]
["Casey Mraz, MD",1659728855,"75-2656723","TX","PE - Premier Family Care I, Inc","United Health Care","Participating","Enrollment Complete","2019-05-29","7093824","","2020-07-30",""]
["Casey Mraz, MD",1659728855,"75-2656723","TX","PE - Premier Family Care I, Inc","Boon Chapman","Participating","Enrollment Complete","2019-08-07","","","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 8/7/2019.  DCannon"]
["Casey Mraz, MD",1659728855,"75-2656723","TX","PE - Premier Family Care I, Inc","Triwest VA","Facility Enrollment","Application Submitted","","","","2022-11-23","08/19/2022 - Submitted application to TriWest VA (sent to Scarlett Abigail, Scarlett_Abigail@bcbstx.com)"]
["Casey Mraz, MD",1659728855,"75-2656723","TX","","Triwest VA","Facility Enrollment","Application Submitted","","","","2022-11-23","08/19/2022 - Submitted application to TriWest VA (sent to Scarlett Abigail, Scarlett_Abigail@bcbstx.com)"]
["Casey Mraz, MD",1659728855,"75-2656723","TX","PE - Premier Family Care I, Inc","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.\""]
["Casey Mraz, MD",1659728855,"75-2656723","TX","","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.\""]
["Casey Mraz, MD",1659728855,"75-2656723","TX","PE - Premier Family Care I, Inc","CAQH","Participating","CAQH Reattested","2023-03-13","14428752","","2023-03-13","3/13/2023 CAQH reviewed and re-attested.  DCannon"]
["Casey Mraz, MD",1659728855,"75-2656723","TX","PE - Premier Family Care I, 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 I, Inc","Scott&White (First Care)","Participating","Enrollment Complete","2019-05-31","1659728855","","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"]
["Casey Mraz, MD",1659728855,"75-2656723","TX","PE - Premier Family Care I, Inc","Humana","Participating","Enrollment Complete","2020-01-01","1659728855","","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"]
["Casey Mraz, MD",1659728855,"75-2656723","TX","PE - Premier Family Care I, Inc","Galaxy Health","Participating","Enrollment Complete","2019-06-12","1659728855","","2020-07-10","07/10/2020 - updated payer line to enrollment complete status instead of \"Delegated status\" for report running purposes - Stacey Hudak"]
["Casey Mraz, MD",1659728855,"75-2656723","TX","PE - Premier Family Care I, Inc","Omni PPO","Participating","Enrollment Complete","2019-06-14","1659728855","","2020-06-25",""]
["Casey Mraz, MD",1659728855,"75-2656723","TX","PE - Premier Family Care I, Inc","Caprock (CapStar)","Participating","Enrollment Complete","2019-06-12","1659728855","","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"]
["Casey Mraz, MD",1659728855,"75-2656723","TX","PE - Premier Family Care I, Inc","Medicare","Participating","Enrollment Complete","2019-04-01","786679","0008AH","2020-01-29","01/29/2020 - confirmed EFF through PECOS group enrollment - Stacey Hudak"]
["Casey Mraz, MD",1659728855,"75-2656723","TX","PE - Premier Family Care I, Inc","TriCare Standard","Participating","Enrollment Complete","2021-01-08","","","2021-03-31","3/31/2021 Confirmed provider certified at location via Humana-Military portal effective 1/8/2021.  DCannon"]
["Casey Mraz, MD",1659728855,"75-2656723","TX","PE - Premier Family Care I, Inc","Cigna","Participating","Enrollment Complete","2019-09-20","1659728855","","2020-02-20","02/20/2020 - Rec'd verification from the payer that this provider is EFF 9-20-2019 and linked to this service location under a DIRECT CONTRACT with this payer - Stacey Hudak"]
["Ali R Khan, MD",1760714380,"47-5554737","TX","PE - Midland Inpatient Medical Association","Triwest VA","Enrollment Stopped","Enrollment Stopped","","","","","Practice is hospital-based; not eligible for TriWest VA enrollment"]
["Ali R Khan, MD",1760714380,"47-5554737","TX","PE - Midland Inpatient Medical Association","Medicaid","Participating","Enrollment Complete","2017-07-09","378408401","364596201","2020-12-31","12/31/2020 Confirmed provider is participating under group with assigned TPI 378408401, effective 7/9/2017. Next revalidation due 1/16/2023. KFrazier"]
["Ali R Khan, MD",1760714380,"47-5554737","TX","PE - Midland Inpatient Medical Association","HealthSmart PPO","Participating","Enrollment Complete","2021-01-07","","","2021-03-01","3/1/2021 Rcvd confirmation that provider is participating with Healthsmart PPO effective 1/7/2021.  DCannon"]
["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","Boon Chapman","Participating","Enrollment Complete","2021-01-07","","","2022-09-13","9/13/2022 Per roster received from Multiplan provider is PAR and linked to group TIN/location effective 1/7/2021.  DCannon"]
["Ali R Khan, MD",1760714380,"47-5554737","TX","PE - Midland Inpatient Medical Association","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"]
["Ali R Khan, MD",1760714380,"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"]
["Ali R Khan, MD",1760714380,"47-5554737","TX","PE - Midland Inpatient Medical Association","United Health Care","Participating","Enrollment Complete","2020-11-01","003488587","","2021-05-12","5/12/2021 Recevied an email from United_Healthcare_Provider_Operations@uhc.com confirming provider has been loaded under group Tax ID and is now participating effective 11/1/2020 under PR-5736425 with assigned MPIN 003488587. KFrazier"]
["Ali R Khan, MD",1760714380,"47-5554737","TX","PE - Midland Inpatient Medical Association","Cigna","Participating","Enrollment Complete","2020-11-01","0843337","","2021-02-26","2/26/2021 Received internal email of approval with an effective date of 11/1/2020 and assigned PID 0843337. KFrazier"]
["Ali R Khan, MD",1760714380,"47-5554737","TX","PE - Midland Inpatient Medical Association","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"]
["Ali R Khan, MD",1760714380,"47-5554737","TX","PE - Midland Inpatient Medical Association","Scott&White (First Care)","Participating","Enrollment Complete","2019-08-09","","","2021-01-29","1/29/2021 - Rcvd roster from Scott&White (First Care) confirming participation of provider with TIN and location effective dates.  DCannon"]
["Ali R Khan, MD",1760714380,"47-5554737","TX","PE - Midland Inpatient Medical Association","CAQH","Participating","CAQH Reattested","2022-11-15","","","2022-11-15","11/15/2022 CAQH reviewed and re-attested.  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","USA PPO","Participating","Enrollment Complete","2021-01-07","1297078","","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"]
["Ali R Khan, MD",1760714380,"47-5554737","TX","PE - Midland Inpatient Medical Association","First Health Coventry","In Process","Enrollment Complete","","","","2023-01-18","01.18.2023: S/W Teresita 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# 2438435. Physical location is on file. Don't have payer#. Call Ref# 516478. - Mary Rose Acebedo"]
["Ali R Khan, MD",1760714380,"47-5554737","TX","PE - Midland Inpatient Medical Association","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"]
["Ali R Khan, MD",1760714380,"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."]
["Ali R Khan, MD",1760714380,"47-5554737","TX","PE - Midland Inpatient Medical Association","Medicare","Participating","Enrollment Complete","2017-07-09","590902ZV0W","519061","2020-12-31","12/31/2020 Confirmed provider is participating under group with assigned PTAN 590902ZV0W effective 7/9/2017. KFrazier"]
["Ali R Khan, MD",1760714380,"47-5554737","TX","PE - Midland Inpatient Medical Association","Rail Road Medicare","Participating","Enrollment Complete","2017-07-07","P01936022","DW7662","2020-12-31","12/31/2020 Confirmed provider is participating under group with RR PTAN P01936022, effective 7/7/2017. KFrazier"]
["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"]
["Ali R Khan, MD",1760714380,"47-5554737","TX","PE - Midland Inpatient Medical Association","TriCare Standard","Participating","Enrollment Complete","2017-08-01","","","2020-12-31","12/31/2020 Confirmed via self-service portal, provider is certified as non-network under group effective 08/01/2017. KFrazier"]
["Ali R Khan, MD",1760714380,"47-5554737","TX","PE - Midland Inpatient Medical Association","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"]
["Ali R Khan, MD",1760714380,"47-5554737","TX","PE - Midland Inpatient Medical Association","Galaxy Health","Participating","Enrollment Complete","2020-03-24","","","2021-03-15","3/15/2021 Rcvd email from Michelle Monroe at Galaxy Health confirming provider is participating under TIN and at location effective 03/24/2020.  DCannon"]
["Saranya Rajasekar, MD",1871028365,"75-2656723","TX","PE - Premier Family Care I, Inc","Triwest VA","Facility Enrollment","Application Submitted","","","","2022-11-28","08/19/2022 - Submitted application to TriWest VA (sent to Scarlett Abigail, Scarlett_Abigail@bcbstx.com)"]
["Saranya Rajasekar, MD",1871028365,"75-2656723","TX","","Triwest VA","Facility Enrollment","Application Submitted","","","","2022-11-28","08/19/2022 - Submitted application to TriWest VA (sent to Scarlett Abigail, Scarlett_Abigail@bcbstx.com)"]
["Saranya Rajasekar, MD",1871028365,"75-2656723","TX","","Triwest VA","Facility Enrollment","Application Submitted","","","","2022-11-28","08/19/2022 - Submitted application to TriWest VA (sent to Scarlett Abigail, Scarlett_Abigail@bcbstx.com)"]
["Saranya Rajasekar, MD",1871028365,"75-2656723","TX","PE - Premier Family Care I, Inc","Triwest VA","Facility 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.\""]
["Saranya Rajasekar, MD",1871028365,"75-2656723","TX","","Triwest VA","Facility 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.\""]
["Saranya Rajasekar, MD",1871028365,"75-2656723","TX","","Triwest VA","Facility 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.\""]
["Saranya Rajasekar, MD",1871028365,"75-2656723","TX","PE - Premier Family Care I, Inc","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","","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","","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","PE - Premier Family Care I, 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"]
["Saranya Rajasekar, MD",1871028365,"75-2656723","TX","","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"]
["Saranya Rajasekar, MD",1871028365,"75-2656723","TX","","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"]
["Saranya Rajasekar, MD",1871028365,"75-2656723","TX","PE - Premier Family Care I, Inc","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","","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","","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 I, Inc","CAQH","Participating","CAQH Reattested","2023-01-17","","","2023-01-17","1/17/2023 CAQH reviewed and re-attested.  DCannon"]
["Saranya Rajasekar, MD",1871028365,"75-2656723","TX","","CAQH","Participating","CAQH Reattested","2023-01-17","","","2023-01-17","1/17/2023 CAQH reviewed and re-attested.  DCannon"]
["Saranya Rajasekar, MD",1871028365,"75-2656723","TX","","CAQH","Participating","CAQH Reattested","2023-01-17","","","2023-01-17","1/17/2023 CAQH reviewed and re-attested.  DCannon"]
["Saranya Rajasekar, MD",1871028365,"75-2656723","TX","PE - Premier Family Care I, 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","","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","","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","PE - Premier Family Care I, Inc","Cigna","Participating","Enrollment Complete","2022-07-01","7352247","","2022-04-18","4/18/2022 Received email from pdmcogz@cigna.com, PID- 7352247. Request has been completed  under Cigna internal reference #  “W202204052277847 \" Eff 7.1.2022. Cbankston"]
["Saranya Rajasekar, MD",1871028365,"75-2656723","TX","","Cigna","Participating","Enrollment Complete","2022-07-01","7352247","","2022-04-18","4/18/2022 Received email from pdmcogz@cigna.com, PID- 7352247. Request has been completed  under Cigna internal reference #  “W202204052277847 \" Eff 7.1.2022. Cbankston"]
["Saranya Rajasekar, MD",1871028365,"75-2656723","TX","","Cigna","Participating","Enrollment Complete","2022-07-01","7352247","","2022-04-18","4/18/2022 Received email from pdmcogz@cigna.com, PID- 7352247. Request has been completed  under Cigna internal reference #  “W202204052277847 \" Eff 7.1.2022. Cbankston"]
["Saranya Rajasekar, MD",1871028365,"75-2656723","TX","PE - Premier Family Care I, Inc","First Health Coventry","In Process","Enrollment Complete","","","","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","","First Health Coventry","In Process","Enrollment Complete","","","","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","","First Health Coventry","In Process","Enrollment Complete","","","","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","PE - Premier Family Care I, Inc","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"]
["Saranya Rajasekar, MD",1871028365,"75-2656723","TX","","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"]
["Saranya Rajasekar, MD",1871028365,"75-2656723","TX","","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"]
["Saranya Rajasekar, MD",1871028365,"75-2656723","TX","PE - Premier Family Care I, Inc","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","","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","","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","PE - Premier Family Care I, Inc","Amerigroup","Participating","Enrollment Complete","2022-04-11","","","2022-10-11","10/11/2022 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 4/11/2022.  DCannon"]
["Saranya Rajasekar, MD",1871028365,"75-2656723","TX","","Amerigroup","Participating","Enrollment Complete","2022-04-11","","","2022-10-11","10/11/2022 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 4/11/2022.  DCannon"]
["Saranya Rajasekar, MD",1871028365,"75-2656723","TX","","Amerigroup","Participating","Enrollment Complete","2022-04-11","","","2022-10-11","10/11/2022 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 4/11/2022.  DCannon"]
["Saranya Rajasekar, MD",1871028365,"75-2656723","TX","PE - Premier Family Care I, 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"]
["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","","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","PE - Premier Family Care I, Inc","USA PPO","Participating","Enrollment Complete","2022-04-11","","","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 4/11/2022.  DCannon"]
["Saranya Rajasekar, MD",1871028365,"75-2656723","TX","","USA PPO","Participating","Enrollment Complete","2022-04-11","","","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 4/11/2022.  DCannon"]
["Saranya Rajasekar, MD",1871028365,"75-2656723","TX","","USA PPO","Participating","Enrollment Complete","2022-04-11","","","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 4/11/2022.  DCannon"]
["Saranya Rajasekar, MD",1871028365,"75-2656723","TX","PE - Premier Family Care I, 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.  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","","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 I, 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"]
["Saranya Rajasekar, MD",1871028365,"75-2656723","TX","","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"]
["Saranya Rajasekar, MD",1871028365,"75-2656723","TX","","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"]
["Saranya Rajasekar, MD",1871028365,"75-2656723","TX","PE - Premier Family Care I, 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","","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","","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","PE - Premier Family Care I, 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"]
["Saranya Rajasekar, MD",1871028365,"75-2656723","TX","","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"]
["Saranya Rajasekar, MD",1871028365,"75-2656723","TX","","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"]
["Saranya Rajasekar, MD",1871028365,"75-2656723","TX","PE - Premier Family Care I, Inc","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","","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","","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","PE - Premier Family Care I, Inc","Galaxy Health","Participating","Enrollment Complete","2022-04-11","","","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  4/11/2022.  DCannon"]
["Saranya Rajasekar, MD",1871028365,"75-2656723","TX","","Galaxy Health","Participating","Enrollment Complete","2022-04-11","","","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  4/11/2022.  DCannon"]
["Saranya Rajasekar, MD",1871028365,"75-2656723","TX","","Galaxy Health","Participating","Enrollment Complete","2022-04-11","","","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  4/11/2022.  DCannon"]
["Saranya Rajasekar, MD",1871028365,"75-2656723","TX","PE - Premier Family Care I, 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"]
["Saranya Rajasekar, MD",1871028365,"75-2656723","TX","","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"]
["Saranya Rajasekar, MD",1871028365,"75-2656723","TX","","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"]
["Saranya Rajasekar, MD",1871028365,"75-2656723","TX","PE - Premier Family Care I, Inc","Omni PPO","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"]
["Saranya Rajasekar, MD",1871028365,"75-2656723","TX","","Omni PPO","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"]
["Saranya Rajasekar, MD",1871028365,"75-2656723","TX","","Omni PPO","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"]
["Saranya Rajasekar, MD",1871028365,"75-2656723","TX","PE - Premier Family Care I, Inc","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"]
["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","PE - Premier Family Care I, Inc","Medicare","Participating","Enrollment Complete","2022-06-01","2D4132","0008AH","2022-05-18","5/18/2022 Per PECOS provider is PAR and linked to group/location effective 6/1/2022.  PTAN # 2D4132.  DCannon"]
["Saranya Rajasekar, MD",1871028365,"75-2656723","TX","","Medicare","Participating","Enrollment Complete","2022-06-01","2D4132","0008AH","2022-05-18","5/18/2022 Per PECOS provider is PAR and linked to group/location effective 6/1/2022.  PTAN # 2D4132.  DCannon"]
["Saranya Rajasekar, MD",1871028365,"75-2656723","TX","","Medicare","Participating","Enrollment Complete","2022-06-01","2D4132","0008AH","2022-05-18","5/18/2022 Per PECOS provider is PAR and linked to group/location effective 6/1/2022.  PTAN # 2D4132.  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",1265872592,863825791,"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",1265872592,863825791,"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,"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"]
["Deepika Devalla, MD",1265872592,"86-3825791","TX","PE - West Texas Ob/Gyn","Medicare","In Process","Application Submitted","","","","2023-03-16","3/16/2023 App submitted online via PECOS to add provider to group/locations.  App Tracking ID: T031620230002885  DCannon"]
["Deepika Devalla, MD",1265872592,"86-3825791","TX","PE - West Texas Ob/Gyn","Medicare","In Process","Application Submitted","","","","2023-03-16","3/16/2023 App submitted online via PECOS to add provider to group/locations.  App Tracking ID: T031620230002885  DCannon"]
["Deepika Devalla, MD",1265872592,863825791,"TX","PE - West Texas Ob/Gyn","Medicare","In Process","Application Submitted","","","","2023-03-16","3/16/2023 App submitted online via PECOS to add provider to group/locations.  App Tracking ID: T031620230002885  DCannon"]
["Deepika Devalla, MD",1265872592,863825791,"TX","PE - West Texas Ob/Gyn","Medicare","In Process","Application Submitted","","","","2023-03-16","3/16/2023 App submitted online via PECOS to add provider to group/locations.  App Tracking ID: T031620230002885  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",1265872592,863825791,"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",1265872592,863825791,"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",1265872592,863825791,"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",1265872592,863825791,"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,"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","Aetna","Participating","Enrollment Complete","2016-09-22","1265872592","","2020-06-09","06/09/2020 - S/W Nathan of Aetna @ 8003531232, provider NPI# is on file for the provider and is participating effective 09/22/2016 under the group and TIN#. Provider is delegated to  PE - Midland Inpatient Medical Association. Physical location is on file. Call ref# 5309657469. - Stacey Hudak"]
["Deepika Devalla, MD",1265872592,"47-5554737","TX","PE - Midland Inpatient Medical Association","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"]
["Deepika Devalla, MD",1265872592,"86-3825791","TX","PE - West Texas Ob/Gyn","Medicaid","Provider Load","Provider Load","","","","2022-04-13",""]
["Deepika Devalla, MD",1265872592,"86-3825791","TX","PE - West Texas Ob/Gyn","Medicaid","Provider Load","Provider Load","","","","2022-04-13",""]
["Deepika Devalla, MD",1265872592,863825791,"TX","PE - West Texas Ob/Gyn","Medicaid","Provider Load","Provider Load","","","","2022-04-13",""]
["Deepika Devalla, MD",1265872592,863825791,"TX","PE - West Texas Ob/Gyn","Medicaid","Provider Load","Provider Load","","","","2022-04-13",""]
["Deepika Devalla, MD",1265872592,"47-5554737","TX","PE - Midland Inpatient Medical Association","Galaxy Health","Participating","Enrollment Complete","2019-09-01","1265872592","","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"]
["Deepika Devalla, MD",1265872592,"47-5554737","TX","PE - Midland Inpatient Medical Association","TriCare Standard","Participating","Enrollment Complete","2018-09-27","1265872592","","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"]
["Deepika Devalla, MD",1265872592,"47-5554737","TX","PE - Midland Inpatient Medical Association","IMS","Participating","Enrollment Complete","2019-09-01","1265872592","","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"]
["Deepika Devalla, MD",1265872592,"47-5554737","TX","PE - Midland Inpatient Medical Association","Caprock (CapStar)","Participating","Enrollment Complete","2019-09-01","1265872592","","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"]
["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",1265872592,863825791,"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",1265872592,863825791,"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,"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,"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",1265872592,863825791,"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",1265872592,863825791,"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,"47-5554737","TX","PE - Midland Inpatient Medical Association","CAQH","Participating","CAQH Reattested","2023-02-12","13885700","","2023-02-12","2/12/2023 CAQH reviewed and re-attested.  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",1265872592,863825791,"TX","PE - West Texas Ob/Gyn","Triwest VA","In House Enrollment","In House Enrollment","","","","2022-04-13",""]
["Deepika Devalla, MD",1265872592,863825791,"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",1265872592,863825791,"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",1265872592,863825791,"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",1265872592,863825791,"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",1265872592,863825791,"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",1265872592,863825791,"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",1265872592,863825791,"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","Pending Other Enrollment","Application Submitted","","","","2022-09-21","9/21/2022 Faxed letter requesting to add First Health line of business to provider under this TIN and location to network management at 859-455-8650. HSmith."]
["Deepika Devalla, MD",1265872592,"86-3825791","TX","PE - West Texas Ob/Gyn","First Health Coventry","Pending Other Enrollment","Application Submitted","","","","2022-09-21","9/21/2022 Faxed letter requesting to add First Health line of business to provider under this TIN and location to network management at 859-455-8650. HSmith."]
["Deepika Devalla, MD",1265872592,863825791,"TX","PE - West Texas Ob/Gyn","First Health Coventry","Pending Other Enrollment","Application Submitted","","","","2022-09-21","9/21/2022 Faxed letter requesting to add First Health line of business to provider under this TIN and location to network management at 859-455-8650. HSmith."]
["Deepika Devalla, MD",1265872592,863825791,"TX","PE - West Texas Ob/Gyn","First Health Coventry","Pending Other Enrollment","Application Submitted","","","","2022-09-21","9/21/2022 Faxed letter requesting to add First Health line of business to provider under this TIN and location to network management at 859-455-8650. HSmith."]
["Deepika Devalla, MD",1265872592,"47-5554737","TX","PE - Midland Inpatient Medical Association","HealthSmart PPO","Participating","Enrollment Complete","2016-10-05","","","2021-04-11","4/11/2021 Rcvd email from HealthSmart <mdipsupport@healthsmart.com> confirming participation of provider under TIN and location effective 10/5/2016.  DCannon"]
["Deepika Devalla, MD",1265872592,"47-5554737","TX","PE - Midland Inpatient Medical Association","Rail Road Medicare","Participating","Enrollment Complete","2018-01-23","P02003362","DW7662","2020-05-04","05/04/2020 - Verified and updated payer line - Stacey Hudak"]
["Deepika Devalla, MD",1265872592,"47-5554737","TX","PE - Midland Inpatient Medical Association","Triwest VA","Enrollment Stopped","Enrollment Stopped","","","","","Practice is hospital-based; not eligible for TriWest VA enrollment"]
["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",1265872592,863825791,"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",1265872592,863825791,"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,"47-5554737","TX","PE - Midland Inpatient Medical Association","Cigna","Participating","Enrollment Complete","2018-02-15","1265872592","","2020-02-20","02/20/2020 - Payer confirmed that this provider is EFF as of 2-15-2018 at this service location under a DIRECT CONTRACT with this payer - Stacey Hudak"]
["Deepika Devalla, MD",1265872592,"86-3825791","TX","PE - West Texas Ob/Gyn","Rail Road Medicare","Pending Other Enrollment","Pending Other Enrollment","","","","2022-04-16","4/16/2022 Pending Medicare enrollment.  DCannon"]
["Deepika Devalla, MD",1265872592,"86-3825791","TX","PE - West Texas Ob/Gyn","Rail Road Medicare","Pending Other Enrollment","Pending Other Enrollment","","","","2022-04-16","4/16/2022 Pending Medicare enrollment.  DCannon"]
["Deepika Devalla, MD",1265872592,863825791,"TX","PE - West Texas Ob/Gyn","Rail Road Medicare","Pending Other Enrollment","Pending Other Enrollment","","","","2022-04-16","4/16/2022 Pending Medicare enrollment.  DCannon"]
["Deepika Devalla, MD",1265872592,863825791,"TX","PE - West Texas Ob/Gyn","Rail Road Medicare","Pending Other Enrollment","Pending Other Enrollment","","","","2022-04-16","4/16/2022 Pending Medicare enrollment.  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",1265872592,863825791,"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",1265872592,863825791,"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",1265872592,863825791,"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",1265872592,863825791,"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",1265872592,863825791,"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",1265872592,863825791,"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,"47-5554737","TX","PE - Midland Inpatient Medical Association","Omni PPO","Participating","Enrollment Complete","2019-09-01","1265872592","","2020-07-27","IMS complete"]
["Deepika Devalla, MD",1265872592,"47-5554737","TX","PE - Midland Inpatient Medical Association","USA PPO","Participating","Enrollment Complete","2021-01-26","1238661","","2021-01-01","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"]
["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,"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"]
["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",1265872592,863825791,"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",1265872592,863825791,"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","","","","2023-03-08","3/8/2023 Emailed USA PPO at ipa@usamco.com to check status of provider.  DCannon"]
["Deepika Devalla, MD",1265872592,"86-3825791","TX","PE - West Texas Ob/Gyn","USA PPO","In Process","Payor Follow Up","","","","2023-03-08","3/8/2023 Emailed USA PPO at ipa@usamco.com to check status of provider.  DCannon"]
["Deepika Devalla, MD",1265872592,863825791,"TX","PE - West Texas Ob/Gyn","USA PPO","In Process","Payor Follow Up","","","","2023-03-08","3/8/2023 Emailed USA PPO at ipa@usamco.com to check status of provider.  DCannon"]
["Deepika Devalla, MD",1265872592,863825791,"TX","PE - West Texas Ob/Gyn","USA PPO","In Process","Payor Follow Up","","","","2023-03-08","3/8/2023 Emailed USA PPO at ipa@usamco.com to check status of provider.  DCannon"]
["Deepika Devalla, MD",1265872592,"47-5554737","TX","PE - Midland Inpatient Medical Association","Scott&White (First Care)","Participating","Enrollment Complete","2018-01-23","1265872592","","2020-02-13","02/13/2020 - Rec'd emailed confirmation from the payer that this provider is EFF and DIRECT CONTRACTED under this TIN/Service Location - Stacey Hudak\n\n**rec'd confirmation that 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"]
["Deepika Devalla, MD",1265872592,"47-5554737","TX","PE - Midland Inpatient Medical Association","Superior","Participating","Enrollment Complete","2020-08-01","1265872592","","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"]
["Deepika Devalla, MD",1265872592,"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"]
["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"]
["Deepika Devalla, MD",1265872592,"47-5554737","TX","PE - Midland Inpatient Medical Association","Medicare","Participating","Enrollment Complete","2018-01-23","512648ZV0W","519061","2020-04-20","04/20/2020 - confirmed provider EFF through PECOS group enrollment - Stacey Hudak"]
["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",1265872592,863825791,"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",1265872592,863825791,"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)","In Process","Payor Follow Up","","","","2023-02-17","02.17.2023: Called Scott&White (First Care) @1-737-401-9207 however unable to reach a live representative and was routed to voicemail. Per IVR, Paul Cuter is not available at the moment. Leave detailed message including provider's information and consultant's email address and phone number for the call back. Verification request has been emailed to hpdelegation@bswhealth.org to verify provider credentialing status. - Danico Gabriel Melendres"]
["Deepika Devalla, MD",1265872592,"86-3825791","TX","PE - West Texas Ob/Gyn","Scott&White (First Care)","In Process","Payor Follow Up","","","","2023-02-17","02.17.2023: Called Scott&White (First Care) @1-737-401-9207 however unable to reach a live representative and was routed to voicemail. Per IVR, Paul Cuter is not available at the moment. Leave detailed message including provider's information and consultant's email address and phone number for the call back. Verification request has been emailed to hpdelegation@bswhealth.org to verify provider credentialing status. - Danico Gabriel Melendres"]
["Deepika Devalla, MD",1265872592,863825791,"TX","PE - West Texas Ob/Gyn","Scott&White (First Care)","In Process","Payor Follow Up","","","","2023-02-17","02.17.2023: Called Scott&White (First Care) @1-737-401-9207 however unable to reach a live representative and was routed to voicemail. Per IVR, Paul Cuter is not available at the moment. Leave detailed message including provider's information and consultant's email address and phone number for the call back. Verification request has been emailed to hpdelegation@bswhealth.org to verify provider credentialing status. - Danico Gabriel Melendres"]
["Deepika Devalla, MD",1265872592,863825791,"TX","PE - West Texas Ob/Gyn","Scott&White (First Care)","In Process","Payor Follow Up","","","","2023-02-17","02.17.2023: Called Scott&White (First Care) @1-737-401-9207 however unable to reach a live representative and was routed to voicemail. Per IVR, Paul Cuter is not available at the moment. Leave detailed message including provider's information and consultant's email address and phone number for the call back. Verification request has been emailed to hpdelegation@bswhealth.org to verify provider credentialing status. - Danico Gabriel Melendres"]
["Deepika Devalla, MD",1265872592,"47-5554737","TX","PE - Midland Inpatient Medical Association","First Health Coventry","Participating","Enrollment Complete","2020-09-01","1265872592","","2020-11-02","11/2/2020 - moved to completed status after reviewing follow up complete - Stacey Hudak"]
["Jeremiah L Stewart",1649713595,"47-5554737","TX","PE - Midland Inpatient Medical Association","Omni PPO","Participating","Enrollment Complete","2019-09-01","1649713595","","2020-07-27","IMS  complete"]
["Jeremiah L Stewart",1649713595,"47-5554737","TX","PE - Midland Inpatient Medical Association","Rail Road Medicare","Participating","Enrollment Complete","2016-11-17","P01787070","DW7662","2020-05-04","05/04/2020 - verified and moved to effective status - Stacey Hudak"]
["Jeremiah L Stewart",1649713595,"47-5554737","TX","PE - Midland Inpatient Medical Association","HealthSmart PPO","Participating","Enrollment Complete","2016-12-15","1649713595","","2020-06-05","06/05/2020 - Rec'd email from the payer stating this provider is EFF - Stacey Hudak"]
["Jeremiah L Stewart",1649713595,"47-5554737","TX","PE - Midland Inpatient Medical Association","Triwest VA","Enrollment Stopped","Enrollment Stopped","","","","","Practice is hospital-based; not eligible for TriWest VA enrollment"]
["Jeremiah L Stewart",1649713595,"47-5554737","TX","PE - Midland Inpatient Medical Association","Cigna","Participating","Enrollment Complete","2018-05-29","1649713595","","2020-02-20","02/20/2020 - Payer confirmed that this provider is EFF as of 5-29-2018 at this service location under a DIRECT CONTRACT with this payer - Stacey Hudak"]
["Jeremiah L Stewart",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",1649713595,"47-5554737","TX","PE - Midland Inpatient Medical Association","First Health Coventry","Participating","Enrollment Complete","2020-09-01","1649713595","","2020-09-24","09/24/2020 - moved to completed status after reviewing follow up complete note - Stacey Hudak"]
["Jeremiah L Stewart",1649713595,"47-5554737","TX","PE - Midland Inpatient Medical Association","TriCare Standard","Participating","Enrollment Complete","2016-12-15","1649713595","","2020-04-30","04/30/2020 - confirmed this provider/service location are linked to TIN through payer portal - Stacey Hudak"]
["Jeremiah L Stewart",1649713595,"47-5554737","TX","PE - Midland Inpatient Medical Association","Humana","Participating","Enrollment Complete","2020-01-01","1649713595","","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"]
["Jeremiah L Stewart",1649713595,"47-5554737","TX","PE - Midland Inpatient Medical Association","USA PPO","Participating","Enrollment Complete","2021-01-26","1312372","","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"]
["Jeremiah L Stewart",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",1649713595,"47-5554737","TX","PE - Midland Inpatient Medical Association","Medicaid","Participating","Enrollment Complete","2021-03-01","367256001","364596201","2021-03-01","3/1/2021 Received nofication TMHP revalidation has been completed successfully and provider is due for revalidation 2/25/2026. KFrazier"]
["Jeremiah L Stewart",1649713595,"47-5554737","TX","PE - Midland Inpatient Medical Association","IMS","Participating","Enrollment Complete","2019-09-01","1649713595","","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"]
["Jeremiah L Stewart",1649713595,"47-5554737","TX","PE - Midland Inpatient Medical Association","Superior","Participating","Enrollment Complete","2020-10-01","1649713595","","2020-10-02","10/02/2020 - Rec'd email from the payer stating this provider has been added to the primed roster - Stacey Hudak"]
["Jeremiah L Stewart",1649713595,"47-5554737","TX","PE - Midland Inpatient Medical Association","Caprock (CapStar)","Participating","Enrollment Complete","2020-03-01","1649713595","","",""]
["Jeremiah L Stewart",1649713595,"47-5554737","TX","PE - Midland Inpatient Medical Association","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"]
["Jeremiah L Stewart",1649713595,"47-5554737","TX","PE - Midland Inpatient Medical Association","United Health Care","Participating","Enrollment Complete","2020-03-12","1649713595","","2020-08-31","08/31/2020 - moved to completed status after reviewing follow up completed status - Stacey Hudak"]
["Jeremiah L Stewart",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"]
["Jeremiah L Stewart",1649713595,"47-5554737","TX","PE - Midland Inpatient Medical Association","Amerigroup","Participating","Enrollment Complete","2017-02-23","1649713595","","2020-03-20","03/20/2020 - Rec'd email from the payer (Multiplan/Texas True Choice) stating this provider is effective with Amerigroup at this service location. - Stacey Hudak"]
["Jeremiah L Stewart",1649713595,"47-5554737","TX","PE - Midland Inpatient Medical Association","Aetna","Participating","Enrollment Complete","2020-08-01","1649713595","","2020-08-31","08/31/2020 -moved to completed status after reviewing follow up complete note - Stacey Hudak"]
["Jeremiah L Stewart",1649713595,"47-5554737","TX","PE - Midland Inpatient Medical Association","Medicare","Participating","Enrollment Complete","2016-11-17","553519ZV0W","519061","2020-04-20","04/20/2020 - verified completed enrollment through group PECOS - Stacey Hudak"]
["Gypsy J Jasso, APRN, FNP-C",1013456649,"47-5554737","TX","PE - Midland Inpatient Medical Association","Galaxy Health","Participating","Enrollment Complete","2019-09-01","1013456649","","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"]
["Gypsy J Jasso, APRN, FNP-C",1013456649,"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","Rail Road Medicare","Participating","Enrollment Complete","2017-05-14","P01880121","DW7662","2020-05-04","05/04/2020 - verified and moved to effective status - Stacey Hudak"]
["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","Travelers WC","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"]
["Gypsy J Jasso, APRN, FNP-C",1013456649,"47-5554737","TX","PE - Midland Inpatient Medical Association","Superior","Participating","Enrollment Complete","2020-08-01","1013456649","","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"]
["Gypsy J Jasso, APRN, FNP-C",1013456649,"47-5554737","TX","PE - Midland Inpatient Medical Association","USA PPO","Participating","Enrollment Complete","2021-01-26","1312317","","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"]
["Gypsy J Jasso, APRN, FNP-C",1013456649,"47-5554737","TX","PE - Midland Inpatient Medical Association","HealthSmart PPO","Participating","Enrollment Complete","2017-06-06","1013456649","","2020-06-05","06/05/2020 - Rec'd an email from the payer stating this provider is EFF - Stacey Hudak"]
["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","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"]
["Gypsy J Jasso, APRN, FNP-C",1013456649,"47-5554737","TX","PE - Midland Inpatient Medical Association","Cigna","Participating","Enrollment Complete","2018-02-01","1013456649","","2020-02-20","02/20/2020 - Payer confirmed that this provider is EFF as of 2-1-2018 at this service location under a DIRECT CONTRACT with this payer - Stacey Hudak"]
["Gypsy J Jasso, APRN, FNP-C",1013456649,"47-5554737","TX","PE - Midland Inpatient Medical Association","Rail Road Medicare","Participating","Enrollment Complete","2020-05-08","1013456649","","2020-06-09","06/09/2020 - S/W Nathan of Aetna @ 8003531232, provider NPI# is on file for the provider and is participating effective 05/08/2020 under the group and TIN#. Provider is direct contract with Aertna. Physical location is on file. Call ref# 5309689188. - Stacey Hudak"]
["Gypsy J Jasso, APRN, FNP-C",1013456649,"47-5554737","TX","PE - Midland Inpatient Medical Association","Medicaid","Participating","Enrollment Complete","2017-05-17","372790101","364596201","2022-02-08","2/8/2022 Per TMHP web portal license has been updated.  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","Triwest VA","Enrollment Stopped","Enrollment Stopped","","","","","Practice is hospital-based; not eligible for TriWest VA enrollment"]
["Gypsy J Jasso, APRN, FNP-C",1013456649,"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"]
["Gypsy J Jasso, APRN, FNP-C",1013456649,"47-5554737","TX","PE - Midland Inpatient Medical Association","TriCare Standard","Participating","Enrollment Complete","2017-06-01","1013456649","","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"]
["Gypsy J Jasso, APRN, FNP-C",1013456649,"47-5554737","TX","PE - Midland Inpatient Medical Association","Humana","Participating","Enrollment Complete","2020-01-01","1013456649","","2020-07-15","7/15/2020 - Received email spreadsheet from the payor confirming that this provider is EFF at this service locatin and PAR with the PRIMED DELEGATED agreement - Pam Porter"]
["Gypsy J Jasso, APRN, FNP-C",1013456649,"47-5554737","TX","PE - Midland Inpatient Medical Association","IMS","Participating","Enrollment Complete","2019-09-01","1013456649","","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"]
["Gypsy J Jasso, APRN, FNP-C",1013456649,"47-5554737","TX","PE - Midland Inpatient Medical Association","Caprock (CapStar)","Participating","Enrollment Complete","2020-03-01","1013456649","","",""]
["Gypsy J Jasso, APRN, FNP-C",1013456649,"47-5554737","TX","PE - Midland Inpatient Medical Association","Gallagher","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"]
["Gypsy J Jasso, APRN, FNP-C",1013456649,"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"]
["Gypsy J Jasso, APRN, FNP-C",1013456649,"47-5554737","TX","PE - Midland Inpatient Medical Association","Amerigroup","Participating","Enrollment Complete","2018-04-20","1013456649","","2020-03-19","03/19/2020 - Rec'd email from the payer (Multiplan/Texas True Choice) confirming that this provider is EFF with Amerigroup at this serivce location. - Stacey Hudak"]
["Gypsy J Jasso, APRN, FNP-C",1013456649,"47-5554737","TX","PE - Midland Inpatient Medical Association","Omni PPO","Participating","Enrollment Complete","2019-09-01","1013456649","","2020-07-27","IMS complete"]
["Tzu-Ching Wu, MD",1396930426,"75-2656723","TX","PE - Premier Family Care I, Inc","Cigna","Terminated","Terminated","2019-01-01","1396930426","","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"]
["Tzu-Ching Wu, MD",1396930426,"75-2656723","TX","PE - Premier Family Care I, Inc","Caprock (CapStar)","Participating","Enrollment Complete","2019-05-21","1396930426","","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"]
["Tzu-Ching Wu, MD",1396930426,"75-2656723","TX","PE - Premier Family Care I, Inc","Triwest VA","Facility Enrollment","Application Submitted","","","","2022-11-28","08/19/2022 - Submitted application to TriWest VA (sent to Scarlett Abigail, Scarlett_Abigail@bcbstx.com)"]
["Tzu-Ching Wu, MD",1396930426,"75-2656723","TX","","Triwest VA","Facility Enrollment","Application Submitted","","","","2022-11-28","08/19/2022 - Submitted application to TriWest VA (sent to Scarlett Abigail, Scarlett_Abigail@bcbstx.com)"]
["Tzu-Ching Wu, MD",1396930426,"75-2656723","TX","PE - Premier Family Care I, Inc","Triwest VA","Facility 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.\""]
["Tzu-Ching Wu, MD",1396930426,"75-2656723","TX","","Triwest VA","Facility 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.\""]
["Tzu-Ching Wu, MD",1396930426,"75-2656723","TX","PE - Premier Family Care I, Inc","Multiplan","Delegated - Third Party","Delegated - Third Party","2019-04-05","1396930426","West Texas Physicians Alliance","2020-09-28","09/28/2020 - moved to completed status after receiving a spreadsheet from the payer stating this provider is EFF with West Texas Physicians Alliance under the following networks: Multiplan/PHCS/BeechStreet - Stacey Hudak"]
["Tzu-Ching Wu, MD",1396930426,"75-2656723","TX","PE - Premier Family Care I, 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 I, Inc","Medicare","Participating","Enrollment Complete","2019-01-07","761311","0008AH","2020-04-27","04/27/2020 - Confirmed enrollment through GROUP PECOS enrollment - Stacey Hudak"]
["Tzu-Ching Wu, MD",1396930426,"75-2656723","TX","PE - Premier Family Care I, Inc","Cigna","Participating","Enrollment Complete","2021-03-31","0669817","","2021-07-06","7/6/2021 Received an email from PDMCOGZ@cigna.com confirming provider is participating under group Tax ID effective 3/31/2021, with assigned ID 0669817. KFrazier"]
["Tzu-Ching Wu, MD",1396930426,"75-2656723","TX","PE - Premier Family Care I, Inc","Boon Chapman","Participating","Enrollment Complete","2019-04-05","","","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 4/5/2019.  DCannon"]
["Tzu-Ching Wu, MD",1396930426,"75-2656723","TX","PE - Premier Family Care I, Inc","Omni PPO","Participating","Enrollment Complete","2019-05-21","1396930426","","2020-06-26",""]
["Tzu-Ching Wu, MD",1396930426,"75-2656723","TX","PE - Premier Family Care I, Inc","Galaxy Health","Participating","Enrollment Complete","2019-05-21","1396930426","","2020-07-17","7/17/2020 - Received a spreadsheet from the payer stating this provider is effective as of 5/21/2019 - Jesriel Segovia"]
["Tzu-Ching Wu, MD",1396930426,"75-2656723","TX","PE - Premier Family Care I, Inc","IMS","Participating","Enrollment Complete","2019-05-21","1396930426","","2020-06-22","06/22/2020- Rec'd email from the payer confirming this provider is PAR with this group/service location - Stacey Hudak"]
["Tzu-Ching Wu, MD",1396930426,"75-2656723","TX","PE - Premier Family Care I, Inc","Aetna","Participating","Enrollment Complete","2019-01-31","1396930426","","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 1/31/2019. Physical Location is on file. Provider ID #9109842. Call ref # 5234162545\ncopied note from spreadsheet-tisha rader"]
["Tzu-Ching Wu, MD",1396930426,"75-2656723","TX","PE - Premier Family Care I, Inc","TriCare Standard","Participating","Enrollment Complete","2020-05-01","","","2021-04-02","4/2/2021 Per Humana Military Portal provider is certified and linked to group TIN and location effective 5/1/2020.  DCannon"]
["Tzu-Ching Wu, MD",1396930426,"75-2656723","TX","PE - Premier Family Care I, Inc","First Health Coventry","Participating","Enrollment Complete","2019-05-01","2323463","","2020-03-20","3/20/2020-receieved email with roster stating provider PAR 5/1/2019 PID # 2323463\ntisha rader"]
["Tzu-Ching Wu, MD",1396930426,"75-2656723","TX","PE - Premier Family Care I, Inc","HealthSmart PPO","Participating","Enrollment Complete","2019-05-31","1396930426","","2020-06-10","06/10/2020 - Rec'd email from the payer stating this provider is EFF - Stacey Hudak"]
["Tzu-Ching Wu, MD",1396930426,"75-2656723","TX","PE - Premier Family Care I, 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 I, 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"]
["Tzu-Ching Wu, MD",1396930426,"75-2656723","TX","PE - Premier Family Care I, Inc","Medicaid","Participating","Enrollment Complete","","283737907","079837301","2020-01-29","01/29/2020 - found provider PAR through Medicaid portal. Provider is linked to the following plans: Texas Children's Health Plan - Harris, UnitedHealthcare Community Plan - Harris, UnitedHealthCare Community Plan - Harris - Mmp, Texas Children's Health Plan - Jefferson, UnitedHealthcare Community Plan - Jefferson, TRADITIONAL MEDICAID, Texas Children's Health Plan - Harris, Texas Children's Health Plan - Jefferson, Texas Children's Health Plan - MRSA Northeast, United Healthcare - Texas - Harris, United Healthcare - Texas - Jefferson, Amerigroup - MRSA West, Amerigroup Texas, Inc. - MRSA West - Stacey Hudak"]
["Tzu-Ching Wu, MD",1396930426,"75-2656723","TX","PE - Premier Family Care I, Inc","Tricare Prime","Participating","Enrollment Complete","2020-05-01","","","2020-10-08","10/8/2020 Confirmed via Self-Service Portal provider is participating under Tax ID and location. Kimberly Frazier"]
["Tzu-Ching Wu, MD",1396930426,"75-2656723","TX","PE - Premier Family Care I, Inc","Superior","Participating","Enrollment Complete","2020-11-01","","","2020-11-25","11/25/2020 -  Rcvd email confirmation that Oct monthly roster was processed and this provider was made effective with the requested eff date of 11/1/2020.  DCannon"]
["Tzu-Ching Wu, MD",1396930426,"75-2656723","TX","PE - Premier Family Care I, Inc","Humana","Participating","Enrollment Complete","2019-04-04","1396930426","","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"]
["Tzu-Ching Wu, MD",1396930426,"75-2656723","TX","PE - Premier Family Care I, Inc","First Health Coventry","Participating","Enrollment Complete","2019-05-01","2323463","","2020-03-20","3/20/2020-receieved email with roster stating provider PAR 5/1/2019 PID # 2323463\ntisha rader"]
["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"]

{"sheet":"TaxIDSearch","index":2,"n_rows":1589,"n_cols":11,"rows_kept":1589,"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"]
["Douglas J Colson, MD","PE - Premier Family Care I, Inc","Caprock (CapStar)","Participating","Enrollment Complete","2018-08-30",1790767119,null,"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"]
["Douglas J Colson, MD","PE - Premier Family Care I, Inc","Cigna","Terminated","Terminated","2018-08-31",1790767119,null,"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"]
["Douglas J Colson, MD","PE - Premier Family Care I, Inc","Superior","Participating","Enrollment Complete","2018-10-01",1790767119,null,"2020-07-14","07/14/2020 - Rec'd email from the payer stating this provider is EFF under PRIMED DELEGATED agreement - Stacey Hudak"]
["Douglas J Colson, MD","PE - Premier Family Care I, Inc","Ambetter","Participating","Enrollment Complete","2022-06-01",null,null,"2022-06-13","6/13/2022 Per roster received from Superior provider is PAR and linked to group delegation roster effective 6/1/2022."]
["Douglas J Colson, MD","PE - Premier Family Care I, Inc","Cigna","Participating","Enrollment Complete","2021-03-31",null,null,"2021-08-25","8/25/2021 Received an email from PDMCOGZ@cigna.com confirming provider is now participating under group Tax ID and location effective 3/31/2021 with assigned provider ID 6670877. KFrazier"]
["Douglas J Colson, MD","PE - Premier Family Care I, Inc","Aetna","Participating","Enrollment Complete","2018-09-01",1790767119,null,"2020-02-03","02/03/2020 - Rec'd confirmation from the payer that this provider is EFF 9-1-2018 with a DIRECT CONTRACT. The proper service location is in file - Stacey Hudak"]
["Douglas J Colson, MD","PE - Premier Family Care I, Inc","Tricare Prime","Participating","Enrollment Complete","2018-07-14",null,null,"2020-10-08","10/8/2020 Confirmed via Self-Service Portal provider is participating under Tax ID and location. Kimberly Frazier"]
["Douglas J Colson, MD","PE - Premier Family Care I, Inc","United Health Care","Participating","Enrollment Complete","2018-07-10",1790767119,null,"2020-07-30","7/30/2020 - moved to completed status after reviewing follow up complete note - Stacey Hudak"]
["Douglas J Colson, MD","PE - Premier Family Care I, Inc","Boon Chapman","Participating","Enrollment Complete","2018-08-01",null,null,"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 8/1/2018.  DCannon"]
["Douglas J Colson, MD","PE - Premier Family Care I, Inc","Scott&White (First Care)","Participating","Enrollment Complete","2019-01-11",1790767119,null,"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\n\n**Rec'd confirmation from the payer that this provider is tied to this TIN/Service location and networked with: \nFirstCare MyChoice PPO\nCHIP\nFirstCare Select Benefit Network\nHMO Enhanced Benefit Network\nMedicaid (FC)\nMedicare (FC)\nPPO Limited Benefit Network"]
["Douglas J Colson, MD","PE - Premier Family Care I, Inc","Triwest VA","Facility Enrollment","Application Submitted",null,null,null,"2022-11-23","08/19/2022 - Submitted application to TriWest VA (sent to Scarlett Abigail, Scarlett_Abigail@bcbstx.com)"]
["Douglas J Colson, MD",null,"Triwest VA","Facility Enrollment","Application Submitted",null,null,null,"2022-11-23","08/19/2022 - Submitted application to TriWest VA (sent to Scarlett Abigail, Scarlett_Abigail@bcbstx.com)"]
["Douglas J Colson, MD","PE - Premier Family Care I, Inc","Triwest VA","Facility Enrollment","Facility Enrollment",null,null,null,"2022-11-23","10/17/2022 - Received roster from Scarlett of TriWest VA; provider status: \"No Action.  TIN is CCN participating under own DCN.\""]
["Douglas J Colson, MD",null,"Triwest VA","Facility Enrollment","Facility Enrollment",null,null,null,"2022-11-23","10/17/2022 - Received roster from Scarlett of TriWest VA; provider status: \"No Action.  TIN is CCN participating under own DCN.\""]
["Douglas J Colson, MD","PE - Premier Family Care I, Inc","Amerigroup","Participating","Enrollment Complete","2018-08-29",1790767119,null,"2020-02-11","2/11/2020 – Received Roster from Amerigroup and provider is now PAR- Tisha Rader\n\n3/18/2020 - rec'd confirmation from Multiplan/Texas True Choice that this is correct - Stacey Hudak"]
["Douglas J Colson, MD","PE - Premier Family Care I, Inc","Medicare","Participating","Enrollment Complete","2018-07-01",679507,"0008AH","2020-01-29","01/29/2020 - confirmed EFF through PECOS group enrollment - Stacey Hudak"]
["Douglas J Colson, MD","PE - Premier Family Care I, Inc","First Health Coventry","Participating","Enrollment Complete","2018-08-01",1046218,null,"2020-03-24","3/24/2020-received email with roster from payor stating provider is PAR 8/1/2018 PID # 1046218\ntisha rader"]
["Douglas J Colson, MD","PE - Premier Family Care I, Inc","Omni PPO","Participating","Enrollment Complete","2018-08-30",1790767119,null,"2020-07-14"]
["Douglas J Colson, MD","PE - Premier Family Care I, Inc","Medicaid","Participating","Enrollment Complete",null,386238501,79837301,"2020-01-29","01/29/2020 - Found provider PAR through payer portal. This provider is linked to the following plans: FirstCare - Lubbock, TRADITIONAL MEDICAID, Amerigroup - MRSA West, FirstCare - MRSA West, Amerigroup Texas, Inc. - MRSA West - Stacey Hudak"]
["Douglas J Colson, MD","PE - Premier Family Care I, Inc","Multiplan","Participating","Enrollment Complete","2018-08-01",1790767119,null,"2020-02-12","02/12/2020 - this provider has been confirmed to be effective through the payer portal. EFF 8-1-2018 THROUGH WEST TEXAS PHYSICIANS ALLIANCE DELEGATED PARTY - networked to MPI. - Stacey Hudak"]
["Douglas J Colson, MD","PE - Premier Family Care I, Inc","TriCare Standard","Participating","Enrollment Complete","2018-07-14",null,null,"2020-11-03","11/3/2020 Upon review of the self-service portal provider reflects as 'complete'. Kimberly Frazier"]
["Douglas J Colson, MD","PE - Premier Family Care I, Inc","Humana","Participating","Enrollment Complete","2020-01-01",1790767119,null,"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"]
["Douglas J Colson, MD","PE - Premier Family Care I, Inc","USA PPO","Participating","Enrollment Complete","2018-08-29",1790767119,752656723,"2020-08-18","Confirmed provider is enrolled and participating under delegated agreement with the PPO and H&W networks (list attached in images). Kimberly Frazier"]
["Douglas J Colson, MD","PE - Premier Family Care I, Inc","Galaxy Health","Participating","Enrollment Complete","2018-08-01",1790767119,null,"2020-07-10","07/10/2020 - updated payer line to enrollment complete status instead of \"Delegated status\" for report running purposes - Stacey Hudak"]
["Douglas J Colson, MD","PE - Premier Family Care I, Inc","HealthSmart PPO","Participating","Enrollment Complete","2018-08-28",1790767119,null,"2020-06-05","06/05/2020 - Rec'd email from the payer stating this provider is EFF - Stacey Hudak"]
["Douglas J Colson, MD","PE - Premier Family Care I, Inc","Wellcare","Participating","Enrollment Complete","2021-11-01",null,null,"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"]
["Douglas J Colson, MD","PE - Premier Family Care I, Inc","IMS","Participating","Enrollment Complete","2018-08-30",1790767119,null,"2020-06-22","06/22/2020 0- Rec'd email from the payer confirming this provider is PAR with this group/service location - Stacey Hudak"]
["Douglas J Colson, MD","PE - Premier Family Care I, Inc","CAQH","Participating","CAQH Reattested","2023-01-25",11483093,null,"2022-10-18","10/18/2022 CAQH reviewed and re-attested.  Uploaded current malpractice COI.  DCannon"]
["Lori Ann Reeves, FNP-C","PE - Premier Family Care I, 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, FNP-C","PE - Premier Family Care I, Inc","Caprock (CapStar)","Participating","Enrollment Complete","2019-09-01",null,null,"2020-09-11"]
["Lori Ann Reeves, FNP-C","PE - Premier Family Care I, Inc","Galaxy Health","Participating","Enrollment Complete","2018-05-02",1023520830,null,"2020-07-10","07/10/2020 - updated payer line to enrollment complete status instead of \"Delegated status\" for report running purposes - Stacey Hudak"]
["Lori Ann Reeves, FNP-C","PE - Premier Family Care I, Inc","TriCare Standard","Participating","Enrollment Complete","2020-06-20",null,null,"2021-03-24","3/24/2021 Confirmed provider is already certified as a non-network provider. KFrazier"]
["Lori Ann Reeves, FNP-C","PE - Premier Family Care I, Inc","IMS","Participating","Enrollment Complete","2019-09-01",1023520830,null,"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, FNP-C","PE - Premier Family Care I, Inc","Aetna","Participating","Enrollment Complete","2019-09-01",1023520830,null,"2020-08-27","08/27/2020 - moved to completed status after reviewing the follow up complete note - Stacey Hudak"]
["Lori Ann Reeves, FNP-C","PE - Premier Family Care I, Inc","United Health Care","Participating","Enrollment Complete","2019-11-01",1023520830,null,"2020-08-27","08/27/2020 - moved to completed status after reviewing follow up complete note - Stacey Hudak"]
["Lori Ann Reeves, FNP-C","PE - Premier Family Care I, Inc","Tricare Prime","Participating","Enrollment Complete","2020-11-10",null,null,"2021-09-14","9/14/2021 Per Tricare portal, provider is participating with TaxID as of 11/10/2020. Cbankston"]
["Lori Ann Reeves, FNP-C","PE - Premier Family Care I, Inc","Medicare","Participating","Enrollment Complete","2018-03-19","626806YPVD","0008AH","2020-07-21","07/21/20220 - Rec'd email confirmation that this name change has been completed. Signed into PECOS to verify - Stacey Hudak"]
["Lori Ann Reeves, FNP-C","PE - Premier Family Care I, Inc","Humana","Participating","Enrollment Complete","2020-01-01",1023520830,null,"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"]
["Lori Ann Reeves, FNP-C","PE - Premier Family Care I, Inc","Ambetter","Participating","Enrollment Complete","2022-06-01",null,null,"2022-06-13","6/13/2022 Per roster received from Superior provider is PAR and linked to group delegation roster effective 6/1/2022."]
["Lori Ann Reeves, FNP-C","PE - Premier Family Care I, Inc","Medicaid","Participating","Enrollment Complete",null,382485601,79837301,"2020-01-29","01/29/2020 - provider found through payer portal. Provider is PAR with the following plans: FirstCare - Lubbock, TRADITIONAL MEDICAID, Amerigroup - MRSA West, Amerigroup - MRSA West, FirstCare - MRSA West, Amerigroup Texas, Inc. - MRSA West - Stacey Hudak"]
["Lori Ann Reeves, FNP-C","PE - Premier Family Care I, Inc","Boon Chapman","Participating","Enrollment Complete","2018-06-15",1023520830,null,"2020-10-05","Enrolled thru PHCS"]
["Lori Ann Reeves, FNP-C","PE - Premier Family Care I, Inc","Scott&White (First Care)","Participating","Enrollment Complete","2018-07-11",1023520830,null,"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, FNP-C","PE - Premier Family Care I, Inc","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"]
["Lori Ann Reeves, FNP-C","PE - Premier Family Care I, Inc","HealthSmart PPO","Participating","Enrollment Complete","2018-05-30",1023520830,null,"2020-06-05","06/05/2020 - Rec'd email from payer stating this provider is EFF - Stacey Hudak"]
["Lori Ann Reeves, FNP-C","PE - Premier Family Care I, 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"]
["Lori Ann Reeves, FNP-C","PE - Premier Family Care I, Inc","CAQH","Participating","CAQH Reattested","2023-01-25",14145595,null,"2023-01-25","1/25/2023 CAQH reviewed and re-attested.  DCannon"]
["Lori Ann Reeves, FNP-C","PE - Premier Family Care I, Inc","Amerigroup","Participating","Enrollment Complete","2020-06-29",1023520830,null,"2020-07-09","07/09/2020 - Rec'd welcome letter from Multiplan stating provider is covered for all governmental payers - Amerigroup is covered (STAR, Star Plus, Star Kids) - Stacey Hudak"]
["Lori Ann Reeves, FNP-C","PE - Premier Family Care I, Inc","Cigna","Participating","Enrollment Complete","2020-05-19",12623755,null,"2021-08-05","7/26/2021 Received an email from PDMCOGZ@cigna.com with confirmation provider is now participating under group Tax ID effective 5/19/2020 with assigned provider number 12623755. KFrazier"]
["Lori Ann Reeves, FNP-C","PE - Premier Family Care I, Inc","Omni PPO","Participating","Enrollment Complete","2019-09-01",1023520830,null,"2020-07-27","IMS is complete"]
["Lori Ann Reeves, FNP-C","PE - Premier Family Care I, Inc","Superior","Participating","Enrollment Complete","2020-09-01",1023520830,null,"2020-09-02","09/02/2020 - Rec'd email from the payer stating this providers name update from Brown to Reeves has been completed EFF 9-1-2020 - Stacey Hudak"]
["Lori Ann Reeves, FNP-C","PE - Premier Family Care I, Inc","Triwest VA","Facility Enrollment","Application Submitted",null,null,null,"2022-11-23","08/19/2022 - Submitted application to TriWest VA (sent to Scarlett Abigail, Scarlett_Abigail@bcbstx.com)"]
["Lori Ann Reeves, FNP-C",null,"Triwest VA","Facility Enrollment","Application Submitted",null,null,null,"2022-11-23","08/19/2022 - Submitted application to TriWest VA (sent to Scarlett Abigail, Scarlett_Abigail@bcbstx.com)"]
["Lori Ann Reeves, FNP-C","PE - Premier Family Care I, Inc","Triwest VA","Facility Enrollment","Facility Enrollment",null,null,null,"2022-11-23","10/17/2022 - Received roster from Scarlett of TriWest VA; provider status: \"No Action.  TIN is CCN participating under own DCN.\""]
["Lori Ann Reeves, FNP-C",null,"Triwest VA","Facility Enrollment","Facility Enrollment",null,null,null,"2022-11-23","10/17/2022 - Received roster from Scarlett of TriWest VA; provider status: \"No Action.  TIN is CCN participating under own DCN.\""]
["Lori Ann Reeves, FNP-C","PE - Premier Family Care I, Inc","First Health Coventry","Participating","Enrollment Complete","2018-05-01",3128029,null,"2020-03-24","3/24/2020-received email with roster from payor stating provider is PAR 5/1/2018 PID # 3128029\ntisha rader"]
["Rachel K Longacre, FNP-C","PE - Premier Family Care I, 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","PE - Premier Family Care I, Inc","Omni PPO","Participating","Enrollment Complete","2019-05-21",1639524861,null,"2020-06-25"]
["Rachel K Longacre, FNP-C","PE - Premier Family Care I, Inc","Medicare","Participating","Enrollment Complete","2019-05-01",793339,"0008AH","2020-01-29","01/29/2020 - confirmed EFF through PECOS group enrollment - Stacey Hudak"]
["Rachel K Longacre, FNP-C","PE - Premier Family Care I, Inc","CAQH","Participating","CAQH Reattested","2023-01-25",13859704,null,"2023-01-25","1/25/2023 CAQH reviewed and re-attested.  DCannon"]
["Rachel K Longacre, FNP-C","PE - Premier Family Care I, Inc","Triwest VA","Facility Enrollment","Application Submitted",null,null,null,"2022-11-28","08/19/2022 - Submitted application to TriWest VA (sent to Scarlett Abigail, Scarlett_Abigail@bcbstx.com)"]
["Rachel K Longacre, FNP-C",null,"Triwest VA","Facility Enrollment","Application Submitted",null,null,null,"2022-11-28","08/19/2022 - Submitted application to TriWest VA (sent to Scarlett Abigail, Scarlett_Abigail@bcbstx.com)"]
["Rachel K Longacre, FNP-C","PE - Premier Family Care I, Inc","Triwest VA","Facility Enrollment","Facility Enrollment",null,null,null,"2022-11-28","10/17/2022 - Received roster from Scarlett of TriWest VA; provider status: \"No Action.  TIN is CCN participating under own DCN.\""]
["Rachel K Longacre, FNP-C",null,"Triwest VA","Facility Enrollment","Facility Enrollment",null,null,null,"2022-11-28","10/17/2022 - Received roster from Scarlett of TriWest VA; provider status: \"No Action.  TIN is CCN participating under own DCN.\""]
["Rachel K Longacre, FNP-C","PE - Premier Family Care I, Inc","Humana","Participating","Enrollment Complete","2020-01-01",1639524861,null,"2020-07-17","7/17/2020 - 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"]
["Rachel K Longacre, FNP-C","PE - Premier Family Care I, Inc","First Health Coventry","Participating","Enrollment Complete","2019-05-01",3041792,null,"2020-03-24","3/24/2020-received email with roster from payor stating provider PAR 5/1/2019 PID # 3041792\ntisha rader"]
["Rachel K Longacre, FNP-C","PE - Premier Family Care I, Inc","Galaxy Health","Participating","Enrollment Complete","2019-05-03",1639524861,null,"2020-07-10","07/10/2020 - updated payer line to enrollment complete status instead of \"Delegated status\" for report running purposes - Stacey Hudak"]
["Rachel K Longacre, FNP-C","PE - Premier Family Care I, Inc","USA PPO","Participating","Enrollment Complete","2019-05-31",1639524861,752656723,"2020-08-18","Confirmed provider is participating with PPO and H&W networks (list of networks attached). Kimberly Frazier"]
["Rachel K Longacre, FNP-C","PE - Premier Family Care I, Inc","Caprock (CapStar)","Participating","Enrollment Complete","2019-05-21",1639524861,null,"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","PE - Premier Family Care I, Inc","IMS","Participating","Enrollment Complete","2019-05-21",1639524861,null,"2020-06-22","06/22/2020- Rec'd email from the payer confirming this provider is PAR with this group/service location - Stacey Hudak"]
["Rachel K Longacre, FNP-C","PE - Premier Family Care I, Inc","Boon Chapman","Participating","Enrollment Complete","2019-04-16",null,null,"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 4/16/2019.  DCannon"]
["Rachel K Longacre, FNP-C","PE - Premier Family Care I, Inc","HealthSmart PPO","Participating","Enrollment Complete","2019-05-31",1639524861,null,"2020-06-05","06/05/2020 - Rec'd email from the payer stating this provider is EFF - Stacey Hudak"]
["Rachel K Longacre, FNP-C","PE - Premier Family Care I, Inc","Medicaid","Participating","Enrollment Complete",null,360348204,79837301,"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","PE - Premier Family Care I, Inc","United Health Care","Participating","Enrollment Complete","2017-06-26",1639524861,null,"2020-08-03","8/3/2020 - moved to completed status after reviewing follow up complete note - Stacey Hudak"]
["Rachel K Longacre, FNP-C","PE - Premier Family Care I, Inc","Aetna","Participating","Enrollment Complete","2020-09-15",1639524861,null,"2020-09-23","09/23/2020 - moved to completed status after reviewing follow up complete note - Stacey Hudak"]
["Rachel K Longacre, FNP-C","PE - Premier Family Care I, Inc","Scott&White (First Care)","Participating","Enrollment Complete","2019-10-15",1639524861,null,"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"]
["Rachel K Longacre, FNP-C","PE - Premier Family Care I, Inc","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"]
["Rachel K Longacre, FNP-C","PE - Premier Family Care I, Inc","Cigna","Terminated","Terminated","2020-03-01",1639524861,null,"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"]
["Rachel K Longacre, FNP-C","PE - Premier Family Care I, Inc","Cigna","Participating","Enrollment Complete","2021-03-31",2017791,null,"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","PE - Premier Family Care I, Inc","Tricare Prime","Participating","Enrollment Complete","2020-01-05",null,null,"2020-10-08","10/8/2020 Confirmed via Self-Service Portal provider is participating under Tax ID and location. Kimberly Frazier"]
["Rachel K Longacre, FNP-C","PE - Premier Family Care I, Inc","Amerigroup","Participating","Enrollment Complete","2019-05-31",1639524861,null,"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"]
["Rachel K Longacre, FNP-C","PE - Premier Family Care I, Inc","TriCare Standard","Participating","Enrollment Complete","2020-10-27",null,null,"2020-11-03","11/3/2020 Confirmed via self-service portal provider is approved and participating under Group Tax ID and location effective 10/27/2020. Kimberly Frazier"]
["Rachel K Longacre, FNP-C","PE - Premier Family Care I, Inc","Superior","Participating","Enrollment Complete","2019-08-01",1639524861,null,"2020-07-14","07/14/2020 - Rec'd email from the payer stating this provider is EFF under PRIMED DELEGATED agreement - Stacey Hudak"]
["Madhavi Gadiraju, MD","PE - Premier Family Care I, Inc","Superior","Participating","Enrollment Complete","2019-11-01",1932541406,null,"2020-07-14","07/14/2020 - Rec'd spreadsheet from the delegated team stating this provider has been linked to the PriMed contract since 11-1-2019 **see the other enrollment complete line to see details about when this provider became effective with various specific products** - stacey Hudak"]
["Madhavi Gadiraju, MD","PE - Premier Family Care I, Inc","Ambetter","Participating","Enrollment Complete","2022-06-01",null,null,"2022-06-13","6/13/2022 Per roster received from Superior provider is PAR and linked to group delegation roster effective 6/1/2022."]
["Madhavi Gadiraju, MD","PE - Premier Family Care I, Inc","CAQH","Participating","CAQH Reattested","2023-01-03",13876531,null,"2023-01-03","1/3/2023 CAQH reviewed and re-attested.  DCannon"]
["Madhavi Gadiraju, MD","PE - Premier Family Care I, Inc","Humana","Participating","Enrollment Complete","2020-01-01",1932541406,null,"2020-07-17","7/17/2020 - 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"]
["Madhavi Gadiraju, MD","PE - Premier Family Care I, Inc","IMS","Participating","Enrollment Complete","2019-09-30",1932541406,null,"2020-06-22","06/22/2020- Rec'd email from the payer confirming this provider is PAR with this group/service location - Stacey Hudak"]
["Madhavi Gadiraju, MD","PE - Premier Family Care I, Inc","Triwest VA","Facility Enrollment","Application Submitted",null,null,null,"2022-11-23","08/19/2022 - Submitted application to TriWest VA (sent to Scarlett Abigail, Scarlett_Abigail@bcbstx.com)"]
["Madhavi Gadiraju, MD",null,"Triwest VA","Facility Enrollment","Application Submitted",null,null,null,"2022-11-23","08/19/2022 - Submitted application to TriWest VA (sent to Scarlett Abigail, Scarlett_Abigail@bcbstx.com)"]
["Madhavi Gadiraju, MD","PE - Premier Family Care I, Inc","Triwest VA","Facility Enrollment","Facility Enrollment",null,null,null,"2022-11-23","10/17/2022 - Received roster from Scarlett of TriWest VA; provider status: \"No Action.  TIN is CCN participating under own DCN.\""]
["Madhavi Gadiraju, MD",null,"Triwest VA","Facility Enrollment","Facility Enrollment",null,null,null,"2022-11-23","10/17/2022 - Received roster from Scarlett of TriWest VA; provider status: \"No Action.  TIN is CCN participating under own DCN.\""]
["Madhavi Gadiraju, MD","PE - Premier Family Care I, Inc","USA PPO","Participating","Enrollment Complete","2019-09-30",1932541406,752656723,"2020-08-18","Confirmed provider is participating with PPO, H&W and WIN networks (list of all networks attached). Kimberly Frazier"]
["Madhavi Gadiraju, MD","PE - Premier Family Care I, Inc","TriCare Standard","Participating","Enrollment Complete","2019-07-02",1932541406,null,"2020-09-14","Upon review of the Self-Service portal, provider is completed and loaded as participating under practice location. Kimberly Frazier"]
["Madhavi Gadiraju, MD","PE - Premier Family Care I, Inc","United Health Care","Participating","Enrollment Complete","2019-04-15",1932541406,null,"2020-07-30","7/30/2020 - Moved to completed status after reviewing follow up complete note - Stacey Hudak"]
["Madhavi Gadiraju, MD","PE - Premier Family Care I, Inc","Amerigroup","Participating","Enrollment Complete","2019-09-30",1932541406,null,"2020-02-11","2/11/2020 – Received Roster from Amerigroup and provider is now PAR- Tisha Rader\n\n3/18/2020 - Rec'd email confirmation from Multiplan/Texas True Chioce stating EFF information is correct - Stacey Hudak"]
["Madhavi Gadiraju, MD","PE - Premier Family Care I, Inc","Boon Chapman","Participating","Enrollment Complete","2019-07-20",null,null,"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 7/20/2019.  DCannon"]
["Madhavi Gadiraju, MD","PE - Premier Family Care I, Inc","Medicare","Participating","Enrollment Complete","2019-05-01",804641,"0008AH","2020-01-29","01/29/2020 - confirmed EFF through PECOS group enrollment - Stacey Hudak"]
["Madhavi Gadiraju, MD","PE - Premier Family Care I, Inc","Cigna","Participating","Enrollment Complete","2019-08-14",1932541406,null,"2020-02-20","02/20/2020 - Rec'd verification from the payer that this provider is EFF 8-14-2019 and linked to this service location under a DIRECT CONTRACT with this payer - Stacey Hudak"]
["Madhavi Gadiraju, MD","PE - Premier Family Care I, Inc","Multiplan","Participating","Enrollment Complete","2019-07-20",1932541406,"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 7-20-2019. Provider is networked with Beechstreet. - Stacey Hudak"]
["Madhavi Gadiraju, MD","PE - Premier Family Care I, Inc","Medicaid","Participating","Enrollment Complete","2019-05-01",397298601,79837301,"2021-10-06","10/6/2021 Confirmed license update complete via TMHP Portal.  DCannon"]
["Madhavi Gadiraju, MD","PE - Premier Family Care I, Inc","Caprock (CapStar)","Participating","Enrollment Complete","2019-06-12",1932541406,null,"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"]
["Madhavi Gadiraju, MD","PE - Premier Family Care I, Inc","Scott&White (First Care)","Participating","Enrollment Complete","2019-05-01",1932541406,null,"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","PE - Premier Family Care I, Inc","First Health Coventry","Participating","Enrollment Complete","2019-09-01",3002056,null,"2020-03-24","3/24/2020-received email with roster from payor stating provider PAR 9/1/2019 PID # 3002056\ntisha rader"]
["Madhavi Gadiraju, MD","PE - Premier Family Care I, Inc","Galaxy Health","Participating","Enrollment Complete","2019-06-12",1932541406,null,"2020-07-10","07/10/2020 - updated payer line to enrollment complete status instead of \"Delegated status\" for report running purposes - Stacey Hudak"]
["Madhavi Gadiraju, MD","PE - Premier Family Care I, Inc","HealthSmart PPO","Participating","Enrollment Complete","2019-06-12",1932541406,null,"2020-09-23","09/23/2020 - moved to completed status after reviewing follow up complete - Stacey Hudak"]
["Madhavi Gadiraju, MD","PE - Premier Family Care I, Inc","Aetna","Participating","Enrollment Complete","2019-05-01",1932541406,null,"2020-02-03","02/03/2020 - Rec'd confirmation from the payer that this provider is under DIRECT CONTRACT EFF 5-1-2019 - Stacey Hudak"]
["Madhavi Gadiraju, MD","PE - Premier Family Care I, Inc","Omni PPO","Participating","Enrollment Complete","2019-09-30",1932541406,null,"2020-06-25"]
["Deborah A Frempong, APRN-FNP-BC","PE - Premier Family Care I, Inc","IMS","Participating","Enrollment Complete","2019-08-26",1811423981,null,"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","PE - Premier Family Care I, Inc","Caprock (CapStar)","Participating","Enrollment Complete","2019-08-26",1811423981,null,"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"]
["Deborah A Frempong, APRN-FNP-BC","PE - Premier Family Care I, Inc","Multiplan","Participating","Enrollment Complete","2020-07-01",1811423981,null,"2020-09-09","09/09/2020 - moved to completed status after reviewing last note - Stacey Hudak"]
["Deborah A Frempong, APRN-FNP-BC","PE - Premier Family Care I, Inc","Amerigroup","Participating","Enrollment Complete","2019-08-30",1811423981,null,"2020-02-11","2/11/2020 – Received Roster from Amerigroup and provider is now PAR- Tisha Rader\n\n3/18/2020 - rec'd email from the payer Multiplan/Texas True Choie stating that this effective info is true - Stacey Hudak"]
["Deborah A Frempong, APRN-FNP-BC","PE - Premier Family Care I, Inc","Cigna","Participating","Enrollment Complete","2020-04-07",1811423981,null,"2020-07-20","07/20/2020 - Moved to completed status after reviewing follow up complete note - Stacey Hudak"]
["Deborah A Frempong, APRN-FNP-BC","PE - Premier Family Care I, Inc","Ambetter","Participating","Enrollment Complete","2022-06-01",null,null,"2022-06-13","6/13/2022 Per roster received from Superior provider is PAR and linked to group delegation roster effective 6/1/2022."]
["Deborah A Frempong, APRN-FNP-BC","PE - Premier Family Care I, Inc","HealthSmart PPO","Participating","Enrollment Complete","2019-06-26",1811423981,null,"2020-06-05","06/05/2020 - Rec'd email from the payer stating this provider is EFF - Stacey Hudak"]
["Deborah A Frempong, APRN-FNP-BC","PE - Premier Family Care I, Inc","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"]
["Deborah A Frempong, APRN-FNP-BC","PE - Premier Family Care I, Inc","Galaxy Health","Participating","Enrollment Complete","2019-06-12",1811423981,null,"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","PE - Premier Family Care I, Inc","USA PPO","Participating","Enrollment Complete","2019-08-30",1811423981,752656723,"2020-08-18","Confirmed provider is participating with PPO and H&W networks (list of networks attached). Kimberly Frazier"]
["Deborah A Frempong, APRN-FNP-BC","PE - Premier Family Care I, Inc","TriCare Standard","Participating","Enrollment Complete","2019-01-01",null,null,"2020-10-30","10/30/2020 Provider is certified as non-network effective 1/1/2019, as she is currently participating under group Tax ID and location is being updated. Kimberly Frazier"]
["Deborah A Frempong, APRN-FNP-BC","PE - Premier Family Care I, Inc","Humana","Participating","Enrollment Complete","2020-01-01",1811423981,null,"2020-07-19","7/19/2020 - Received email spredsheet from the payor confirming that this provider is EFF at this service location and PAR with the PRIMED DELEGATED agreement - Pam Porter"]
["Deborah A Frempong, APRN-FNP-BC","PE - Premier Family Care I, Inc","Scott&White (First Care)","Participating","Enrollment Complete","2019-06-01",1811423981,null,"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"]
["Deborah A Frempong, APRN-FNP-BC","PE - Premier Family Care I, Inc","Omni PPO","Participating","Enrollment Complete","2019-08-26",1811423981,null,"2020-06-25"]
["Deborah A Frempong, APRN-FNP-BC","PE - Premier Family Care I, Inc","Aetna","Participating","Enrollment Complete","2020-06-15",6103957,null,"2020-06-08","06/08/2020 - Rec'd email from the payer stating this provider is PAR with the network effective 6/15/2020. Your Provider Identification Number (PIN) is: 6103957 - Stacey Hudak"]
["Deborah A Frempong, APRN-FNP-BC","PE - Premier Family Care I, Inc","Superior","Participating","Enrollment Complete","2019-10-01",1811423981,null,"2020-07-14","07/14/2020 - Rec'd spreadsheet from the delegated team stating this provider has been linked to the PriMed contract since 10-1-2019 **see the other enrollment complete line to see details about when this provider became effective with various specific products** - stacey Hudak"]
["Deborah A Frempong, APRN-FNP-BC","PE - Premier Family Care I, Inc","Medicare","Participating","Enrollment Complete","2019-06-01",805590,"0008AH","2020-01-29","01/29/2020 - confirmed EFF through PECOS group enrollment - Stacey Hudak"]
["Deborah A Frempong, APRN-FNP-BC","PE - Premier Family Care I, Inc","Tricare Prime","Participating","Enrollment Complete","2020-10-23",null,null,"2020-12-04","12/4/2020 Upon review of self-service portal provider is now participating under Group Tax ID and location. KFrazier"]
["Deborah A Frempong, APRN-FNP-BC","PE - Premier Family Care I, Inc","CAQH","Participating","CAQH Reattested","2023-01-09",14074150,null,"2023-01-09","1/9/2023 CAQH reviewed and re-attested.  DCannon"]
["Deborah A Frempong, APRN-FNP-BC","PE - Premier Family Care I, Inc","Boon Chapman","Participating","Enrollment Complete","2020-07-01",null,null,"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","PE - Premier Family Care I, Inc","Triwest VA","Facility Enrollment","Application Submitted",null,null,null,"2022-11-23","08/19/2022 - Submitted application to TriWest VA (sent to Scarlett Abigail, Scarlett_Abigail@bcbstx.com)"]
["Deborah A Frempong, APRN-FNP-BC",null,"Triwest VA","Facility Enrollment","Application Submitted",null,null,null,"2022-11-23","08/19/2022 - Submitted application to TriWest VA (sent to Scarlett Abigail, Scarlett_Abigail@bcbstx.com)"]
["Deborah A Frempong, APRN-FNP-BC","PE - Premier Family Care I, Inc","Triwest VA","Facility Enrollment","Facility Enrollment",null,null,null,"2022-11-23","10/17/2022 - Received roster from Scarlett of TriWest VA; provider status: \"No Action.  TIN is CCN participating under own DCN.\""]
["Deborah A Frempong, APRN-FNP-BC",null,"Triwest VA","Facility Enrollment","Facility Enrollment",null,null,null,"2022-11-23","10/17/2022 - Received roster from Scarlett of TriWest VA; provider status: \"No Action.  TIN is CCN participating under own DCN.\""]
["Deborah A Frempong, APRN-FNP-BC","PE - Premier Family Care I, Inc","United Health Care","Participating","Enrollment Complete","2019-06-01",6730214,null,"2020-07-30","7/30/2020 - moved to completed status after reviewing follow up complete - Stacey Hudak"]
["Deborah A Frempong, APRN-FNP-BC","PE - Premier Family Care I, Inc","Medicaid","Participating","Enrollment Complete",null,397315801,79837301,"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"]
["Deborah A Frempong, APRN-FNP-BC","PE - Premier Family Care I, Inc","First Health Coventry","Participating","Enrollment Complete","2019-08-01",3304172,null,"2020-03-24","3/24/2020-receieved email with roster from payor stating provider PAR 8/1/2019 PID # 3304172\ntisha rader"]
["Richard E Winn, MD","PE - Premier Family Care I, Inc","Boon Chapman","Participating","Enrollment Complete","2019-09-30",null,null,"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 9/30/2019.  DCannon"]
["Richard E Winn, MD","PE - Premier Family Care I, Inc","Cigna","Terminated","Terminated","2020-07-21",null,null,"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"]
["Richard E Winn, MD","PE - Premier Family Care I, Inc","IMS","Participating","Enrollment Complete","2019-09-15",null,null,"2020-08-25","Confirmed provider is participating under delegation effective 9/15/2019. Kimberly Frazier"]
["Richard E Winn, MD","PE - Premier Family Care I, Inc","Tricare Prime","Participating","Enrollment Complete","2021-11-08",null,null,"2021-11-30","11/30/2021 Checked portal and provide is added to location. Cbankston"]
["Richard E Winn, MD","PE - Premier Family Care I, Inc","Omni PPO","Participating","Enrollment Complete","2019-09-15",null,null,"2020-08-25","Confirmed provider is participating under delegation effective 9/15/2019. Kimberly Frazier"]
["Richard E Winn, MD","PE - Premier Family Care I, Inc","Amerigroup","Participating","Enrollment Complete","2020-07-17",null,null,"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"]
["Richard E Winn, MD","PE - Premier Family Care I, Inc","HealthSmart PPO","Participating","Enrollment Complete","2019-09-26",null,null,"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"]
["Richard E Winn, MD","PE - Premier Family Care I, Inc","TriCare Standard","Participating","Enrollment Complete","2019-08-12",null,null,"2020-12-22","12/22/2020 Upon review of the Self-Service portal, provider is participating under group Tax ID, which confirmed provider is certified as non-network provider since that's a requirement before able to become a PAR provider. KFrazier"]
["Richard E Winn, MD","PE - Premier Family Care I, Inc","Medicaid","Participating","Enrollment Complete","2019-07-01",129062909,null,"2020-08-07","8/7/2020 - rec'd welcome letter from the clinic stating this provider is EFF and linked to TIN - Stacey Hudak"]
["Richard E Winn, MD","PE - Premier Family Care I, Inc","United Health Care","Participating","Enrollment Complete","2019-07-01",null,null,"2020-11-20","11/20/20 - Rcvd confirmation email from UHC confirming enrollment at this location.  DCannon"]
["Richard E Winn, MD","PE - Premier Family Care I, Inc","Triwest VA","Facility Enrollment","Application Submitted",null,null,null,"2022-11-28","08/19/2022 - Submitted application to TriWest VA (sent to Scarlett Abigail, Scarlett_Abigail@bcbstx.com)"]
["Richard E Winn, MD",null,"Triwest VA","Facility Enrollment","Application Submitted",null,null,null,"2022-11-28","08/19/2022 - Submitted application to TriWest VA (sent to Scarlett Abigail, Scarlett_Abigail@bcbstx.com)"]
["Richard E Winn, MD","PE - Premier Family Care I, Inc","Triwest VA","Facility Enrollment","Facility Enrollment",null,null,null,"2022-11-28","10/17/2022 - Received roster from Scarlett of TriWest VA; provider status: \"No Action.  TIN is CCN participating under own DCN.\""]
["Richard E Winn, MD",null,"Triwest VA","Facility Enrollment","Facility Enrollment",null,null,null,"2022-11-28","10/17/2022 - Received roster from Scarlett of TriWest VA; provider status: \"No Action.  TIN is CCN participating under own DCN.\""]
["Richard E Winn, MD","PE - Premier Family Care I, Inc","Caprock (CapStar)","Participating","Enrollment Complete","2019-09-18",1073672994,null,"2020-09-24"]
["Richard E Winn, MD","PE - Premier Family Care I, Inc","Humana","Participating","Enrollment Complete","2019-09-18",null,null,"2021-11-18","11/18/2021 Rcvd full roster from Humana listing provider as PAR and linked to group TIN/location effective 9/18/2019.  DCannon"]
["Richard E Winn, MD","PE - Premier Family Care I, Inc","Multiplan","Participating","Enrollment Complete","2019-09-30",1073672994,"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 9-30-2019. Provider is networked with Beechstreet. - Stacey Hudak"]
["Richard E Winn, MD","PE - Premier Family Care I, Inc","First Health Coventry","Participating","Enrollment Complete","2020-09-01",1073672994,null,"2020-11-02","11/2/2020 - moved to completed status due to follow up note -Stacey Hudak"]
["Richard E Winn, MD","PE - Premier Family Care I, Inc","Superior","Participating","Enrollment Complete","2019-11-01",1073672994,null,"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","PE - Premier Family Care I, Inc","Medicare","Participating","Enrollment Complete","2019-07-01",823276,null,"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","PE - Premier Family Care I, Inc","Aetna","Participating","Enrollment Complete","2019-09-01",null,null,"2020-12-09","12/9/2020 - Rcvd confirmation from payor that provider is now active and linked to this location.  DCannon"]
["Richard E Winn, MD","PE - Premier Family Care I, Inc","CAQH","Participating","CAQH Reattested","2023-01-25",10606333,null,"2023-01-25","1/25/2023 CAQH reviewed and re-attested.  DCannon"]
["Richard E Winn, MD","PE - Premier Family Care I, Inc","Cigna","Participating","Enrollment Complete","2021-03-31",2740972,null,"2021-07-27","7/27/2021 Received an email from PDMCOGZ@cigna.com with confirmation of approval for participation effective 3/31/2021 with assigned provider ID 2740972. KFrazier"]
["Richard E Winn, MD","PE - Premier Family Care I, Inc","USA PPO","Participating","Enrollment Complete","2019-09-30",1073672994,752656723,"2020-08-18","Confirmed provider is participating with PPO and H&W networks (list of networks attached). Kimberly Frazier"]
["Richard E Winn, MD","PE - Premier Family Care I, Inc","Scott&White (First Care)","Participating","Enrollment Complete","2019-08-23",null,null,"2021-03-15","3/15/2021 Rcvd email from Christelle Tchampo at Scott & White confirming provider is participating under TIN and at location effective 8/23/2019.  DCannon"]
["Richard E Winn, MD","PE - Premier Family Care I, Inc","Ambetter","Participating","Enrollment Complete","2022-06-01",null,null,"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"]
["Richard E Winn, MD","PE - Premier Family Care I, Inc","Galaxy Health","Participating","Enrollment Complete","2020-01-01",1073672994,null,"2020-10-05","10/5/2020 - Rec'd email back from the payer stating this enrollment has been completed - Stacey"]
["Richard E Winn, MD","PE - Premier Family Care I, Inc","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"]
["Megan Casselman, NP-C","PE - Premier Family Care I, Inc","CAQH","Participating","CAQH Reattested","2023-03-13",14530139,null,"2023-03-13","3/13/2023 CAQH reviewed and re-attested.  DCannon"]
["Megan Casselman, NP-C","PE - Premier Family Care I, Inc","Humana","Participating","Enrollment Complete","2020-01-01",1528619525,null,"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"]
["Megan Casselman, NP-C","PE - Premier Family Care I, Inc","Medicaid","Participating","Enrollment Complete",null,403199901,79837301,"2020-01-29","01/29/2020 - Found provider through payer portal. Provider is par with Traditional Medicaid only - Stacey Hudak"]
["Megan Casselman, NP-C","PE - Premier Family Care I, Inc","Superior","Participating","Enrollment Complete","2020-08-01",1528619525,null,"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"]
["Megan Casselman, NP-C","PE - Premier Family Care I, Inc","Galaxy Health","Participating","Enrollment Complete","2019-09-01",1528619525,null,"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"]
["Megan Casselman, NP-C","PE - Premier Family Care I, Inc","Caprock (CapStar)","Participating","Enrollment Complete","2019-12-11",1528619525,null,"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"]
["Megan Casselman, NP-C","PE - Premier Family Care I, Inc","USA PPO","Participating","Enrollment Complete","2021-01-26",1312274,null,"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"]
["Megan Casselman, NP-C","PE - Premier Family Care I, Inc","Aetna","Participating","Enrollment Complete","2020-07-01",6345073,null,"2020-07-10","07/10/2020 - Rec'd EFF email from the payer stating \"Welcome to the provider network effective 7/1/2020. Your Provider Identification Number (PIN) is: 6345073\" - Stacey Hudak"]
["Megan Casselman, NP-C","PE - Premier Family Care I, Inc","Medicare","Participating","Enrollment Complete","2019-10-01",869041,"0008AH","2020-01-29","01/29/2020 - confirmed EFF through PECOS group enrollment - Stacey Hudak"]
["Megan Casselman, NP-C","PE - Premier Family Care I, Inc","United Health Care","Participating","Enrollment Complete","2019-10-01",1528619525,null,"2020-08-31","08/31/2020 - moved to completed status after reviewing follow up complete note - stacey Hudak"]
["Megan Casselman, NP-C","PE - Premier Family Care I, Inc","First Health Coventry","Participating","Enrollment Complete","2020-09-01",1528619525,null,"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","PE - Premier Family Care I, Inc","Ambetter","Participating","Enrollment Complete","2022-06-01",null,null,"2022-06-13","6/13/2022 Per roster received from Superior provider is PAR and linked to group delegation roster effective 6/1/2022."]
["Megan Casselman, NP-C","PE - Premier Family Care I, Inc","Wellcare","Participating","Enrollment Complete","2021-11-01",null,null,"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"]
["Megan Casselman, NP-C","PE - Premier Family Care I, Inc","Amerigroup","Participating","Enrollment Complete","2020-01-01",9832854,null,"2021-02-13","2/13/2021 - Rcvd complete roster from Amerigroup provider is participating and linked to TIN and location for the following plans CHIP, CHIP-PERINATAL, STAR, STAR-KIDS, STAR-PLUS.  DCannon"]
["Megan Casselman, NP-C","PE - Premier Family Care I, Inc","IMS","Participating","Enrollment Complete","2019-09-01",1528619525,null,"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"]
["Megan Casselman, NP-C","PE - Premier Family Care I, Inc","Omni PPO","Participating","Enrollment Complete","2020-09-01",1528619525,null,"2020-07-27","IMS complete"]
["Megan Casselman, NP-C","PE - Premier Family Care I, Inc","Triwest VA","Facility Enrollment","Application Submitted",null,null,null,"2022-11-23","08/19/2022 - Submitted application to TriWest VA (sent to Scarlett Abigail, Scarlett_Abigail@bcbstx.com)"]
["Megan Casselman, NP-C",null,"Triwest VA","Facility Enrollment","Application Submitted",null,null,null,"2022-11-23","08/19/2022 - Submitted application to TriWest VA (sent to Scarlett Abigail, Scarlett_Abigail@bcbstx.com)"]
["Megan Casselman, NP-C","PE - Premier Family Care I, Inc","Triwest VA","Facility Enrollment","Facility Enrollment",null,null,null,"2022-11-23","10/17/2022 - Received roster from Scarlett of TriWest VA; provider status: \"No Action.  TIN is CCN participating under own DCN.\""]
["Megan Casselman, NP-C",null,"Triwest VA","Facility Enrollment","Facility Enrollment",null,null,null,"2022-11-23","10/17/2022 - Received roster from Scarlett of TriWest VA; provider status: \"No Action.  TIN is CCN participating under own DCN.\""]
["Megan Casselman, NP-C","PE - Premier Family Care I, Inc","Boon Chapman","Participating","Enrollment Complete","2019-12-30",null,null,"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 12/30/2019.  DCannon"]
["Megan Casselman, NP-C","PE - Premier Family Care I, Inc","Scott&White (First Care)","Participating","Enrollment Complete","2019-10-01",1528619525,null,"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"]
["Megan Casselman, NP-C","PE - Premier Family Care I, Inc","TriCare Standard","Participating","Enrollment Complete","2020-04-01",1528619525,null,"2020-09-24","09/24/2020 - moved to completed after reviewing follow up complete - Stacey Hudak"]
["Megan Casselman, NP-C","PE - Premier Family Care I, Inc","HealthSmart PPO","Participating","Enrollment Complete","2019-12-11",13706552,null,"2020-07-21","07/21/2020 - Rec'd spreadsheet from the payer stating this provider/TIN/service location are PAR with WEST TEXAS PHYSICIANS ALLIANCE Delegated  - Stacey Hudak"]
["Megan Casselman, NP-C","PE - Premier Family Care I, Inc","Cigna","Participating","Enrollment Complete","2019-12-30",1528619525,null,"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"]
["Megan Casselman, NP-C","PE - Premier Family Care I, Inc","Multiplan","Participating","Enrollment Complete","2019-12-13",1528619525,"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 12-13-2019. Provider is networked with Beechstreet. - Stacey Hudak"]
["Venessa Saldana, APRN-FNP-BC","PE - Premier Family Care I, Inc","Triwest VA","Facility Enrollment","Facility Enrollment",null,null,null,"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 Saldana, APRN-FNP-BC","PE - Premier Family Care I, Inc","Triwest VA","Facility Enrollment","Facility Enrollment",null,null,null,"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 Saldana, APRN-FNP-BC","PE - Premier Family Care I, Inc","First Health Coventry","Participating","Enrollment Complete","2022-11-15",null,null,"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 Saldana, APRN-FNP-BC","PE - Premier Family Care I, Inc","First Health Coventry","Participating","Enrollment Complete","2022-11-15",null,null,"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 Saldana, APRN-FNP-BC","PE - Premier Family Care I, Inc","Wellcare","Participating","Enrollment Complete","2022-09-01",null,null,"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 Saldana, APRN-FNP-BC","PE - Premier Family Care I, Inc","Wellcare","Participating","Enrollment Complete","2022-09-01",null,null,"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 Saldana, APRN-FNP-BC","PE - Premier Family Care I, Inc","Galaxy Health","Participating","Enrollment Complete","2022-08-12",null,null,"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 Saldana, APRN-FNP-BC","PE - Premier Family Care I, Inc","Galaxy Health","Participating","Enrollment Complete","2022-08-12",null,null,"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 Saldana, APRN-FNP-BC","PE - Premier Family Care I, Inc","Superior","Participating","Enrollment Complete","2022-09-01",null,null,"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 Saldana, APRN-FNP-BC","PE - Premier Family Care I, Inc","Superior","Participating","Enrollment Complete","2022-09-01",null,null,"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 Saldana, APRN-FNP-BC","PE - Premier Family Care I, Inc","Ambetter","Participating","Enrollment Complete","2022-09-01",null,null,"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 Saldana, APRN-FNP-BC","PE - Premier Family Care I, Inc","Ambetter","Participating","Enrollment Complete","2022-09-01",null,null,"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 Saldana, APRN-FNP-BC","PE - Premier Family Care I, Inc","Amerigroup","Participating","Enrollment Complete","2022-08-12",null,null,"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 Saldana, APRN-FNP-BC","PE - Premier Family Care I, Inc","Amerigroup","Participating","Enrollment Complete","2022-08-12",null,null,"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 Saldana, APRN-FNP-BC","PE - Premier Family Care I, Inc","Rail Road Medicare","Participating","Enrollment Complete","2022-08-28",null,null,"2022-09-08","9/8/2022 Rcvd RR Medicare approval letter.  PTAN # Q00322530 - effective 8/28/2022.  DCannon"]
["Venessa Saldana, APRN-FNP-BC","PE - Premier Family Care I, Inc","Rail Road Medicare","Participating","Enrollment Complete","2022-08-28",null,null,"2022-09-08","9/8/2022 Rcvd RR Medicare approval letter.  PTAN # Q00322530 - effective 8/28/2022.  DCannon"]
["Venessa Saldana, APRN-FNP-BC","PE - Premier Family Care I, Inc","CAQH","Participating","CAQH Reattested","2023-02-12",null,null,"2023-02-12","2/12/2023 CAQH reviewed and re-attested.  DCannon"]
["Venessa Saldana, APRN-FNP-BC","PE - Premier Family Care I, Inc","CAQH","Participating","CAQH Reattested","2023-02-12",null,null,"2023-02-12","2/12/2023 CAQH reviewed and re-attested.  DCannon"]
["Venessa Saldana, APRN-FNP-BC","PE - Premier Family Care I, Inc","Humana","Participating","Enrollment Complete","2022-09-12",null,null,"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 Saldana, APRN-FNP-BC","PE - Premier Family Care I, Inc","Humana","Participating","Enrollment Complete","2022-09-12",null,null,"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 Saldana, APRN-FNP-BC","PE - Premier Family Care I, Inc","United Health Care","Participating","Enrollment Complete","2022-09-12",null,null,"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 Saldana, APRN-FNP-BC","PE - Premier Family Care I, Inc","United Health Care","Participating","Enrollment Complete","2022-09-12",null,null,"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 Saldana, APRN-FNP-BC","PE - Premier Family Care I, Inc","Omni PPO","Participating","Enrollment Complete","2022-08-12",null,null,"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 Saldana, APRN-FNP-BC","PE - Premier Family Care I, Inc","Omni PPO","Participating","Enrollment Complete","2022-08-12",null,null,"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 Saldana, APRN-FNP-BC","PE - Premier Family Care I, Inc","HealthSmart PPO","Participating","Enrollment Complete","2022-09-12",null,null,"2022-10-13","10/13/2022 Per Healthsmart website provider is PAR and loaded under TIN/location effective 9/12/2022.  DCannon"]
["Venessa Saldana, APRN-FNP-BC","PE - Premier Family Care I, Inc","HealthSmart PPO","Participating","Enrollment Complete","2022-09-12",null,null,"2022-10-13","10/13/2022 Per Healthsmart website provider is PAR and loaded under TIN/location effective 9/12/2022.  DCannon"]
["Venessa Saldana, APRN-FNP-BC","PE - Premier Family Care I, Inc","Tricare Prime","Panel Closed","Panel Closed",null,null,null,"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 Saldana, APRN-FNP-BC","PE - Premier Family Care I, Inc","Tricare Prime","Panel Closed","Panel Closed",null,null,null,"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 Saldana, APRN-FNP-BC","PE - Premier Family Care I, Inc","Boon Chapman","Pending Other Enrollment","Pending Other Enrollment",null,null,null,"2022-07-20","7/20/2022 Pending Multiplan enrollment.  DCannon"]
["Venessa Saldana, APRN-FNP-BC","PE - Premier Family Care I, Inc","Boon Chapman","Pending Other Enrollment","Pending Other Enrollment",null,null,null,"2022-07-20","7/20/2022 Pending Multiplan enrollment.  DCannon"]
["Venessa Saldana, APRN-FNP-BC","PE - Premier Family Care I, Inc","Cigna","Participating","Enrollment Complete","2023-03-10",8909854,null,"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 Saldana, APRN-FNP-BC","PE - Premier Family Care I, Inc","Cigna","Participating","Enrollment Complete","2023-03-10",8909854,null,"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 Saldana, APRN-FNP-BC","PE - Premier Family Care I, Inc","Medicaid","Participating","Enrollment Complete","2022-08-28",1922658319,null,"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 Saldana, APRN-FNP-BC","PE - Premier Family Care I, Inc","Medicaid","Participating","Enrollment Complete","2022-08-28",1922658319,null,"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 Saldana, APRN-FNP-BC","PE - Premier Family Care I, Inc","Scott&White (First Care)","Participating","Enrollment Complete","2022-09-12",null,null,"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 Saldana, APRN-FNP-BC","PE - Premier Family Care I, Inc","Scott&White (First Care)","Participating","Enrollment Complete","2022-09-12",null,null,"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 Saldana, APRN-FNP-BC","PE - Premier Family Care I, Inc","IMS","Participating","Enrollment Complete","2022-08-12",null,null,"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 Saldana, APRN-FNP-BC","PE - Premier Family Care I, Inc","IMS","Participating","Enrollment Complete","2022-08-12",null,null,"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 Saldana, APRN-FNP-BC","PE - Premier Family Care I, 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 Saldana, APRN-FNP-BC","PE - Premier Family Care I, 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 Saldana, APRN-FNP-BC","PE - Premier Family Care I, Inc","Caprock (CapStar)","Participating","Enrollment Complete","2020-01-01",null,null,"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 Saldana, APRN-FNP-BC","PE - Premier Family Care I, Inc","Caprock (CapStar)","Participating","Enrollment Complete","2020-01-01",null,null,"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 Saldana, APRN-FNP-BC","PE - Premier Family Care I, Inc","Aetna","Participating","Enrollment Complete","2022-11-15",null,null,"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 Saldana, APRN-FNP-BC","PE - Premier Family Care I, Inc","Aetna","Participating","Enrollment Complete","2022-11-15",null,null,"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 Saldana, APRN-FNP-BC","PE - Premier Family Care I, Inc","Multiplan","In Process","Application Submitted",null,null,null,"2022-08-15","8/15/2022 Emailed monthly delegated roster to Multiplan to have providers loaded.  DCannon"]
["Venessa Saldana, APRN-FNP-BC","PE - Premier Family Care I, Inc","Multiplan","In Process","Application Submitted",null,null,null,"2022-08-15","8/15/2022 Emailed monthly delegated roster to Multiplan to have providers loaded.  DCannon"]
["Venessa Saldana, APRN-FNP-BC","PE - Premier Family Care I, Inc","TriCare Standard","Participating","Enrollment Complete","2023-01-05",null,null,"2023-01-18","1/18/2023 Rcvd letter from Tricare that provider is now Tricare certified effective 1//5/2023.  DCannon"]
["Venessa Saldana, APRN-FNP-BC","PE - Premier Family Care I, Inc","TriCare Standard","Participating","Enrollment Complete","2023-01-05",null,null,"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","PE - Premier Family Care I, Inc","Superior","Participating","Enrollment Complete","2020-12-01",null,null,"2020-12-07","12/7/21020 - Rcvd confirmation email from Superior that provider has been loaded effective 12/1/2020.  DCannon"]
["Ana M Rodriguez, APRN-FNP","PE - Premier Family Care I, Inc","HealthSmart PPO","Participating","Enrollment Complete","2020-10-13",13747034,null,"2020-12-23","12/23/2020 - Confirmed with HealthSmart that provider has been loaded effective 10/13/2020.  DCannon"]
["Ana M Rodriguez, APRN-FNP","PE - Premier Family Care I, Inc","USA PPO","Participating","Enrollment Complete","2021-01-26",1312370,null,"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"]
["Ana M Rodriguez, APRN-FNP","PE - Premier Family Care I, Inc","Triwest VA","Facility Enrollment","Application Submitted",null,null,null,"2022-11-23","08/19/2022 - Submitted application to TriWest VA (sent to Scarlett Abigail, Scarlett_Abigail@bcbstx.com)"]
["Ana M Rodriguez, APRN-FNP",null,"Triwest VA","Facility Enrollment","Application Submitted",null,null,null,"2022-11-23","08/19/2022 - Submitted application to TriWest VA (sent to Scarlett Abigail, Scarlett_Abigail@bcbstx.com)"]
["Ana M Rodriguez, APRN-FNP","PE - Premier Family Care I, Inc","Triwest VA","Facility Enrollment","Facility Enrollment",null,null,null,"2022-11-23","10/17/2022 - Received roster from Scarlett of TriWest VA; provider status: \"No Action.  TIN is CCN participating under own DCN.\""]
["Ana M Rodriguez, APRN-FNP",null,"Triwest VA","Facility Enrollment","Facility Enrollment",null,null,null,"2022-11-23","10/17/2022 - Received roster from Scarlett of TriWest VA; provider status: \"No Action.  TIN is CCN participating under own DCN.\""]
["Ana M Rodriguez, APRN-FNP","PE - Premier Family Care I, Inc","Triwest VA","Facility Enrollment","Facility Enrollment",null,null,null,null,"10/17/2022 - Received roster from Scarlett; provider status: \"KJ to process.\""]
["Ana M Rodriguez, APRN-FNP",null,"Triwest VA","Facility Enrollment","Facility Enrollment",null,null,null,null,"10/17/2022 - Received roster from Scarlett; provider status: \"KJ to process.\""]
["Ana M Rodriguez, APRN-FNP","PE - Premier Family Care I, Inc","Triwest VA","Facility Enrollment","Application Submitted",null,null,null,null,"08/19/2022 - Submitted application to TriWest VA (sent to Scarlett Abigail, Scarlett_Abigail@bcbstx.com)"]
["Ana M Rodriguez, APRN-FNP",null,"Triwest VA","Facility Enrollment","Application Submitted",null,null,null,null,"08/19/2022 - Submitted application to TriWest VA (sent to Scarlett Abigail, Scarlett_Abigail@bcbstx.com)"]
["Ana M Rodriguez, APRN-FNP","PE - Premier Family Care I, Inc","Medicaid","Participating","Enrollment Complete","2020-10-01",403920802,null,"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","PE - Premier Family Care I, Inc","United Health Care","Participating","Enrollment Complete","2020-10-15",null,null,"2020-11-20","11/20/20 - Rcvd confirmation email from UHC confirming enrollment at this location.  DCannon"]
["Ana M Rodriguez, APRN-FNP","PE - Premier Family Care I, Inc","Tricare Prime","Participating","Enrollment Complete","2020-12-24",null,null,"2021-05-09","5/9/2021 Upon review of the self-service portal, provider is participating under group Tax ID and practice location effective 12/24/2020. KFrazier"]
["Ana M Rodriguez, APRN-FNP","PE - Premier Family Care I, Inc","Medicare","Participating","Enrollment Complete","2020-10-01","1J2798","0008AH","2020-11-18","11/18/2020 - Rcvd notification from Novitas that Change of Information app has been approved.  DCannon"]
["Ana M Rodriguez, APRN-FNP","PE - Premier Family Care I, Inc","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"]
["Ana M Rodriguez, APRN-FNP","PE - Premier Family Care I, Inc","TriCare Standard","Participating","Enrollment Complete","2020-10-01",null,null,"2020-10-09","10/9/2020 Confirmed provider is certified as a non-network provider with TriCare East. Kimberly Frazier"]
["Ana M Rodriguez, APRN-FNP","PE - Premier Family Care I, Inc","Ambetter","Participating","Enrollment Complete","2022-06-01",null,null,"2022-06-13","6/13/2022 Per roster received from Superior provider is PAR and linked to group delegation roster effective 6/1/2022."]
["Ana M Rodriguez, APRN-FNP","PE - Premier Family Care I, Inc","Scott&White (First Care)","Participating","Enrollment Complete","2021-03-12",null,null,"2021-03-18","3/18/2021 Received email from BSWHPEXPEDITES@BSWHealth.org confirming provider has been approved and is participating under group effective 3/12/3021. KFrazier"]
["Ana M Rodriguez, APRN-FNP","PE - Premier Family Care I, Inc","Cigna","Participating","Enrollment Complete","2021-02-09",1299432,null,"2021-02-20","2/20/2021 - Rcvd email from Cigna that provider has been approved effective 2/09/2021 PIN # 1299432.  DCannon"]
["Ana M Rodriguez, APRN-FNP","PE - Premier Family Care I, Inc","IMS","Participating","Enrollment Complete","2020-10-13",null,null,"2020-11-25","11/25/2020 - Rcvd email confirmation that Nov monthly roster was processed and this provider was made effective with the requested eff date of 10/13/2020.  DCannon"]
["Ana M Rodriguez, APRN-FNP","PE - Premier Family Care I, Inc","Galaxy Health","Participating","Enrollment Complete","2020-10-13",null,null,"2020-12-14","12/14/2020 - Rcvd email confirmation from Galaxy Health that the November Delegation Roster was completed. DCannon"]
["Ana M Rodriguez, APRN-FNP","PE - Premier Family Care I, Inc","Boon Chapman","Participating","Enrollment Complete","2021-12-01",3873524,null,"2022-03-23","3/23/2022 Per follow-up note - 03.10.2022.S/W Lania of Boon Chapman @ 800-950-7040. Provider NPI# is on file  and is participating effective 12/1/2021 under the group and TIN #. Provider ID#3873524.  Physical location is on file.Call ref# 7943427.- DCannon"]
["Ana M Rodriguez, APRN-FNP","PE - Premier Family Care I, Inc","CAQH","Participating","CAQH Reattested","2022-12-09",14485629,null,"2022-12-09","12/9/2022 CAQH re-attested.  DCannon"]
["Ana M Rodriguez, APRN-FNP","PE - Premier Family Care I, Inc","Aetna","Participating","Enrollment Complete","2021-04-01",null,null,"2021-03-24","3/19/21 (kstrickland) Called Atena SW Daniel Call Ref# 6008130068. He stated provider is in network but couldn't get me a provider ID bc they are waiting for the demographics team to load the date. It will take 30 days. But then you can call back to get a provider id.  DCannon"]
["Ana M Rodriguez, APRN-FNP","PE - Premier Family Care I, Inc","Amerigroup","Participating","Enrollment Complete","2020-10-13",null,null,"2021-08-26","8/26/2021 Rcvd full roster from Joe Rodriguez at Amerigroup listing provider as PAR w/ group TIN and location effective 10/13/2020.  DCannon"]
["Ana M Rodriguez, APRN-FNP","PE - Premier Family Care I, Inc","Caprock (CapStar)","Participating","Enrollment Complete","2020-10-13",null,null,"2021-08-06","8/6/2021 Rcvd confirmation from Caprock that provider is par and linked to TIN/locations effective 10/13/2020.  DCannon"]
["Ana M Rodriguez, APRN-FNP","PE - Premier Family Care I, Inc","First Health Coventry","Participating","Enrollment Complete","2020-10-13",3546328,null,"2022-08-10","8/10/2022 Per First Health web portal provider is PAR and linked to group TIN/location effective 10/13/2020.  PID # 3546238.  DCannon"]
["James D Richardson, MD","PE - Premier Family Care I, Inc","Amerigroup","Participating","Enrollment Complete","2020-05-04",null,null,"2021-08-26","8/26/2021 Rcvd full roster from Joe Rodriguez at Amerigroup listing provider as PAR w/ group TIN and location effective 5/4/2020.  DCannon"]
["James D Richardson, MD","PE - Premier Family Care I, Inc","Scott&White (First Care)","Participating","Enrollment Complete","2020-05-08",1306827266,null,"2020-08-14","8/14/2020 - Rec'd email response from the payer to verify that this provider is effective - Stacey Hudak"]
["James D Richardson, MD","PE - Premier Family Care I, Inc","CAQH","Participating","CAQH Reattested","2023-01-25",null,null,"2023-01-25","1/25/2023 CAQH reviewed and re-attested.  DCannon"]
["James D Richardson, MD","PE - Premier Family Care I, Inc","Ambetter","Participating","Enrollment Complete","2022-06-01",null,null,"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 D Richardson, MD","PE - Premier Family Care I, Inc","Medicaid","Participating","Enrollment Complete","2020-04-09",408517701,79837301,"2020-09-17","09/17/2020 - address added to medicare. address successfully added to TMHP group and as of today, the address has been linked to this providers account. - Stacey Hudak"]
["James D Richardson, MD","PE - Premier Family Care I, Inc","Multiplan","Participating","Enrollment Complete","2020-02-14",1306827266,"52669 - West Texas Physicians Alliance","2020-08-13","8/13/2020 - Rec'd email response from the payer stating \"The MultiPlan / PHCS Network Application for Richardson, James is complete.\n\nNetwork participation became effective as of 02/14/2020 with PHCS. The provider’s network participation is through 23655 - West Texas Physicians Alliance contract.\n\nNetwork participation became effective as of 02/12/2020 with MPI. The provider’s network participation is through 5026 - West Texas Physicians Alliance contract.\n\nNetwork participation became effective as of 02/14/2020 with MPI. The provider’s network participation is through 52669 - West Texas Physicians Alliance contract.\"  - Stacey Hudak"]
["James D Richardson, MD","PE - Premier Family Care I, Inc","IMS","Participating","Enrollment Complete","2019-09-01",1306827266,null,"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"]
["James D Richardson, MD","PE - Premier Family Care I, Inc","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"]
["James D Richardson, MD","PE - Premier Family Care I, Inc","Triwest VA","Facility Enrollment","Application Submitted",null,null,null,"2022-11-23","08/19/2022 - Submitted application to TriWest VA (sent to Scarlett Abigail, Scarlett_Abigail@bcbstx.com)"]
["James D Richardson, MD",null,"Triwest VA","Facility Enrollment","Application Submitted",null,null,null,"2022-11-23","08/19/2022 - Submitted application to TriWest VA (sent to Scarlett Abigail, Scarlett_Abigail@bcbstx.com)"]
["James D Richardson, MD","PE - Premier Family Care I, Inc","Triwest VA","Facility Enrollment","Facility Enrollment",null,null,null,"2022-11-23","10/17/2022 - Received roster from Scarlett of TriWest VA; provider status: \"No Action.  TIN is CCN participating under own DCN.\""]
["James D Richardson, MD",null,"Triwest VA","Facility Enrollment","Facility Enrollment",null,null,null,"2022-11-23","10/17/2022 - Received roster from Scarlett of TriWest VA; provider status: \"No Action.  TIN is CCN participating under own DCN.\""]
["James D Richardson, MD","PE - Premier Family Care I, Inc","Medicare","Participating","Enrollment Complete","2020-01-24",937962,"0008AH","2020-03-04","03/04/2020 - rec'd welcome letter from the payer stating APPROVED eff 1-24-2020 and linked to group PTAN 0008AH - Stacey Hudak"]
["James D Richardson, MD","PE - Premier Family Care I, Inc","Superior","Participating","Enrollment Complete","2020-08-01",1306827266,null,"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"]
["James D Richardson, MD","PE - Premier Family Care I, Inc","Boon Chapman","Participating","Enrollment Complete","2020-02-14",1306827266,null,"2020-10-05","Enrollment thru PHCS"]
["James D Richardson, MD","PE - Premier Family Care I, Inc","Aetna","Participating","Enrollment Complete","2020-06-01",1306827266,null,"2020-05-01","05/01/2020 - Rec'd email from the payer stating \"Welcome to the provider network effective 6/1/2020.\" - Stacey Hudak"]
["James D Richardson, MD","PE - Premier Family Care I, Inc","USA PPO","Participating","Enrollment Complete","2021-01-26",1312349,null,"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","PE - Premier Family Care I, Inc","TriCare Standard","Participating","Enrollment Complete","2020-06-11",null,null,"2020-11-03","11/3/2020 Confirmed via self-service portal provider is participating under Group Tax ID and correct location effective 6/11/2020. Kimberly Frazier"]
["James D Richardson, MD","PE - Premier Family Care I, Inc","HealthSmart PPO","Participating","Enrollment Complete","2020-02-12",null,null,"2020-07-21","07/21/2020 - moved to completed status. Provider is enrolled with this TIN under WEST TEXAS PHYSICIANS ALLIANCE MDDO Delegated group - Stacey Hudak"]
["James D Richardson, MD","PE - Premier Family Care I, Inc","Humana","Participating","Enrollment Complete","2020-02-11",null,null,"2021-11-18","11/18/2021 Rcvd full roster from Humana listing provider as PAR and linked to group TIN/location effective 2/11/2020.  DCannon"]
["James D Richardson, MD","PE - Premier Family Care I, Inc","United Health Care","Participating","Enrollment Complete","2020-02-04",1306827266,null,"2020-10-14","10/14/2020 - moved to completed status after reviewing follow up complete note - Stacey Hudak"]
["James D Richardson, MD","PE - Premier Family Care I, Inc","Galaxy Health","Participating","Enrollment Complete","2019-09-01",1306827266,null,"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"]
["James D Richardson, MD","PE - Premier Family Care I, Inc","Cigna","Participating","Enrollment Complete","2020-05-05",6886462,null,"2020-05-06","05/06/2020 - Rec;d email from the payer stating \"Congratulations! Your application to participate in the Cigna network has been approved. Your effective date is 05/05/2020. Your provider identification number is? ?6886462.\" - Stacey Hudak"]
["James D Richardson, MD","PE - Premier Family Care I, Inc","Omni PPO","Participating","Enrollment Complete","2019-09-01",1306827266,null,"2020-07-27","IMS complete"]
["James D Richardson, MD","PE - Premier Family Care I, Inc","First Health Coventry","Participating","Enrollment Complete","2020-09-01",1306827266,null,"2020-10-01","10/01/2020 - moved to completed status after getting confirmation effective email from the payer - Stacey Hudak"]
["James D Richardson, MD","PE - Premier Family Care I, Inc","Caprock (CapStar)","Participating","Enrollment Complete","2019-09-01",1306827266,null,"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"]
["Kristie M Chu, MD","PE - Premier Family Care I, Inc","HealthSmart PPO","Participating","Enrollment Complete","2021-05-10",null,null,"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","PE - Premier Family Care I, Inc","Cigna","Participating","Enrollment Complete","2021-05-27",null,null,"2021-06-01","6/1/2021 Received an email from discovercigna@information.cigna.com confirming provider is now participating under group effective 5/27/2021 with assigned PIN number 8559734. KFrazier"]
["Kristie M Chu, MD","PE - Premier Family Care I, Inc","Galaxy Health","Participating","Enrollment Complete","2021-05-10",null,null,"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"]
["Kristie M Chu, MD","PE - Premier Family Care I, Inc","TriCare Standard","Participating","Enrollment Complete","2021-04-12",null,null,"2021-04-12","4/12/2021 Received email from Latisha Green at Latisha.Green@wpsic.com with written confirmation of certification approval under group Tax ID and location, effective 3/12/2021, and assigned TERV ID 752656723 79701 X012. KFrazier"]
["Kristie M Chu, MD","PE - Premier Family Care I, Inc","Wellcare","Participating","Enrollment Complete","2021-11-01",null,null,"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"]
["Kristie M Chu, MD","PE - Premier Family Care I, Inc","Superior","Participating","Enrollment Complete","2021-06-01",null,null,"2021-06-03","6/3/2021 Rcvd email from Superior that monthly delegation roster for May is complete and providers are loaded under TIN/locations effective 6/1/2021.  DCannon"]
["Kristie M Chu, MD","PE - Premier Family Care I, Inc","CAQH","Participating","CAQH Reattested","2023-01-25",null,null,"2023-01-25","1/25/2023 CAQH reviewed and re-attested.  DCannon"]
["Kristie M Chu, MD","PE - Premier Family Care I, Inc","Rail Road Medicare","Participating","Enrollment Complete","2021-03-01","Q00078955","CE1588","2021-06-01","6/1/2021 Immediately assigned RR PTAN Q00078955 which is effective 3/1/2021 under group RR PTAN CE1588. KFrazier"]
["Kristie M Chu, MD","PE - Premier Family Care I, Inc","IMS","Participating","Enrollment Complete","2021-05-10",null,null,"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","PE - Premier Family Care I, Inc","Multiplan","Participating","Enrollment Complete","2021-05-10",null,null,"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 5/10/2021.  DCannon"]
["Kristie M Chu, MD","PE - Premier Family Care I, Inc","Aetna","Participating","Enrollment Complete","2021-05-15",6198680,null,"2021-07-08","7/1/2021-S/W Mark of AETNA @ 8003531232, NPI# of the provider is on file and shows link and PAR under the group and TIN# effective 5/15/2021, physical location is on file. Provider ID is 6198680.   Rep confirmed that once provider is credentialed w/ Aetna automatically, provider is also credentialed w/First Health and Coventry. Call ref#6028239169. herminia Gilongos"]
["Kristie M Chu, MD","PE - Premier Family Care I, Inc","Triwest VA","Facility Enrollment","Application Submitted",null,null,null,"2022-11-23","08/19/2022 - Submitted application to TriWest VA (sent to Scarlett Abigail, Scarlett_Abigail@bcbstx.com)"]
["Kristie M Chu, MD",null,"Triwest VA","Facility Enrollment","Application Submitted",null,null,null,"2022-11-23","08/19/2022 - Submitted application to TriWest VA (sent to Scarlett Abigail, Scarlett_Abigail@bcbstx.com)"]
["Kristie M Chu, MD","PE - Premier Family Care I, Inc","Triwest VA","Facility Enrollment","Facility Enrollment",null,null,null,"2022-11-23","10/17/2022 - Received roster from Scarlett of TriWest VA; provider status: \"No Action.  TIN is CCN participating under own DCN.\""]
["Kristie M Chu, MD",null,"Triwest VA","Facility Enrollment","Facility Enrollment",null,null,null,"2022-11-23","10/17/2022 - Received roster from Scarlett of TriWest VA; provider status: \"No Action.  TIN is CCN participating under own DCN.\""]
["Kristie M Chu, MD","PE - Premier Family Care I, Inc","Amerigroup","Participating","Enrollment Complete","2021-05-10",null,null,"2021-08-26","8/26/2021 Rcvd full roster from Joe Rodriguez at Amerigroup listing provider as PAR w/ group TIN and location effective 5/10/2021.  DCannon"]
["Kristie M Chu, MD","PE - Premier Family Care I, Inc","Tricare Prime","Participating","Enrollment Complete","2021-04-12",null,null,"2021-11-03","11/3/2021 Per follow-up notes.  Provider NPI# is on file for the provider and is participating effective 04/12/2021 under the group and TIN#.   Physical location is on file. Call ref# 14226636.  DCannon"]
["Kristie M Chu, MD","PE - Premier Family Care I, Inc","Medicaid","Participating","Enrollment Complete","2021-03-01",423389201,79837301,"2021-07-22","7/22/2021 Received a copy of the TMHP approval letter from Candace Wynne at Premier.  TPI # 423389201 effective 3/1/2021.  DCannon"]
["Kristie M Chu, MD","PE - Premier Family Care I, Inc","United Health Care","Participating","Enrollment Complete","2021-06-21",7565313,null,"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 6/21/2021 and assigned provider ID 7565313. KFrazier"]
["Kristie M Chu, MD","PE - Premier Family Care I, Inc","Omni PPO","Participating","Enrollment Complete","2021-05-10",null,null,"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","PE - Premier Family Care I, Inc","Caprock (CapStar)","Participating","Enrollment Complete","2021-05-10",null,null,"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 5/10/2021.  DCannon"]
["Kristie M Chu, MD","PE - Premier Family Care I, Inc","Boon Chapman","Participating","Enrollment Complete","2021-05-10",null,null,"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 5/10/2021.  DCannon"]
["Kristie M Chu, MD","PE - Premier Family Care I, Inc","Scott&White (First Care)","Participating","Enrollment Complete","2021-05-10",null,null,"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"]
["Kristie M Chu, MD","PE - Premier Family Care I, Inc","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"]
["Kristie M Chu, MD","PE - Premier Family Care I, Inc","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"]
["Kristie M Chu, MD","PE - Premier Family Care I, Inc","Medicare","Participating","Enrollment Complete","2021-03-01","1P4382","0008AH","2021-05-20","5/20/2021 Rcvd Medicare approval letter from Candace Wynne.  PTAN # 1P4382 - effective 3/1/2021.  DCannon"]
["Kristie M Chu, MD","PE - Premier Family Care I, Inc","USA PPO","Participating","Enrollment Complete","2021-05-10",null,null,"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"]
["Kristie M Chu, MD","PE - Premier Family Care I, Inc","Alliance WC","Participating","Enrollment Complete","2021-05-21",null,null,"2021-12-02","12/2/21 Received email from michelle.killough@pswca.org, provider eff 05/21/2021 with Tax ID 75-2656723. Cbankston"]
["Leslie Michelle Rowland, FNP","PE - Premier Family Care I, Inc","Scott&White (First Care)","Participating","Enrollment Complete","2021-02-12",null,null,"2021-01-29","1/29/2021 - Rcvd roster from Scott&White (First Care) confirming participation of provider with TIN and location effective dates.  DCannon"]
["Leslie Michelle Rowland, FNP","PE - Premier Family Care I, Inc","Cigna","Participating","Enrollment Complete","2020-10-12",null,null,"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","PE - Premier Family Care I, Inc","Boon Chapman","Participating","Enrollment Complete","2020-09-17",null,null,"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"]
["Leslie Michelle Rowland, FNP","PE - Premier Family Care I, Inc","Aetna","Participating","Enrollment Complete","2021-04-01",9212791,null,"2021-05-07","5/7/2021 Called Aetna (888-632-3862 spoke with Andrea (call ref # 6017548190) she informed me that provider is PAR and linked to TIN/location effective 4/1/2021 PID 9212791.  DCannon"]
["Leslie Michelle Rowland, FNP","PE - Premier Family Care I, Inc","Medicare","Participating","Enrollment Complete","2020-10-12","1H6228","0008AH","2020-11-23","11/23/2020 Provider has been approved under group PTAN and issued PTAN 1H6228 effective 10/12/2020. Kimberly Frazier"]
["Leslie Michelle Rowland, FNP","PE - Premier Family Care I, Inc","Amerigroup","Participating","Enrollment Complete","2011-05-12",null,null,"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","PE - Premier Family Care I, Inc","United Health Care","Participating","Enrollment Complete","2020-09-30",5196033,null,"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 9/30/2020 and assigned provider ID 5196033. KFrazier"]
["Leslie Michelle Rowland, FNP","PE - Premier Family Care I, Inc","Aetna","Participating","Enrollment Complete","2021-04-01",9212791,null,"2021-05-07","5/7/2021 Called Aetna (888-632-3862 spoke with Andrea (call ref # 6017548190) she informed me that provider is PAR and linked to TIN/location effective 4/1/2021 PID 9212791.  DCannon"]
["Leslie Michelle Rowland, FNP","PE - Premier Family Care I, Inc","Medicaid","In House Enrollment","In House Enrollment",null,null,null,"2021-08-12","8/12/2021 Per email received from Candace Wynne, she has submitted an application to add provider to location via the TMHP portal. KFrazier"]
["Leslie Michelle Rowland, FNP","PE - Premier Family Care I, Inc","HealthSmart PPO","Participating","Enrollment Complete","2020-09-17",null,null,"2021-01-27","1/27/2021 - Rcvd confirmation email that provider is participating and linked to location and TIN effective 9/17/2020.  DCannon"]
["Leslie Michelle Rowland, FNP","PE - Premier Family Care I, Inc","HealthSmart PPO","Participating","Enrollment Complete","2020-09-17",null,null,"2021-01-27","1/27/2021 - Rcvd confirmation email that provider is participating and linked to location and TIN effective 9/17/2020.  DCannon"]
["Leslie Michelle Rowland, FNP","PE - Premier Family Care I, Inc","United Health Care","Participating","Enrollment Complete","2020-12-14",null,null,"2021-01-26","1/26/2021 - Per follow-up notes provider is par with TIN and location effective 12/14/2020.  DCannon"]
["Leslie Michelle Rowland, FNP","PE - Premier Family Care I, Inc","Multiplan","Participating","Enrollment Complete","2020-09-17",null,null,"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"]
["Leslie Michelle Rowland, FNP","PE - Premier Family Care I, Inc","Superior","Participating","Enrollment Complete","2020-12-01",null,null,"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","PE - Premier Family Care I, Inc","Cigna","Participating","Enrollment Complete","2020-10-12",null,null,"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","PE - Premier Family Care I, Inc","Triwest VA","Facility Enrollment","In House Enrollment",null,null,null,"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","PE - Premier Family Care I, Inc","Cigna","Participating","Enrollment Complete","2020-10-12",null,null,"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","PE - Premier Family Care I, Inc","Galaxy Health","Participating","Enrollment Complete","2020-09-17",null,null,"2020-12-14","12/14/2020 - Rcvd email confirmation from Galaxy Health that the November Delegation Roster was completed. DCannon"]
["Leslie Michelle Rowland, FNP","PE - Premier Family Care I, Inc","TriCare Standard","Participating","Enrollment Complete","2021-11-08",null,null,"2021-11-30","11/30/21 Per Tricare portal, provider added to location. Cbankston"]
["Leslie Michelle Rowland, FNP","PE - Premier Family Care I, Inc","Caprock (CapStar)","Participating","Enrollment Complete","2020-09-17",null,null,"2021-04-09","4/9/2020 Rcvd roster from Mary Rodriguez <mary.rodriguez@90degreebenefits.com> at Caprock listing provider as participating under TIN.  DCannon"]
["Leslie Michelle Rowland, FNP","PE - Premier Family Care I, Inc","Triwest VA","Facility Enrollment","In House Enrollment",null,null,null,"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",null,"Triwest VA","Facility Enrollment","In House Enrollment",null,null,null,"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","PE - Premier Family Care I, Inc","Triwest VA","Facility Enrollment","Application Submitted",null,null,null,"2022-11-23","08/19/2022 - Submitted application to TriWest VA (sent to Scarlett Abigail, Scarlett_Abigail@bcbstx.com)"]
["Leslie Michelle Rowland, FNP",null,"Triwest VA","Facility Enrollment","Application Submitted",null,null,null,"2022-11-23","08/19/2022 - Submitted application to TriWest VA (sent to Scarlett Abigail, Scarlett_Abigail@bcbstx.com)"]
["Leslie Michelle Rowland, FNP","PE - Premier Family Care I, Inc","Triwest VA","Facility Enrollment","Facility Enrollment",null,null,null,"2022-11-23","10/17/2022 - Received roster from Scarlett of TriWest VA; provider status: \"No Action.  TIN is CCN participating under own DCN.\""]
["Leslie Michelle Rowland, FNP",null,"Triwest VA","Facility Enrollment","Facility Enrollment",null,null,null,"2022-11-23","10/17/2022 - Received roster from Scarlett of TriWest VA; provider status: \"No Action.  TIN is CCN participating under own DCN.\""]
["Leslie Michelle Rowland, FNP","PE - Premier Family Care I, Inc","HealthSmart PPO","Participating","Enrollment Complete","2020-09-17",null,null,"2021-01-22","1/22/2021 - Rcvd email from Healthsmart Provider Services that provider is participating at location under TIN effective 9/17/2020.  DCannon"]
["Leslie Michelle Rowland, FNP","PE - Premier Family Care I, Inc","Medicare","Participating","Enrollment Complete","2020-10-12","1H6228","0008AH","2020-10-30","10/30/2020 Confirmed provider is participating under group and assigned PTAN 1H6228 effective 10/12/2020. Kimberly Frazier"]
["Leslie Michelle Rowland, FNP","PE - Premier Family Care I, Inc","Omni PPO","Participating","Enrollment Complete","2020-09-17",null,null,"2021-01-06","1/6/2020 - Rcvd confirmation from payor that provider load is complete.  DCannon"]
["Leslie Michelle Rowland, FNP","PE - Premier Family Care I, Inc","IMS","Participating","Enrollment Complete","2020-09-17",null,null,"2020-11-25","11/25/2020 - Rcvd email confirmation that Nov monthly roster was processed and this provider was made effective with the requested eff date of 9/17/2020.  DCannon"]
["Leslie Michelle Rowland, FNP","PE - Premier Family Care I, Inc","Ambetter","Participating","Enrollment Complete","2022-06-01",null,null,"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","PE - Premier Family Care I, Inc","Ambetter","Participating","Enrollment Complete","2022-06-01",null,null,"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","PE - Premier Family Care I, Inc","Ambetter","Participating","Enrollment Complete","2022-06-01",null,null,"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","PE - Premier Family Care I, Inc","Ambetter","Participating","Enrollment Complete","2022-06-01",null,null,"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","PE - Premier Family Care I, Inc","Ambetter","Participating","Enrollment Complete","2022-06-01",null,null,"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","PE - Premier Family Care I, Inc","Ambetter","Participating","Enrollment Complete","2022-06-01",null,null,"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","PE - Premier Family Care I, Inc","Amerigroup","Participating","Enrollment Complete","2011-05-12",null,null,"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","PE - Premier Family Care I, Inc","Omni PPO","Participating","Enrollment Complete","2020-09-17",null,null,"2020-11-12","11/12/20 - Received email from payer 10/20/20 that provider has been loaded in their system as a participating provider effective 9/17/20.  DCannon"]
["Leslie Michelle Rowland, FNP","PE - Premier Family Care I, Inc","USA PPO","Participating","Enrollment Complete","2021-01-26",1312371,null,"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","PE - Premier Family Care I, Inc","Medicaid","Participating","Enrollment Complete","2020-10-12",142128104,79837301,"2020-12-09","12/9/2020 Upon review of the TMHP group portal, provider has been approved and assigned TPI 142128104, and effective date is that of 10/12/2020. KFrazier"]
["Leslie Michelle Rowland, FNP","PE - Premier Family Care I, Inc","First Health Coventry","Participating","Enrollment Complete","2021-11-22",9212791,null,"2022-05-11","5/11/2022 Per follow-up note from 12/20/2021 provider is PAR and linked to group TIN/location effective 11/22/2021.  PID # 9212791.  DCannon"]
["Leslie Michelle Rowland, FNP","PE - Premier Family Care I, Inc","Multiplan","Participating","Enrollment Complete","2020-09-17",null,null,"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"]
["Leslie Michelle Rowland, FNP","PE - Premier Family Care I, Inc","United Health Care","Participating","Enrollment Complete","2020-12-14",null,null,"2021-01-26","1/26/2021 - Per follow-up notes provider is par with TIN and location effective 12/14/2020.  DCannon"]
["Leslie Michelle Rowland, FNP","PE - Premier Family Care I, Inc","USA PPO","Participating","Enrollment Complete","2021-01-26",1312371,null,"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","PE - Premier Family Care I, Inc","Medicare","Participating","Enrollment Complete","2020-10-12","1H6228","0008AH","2020-11-23","11/23/2020 Provider has been reassigned under group PTAN and assigned PTAN 1H6228 effective 10/12/2020. Kimberly Frazier"]
["Leslie Michelle Rowland, FNP","PE - Premier Family Care I, Inc","Medicaid","Participating","Enrollment Complete","2020-10-12",142128104,null,"2021-01-26","1/26/2021 - Per follow-up notes provider is participating and linked to address/TIN effective 10/12/2020; provider ID 142128104.  DCannon"]
["Leslie Michelle Rowland, FNP","PE - Premier Family Care I, Inc","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"]
["Leslie Michelle Rowland, FNP","PE - Premier Family Care I, Inc","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"]
["Leslie Michelle Rowland, FNP","PE - Premier Family Care I, Inc","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"]
["Leslie Michelle Rowland, FNP","PE - Premier Family Care I, Inc","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"]
["Leslie Michelle Rowland, FNP","PE - Premier Family Care I, Inc","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"]
["Leslie Michelle Rowland, FNP","PE - Premier Family Care I, Inc","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"]
["Leslie Michelle Rowland, FNP","PE - Premier Family Care I, Inc","Superior","Participating","Enrollment Complete","2020-11-01",null,null,"2020-11-25","11/25/2020 -  Rcvd email confirmation that Oct monthly roster was processed and this provider was made effective with the requested eff date of 11/1/2020.  DCannon"]
["Leslie Michelle Rowland, FNP","PE - Premier Family Care I, Inc","Amerigroup","Participating","Enrollment Complete","2011-05-12",null,null,"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","PE - Premier Family Care I, Inc","Caprock (CapStar)","Participating","Enrollment Complete","2020-09-17",null,null,"2021-04-09","4/9/2020 Rcvd roster from Mary Rodriguez <mary.rodriguez@90degreebenefits.com> at Caprock listing provider as participating under TIN.  DCannon"]
["Leslie Michelle Rowland, FNP","PE - Premier Family Care I, Inc","Superior","Participating","Enrollment Complete","2020-11-01",null,null,"2020-11-25","11/25/2020 -  Rcvd email confirmation that Oct monthly roster was processed and this provider was made effective with the requested eff date of 11/1/2020.  DCannon"]
["Leslie Michelle Rowland, FNP","PE - Premier Family Care I, Inc","CAQH","Participating","CAQH Reattested","2023-01-03",null,null,"2023-01-03","1/3/2023 CAQH Reviewed and re-attested.  DCannon"]
["Leslie Michelle Rowland, FNP","PE - Premier Family Care I, Inc","Scott&White (First Care)","Participating","Enrollment Complete","2021-02-12",null,null,"2021-01-29","1/29/2021 - Rcvd roster from Scott&White (First Care) confirming participation of provider with TIN and location effective dates.  DCannon"]
["Leslie Michelle Rowland, FNP","PE - Premier Family Care I, Inc","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"]
["Leslie Michelle Rowland, FNP","PE - Premier Family Care I, Inc","Multiplan","Participating","Enrollment Complete","2020-09-17",null,null,"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"]
["Leslie Michelle Rowland, FNP","PE - Premier Family Care I, Inc","Caprock (CapStar)","Participating","Enrollment Complete","2020-09-17",null,null,"2021-04-09","4/9/2020 Rcvd roster from Mary Rodriguez <mary.rodriguez@90degreebenefits.com> at Caprock listing provider as participating under TIN.  DCannon"]
["Leslie Michelle Rowland, FNP","PE - Premier Family Care I, Inc","Galaxy Health","Participating","Enrollment Complete","2020-09-17",null,null,"2020-12-14","12/14/2020 - Rcvd email confirmation from Galaxy Health that the November Delegation Roster was completed. DCannon"]
["Leslie Michelle Rowland, FNP","PE - Premier Family Care I, Inc","Omni PPO","Participating","Enrollment Complete","2020-09-17",null,null,"2020-11-12","11/12/20 - Received email from payer 10/20/20 that provider has been loaded in their system as a participating provider effective 9/17/20.  DCannon"]
["Leslie Michelle Rowland, FNP","PE - Premier Family Care I, Inc","TriCare Standard","Participating","Enrollment Complete","2021-05-20",null,null,"2021-08-03","8/3/2021 Per follow-up complete notes provider is PAR under the group and TIN# effective 5/20/2021 w/ no term date under this location. Provider ID is 75-2656723-79703-A004.  DCannon"]
["Leslie Michelle Rowland, FNP","PE - Premier Family Care I, Inc","First Health Coventry","In Process","Enrollment Complete",null,9212791,null,"2023-01-19","1.19.2023 S/W Ashanti of First Health @ 800-226-5116. Transferred the call and spoke with Stacey. Provider is on file and participating. Link under the group and TIN effective 12/1/2022. Location is on file. Provider ID is 3628663. Next recredentialing date is every 3 years (12/1/2025). No information for the payer#. -Kim Monique Fabian"]
["Leslie Michelle Rowland, FNP","PE - Premier Family Care I, Inc","Triwest VA","Facility Enrollment","In House Enrollment",null,null,null,"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","PE - Premier Family Care I, Inc","Boon Chapman","Participating","Enrollment Complete","2020-09-17",null,null,"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"]
["Leslie Michelle Rowland, FNP","PE - Premier Family Care I, Inc","Boon Chapman","Participating","Enrollment Complete","2020-09-17",null,null,"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"]
["Leslie Michelle Rowland, FNP","PE - Premier Family Care I, Inc","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"]
["Leslie Michelle Rowland, FNP","PE - Premier Family Care I, Inc","USA PPO","Participating","Enrollment Complete","2021-01-26",1312371,null,"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","PE - Premier Family Care I, Inc","Scott&White (First Care)","Participating","Enrollment Complete","2021-02-12",null,null,"2021-01-29","1/29/2021 - Rcvd roster from Scott&White (First Care) confirming participation of provider with TIN and location effective dates.  DCannon"]
["Leslie Michelle Rowland, FNP","PE - Premier Family Care I, Inc","Galaxy Health","Participating","Enrollment Complete","2020-09-17",null,null,"2020-12-14","12/14/2020 - Rcvd email confirmation from Galaxy Health that the November Delegation Roster was completed. DCannon"]
["Leslie Michelle Rowland, FNP","PE - Premier Family Care I, Inc","IMS","Participating","Enrollment Complete","2020-09-17",null,null,"2020-11-12","11/12/20 - Received email from payer 10/20/20 that provider has been loaded in their system as a participating provider effective 9/17/20.  DCannon"]
["Leslie Michelle Rowland, FNP","PE - Premier Family Care I, Inc","IMS","Participating","Enrollment Complete","2020-09-17",null,null,"2020-11-12","11/12/20 - Received email from payer 10/20/20 that provider has been loaded in their system as a participating provider effective 9/17/20.  DCannon"]
["Leslie Michelle Rowland, FNP","PE - Premier Family Care I, Inc","First Health Coventry","Participating","Enrollment Complete","2021-11-22",9212791,null,"2022-05-11","5/11/2022 Per follow-up note from 12/20/2021 provider is PAR and linked to group TIN/location effective 11/22/2021.  PID # 9212791.  DCannon"]
["Leslie Michelle Rowland, FNP","PE - Premier Family Care I, Inc","Aetna","Participating","Enrollment Complete","2021-04-01",9212791,null,"2021-03-26","3/26/2021 Per follow-up call Atena SW Daniel Call Ref# 6008130068. He stated provider is in network with this address on file.  effective 4/1/2021.  DCannon"]
["Ni Adams, NP","PE - Premier Family Care I, Inc","Scott&White (First Care)","Participating","Enrollment Complete","2021-03-12",null,null,"2021-03-18","3/18/2021 Received email from BSWHPEXPEDITES@BSWHealth.org confirming provider has been approved and is participating under group effective 3/12/3021. KFrazier"]
["Ni Adams, NP","PE - Premier Family Care I, Inc","Cigna","Participating","Enrollment Complete","2021-02-12",6320597,null,"2021-02-20","2/20/2021 - Rcvd email from Cigna that provider has been approved effective 2/12/2021 PIN # 6320597.  DCannon"]
["Ni Adams, NP","PE - Premier Family Care I, Inc","Triwest VA","Facility Enrollment","In House Enrollment",null,null,null,"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"]
["Ni Adams, NP",null,"Triwest VA","Facility Enrollment","In House Enrollment",null,null,null,"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"]
["Ni Adams, NP","PE - Premier Family Care I, Inc","Triwest VA","Facility Enrollment","Application Submitted",null,null,null,"2022-11-28","08/19/2022 - Submitted application to TriWest VA (sent to Scarlett Abigail, Scarlett_Abigail@bcbstx.com)"]
["Ni Adams, NP",null,"Triwest VA","Facility Enrollment","Application Submitted",null,null,null,"2022-11-28","08/19/2022 - Submitted application to TriWest VA (sent to Scarlett Abigail, Scarlett_Abigail@bcbstx.com)"]
["Ni Adams, NP","PE - Premier Family Care I, Inc","Triwest VA","Facility Enrollment","Facility Enrollment",null,null,null,"2022-11-28","10/17/2022 - Received roster from Scarlett of TriWest VA; provider status: \"No Action.  TIN is CCN participating under own DCN.\""]
["Ni Adams, NP",null,"Triwest VA","Facility Enrollment","Facility Enrollment",null,null,null,"2022-11-28","10/17/2022 - Received roster from Scarlett of TriWest VA; provider status: \"No Action.  TIN is CCN participating under own DCN.\""]
["Ni Adams, NP","PE - Premier Family Care I, Inc","Tricare Prime","Participating","Enrollment Complete","2022-03-02",null,null,"2022-03-09","3/9/2022 Per Tricare portal provider is certified and in network with location as of 3/2/2022. Cbankston"]
["Ni Adams, NP","PE - Premier Family Care I, Inc","Amerigroup","Participating","Enrollment Complete","2020-10-13",null,null,"2021-08-26","8/26/2021 Rcvd full roster from Joe Rodriguez at Amerigroup listing provider as PAR w/ group TIN and location effective 10/13/2020.  DCannon"]
["Ni Adams, NP","PE - Premier Family Care I, Inc","IMS","Participating","Enrollment Complete","2020-10-13",null,null,"2020-11-25","11/25/2020 - Rcvd email confirmation that Nov monthly roster was processed and this provider was made effective with the requested eff date of 10/13/2020.  DCannon"]
["Ni Adams, NP","PE - Premier Family Care I, Inc","Medicare","Participating","Enrollment Complete","2020-10-01","1K2965",null,"2020-12-17","12/17/2020 Received email of Medicare approval with assigned PTAN 1K2965 effective 10/1/2020. KFrazier"]
["Ni Adams, NP","PE - Premier Family Care I, Inc","First Health Coventry","In Process","Enrollment Complete",null,null,null,"2023-01-19","1.19.2023 S/W Ashanti of First Health @ 800-226-5116. Transferred the call and spoke with Stacey. Provider is on file and participating. Link under the group and TIN effective 12/1/2022. Location is on file. Provider ID is 3634130. Next recredentialing date is every 3 years (12/1/2025). No information for the payer#. -Kim Monique Fabian"]
["Ni Adams, NP","PE - Premier Family Care I, Inc","CAQH","Participating","CAQH Reattested","2023-02-12",14969540,null,"2023-02-12","2/12/2023 CAQH reviewed and re-attested.   DCannon"]
["Ni Adams, NP","PE - Premier Family Care I, Inc","USA PPO","Participating","Enrollment Complete","2021-01-26",1312232,null,"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"]
["Ni Adams, NP","PE - Premier Family Care I, Inc","HealthSmart PPO","Participating","Enrollment Complete","2020-10-13",null,null,"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, NP","PE - Premier Family Care I, Inc","Caprock (CapStar)","Participating","Enrollment Complete","2020-10-13",null,null,"2021-04-07","4/7/2021 Rcvd roster from Mary Rodriguez 4/5/2021 listing provider as participating.  DCannon"]
["Ni Adams, NP","PE - Premier Family Care I, Inc","Galaxy Health","Participating","Enrollment Complete","2020-10-13",null,null,"2020-12-14","12/14/2020 - Rcvd email confirmation from Galaxy Health that the November Delegation Roster was completed 12/14/2020. DCannon"]
["Ni Adams, NP","PE - Premier Family Care I, Inc","Aetna","Participating","Enrollment Complete","2021-06-01",6615260,null,"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, NP","PE - Premier Family Care I, Inc","Superior","Participating","Enrollment Complete","2020-12-01",null,null,"2021-02-02","2/2/2021 - Rcvd confirmation from payer that provider is participating and linked to TIN effective 12/1/2020.  DCannon"]
["Ni Adams, NP","PE - Premier Family Care I, Inc","Multiplan","Participating","Enrollment Complete","2020-10-13",null,null,"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 10/13/2020.  DCannon"]
["Ni Adams, NP","PE - Premier Family Care I, Inc","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"]
["Ni Adams, NP","PE - Premier Family Care I, Inc","Medicaid","Participating","Enrollment Complete","2020-10-01","4075624-02","0798373-01","2021-01-04","1/4/2021 Received forwarded approval notice from Candace Wynne in which provider has been assigned TPI 4075624-02, effective 10/1/2020. Revalidation due 12/28/2025. KFrazier"]
["Ni Adams, NP","PE - Premier Family Care I, Inc","United Health Care","Participating","Enrollment Complete","2020-11-11",7533626,null,"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 11/11/2020 and assigned provider ID 7533626. KFrazier"]
["Ni Adams, NP","PE - Premier Family Care I, Inc","Omni PPO","Participating","Enrollment Complete","2020-10-13",null,null,"2020-11-25","11/25/2020 - Rcvd email confirmation that Nov monthly roster was processed and this provider was made effective with the requested eff date of 10/13/2020.  DCannon"]
["Ni Adams, NP","PE - Premier Family Care I, Inc","Ambetter","Participating","Enrollment Complete","2022-06-01",null,null,"2022-06-13","6/13/2022 Per roster received from Superior provider is PAR and linked to group delegation roster effective 6/1/2022."]
["Ni Adams, NP","PE - Premier Family Care I, Inc","TriCare Standard","Participating","Enrollment Complete","2022-03-02",null,null,"2022-03-09","3/9/2022 Per Tricare portal provider is certified and in network with location as of 3/2/2022. Cbankston"]
["Loyce Michelle Daniels, NP","PE - Premier Family Care I, Inc","Cigna","Participating","Enrollment Complete","2021-04-12",1717755,null,"2021-04-14","4/14/2021 Received an email from discovercigna@information.cigna.com confirming provider is now participating under group Tax ID effective 4/12/2021 with assigned PIN number 1717755. KFrazier"]
["Loyce Michelle Daniels, NP","PE - Premier Family Care I, Inc","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"]
["Loyce Michelle Daniels, NP","PE - Premier Family Care I, Inc","USA PPO","Participating","Enrollment Complete","2021-03-15",null,null,"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 3/15/2021.  DCannon"]
["Loyce Michelle Daniels, NP","PE - Premier Family Care I, Inc","IMS","Participating","Enrollment Complete","2021-03-15",null,null,"2021-06-15","6/15/2021 Rcvd email from German Aviles <german.aciles@imsm.net> at CapRock 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 3/15/2021. DCannon"]
["Loyce Michelle Daniels, NP","PE - Premier Family Care I, Inc","Tricare Prime","Participating","Enrollment Complete","2021-08-10",null,null,null,"12/14/2021 Per portal, provider linked to location as of 8/10/2021. Cbankston"]
["Loyce Michelle Daniels, NP","PE - Premier Family Care I, Inc","Medicare","Participating","Enrollment Complete","2021-02-28","1M6747","0008AH","2021-03-01","3/1/2021 Received email notice confirming provider' 855I is complete. Therefore, pulled Medicare ID report and she's been assigned PTAN 1M6747 under group PTAN effective 2/28/2021. KFrazier"]
["Loyce Michelle Daniels, NP","PE - Premier Family Care I, Inc","United Health Care","Participating","Enrollment Complete","2021-02-26",null,null,"2021-05-10","5/10/2021 Received an email from Rep jean.lambert@optum.com confirming provider is participating under group Tax ID effective 2/26/2021. KFrazier"]
["Loyce Michelle Daniels, NP","PE - Premier Family Care I, Inc","Aetna","Participating","Enrollment Complete","2021-04-01",null,null,"2021-03-24","3/19/21 (kstrickland) Called Atena SW Allen Call ref# 6008145974. Provider will be in network and effective on 4/1/21. However they are still loading the demographics. That should be loaded no later then 4/9/21. You can call back and get provider ID on that date. Tracking # PVB-1256016.  DCannon"]
["Loyce Michelle Daniels, NP","PE - Premier Family Care I, Inc","First Health Coventry","Participating","Enrollment Complete","2021-03-15",null,null,"2022-04-28","4/28/2022 Per First Health online provider directory provider is PAR and linked to group/locations  effective 3/15/2021.  DCannon"]
["Loyce Michelle Daniels, NP","PE - Premier Family Care I, Inc","Ambetter","Participating","Enrollment Complete","2022-06-01",null,null,"2022-06-13","6/13/2022 Per roster received from Superior provider is PAR and linked to group delegation roster effective 6/1/2022."]
["Loyce Michelle Daniels, NP","PE - Premier Family Care I, Inc","Medicaid","Participating","Enrollment Complete","2021-02-28",420240001,79837301,"2021-03-25","3/25/2021 Per TMHP Provider Portal application has been processed and approved.  TPI # 420240001 effective 2.28.2021.  DCannon"]
["Loyce Michelle Daniels, NP","PE - Premier Family Care I, Inc","Amerigroup","Participating","Enrollment Complete","2022-04-14",null,null,"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"]
["Loyce Michelle Daniels, NP","PE - Premier Family Care I, Inc","Galaxy Health","Participating","Enrollment Complete","2021-03-15",null,null,"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 3/15/2021.  DCannon"]
["Loyce Michelle Daniels, NP","PE - Premier Family Care I, Inc","Triwest VA","Facility Enrollment","Application Submitted",null,null,null,"2022-11-23","08/19/2022 - Submitted application to TriWest VA (sent to Scarlett Abigail, Scarlett_Abigail@bcbstx.com)"]
["Loyce Michelle Daniels, NP",null,"Triwest VA","Facility Enrollment","Application Submitted",null,null,null,"2022-11-23","08/19/2022 - Submitted application to TriWest VA (sent to Scarlett Abigail, Scarlett_Abigail@bcbstx.com)"]
["Loyce Michelle Daniels, NP","PE - Premier Family Care I, Inc","Triwest VA","Facility Enrollment","Facility Enrollment",null,null,null,"2022-11-23","10/17/2022 - Received roster from Scarlett of TriWest VA; provider status: \"No Action.  TIN is CCN participating under own DCN.\""]
["Loyce Michelle Daniels, NP",null,"Triwest VA","Facility Enrollment","Facility Enrollment",null,null,null,"2022-11-23","10/17/2022 - Received roster from Scarlett of TriWest VA; provider status: \"No Action.  TIN is CCN participating under own DCN.\""]
["Loyce Michelle Daniels, NP","PE - Premier Family Care I, Inc","TriCare Standard","Participating","Enrollment Complete","2021-08-09",null,null,"2021-09-09","9/9/2021 Called 800-444-5445 and spoke with Kaylie. Provider is certified with Tricare Standard as of 8/9/2021 thru 2/28/2022. Prime application can be mailed. Ref: 13742726 Cbankston"]
["Loyce Michelle Daniels, NP","PE - Premier Family Care I, Inc","Multiplan","Participating","Enrollment Complete","2021-03-15",null,null,"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"]
["Loyce Michelle Daniels, NP","PE - Premier Family Care I, Inc","HealthSmart PPO","Participating","Enrollment Complete","2021-03-15",null,null,"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"]
["Loyce Michelle Daniels, NP","PE - Premier Family Care I, Inc","Superior","Participating","Enrollment Complete","2021-05-01",null,null,"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"]
["Loyce Michelle Daniels, NP","PE - Premier Family Care I, Inc","Wellcare","Participating","Enrollment Complete","2021-11-01",null,null,"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"]
["Loyce Michelle Daniels, NP","PE - Premier Family Care I, Inc","Omni PPO","Participating","Enrollment Complete","2021-03-15",null,null,"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 3/15/2021. DCannon"]
["Loyce Michelle Daniels, NP","PE - Premier Family Care I, Inc","Scott&White (First Care)","Participating","Enrollment Complete","2021-04-01",null,null,"2021-03-18","3/18/2021 Received an email from SWHPEXPEDITES@BSWHealth.org confirming provider will be participating effective 4/1/2021. KFrazier"]
["Loyce Michelle Daniels, NP","PE - Premier Family Care I, Inc","CAQH","Participating","CAQH Reattested","2023-01-25",null,null,"2023-01-25","1/25/2023 CAQH reviewed and re-attested.  DCannon"]
["Loyce Michelle Daniels, NP","PE - Premier Family Care I, Inc","Boon Chapman","Participating","Enrollment Complete","2021-03-15",null,null,"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"]
["Loyce Michelle Daniels, NP","PE - Premier Family Care I, Inc","Caprock (CapStar)","Participating","Enrollment Complete","2021-03-15",null,null,"2021-08-05","8/5/2021 Rcvd email from Caprock Provider Services provider_services_shared.t8@90degreebenefits.com  that providers from Mar, April, May and June delegated rosters have been loaded into their systems under requested TINS effective 3/15/2021.  DCannon"]
["Orlando Enrique Garner Cruz, MD","PE - Premier Family Care I, Inc","HealthSmart PPO","Participating","Enrollment Complete","2021-05-10",null,null,"2021-06-03","6/1/2021 Per Healthsmart website provider is PAR and loaded under TIN/location effective 5/10/2021.  DCannon"]
["Orlando Enrique Garner Cruz, MD","PE - Premier Family Care I, Inc","CAQH","Participating","CAQH Reattested","2023-02-09",null,null,"2023-02-09","2/9/2023 CAQH reviewed and re-attested.  DCannon"]
["Orlando Enrique Garner Cruz, MD","PE - Premier Family Care I, Inc","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"]
["Orlando Enrique Garner Cruz, MD","PE - Premier Family Care I, Inc","Scott&White (First Care)","Participating","Enrollment Complete","2021-05-10",null,null,"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","PE - Premier Family Care I, Inc","USA PPO","Participating","Enrollment Complete","2021-05-10",null,null,"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","PE - Premier Family Care I, Inc","First Health Coventry","Participating","Enrollment Complete","2021-11-01",3518705,null,"2022-02-18","2/18/2022 Received email from MadirajuP@aetna.com, provider is active with Coventry/First Health with an effective date of 11/01/2021. CPD ID 3518705. Cbankston"]
["Orlando Enrique Garner Cruz, MD","PE - Premier Family Care I, Inc","TriCare Standard","Participating","Enrollment Complete","2022-03-23",null,null,"2022-06-11","6/11/2022 Per Tricare portal provider is PAR and linked to group TIN/location effective 3/23/2022.  DCannon"]
["Orlando Enrique Garner Cruz, MD","PE - Premier Family Care I, Inc","Medicaid","In House Enrollment","In House Enrollment","2021-07-01",1417309105,null,"2021-09-21","9/21/2021 Per email received from Candace Wynne she has submitted the TMHP application for provider.  DCannon"]
["Orlando Enrique Garner Cruz, MD","PE - Premier Family Care I, Inc","Cigna","Participating","Enrollment Complete","2021-07-04",396521,null,"2021-07-06","6/24/2021 Received email from discovercigna@information.cigna.com confirming provider is participating under group Tax ID effective 7/4/2021 with assigned provider ID 0396521. KFrazier"]
["Orlando Enrique Garner Cruz, MD","PE - Premier Family Care I, Inc","United Health Care","Participating","Enrollment Complete","2021-05-10",null,null,"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","PE - Premier Family Care I, Inc","IMS","Participating","Enrollment Complete","2021-05-10",null,null,"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","PE - Premier Family Care I, Inc","Caprock (CapStar)","Participating","Enrollment Complete","2021-05-10",null,null,"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 5/10/2021.  DCannon"]
["Orlando Enrique Garner Cruz, MD","PE - Premier Family Care I, Inc","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"]
["Orlando Enrique Garner Cruz, MD","PE - Premier Family Care I, Inc","Galaxy Health","Participating","Enrollment Complete","2021-05-10",null,null,"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","PE - Premier Family Care I, Inc","Amerigroup","Participating","Enrollment Complete","2021-05-10",null,null,"2021-08-26","8/26/2021 Rcvd full roster from Joe Rodriguez at Amerigroup listing provider as PAR w/ group TIN and location effective 5/10/2021.  DCannon"]
["Orlando Enrique Garner Cruz, MD","PE - Premier Family Care I, Inc","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"]
["Orlando Enrique Garner Cruz, MD","PE - Premier Family Care I, Inc","Omni PPO","Participating","Enrollment Complete","2021-05-10",null,null,"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","PE - Premier Family Care I, Inc","Multiplan","Participating","Enrollment Complete","2021-05-10",null,null,"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 5/10/2021.  DCannon"]
["Orlando Enrique Garner Cruz, MD","PE - Premier Family Care I, Inc","Medicare","Participating","Enrollment Complete","2021-07-01","1R4716","0008AH","2021-07-13","7/13/2021 Rcvd email from Medicare stating that providers Medicare application has been approved.  PTAN # 1R4716 - effective 7/1/2021"]
["Orlando Enrique Garner Cruz, MD","PE - Premier Family Care I, Inc","Triwest VA","Facility Enrollment","Application Submitted",null,null,null,"2022-11-28","08/19/2022 - Submitted application to TriWest VA (sent to Scarlett Abigail, Scarlett_Abigail@bcbstx.com)"]
["Orlando Enrique Garner Cruz, MD",null,"Triwest VA","Facility Enrollment","Application Submitted",null,null,null,"2022-11-28","08/19/2022 - Submitted application to TriWest VA (sent to Scarlett Abigail, Scarlett_Abigail@bcbstx.com)"]
["Orlando Enrique Garner Cruz, MD","PE - Premier Family Care I, Inc","Triwest VA","Facility Enrollment","Facility Enrollment",null,null,null,"2022-11-28","10/17/2022 - Received roster from Scarlett of TriWest VA; provider status: \"No Action.  TIN is CCN participating under own DCN.\""]
["Orlando Enrique Garner Cruz, MD",null,"Triwest VA","Facility Enrollment","Facility Enrollment",null,null,null,"2022-11-28","10/17/2022 - Received roster from Scarlett of TriWest VA; provider status: \"No Action.  TIN is CCN participating under own DCN.\""]
["Orlando Enrique Garner Cruz, MD","PE - Premier Family Care I, Inc","Superior","Participating","Enrollment Complete","2021-05-10",null,null,"2021-06-03","6/3/2021 Rcvd email from Superior that monthly delegation roster for May is complete and providers are loaded under TIN/locations effective 6/1/2021.  DCannon"]
["Orlando Enrique Garner Cruz, MD","PE - Premier Family Care I, Inc","Rail Road Medicare","Participating","Enrollment Complete","2021-07-01","Q00110005","CE1588","2021-08-03","8/3/2021 Rcvd RR Medicare PTAN instantly after applying via RR Medicare website.  PTAN # Q00110005 effective 7/1/2021.  DCannon"]
["Orlando Enrique Garner Cruz, MD","PE - Premier Family Care I, Inc","Boon Chapman","Participating","Enrollment Complete","2021-05-10",null,null,"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 5/10/2021.  DCannon"]
["Judy J Jia, MD","PE - Premier Family Care I, Inc","Humana","Participating","Enrollment Complete","2022-04-11",null,null,"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"]
["Judy J Jia, MD","PE - Premier Family Care I, Inc","TriCare Standard","Participating","Enrollment Complete","2022-05-06",null,null,"2022-05-19","5/19/2022 Per Tricare portal provider is PAR and linked to group TIN/location effective 5/6/2022.  DCannon"]
["Judy J Jia, MD","PE - Premier Family Care I, Inc","Rail Road Medicare","Participating","Enrollment Complete","2022-03-04","Q00322545","CE1588","2022-09-08","9/8/2022 Rcvd RR Medicare approval letter.  PTAN # Q00322545 - effective 3/4/2022.  DCannon"]
["Judy J Jia, MD","PE - Premier Family Care I, Inc","Wellcare","Participating","Enrollment Complete","2022-05-01",null,null,"2022-07-01","7/1/2022 Received May Monthly Validation roster from Superior and provider is PAR and linked effective 5/1/2022.  DCannon"]
["Judy J Jia, MD","PE - Premier Family Care I, Inc","Medicare","Participating","Enrollment Complete","2022-03-04","2E5656","0008AH","2022-06-13","6/13/2022 Rcvd Medicare approval letter.  PTAN # 2E5656 - effective 3/4/2022.  DCannon"]
["Judy J Jia, MD","PE - Premier Family Care I, Inc","Superior","Participating","Enrollment Complete","2022-05-01",null,null,"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"]
["Judy J Jia, MD","PE - Premier Family Care I, Inc","Ambetter","Participating","Enrollment Complete","2022-05-01",null,null,"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","PE - Premier Family Care I, Inc","Caprock (CapStar)","Participating","Enrollment Complete","2022-04-11",null,null,"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"]
["Judy J Jia, MD","PE - Premier Family Care I, Inc","Omni PPO","Participating","Enrollment Complete","2022-04-11",null,null,"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","PE - Premier Family Care I, Inc","Medicaid","Participating","Enrollment Complete","2021-01-01",1588983134,null,"2022-09-07","9/7/2022 Per TMHP web portal provider is PAR and linked to group effective 1/1/2021.  TPI # 1588983134.  DCannon"]
["Judy J Jia, MD","PE - Premier Family Care I, Inc","USA PPO","Participating","Enrollment Complete","2022-04-11",null,null,"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 4/11/2022.  DCannon"]
["Judy J Jia, MD","PE - Premier Family Care I, Inc","Scott&White (First Care)","Participating","Enrollment Complete","2022-04-08",null,null,"2022-09-16","9/16/2022 Received approval letter from Scott & White.  Provider is PAR and linked to group TIN/location effective 4/8/2022.  DCannon"]
["Judy J Jia, MD","PE - Premier Family Care I, Inc","HealthSmart PPO","Participating","Enrollment Complete","2022-04-11",null,null,"2022-06-10","6/10/2022 Per Healthsmart website provider is PAR and loaded under TIN/location effective 4/11/2022.  DCannon"]
["Judy J Jia, MD","PE - Premier Family Care I, Inc","Triwest VA","Facility Enrollment","Application Submitted",null,null,null,"2022-11-23","08/19/2022 - Submitted application to TriWest VA (sent to Scarlett Abigail, Scarlett_Abigail@bcbstx.com)"]
["Judy J Jia, MD",null,"Triwest VA","Facility Enrollment","Application Submitted",null,null,null,"2022-11-23","08/19/2022 - Submitted application to TriWest VA (sent to Scarlett Abigail, Scarlett_Abigail@bcbstx.com)"]
["Judy J Jia, MD","PE - Premier Family Care I, Inc","Triwest VA","Facility Enrollment","Facility Enrollment",null,null,null,"2022-11-23","10/17/2022 - Received roster from Scarlett of TriWest VA; provider status: \"No Action.  TIN is CCN participating under own DCN.\""]
["Judy J Jia, MD",null,"Triwest VA","Facility Enrollment","Facility Enrollment",null,null,null,"2022-11-23","10/17/2022 - Received roster from Scarlett of TriWest VA; provider status: \"No Action.  TIN is CCN participating under own DCN.\""]
["Judy J Jia, MD","PE - Premier Family Care I, Inc","IMS","Participating","Enrollment Complete","2022-04-11",null,null,"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","PE - Premier Family Care I, Inc","First Health Coventry","Participating","Enrollment Complete","2022-07-01",2763424,null,"2022-08-10","8/10/2022 Per First Health web portal provider is PAR and linked to group TIN/location effective 7/1/2022.  PID # 2763424.  DCannon"]
["Judy J Jia, MD","PE - Premier Family Care I, Inc","Galaxy Health","Participating","Enrollment Complete","2022-04-11",null,null,"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  4/11/2022.  DCannon"]
["Judy J Jia, MD","PE - Premier Family Care I, Inc","Cigna","Participating","Enrollment Complete","2022-02-21",4120898,null,"2022-06-21","6/21/2022 - Per follow-up note - NPI# for the provider is on file, shows par under the group and TIN#, effective 2/21/2022, the physical location is on file and the Provider ID is 4120898.  Call ref # Camaria6142022. - DCannon"]
["Judy J Jia, MD","PE - Premier Family Care I, Inc","United Health Care","Participating","Enrollment Complete","2022-04-11",6052910,null,"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 4/11/2022.   MPIN# 006052910.   DCannon"]
["Judy J Jia, MD","PE - Premier Family Care I, Inc","Multiplan","Participating","Enrollment Complete","2022-04-11",null,null,"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"]
["Judy J Jia, MD","PE - Premier Family Care I, Inc","Aetna","Participating","Enrollment Complete","2022-06-01",5835766,null,"2022-05-18","5/18/2022 Rcvd email from Aetna that provider is PAR and linked to group TIN/locations effective 6/1/2022.  PID # 5835766.  DCannon"]
["Joshuae G Gallardo, MD","PE - Premier Family Care I, Inc","United Health Care","Participating","Enrollment Complete","2022-04-11",5305986,null,"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 4/11/2022.   MPIN# 005305986.   DCannon"]
["Joshuae G Gallardo, MD","PE - Premier Family Care I, Inc","Caprock (CapStar)","Participating","Enrollment Complete","2022-04-11",null,null,"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"]
["Joshuae G Gallardo, MD","PE - Premier Family Care I, Inc","Medicaid","Participating","Enrollment Complete","2018-08-01",1689985962,1275522864,"2022-07-14","7/14/2022 Per TMHP web portal provider is PAR and linked to group effective 8/1/2018.  TPI # 1689985962.  DCannon"]
["Joshuae G Gallardo, MD","PE - Premier Family Care I, Inc","Humana","Participating","Enrollment Complete","2022-04-11",null,null,"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"]
["Joshuae G Gallardo, MD","PE - Premier Family Care I, Inc","Superior","Participating","Enrollment Complete","2022-05-01",null,null,"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"]
["Joshuae G Gallardo, MD","PE - Premier Family Care I, Inc","Omni PPO","Participating","Enrollment Complete","2022-04-11",null,null,"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"]
["Joshuae G Gallardo, MD","PE - Premier Family Care I, Inc","First Health Coventry","Participating","Enrollment Complete","2022-07-01",2701656,null,"2022-08-10","8/10/2022 Per First Health web portal provider is PAR and linked to group TIN/location effective 7/1/2022.  PID # 2701656.  DCannon"]
["Joshuae G Gallardo, MD","PE - Premier Family Care I, Inc","Ambetter","Participating","Enrollment Complete","2022-05-01",null,null,"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."]
["Joshuae G Gallardo, MD","PE - Premier Family Care I, Inc","Scott&White (First Care)","Participating","Enrollment Complete","2022-05-20",null,null,"2022-09-16","9/16/2022 Received approval letter from Scott & White.  Provider is PAR and linked to group TIN/location effective 5/20/2022.  DCannon"]
["Joshuae G Gallardo, MD","PE - Premier Family Care I, Inc","Aetna","Participating","Enrollment Complete","2022-07-01",5369983,null,"2022-06-19","6/19/2022 Per email received from Aetna provider is PAR and linked to group TIN effective 7/1/2022.  DCannon"]
["Joshuae G Gallardo, MD","PE - Premier Family Care I, Inc","Boon Chapman","Participating","Enrollment Complete","2022-04-11",null,null,"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"]
["Joshuae G Gallardo, MD","PE - Premier Family Care I, Inc","Multiplan","Participating","Enrollment Complete","2022-04-11",null,null,"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"]
["Joshuae G Gallardo, MD","PE - Premier Family Care I, Inc","Medicare","Participating","Enrollment Complete","2022-02-01","2B8822","0008AH","2022-04-01","4/1/2022 Rcvd Medicare approval letter.  PTAN# 2B8822 - effective 2/1/2022.  DCannon"]
["Joshuae G Gallardo, MD","PE - Premier Family Care I, Inc","USA PPO","Participating","Enrollment Complete","2022-04-11",null,null,"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 4/11/2022.  DCannon"]
["Joshuae G Gallardo, MD","PE - Premier Family Care I, Inc","TriCare Standard","In Process","Payor Follow Up",null,null,null,"2022-10-28","10/28/2022 Per Tricare portal provider is still in process.  DCannon"]
["Joshuae G Gallardo, MD","PE - Premier Family Care I, Inc","HealthSmart PPO","Participating","Enrollment Complete","2022-04-11",null,null,"2022-06-10","6/10/2022 Per Healthsmart website provider is PAR and loaded under TIN/location effective 4/11/2022.  DCannon"]
["Joshuae G Gallardo, MD","PE - Premier Family Care I, Inc","Wellcare","Participating","Enrollment Complete","2022-05-01",null,null,"2022-07-01","7/1/2022 Received May Monthly Validation roster from Superior and provider is PAR and linked effective 5/1/2022.  DCannon"]
["Joshuae G Gallardo, MD","PE - Premier Family Care I, Inc","Rail Road Medicare","Participating","Enrollment Complete","2022-02-01","Q00267329","CE1588","2022-05-26","5/26/2022 Rcvd RR Medicare approval letter. RR Medicare PTAN #  Q00267329 - effective 2/1/2022.  DCannon"]
["Joshuae G Gallardo, MD","PE - Premier Family Care I, Inc","Triwest VA","Facility Enrollment","In House Enrollment",null,null,null,"2022-03-04"]
["Joshuae G Gallardo, MD",null,"Triwest VA","Facility Enrollment","In House Enrollment",null,null,null,"2022-03-04"]
["Joshuae G Gallardo, MD","PE - Premier Family Care I, Inc","Triwest VA","Facility Enrollment","Application Submitted",null,null,null,null,"08/19/2022 - Submitted application to TriWest VA (sent to Scarlett Abigail, Scarlett_Abigail@bcbstx.com)"]
["Joshuae G Gallardo, MD",null,"Triwest VA","Facility Enrollment","Application Submitted",null,null,null,null,"08/19/2022 - Submitted application to TriWest VA (sent to Scarlett Abigail, Scarlett_Abigail@bcbstx.com)"]
["Joshuae G Gallardo, MD","PE - Premier Family Care I, Inc","Triwest VA","Facility Enrollment","Facility Enrollment",null,null,null,null,"10/17/2022 - Received roster from Scarlett; provider status: \"No Action.  TIN is CCN participating under own DCN.\""]
["Joshuae G Gallardo, MD",null,"Triwest VA","Facility Enrollment","Facility Enrollment",null,null,null,null,"10/17/2022 - Received roster from Scarlett; provider status: \"No Action.  TIN is CCN participating under own DCN.\""]
["Joshuae G Gallardo, MD","PE - Premier Family Care I, Inc","IMS","Participating","Enrollment Complete","2022-04-11",null,null,"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"]
["Joshuae G Gallardo, MD","PE - Premier Family Care I, Inc","Cigna","Participating","Enrollment Complete","2022-02-01",9335065,null,"2022-04-05","4/5/2022 Received email from pdmcogz@cigna.com, provider is eff as of 2.1.2022. PID 9335065. Cbankston"]
["Joshuae G Gallardo, MD","PE - Premier Family Care I, Inc","Galaxy Health","Participating","Enrollment Complete","2022-04-11",null,null,"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  4/11/2022.  DCannon"]
["Claude B Nguyen, MD","PE - Premier Family Care I, Inc","Medicare","Participating","Enrollment Complete","2022-02-21","2B8668","0008AH","2022-04-01","4/1/2022 Rcvd Medicare approval letter.  PTAN# 2B8668 - effective 2/21/2022.  DCannon"]
["Claude B Nguyen, MD","PE - Premier Family Care I, Inc","Triwest VA","Facility Enrollment","In House Enrollment",null,null,null,"2022-03-04"]
["Claude B Nguyen, MD",null,"Triwest VA","Facility Enrollment","In House Enrollment",null,null,null,"2022-03-04"]
["Claude B Nguyen, MD","PE - Premier Family Care I, Inc","Triwest VA","Facility Enrollment","Application Submitted",null,null,null,"2022-11-23","08/19/2022 - Submitted application to TriWest VA (sent to Scarlett Abigail, Scarlett_Abigail@bcbstx.com)"]
["Claude B Nguyen, MD",null,"Triwest VA","Facility Enrollment","Application Submitted",null,null,null,"2022-11-23","08/19/2022 - Submitted application to TriWest VA (sent to Scarlett Abigail, Scarlett_Abigail@bcbstx.com)"]
["Claude B Nguyen, MD","PE - Premier Family Care I, Inc","Triwest VA","Facility Enrollment","Facility Enrollment",null,null,null,"2022-11-23","10/17/2022 - Received roster from Scarlett of TriWest VA; provider status: \"No Action.  TIN is CCN participating under own DCN.\""]
["Claude B Nguyen, MD",null,"Triwest VA","Facility Enrollment","Facility Enrollment",null,null,null,"2022-11-23","10/17/2022 - Received roster from Scarlett of TriWest VA; provider status: \"No Action.  TIN is CCN participating under own DCN.\""]
["Claude B Nguyen, MD","PE - Premier Family Care I, Inc","Medicaid","Participating","Enrollment Complete","2012-06-15",1619130929,null,"2022-08-01","8/1/2022 Per TMHP web portal provider is PAR and linked to group effective 6/15/2012.  DCannon"]
["Claude B Nguyen, MD","PE - Premier Family Care I, Inc","Rail Road Medicare","Participating","Enrollment Complete","2022-02-21","Q00267321","CE1588","2022-05-26","5/26/2022 Rcvd RR Medicare approval letter. RR Medicare PTAN #  Q00267321 - effective 2/21/2022.  DCannon"]
["Claude B Nguyen, MD","PE - Premier Family Care I, Inc","Caprock (CapStar)","Participating","Enrollment Complete","2022-04-11",null,null,"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","PE - Premier Family Care I, Inc","CAQH","Participating","CAQH Reattested","2023-02-06",null,null,"2023-02-06","2/6/2023 CAQH re-attested by provider on 2/6/2023.  DCannon"]
["Claude B Nguyen, MD","PE - Premier Family Care I, Inc","TriCare Standard","Participating","Enrollment Complete","2022-05-06",null,null,"2022-05-19","5/19/2022 Per Tricare portal provider is PAR and linked to group TIN/location effective 5/6/2022.  DCannon"]
["Claude B Nguyen, MD","PE - Premier Family Care I, Inc","Ambetter","Participating","Enrollment Complete","2022-05-01",null,null,"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"]
["Claude B Nguyen, MD","PE - Premier Family Care I, Inc","USA PPO","Participating","Enrollment Complete","2022-04-11",null,null,"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 4/11/2022.  DCannon"]
["Claude B Nguyen, MD","PE - Premier Family Care I, Inc","Superior","Participating","Enrollment Complete","2022-05-01",null,null,"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","PE - Premier Family Care I, Inc","Wellcare","Participating","Enrollment Complete","2022-05-01",null,null,"2022-07-01","7/1/2022 Received May Monthly Validation roster from Superior and provider is PAR and linked effective 5/1/2022.  DCannon"]
["Claude B Nguyen, MD","PE - Premier Family Care I, Inc","Amerigroup","Participating","Enrollment Complete","2022-04-11",null,null,"2022-09-24","9/23/2022 Per roster received from Joe Rodriguez at Amerigroup provider is PAR and linked to group TIN effective 4/11/2022.  DCannon"]
["Claude B Nguyen, MD","PE - Premier Family Care I, Inc","Galaxy Health","Participating","Enrollment Complete","2022-03-02",null,null,"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  3/2/2022.  DCannon"]
["Claude B Nguyen, MD","PE - Premier Family Care I, Inc","Multiplan","Participating","Enrollment Complete","2022-04-11",null,null,"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","PE - Premier Family Care I, Inc","United Health Care","Participating","Enrollment Complete","2022-04-11",3645447,null,"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 4/11/2022.   MPIN# 003645447.   DCannon"]
["Claude B Nguyen, MD","PE - Premier Family Care I, Inc","IMS","Participating","Enrollment Complete","2022-03-02",null,null,"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 3/2/2022. DCannon"]
["Claude B Nguyen, MD","PE - Premier Family Care I, Inc","Scott&White (First Care)","Participating","Enrollment Complete","2022-05-10",null,null,"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"]
["Claude B Nguyen, MD","PE - Premier Family Care I, Inc","Humana","Participating","Enrollment Complete","2022-04-11",null,null,"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"]
["Claude B Nguyen, MD","PE - Premier Family Care I, Inc","Omni PPO","Participating","Enrollment Complete","2022-03-02",null,null,"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 3/2/2022. DCannon"]
["Claude B Nguyen, MD","PE - Premier Family Care I, Inc","Aetna","Participating","Enrollment Complete","2022-07-01",5587864,null,"2022-06-19","6/19/2022 Per email received from Aetna provider is PAR and linked to group TIN effective 7/1/2022.  DCannon"]
["Claude B Nguyen, MD","PE - Premier Family Care I, Inc","Boon Chapman","Participating","Enrollment Complete","2022-04-11",null,null,"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","PE - Premier Family Care I, Inc","Cigna","Participating","Enrollment Complete","2022-02-21",9373023,null,"2022-03-30","3/30/2022 Received email from pdmcogz@cigna.com, provider is par as of 2/21/2022, PID: 9373023. This request has been completed under Cigna Internal Reference#: W202203222253423. Cbankston"]
["Claude B Nguyen, MD","PE - Premier Family Care I, Inc","First Health Coventry","Participating","Enrollment Complete","2022-07-01",2582285,null,"2022-08-10","8/10/2022 Per First Health web portal provider is PAR and linked to group TIN/location effective 7/1/2022.  PID # 2582285.  DCannon"]
["Claude B Nguyen, MD","PE - Premier Family Care I, Inc","HealthSmart PPO","Participating","Enrollment Complete","2022-03-02",null,null,"2022-06-10","6/10/2022 Per Healthsmart website provider is PAR and loaded under TIN/location effective 3/10/2022.  DCannon"]
["John H Ownby, MD","PE - Premier Family Care I, Inc","Aetna","Participating","Enrollment Complete","2022-07-01",5154560,null,"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","PE - Premier Family Care I, Inc","Medicaid","Participating","Enrollment Complete","2000-10-29",1558343988,1275522864,"2022-07-14","7/14/2022 Per TMHP web portal provider is PAR and linked to group effective 10/29/2000.  TPI # 1558343988.  DCannon"]
["John H Ownby, MD","PE - Premier Family Care I, Inc","TriCare Standard","Participating","Enrollment Complete","2022-05-06",null,null,"2022-05-19","5/19/2022 Per Tricare portal provider is PAR and linked to group TIN/location effective 5/6/2022.  DCannon"]
["John H Ownby, MD","PE - Premier Family Care I, Inc","Multiplan","Participating","Enrollment Complete","2022-04-11",null,null,"2022-08-23","8/23/2022 Per email from Multiplan provider is PAR and linked to group TIN/location effective 4/11/2022.  DCannon"]
["John H Ownby, MD","PE - Premier Family Care I, Inc","Scott&White (First Care)","Participating","Enrollment Complete","2022-05-10",null,null,"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"]
["John H Ownby, MD","PE - Premier Family Care I, Inc","IMS","Participating","Enrollment Complete","2022-04-11",null,null,"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","PE - Premier Family Care I, Inc","Amerigroup","Participating","Enrollment Complete","2022-04-11",null,null,"2022-09-23","9/23/2022 Per roster received from Joe Rodriguez at Amerigroup provider is PAR and linked to group TIN effective 4/11/2022.  DCannon"]
["John H Ownby, MD","PE - Premier Family Care I, Inc","Omni PPO","Participating","Enrollment Complete","2022-04-11",null,null,"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","PE - Premier Family Care I, Inc","Galaxy Health","Participating","Enrollment Complete","2022-04-11",null,null,"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  4/11/2022.  DCannon"]
["John H Ownby, MD","PE - Premier Family Care I, Inc","First Health Coventry","Participating","Enrollment Complete","2022-07-01",2359722,null,"2022-08-10","8/10/2022 Per First Health web portal provider is PAR and linked to group TIN/location effective 7/1/2022.  PID# 2359722  DCannon"]
["John H Ownby, MD","PE - Premier Family Care I, Inc","Caprock (CapStar)","Participating","Enrollment Complete","2022-04-11",null,null,"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"]
["John H Ownby, MD","PE - Premier Family Care I, Inc","Triwest VA","Facility Enrollment","In House Enrollment",null,null,null,"2022-03-04"]
["John H Ownby, MD",null,"Triwest VA","Facility Enrollment","In House Enrollment",null,null,null,"2022-03-04"]
["John H Ownby, MD","PE - Premier Family Care I, Inc","Triwest VA","Facility Enrollment","Application Submitted",null,null,null,"2022-11-23","08/19/2022 - Submitted application to TriWest VA (sent to Scarlett Abigail, Scarlett_Abigail@bcbstx.com)"]
["John H Ownby, MD",null,"Triwest VA","Facility Enrollment","Application Submitted",null,null,null,"2022-11-23","08/19/2022 - Submitted application to TriWest VA (sent to Scarlett Abigail, Scarlett_Abigail@bcbstx.com)"]
["John H Ownby, MD","PE - Premier Family Care I, Inc","Triwest VA","Facility Enrollment","Facility Enrollment",null,null,null,"2022-11-23","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",null,"Triwest VA","Facility Enrollment","Facility Enrollment",null,null,null,"2022-11-23","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","PE - Premier Family Care I, Inc","Humana","Participating","Enrollment Complete","2022-04-11",null,null,"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","PE - Premier Family Care I, Inc","USA PPO","Participating","Enrollment Complete","2022-04-11",null,null,"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 4/11/2022.  DCannon"]
["John H Ownby, MD","PE - Premier Family Care I, Inc","Cigna","Participating","Enrollment Complete","2022-02-21",9403276,null,"2022-08-19","8/19/2022 Rcvd email from Cigna that provider is PAR and linked to group TIN/location effective 2/21/2022.  PID# 9403276.  DCannon"]
["John H Ownby, MD","PE - Premier Family Care I, Inc","CAQH","Participating","CAQH Reattested","2023-02-12",null,null,"2023-02-12","2/12/2023 CAQH reviewed and re-attested.  DCannon"]
["John H Ownby, MD","PE - Premier Family Care I, Inc","Ambetter","Participating","Enrollment Complete","2022-05-01",null,null,"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"]
["John H Ownby, MD","PE - Premier Family Care I, Inc","Boon Chapman","Participating","Enrollment Complete","2022-04-11",null,null,"2022-09-13","9/13/2022 Per roster received from Multiplan provider is PAR and linked to group TIN/location effective 4/11/2022.  DCannon"]
["John H Ownby, MD","PE - Premier Family Care I, Inc","Wellcare","Participating","Enrollment Complete","2022-05-01",null,null,"2022-07-01","7/1/2022 Received May Monthly Validation roster from Superior and provider is PAR and linked effective 5/1/2022.  DCannon"]
["John H Ownby, MD","PE - Premier Family Care I, Inc","Superior","Participating","Enrollment Complete","2022-05-01",null,null,"2022-05-19","5/19/2022 Rcvd roster from Superior Health Plan confirming provider is PAR and linked to group TIN/location effective 5/1/2022.  DCannon"]
["John H Ownby, MD","PE - Premier Family Care I, Inc","HealthSmart PPO","Participating","Enrollment Complete","2022-04-11",null,null,"2022-06-10","6/10/2022 Per Healthsmart website provider is PAR and loaded under TIN/location effective 4/11/2022.  DCannon"]
["John H Ownby, MD","PE - Premier Family Care I, 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"]
["John H Ownby, MD","PE - Premier Family Care I, Inc","Medicare","Participating","Enrollment Complete","2022-02-21","2B8895","0008AH","2022-04-01","4/1/2022 Rcvd Medicare approval letter.  PTAN# 2B8895 - effective 2/21/2022.  DCannon"]
["John H Ownby, MD","PE - Premier Family Care I, Inc","United Health Care","Participating","Enrollment Complete","2022-04-11",2074110,null,"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 4/11/2022.   MPIN# 002074110.   DCannon"]
["Vishnu S Brahmandam, MD","PE - Premier Family Care I, Inc","Ambetter","Participating","Enrollment Complete","2022-10-01",null,null,"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",null,"Ambetter","Participating","Enrollment Complete","2022-10-01",null,null,"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","PE - Premier Family Care I, Inc","Medicaid","Participating","Enrollment Complete","2022-08-15",1548447899,null,"2022-09-07","9/7/2022 Per TMHP web portal provider is PAR and linked to group effective 8/15/2022.  TPI # 1548447899.  DCannon"]
["Vishnu S Brahmandam, MD",null,"Medicaid","Participating","Enrollment Complete","2022-08-15",1548447899,null,"2022-09-07","9/7/2022 Per TMHP web portal provider is PAR and linked to group effective 8/15/2022.  TPI # 1548447899.  DCannon"]
["Vishnu S Brahmandam, MD","PE - Premier Family Care I, Inc","Triwest VA","Facility Enrollment","In House Enrollment",null,null,null,"2022-08-06"]
["Vishnu S Brahmandam, MD",null,"Triwest VA","Facility Enrollment","In House Enrollment",null,null,null,"2022-08-06"]
["Vishnu S Brahmandam, MD",null,"Triwest VA","Facility Enrollment","In House Enrollment",null,null,null,"2022-08-06"]
["Vishnu S Brahmandam, MD","PE - Premier Family Care I, Inc","Triwest VA","Facility Enrollment","Application Submitted",null,null,null,"2022-11-28","08/19/2022 - Submitted application to TriWest VA (sent to Scarlett Abigail, Scarlett_Abigail@bcbstx.com)"]
["Vishnu S Brahmandam, MD",null,"Triwest VA","Facility Enrollment","Application Submitted",null,null,null,"2022-11-28","08/19/2022 - Submitted application to TriWest VA (sent to Scarlett Abigail, Scarlett_Abigail@bcbstx.com)"]
["Vishnu S Brahmandam, MD",null,"Triwest VA","Facility Enrollment","Application Submitted",null,null,null,"2022-11-28","08/19/2022 - Submitted application to TriWest VA (sent to Scarlett Abigail, Scarlett_Abigail@bcbstx.com)"]
["Vishnu S Brahmandam, MD","PE - Premier Family Care I, Inc","Triwest VA","Facility Enrollment","Facility Enrollment",null,null,null,"2022-11-28","10/17/2022 - Received roster from Scarlett of TriWest VA; provider status: \"No Action.  TIN is CCN participating under own DCN.\""]
["Vishnu S Brahmandam, MD",null,"Triwest VA","Facility Enrollment","Facility Enrollment",null,null,null,"2022-11-28","10/17/2022 - Received roster from Scarlett of TriWest VA; provider status: \"No Action.  TIN is CCN participating under own DCN.\""]
["Vishnu S Brahmandam, MD",null,"Triwest VA","Facility Enrollment","Facility Enrollment",null,null,null,"2022-11-28","10/17/2022 - Received roster from Scarlett of TriWest VA; provider status: \"No Action.  TIN is CCN participating under own DCN.\""]
["Vishnu S Brahmandam, MD","PE - Premier Family Care I, Inc","Omni PPO","Participating","Enrollment Complete","2022-09-12",null,null,"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 9/12/2022.   DCannon"]
["Vishnu S Brahmandam, MD",null,"Omni PPO","Participating","Enrollment Complete","2022-09-12",null,null,"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 9/12/2022.   DCannon"]
["Vishnu S Brahmandam, MD","PE - Premier Family Care I, Inc","Caprock (CapStar)","Participating","Enrollment Complete","2020-01-01",null,null,"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",null,"Caprock (CapStar)","Participating","Enrollment Complete","2020-01-01",null,null,"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","PE - Premier Family Care I, Inc","HealthSmart PPO","Participating","Enrollment Complete","2022-09-12",null,null,"2022-11-01","11/1/2022 Per Healthsmart website provider is PAR and loaded under TIN/location effective 9/12/2022.  DCannon"]
["Vishnu S Brahmandam, MD",null,"HealthSmart PPO","Participating","Enrollment Complete","2022-09-12",null,null,"2022-11-01","11/1/2022 Per Healthsmart website provider is PAR and loaded under TIN/location effective 9/12/2022.  DCannon"]
["Vishnu S Brahmandam, MD","PE - Premier Family Care I, Inc","IMS","Participating","Enrollment Complete","2022-09-12",null,null,"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 9/12/2022.   DCannon"]
["Vishnu S Brahmandam, MD",null,"IMS","Participating","Enrollment Complete","2022-09-12",null,null,"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 9/12/2022.   DCannon"]
["Vishnu S Brahmandam, MD","PE - Premier Family Care I, Inc","USA PPO","In Process","Payor Follow Up",null,null,null,"2023-03-08","3/8/2023 Emailed USA PPO at ipa@usamco.com to check status of provider.  DCannon"]
["Vishnu S Brahmandam, MD",null,"USA PPO","In Process","Payor Follow Up",null,null,null,"2023-03-08","3/8/2023 Emailed USA PPO at ipa@usamco.com to check status of provider.  DCannon"]
["Vishnu S Brahmandam, MD","PE - Premier Family Care I, Inc","First Health Coventry","Participating","Enrollment Complete","2022-08-15",null,null,"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",null,"First Health Coventry","Participating","Enrollment Complete","2022-08-15",null,null,"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","PE - Premier Family Care I, Inc","Superior","Participating","Enrollment Complete","2022-10-01",null,null,"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"]
["Vishnu S Brahmandam, MD",null,"Superior","Participating","Enrollment Complete","2022-10-01",null,null,"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"]
["Vishnu S Brahmandam, MD","PE - Premier Family Care I, Inc","Medicare","Participating","Enrollment Complete","2022-08-15","2H6458","0008AH","2022-08-25","8/25/2022 Per PECOS provider is PAR and linked to group/location effective 8/15/2022.  PTAN # 2H6458.  DCannon"]
["Vishnu S Brahmandam, MD",null,"Medicare","Participating","Enrollment Complete","2022-08-15","2H6458","0008AH","2022-08-25","8/25/2022 Per PECOS provider is PAR and linked to group/location effective 8/15/2022.  PTAN # 2H6458.  DCannon"]
["Vishnu S Brahmandam, MD","PE - Premier Family Care I, Inc","Wellcare","Participating","Enrollment Complete","2022-12-29",null,null,"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",null,"Wellcare","Participating","Enrollment Complete","2022-12-29",null,null,"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","PE - Premier Family Care I, Inc","TriCare Standard","Participating","Enrollment Complete","2022-08-25",null,null,"2022-09-06","9/6/2022 Rcvd certification approval letter from Tricare that provider is approved and certified for the State of Texas effective 8/25/2022.  DCannon"]
["Vishnu S Brahmandam, MD",null,"TriCare Standard","Participating","Enrollment Complete","2022-08-25",null,null,"2022-09-06","9/6/2022 Rcvd certification approval letter from Tricare that provider is approved and certified for the State of Texas effective 8/25/2022.  DCannon"]
["Vishnu S Brahmandam, MD","PE - Premier Family Care I, Inc","United Health Care","Participating","Enrollment Complete","2022-09-12",3315195,null,"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",null,"United Health Care","Participating","Enrollment Complete","2022-09-12",3315195,null,"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","PE - Premier Family Care I, Inc","Aetna","Participating","Enrollment Complete","2022-08-15",9858576,null,"2022-10-18","10/18/2022 Rcvd email from Priscilla Albertine at MQA that provider is PAR and linked to group TIN effective 8/15/2022.  PID # 9858576.  DCannon"]
["Vishnu S Brahmandam, MD",null,"Aetna","Participating","Enrollment Complete","2022-08-15",9858576,null,"2022-10-18","10/18/2022 Rcvd email from Priscilla Albertine at MQA that provider is PAR and linked to group TIN effective 8/15/2022.  PID # 9858576.  DCannon"]
["Vishnu S Brahmandam, MD","PE - Premier Family Care I, Inc","Tricare Prime","Participating","Enrollment Complete","2022-08-25",null,null,"2022-09-06","9/6/2022 Per Tricare portal provider is PAR and linked to group TIN/locations effective 8/25/2022.    DCannon"]
["Vishnu S Brahmandam, MD",null,"Tricare Prime","Participating","Enrollment Complete","2022-08-25",null,null,"2022-09-06","9/6/2022 Per Tricare portal provider is PAR and linked to group TIN/locations effective 8/25/2022.    DCannon"]
["Vishnu S Brahmandam, MD","PE - Premier Family Care I, 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",null,"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","PE - Premier Family Care I, Inc","CAQH","Participating","CAQH Reattested","2022-11-28",null,null,"2022-11-28","11/28/2022 CAQH reviewed and re-attested.  DCannon"]
["Vishnu S Brahmandam, MD",null,"CAQH","Participating","CAQH Reattested","2022-11-28",null,null,"2022-11-28","11/28/2022 CAQH reviewed and re-attested.  DCannon"]
["Vishnu S Brahmandam, MD","PE - Premier Family Care I, Inc","Multiplan","In Process","Application Submitted",null,null,null,"2022-09-15","9/15/2022 Submitted monthly delegation roster to Multiplan to add provider to delegation roster.  DCannon"]
["Vishnu S Brahmandam, MD",null,"Multiplan","In Process","Application Submitted",null,null,null,"2022-09-15","9/15/2022 Submitted monthly delegation roster to Multiplan to add provider to delegation roster.  DCannon"]
["Vishnu S Brahmandam, MD","PE - Premier Family Care I, Inc","Galaxy Health","Participating","Enrollment Complete","2022-09-12",null,null,"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"]
["Vishnu S Brahmandam, MD",null,"Galaxy Health","Participating","Enrollment Complete","2022-09-12",null,null,"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"]
["Vishnu S Brahmandam, MD","PE - Premier Family Care I, Inc","Scott&White (First Care)","Participating","Enrollment Complete","2022-09-22",null,null,"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",null,"Scott&White (First Care)","Participating","Enrollment Complete","2022-09-22",null,null,"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","PE - Premier Family Care I, Inc","Cigna","Participating","Enrollment Complete","2022-08-15",6692236,null,"2022-10-11","10/11/2022 Per email from Cigna provider is PAR and linked to group TIN/location effective 8/15/2022.  PID# 6692236.  DCannon"]
["Vishnu S Brahmandam, MD",null,"Cigna","Participating","Enrollment Complete","2022-08-15",6692236,null,"2022-10-11","10/11/2022 Per email from Cigna provider is PAR and linked to group TIN/location effective 8/15/2022.  PID# 6692236.  DCannon"]
["Vishnu S Brahmandam, MD","PE - Premier Family Care I, Inc","Humana","Participating","Enrollment Complete","2022-09-12",null,null,"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"]
["Vishnu S Brahmandam, MD",null,"Humana","Participating","Enrollment Complete","2022-09-12",null,null,"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"]
["Vishnu S Brahmandam, MD","PE - Premier Family Care I, Inc","Boon Chapman","Pending Other Enrollment","Pending Other Enrollment",null,null,null,"2022-08-11"]
["Vishnu S Brahmandam, MD",null,"Boon Chapman","Pending Other Enrollment","Pending Other Enrollment",null,null,null,"2022-08-11"]
["Vishnu S Brahmandam, MD","PE - Premier Family Care I, Inc","Amerigroup","Participating","Enrollment Complete","2022-09-12",null,null,"2022-10-11","10.11.2022 Per follow-up note -S/W Qjuana of Amerigroup @ 800-454-3730. Per rep, provider is showing as participating with an Effective date 09/12/2022 and link under the Group and TIN. Provider ID 14402887, Payer ID 26375 and No Recredentialing date. Service location is on file. Call ref#:I-165123663.  DCannon"]
["Vishnu S Brahmandam, MD",null,"Amerigroup","Participating","Enrollment Complete","2022-09-12",null,null,"2022-10-11","10.11.2022 Per follow-up note -S/W Qjuana of Amerigroup @ 800-454-3730. Per rep, provider is showing as participating with an Effective date 09/12/2022 and link under the Group and TIN. Provider ID 14402887, Payer ID 26375 and No Recredentialing date. Service location is on file. Call ref#:I-165123663.  DCannon"]
["Christopher A Stack, MD","PE - Premier Family Care I, Inc","Scott&White (First Care)","Participating","Enrollment Complete","2022-08-26",null,null,"2022-09-15","9/15/2022 Received approval notification from Scott & White that provider is PAR and linked to group TIN/location effective 8/26/2022.  DCannon"]
["Christopher A Stack, MD","PE - Premier Family Care I, Inc","HealthSmart PPO","In Process","Application Submitted",null,null,null,"2022-07-15","7/15/2022 Emailed monthly delegation roster to Healthsmart to add provider to delegated roster.  DCannon"]
["Christopher A Stack, MD","PE - Premier Family Care I, Inc","United Health Care","Participating","Enrollment Complete","2022-06-20",null,null,"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"]
["Christopher A Stack, MD","PE - Premier Family Care I, Inc","CAQH","Participating","CAQH Reattested","2022-11-29",null,null,"2022-11-29","11/29/2022 CAQH reviewed and re-attested.  DCannon"]
["Christopher A Stack, MD","PE - Premier Family Care I, Inc","USA PPO","In Process","Payor Follow Up",null,null,null,"2023-03-08","3/8/2023 Emailed USA PPO at ipa@usamco.com to check status of provider.  DCannon"]
["Christopher A Stack, MD","PE - Premier Family Care I, Inc","Humana","Participating","Enrollment Complete","2022-06-20",null,null,"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","PE - Premier Family Care I, Inc","Boon Chapman","Participating","Enrollment Complete","2022-06-20",null,null,"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","PE - Premier Family Care I, Inc","Superior","Participating","Enrollment Complete","2022-08-01",null,null,"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"]
["Christopher A Stack, MD","PE - Premier Family Care I, Inc","Cigna","Participating","Enrollment Complete","2022-07-18",9368747,null,"2022-10-25","10/25/2022 Rcvd approval notification email from Cigna.  Provider is PAR and linked to group TIN/location effective 7/18/2022.  PID # 9368747.  DCannon"]
["Christopher A Stack, MD","PE - Premier Family Care I, Inc","Medicaid","Participating","Enrollment Complete","2022-07-18",1568704971,null,"2022-08-22","8/22/2022 Per TX Medicaid web portal, provider is PAR and linked to group effective 7/18/2022.  DCannon"]
["Christopher A Stack, MD","PE - Premier Family Care I, Inc","Caprock (CapStar)","Participating","Enrollment Complete","2020-01-01",null,null,"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"]
["Christopher A Stack, MD","PE - Premier Family Care I, Inc","TriCare Standard","Participating","Enrollment Complete","2022-09-22",null,null,"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","PE - Premier Family Care I, Inc","IMS","Participating","Enrollment Complete","2022-06-20",null,null,"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"]
["Christopher A Stack, MD","PE - Premier Family Care I, Inc","Wellcare","Participating","Enrollment Complete","2022-08-01",null,null,"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"]
["Christopher A Stack, MD","PE - Premier Family Care I, Inc","Multiplan","Participating","Enrollment Complete","2022-06-20",null,null,"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","PE - Premier Family Care I, Inc","Galaxy Health","Participating","Enrollment Complete","2022-06-20",null,null,"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"]
["Christopher A Stack, MD","PE - Premier Family Care I, Inc","Triwest VA","Facility Enrollment","In House Enrollment",null,null,null,"2022-06-13"]
["Christopher A Stack, MD",null,"Triwest VA","Facility Enrollment","In House Enrollment",null,null,null,"2022-06-13"]
["Christopher A Stack, MD","PE - Premier Family Care I, Inc","Triwest VA","Facility Enrollment","Application Submitted",null,null,null,null,"08/19/2022 - Submitted application to TriWest VA (sent to Scarlett Abigail, Scarlett_Abigail@bcbstx.com)"]
["Christopher A Stack, MD",null,"Triwest VA","Facility Enrollment","Application Submitted",null,null,null,null,"08/19/2022 - Submitted application to TriWest VA (sent to Scarlett Abigail, Scarlett_Abigail@bcbstx.com)"]
["Christopher A Stack, MD","PE - Premier Family Care I, Inc","Triwest VA","Facility Enrollment","Facility Enrollment",null,null,null,null,"10/17/2022 - Received roster from Scarlett; provider status: \"No Action.  TIN is CCN participating under own DCN.\""]
["Christopher A Stack, MD",null,"Triwest VA","Facility Enrollment","Facility Enrollment",null,null,null,null,"10/17/2022 - Received roster from Scarlett; provider status: \"No Action.  TIN is CCN participating under own DCN.\""]
["Christopher A Stack, MD","PE - Premier Family Care I, 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","PE - Premier Family Care I, Inc","Ambetter","Participating","Enrollment Complete","2022-08-01",null,null,"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"]
["Christopher A Stack, MD","PE - Premier Family Care I, Inc","Aetna","Participating","Enrollment Complete","2022-12-01",null,null,"2022-12-02","12.02.2022 S/W Aaron of Aetna @ 800-353-1232. Per rep, provider is showing participating with an Effective date 12/01/2022 and link under the Group and TIN. Provider ID 6799298, Payer ID 60054 and Recredentialing date 11/18/2025. Service location is on file. Call ref#:6122321344. - Danico Gabriel Melendres\\"]
["Christopher A Stack, MD","PE - Premier Family Care I, Inc","Omni PPO","Participating","Enrollment Complete","2022-06-20",null,null,"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"]
["Christopher A Stack, MD","PE - Premier Family Care I, Inc","First Health Coventry","In Process","Enrollment Complete",null,null,null,"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","PE - Premier Family Care I, Inc","Rail Road Medicare","Participating","Enrollment Complete","2022-07-18","Q00299482","CE1588","2022-07-28","7/28/2022 Rcvd RR Medicare approval letter.  PTAN # Q00299482 - effective 7/18/2022.  DCannon"]
["Christopher A Stack, MD","PE - Premier Family Care I, Inc","Amerigroup","Participating","Enrollment Complete","2022-06-20",null,null,"2022-10-11","10/11/2022 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 6/20/2022.  DCannon"]
["Christopher A Stack, MD","PE - Premier Family Care I, Inc","Tricare Prime","Panel Closed","Panel Closed",null,null,null,"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"]
["Hannah Heflin, RD","PE - Premier Family Care I, Inc","Wellcare","Participating","Enrollment Complete","2022-09-01",null,null,"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","PE - Premier Family Care I, Inc","Tricare Prime","Panel Closed","Panel Closed",null,null,null,"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"]
["Hannah Heflin, RD","PE - Premier Family Care I, Inc","Medicaid","In Process","Application Submitted",null,null,null,"2023-01-24","1/24/2023 App submitted online via TMHP web portal.  Request ID # 20182532.  DCannon"]
["Hannah Heflin, RD","PE - Premier Family Care I, Inc","Boon Chapman","Pending Other Enrollment","Pending Other Enrollment",null,null,null,"2022-07-20","7/20/2022 Pending Multiplan enrollment.  DCannon"]
["Hannah Heflin, RD","PE - Premier Family Care I, Inc","Aetna","Participating","Enrollment Complete","2023-01-01",null,null,"2022-12-13","12/13/2022 Per email received from Priscilla Albertine at MQA provider is PAR and linked to group TIN/locations effective 1/1/2023.  DCannon"]
["Hannah Heflin, RD","PE - Premier Family Care I, Inc","Medicare","Participating","Enrollment Complete","2022-05-07","2H3685","0008AH","2022-08-18","8/18/2022 Rcvd Medicare approval letter.  PTAN # 2H3685 - effective 5/7/2022.  DCannon"]
["Hannah Heflin, RD","PE - Premier Family Care I, Inc","Omni PPO","Participating","Enrollment Complete","2022-08-12",null,null,"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","PE - Premier Family Care I, Inc","Humana","Participating","Enrollment Complete","2022-08-12",null,null,"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 8/12/2022.  DCannon"]
["Hannah Heflin, RD","PE - Premier Family Care I, Inc","Ambetter","Participating","Enrollment Complete","2022-09-01",null,null,"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","PE - Premier Family Care I, Inc","IMS","Participating","Enrollment Complete","2022-08-12",null,null,"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","PE - Premier Family Care I, Inc","Cigna","Participating","Enrollment Complete","2023-02-09",3357467,null,"2023-02-16","02.16.2023  Per follow-up note - S/W Stephanie of Cigna @ 1-800-882-4462. Per rep, provider is showing participating with an Effective date 02/09/2023 and link under the Group and TIN. Provider ID 3357467, No Payer ID and Recredentialing date 02/09/2026. Service location is on file.  DCannon"]
["Hannah Heflin, RD","PE - Premier Family Care I, Inc","Triwest VA","Facility Enrollment","In House Enrollment",null,null,null,"2022-07-20"]
["Hannah Heflin, RD",null,"Triwest VA","Facility Enrollment","In House Enrollment",null,null,null,"2022-07-20"]
["Hannah Heflin, RD","PE - Premier Family Care I, Inc","Triwest VA","Facility Enrollment","Application Submitted",null,null,null,"2022-11-23","08/19/2022 - Submitted application to TriWest VA (sent to Scarlett Abigail, Scarlett_Abigail@bcbstx.com)"]
["Hannah Heflin, RD",null,"Triwest VA","Facility Enrollment","Application Submitted",null,null,null,"2022-11-23","08/19/2022 - Submitted application to TriWest VA (sent to Scarlett Abigail, Scarlett_Abigail@bcbstx.com)"]
["Hannah Heflin, RD","PE - Premier Family Care I, Inc","Triwest VA","Facility Enrollment","Facility Enrollment",null,null,null,"2022-11-23","10/17/2022 - Received roster from Scarlett of TriWest VA; provider status: \"No Action.  TIN is CCN participating under own DCN.\""]
["Hannah Heflin, RD",null,"Triwest VA","Facility Enrollment","Facility Enrollment",null,null,null,"2022-11-23","10/17/2022 - Received roster from Scarlett of TriWest VA; provider status: \"No Action.  TIN is CCN participating under own DCN.\""]
["Hannah Heflin, RD","PE - Premier Family Care I, Inc","Superior","Participating","Enrollment Complete","2022-09-01",null,null,"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","PE - Premier Family Care I, Inc","HealthSmart PPO","Participating","Enrollment Complete","2022-08-12",null,null,"2022-10-10","10/10/2022 Per Healthsmart website provider is PAR and loaded under TIN/location effective 8/12/2022.  DCannon"]
["Hannah Heflin, RD","PE - Premier Family Care I, Inc","CAQH","Participating","CAQH Reattested","2023-02-09",null,null,"2023-02-09","2/9/2023 CAQH reviewed and re-attested.  DCannon"]
["Hannah Heflin, RD","PE - Premier Family Care I, Inc","TriCare Standard","Participating","Enrollment Complete","2023-01-17",null,null,"2023-01-30","1/30/2023 Rcvd Tricare certification approval letter.  Provider is Tricare certified effective 1/17/2023.  DCannon"]
["Hannah Heflin, RD","PE - Premier Family Care I, Inc","Multiplan","In Process","Application Submitted",null,null,null,"2022-08-15","8/15/2022 Emailed monthly delegated roster to Multiplan to add new providers.  DCannon"]
["Hannah Heflin, RD","PE - Premier Family Care I, Inc","Caprock (CapStar)","Participating","Enrollment Complete","2020-01-01",null,null,"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"]
["Hannah Heflin, RD","PE - Premier Family Care I, Inc","Galaxy Health","Participating","Enrollment Complete","2022-08-12",null,null,"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"]
["Hannah Heflin, RD","PE - Premier Family Care I, Inc","United Health Care","Participating","Enrollment Complete","2022-08-12",null,null,"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# 008166641.   DCannon"]
["Hannah Heflin, RD","PE - Premier Family Care I, Inc","Amerigroup","Participating","Enrollment Complete","2022-08-12",null,null,"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"]
["Hannah Heflin, RD","PE - Premier Family Care I, Inc","Scott&White (First Care)","Participating","Enrollment Complete","2022-12-27",null,null,"2022-12-13","12/13/2022 Rcvd email from Scott & White that provider is PAR and linked to group TIN/locations effective 12/27/2022.  DCannon"]
["Hannah Heflin, RD","PE - Premier Family Care I, Inc","USA PPO","Provider Type Not Enrolled","Provider Type Not Enrolled",null,null,null,"2023-03-09","3/9/2023 Per email from LaNetrice Myart at USA PPO provider type - Registered Dietitians are not enrolled by USA PPO.  DCannon"]
["Hannah Heflin, RD","PE - Premier Family Care I, Inc","Rail Road Medicare","Participating","Enrollment Complete","2022-05-07","Q00322576","CE1588","2022-09-08","9/8/2022 Rcvd RR Medicare approval letter.  PTAN # Q00322576 - effective 5/7/2022.  DCannon"]
["Hannah Heflin, RD","PE - Premier Family Care I, Inc","First Health Coventry","Participating","Enrollment Complete","2022-08-12",null,null,"2023-02-28","2/28/2023 Per First Health web portal provider is PAR and linked to group TIN/location effective 8/12/2022.  DCannon"]
["Kathryn A. Lagus, APRN-FNP-BC","PE - Premier Family Care I, Inc","Wellcare","Pending Other Enrollment","Pending Other Enrollment",null,null,null,"2022-12-29","12/29/2022 Pending Superior enrollment.  DCannon"]
["Kathryn A. Lagus, APRN-FNP-BC","PE - Premier Family Care I, Inc","Caprock (CapStar)","Participating","Enrollment Complete","2022-11-28",null,null,"2023-01-20","1/20/2023 Rcvd email  confirmation from Caprock that provider is PAR and linked to group TIN/locations effective 11/28/2022.  DCannon"]
["Kathryn A. Lagus, APRN-FNP-BC","PE - Premier Family Care I, Inc","Triwest VA","In House Enrollment","In House Enrollment",null,null,null,"2022-12-29"]
["Kathryn A. Lagus, APRN-FNP-BC","PE - Premier Family Care I, Inc","Humana","In Process","Application Submitted",null,null,null,"2023-01-14","1/14/2023 Emailed monthly delegated roster to Vernita Young at Humana  to add provider to delegated roster.  DCannon"]
["Kathryn A. Lagus, APRN-FNP-BC","PE - Premier Family Care I, Inc","Omni PPO","Participating","Enrollment Complete","2022-11-28",null,null,"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"]
["Kathryn A. Lagus, APRN-FNP-BC","PE - Premier Family Care I, Inc","Tricare Prime","Panel Closed","Panel Closed",null,null,null,"2023-01-05","1/5/2023 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"]
["Kathryn A. Lagus, APRN-FNP-BC","PE - Premier Family Care I, Inc","CAQH","Participating","CAQH Reattested","2022-12-29",null,null,"2022-12-29","12/29/2022 CAQH profile reviewed and re-attested.  New practice location and group TIN added.  DCannon"]
["Kathryn A. Lagus, APRN-FNP-BC","PE - Premier Family Care I, Inc","Medicare","Participating","Enrollment Complete","2023-03-01","2O0411","0008AH","2023-01-18","1/18/2023 Rcvd Medicare approval letter.  Provider is PAR and linked to group/location effective 3/1/2023.  PTAN # 2O0411.  DCannon"]
["Kathryn A. Lagus, APRN-FNP-BC","PE - Premier Family Care I, Inc","First Health Coventry","Pending Other Enrollment","Pending Other Enrollment",null,null,null,"2022-12-29","12/29/2022 Pending Aetna enrollment.  DCannon"]
["Kathryn A. Lagus, APRN-FNP-BC","PE - Premier Family Care I, Inc","Medicaid","Participating","Enrollment Complete","2022-09-27",1285983155,null,"2023-02-25","2/25/2023 Per the TMHP web portal the provider is PAR and linked to group effective 9/27/2022. PID # 1285983155.  DCannon"]
["Kathryn A. Lagus, APRN-FNP-BC","PE - Premier Family Care I, Inc","Scott&White (First Care)","Participating","Enrollment Complete","2023-02-23",null,null,"2023-02-28","2/28/2023 Per email received from Scott & White provider is PAR and linked to group TIN effective 2/23/2023.  DCannon"]
["Kathryn A. Lagus, APRN-FNP-BC","PE - Premier Family Care I, Inc","USA PPO","In Process","Application Submitted",null,null,null,"2023-01-14","1/14/2023 Emailed monthly delegated roster to USA PPO to add provider to delegated roster.  DCannon"]
["Kathryn A. Lagus, APRN-FNP-BC","PE - Premier Family Care I, Inc","Galaxy Health","Participating","Enrollment Complete","2022-11-28",null,null,"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 11/28/2022.  DCannon"]
["Kathryn A. Lagus, APRN-FNP-BC","PE - Premier Family Care I, Inc","Cigna","Provider Load","Provider Load",null,null,null,"2022-12-29"]
["Kathryn A. Lagus, APRN-FNP-BC","PE - Premier Family Care I, Inc","Rail Road Medicare","Pending Other Enrollment","Pending Medicare",null,null,null,"2022-12-29"]
["Kathryn A. Lagus, APRN-FNP-BC","PE - Premier Family Care I, Inc","Aetna","Participating","Enrollment Complete","2023-03-01",826647,null,"2023-03-06","03.06.2023 Per follow-up note -  provider is showing participating with an Effective date of 03/01/2023 and link under the Group and TIN. Provider ID 826647. Service location is on file.  DCannon"]
["Kathryn A. Lagus, APRN-FNP-BC","PE - Premier Family Care I, Inc","Ambetter","Pending Other Enrollment","Pending Other Enrollment",null,null,null,"2022-12-29","12/29/2022 Pending Superior enrollment.  DCannon"]
["Kathryn A. Lagus, APRN-FNP-BC","PE - Premier Family Care I, Inc","HealthSmart PPO","Participating","Enrollment Complete","2022-11-28",null,null,"2023-02-28","2/28/2023 Per Healthsmart website provider is PAR and loaded under TIN/location effective 11/28/2022.  DCannon"]
["Kathryn A. Lagus, APRN-FNP-BC","PE - Premier Family Care I, Inc","Multiplan","In Process","Application Submitted",null,null,null,"2023-01-14","1/14/2023 Emailed monthly delegated roster to Multiplan to add provider to delegated roster.  DCannon"]
["Kathryn A. Lagus, APRN-FNP-BC","PE - Premier Family Care I, Inc","Superior","Participating","Enrollment Complete","2023-02-01",null,null,"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"]
["Kathryn A. Lagus, APRN-FNP-BC","PE - Premier Family Care I, Inc","United Health Care","Participating","Enrollment Complete","2022-11-28",null,null,"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 11/28/2022.  MPIN# 007977253.  DCannon"]
["Kathryn A. Lagus, APRN-FNP-BC","PE - Premier Family Care I, Inc","Amerigroup","Participating","Enrollment Complete","2022-11-28",null,null,"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"]
["Kathryn A. Lagus, APRN-FNP-BC","PE - Premier Family Care I, Inc","Boon Chapman","Pending Other Enrollment","Pending Other Enrollment",null,null,null,"2022-12-29","12/29/2022 Pending Multiplan enrollment.  DCannon"]
["Kathryn A. Lagus, APRN-FNP-BC","PE - Premier Family Care I, Inc","IMS","Participating","Enrollment Complete","2022-11-28",null,null,"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"]
["Kathryn A. Lagus, APRN-FNP-BC","PE - Premier Family Care I, Inc","TriCare Standard","In Process","Payor Follow Up",null,null,null,"2023-03-08","3/8/2023 Per Tricare portal application is still pending.  DCannon"]
["Hilary Cosby, RD","PE - Premier Family Care I, Inc","Tricare Prime","Panel Closed","Panel Closed",null,null,null,"2022-12-22","12/22/2022 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"]
["Hilary Cosby, RD","PE - Premier Family Care I, Inc","Medicaid","In Process","Application Submitted",null,null,null,"2023-01-24","1/24/2023 App submitted online via TMHP web portal.  Request ID # 20183686.  DCannon"]
["Hilary Cosby, RD","PE - Premier Family Care I, Inc","Caprock (CapStar)","In Process","Pending PSV",null,null,null,"2022-12-22"]
["Hilary Cosby, RD","PE - Premier Family Care I, Inc","Omni PPO","In Process","Pending PSV",null,null,null,"2022-12-22"]
["Hilary Cosby, RD","PE - Premier Family Care I, Inc","Galaxy Health","In Process","Pending PSV",null,null,null,"2022-12-22"]
["Hilary Cosby, RD","PE - Premier Family Care I, Inc","TriCare Standard","Participating","Enrollment Complete","2023-01-10",null,null,"2023-03-08","3/8/2023 Received Tricare certification approval letter.  Provider is Tricare certified in the state of Texas effective 1/10/2023.  DCannon"]
["Hilary Cosby, RD","PE - Premier Family Care I, Inc","Humana","In Process","Pending PSV",null,null,null,"2022-12-22"]
["Hilary Cosby, RD","PE - Premier Family Care I, Inc","Wellcare","Provider Load","Provider Load",null,null,null,"2022-12-12"]
["Hilary Cosby, RD","PE - Premier Family Care I, Inc","IMS","In Process","Pending PSV",null,null,null,"2022-12-22"]
["Hilary Cosby, RD","PE - Premier Family Care I, Inc","United Health Care","In Process","Pending PSV",null,null,null,"2022-12-22"]
["Hilary Cosby, RD","PE - Premier Family Care I, Inc","CAQH","Participating","CAQH Reattested","2022-12-22",null,null,"2022-12-22","12/22/2022 CAQH profile reviewed and re-attested.  Uploaded current copy of COI.  DCannon"]
["Hilary Cosby, RD","PE - Premier Family Care I, Inc","Triwest VA","In House Enrollment","In House Enrollment",null,null,null,"2022-12-22"]
["Hilary Cosby, RD","PE - Premier Family Care I, Inc","Multiplan","In Process","Pending PSV",null,null,null,"2022-12-22"]
["Hilary Cosby, RD","PE - Premier Family Care I, Inc","Aetna","Participating","Enrollment Complete","2023-03-01",null,null,"2023-01-25","1/25/2023 Rcvd approval email from Aetna.  Provider is PAR w/ group TIN/Location effective 3/1/2023.  PIN # 8706961.  DCannon"]
["Hilary Cosby, RD","PE - Premier Family Care I, Inc","First Health Coventry","In Process","Pending Other Enrollment",null,null,null,"2022-12-22","12/22/2022 Pending Aetna enrollment."]
["Hilary Cosby, RD","PE - Premier Family Care I, Inc","Amerigroup","In Process","Pending PSV",null,null,null,"2022-12-22"]
["Hilary Cosby, RD","PE - Premier Family Care I, Inc","HealthSmart PPO","In Process","Pending PSV",null,null,null,"2022-12-22"]
["Hilary Cosby, RD","PE - Premier Family Care I, Inc","Rail Road Medicare","Pending Other Enrollment","Pending Medicare",null,null,null,"2022-12-22","12/22/2022 Pending Medicare enrollment.  DCannon"]
["Hilary Cosby, RD","PE - Premier Family Care I, Inc","Medicare","Participating","Enrollment Complete","2022-11-28","2N4110","0008AH","2023-01-05","1/5/2022 Rcvd Medicare approval letter.  Provider is PAR and linked to group/location effective 11/28/2022.  PTAN # 2N4110.  DCannon"]
["Hilary Cosby, RD","PE - Premier Family Care I, Inc","Scott&White (First Care)","Participating","Enrollment Complete","2023-02-14",null,null,"2023-01-31","1/31/2023 Received email from Scott & White with approval letter.  Provider is PAR and linked to group TIN/location effective 2/14/2023.  DCannon"]
["Hilary Cosby, RD","PE - Premier Family Care I, Inc","Ambetter","Pending Other Enrollment","Pending Other Enrollment",null,null,null,"2022-12-22","12/22/2022 Pending Superior enrollment.  DCannon"]
["Hilary Cosby, RD","PE - Premier Family Care I, Inc","Boon Chapman","In Process","Pending Other Enrollment",null,null,null,"2022-12-22","12/22/2022 Pending Multiplan enrollment.  DCannon"]
["Hilary Cosby, RD","PE - Premier Family Care I, Inc","USA PPO","In Process","Pending PSV",null,null,null,"2022-12-22"]
["Hilary Cosby, RD","PE - Premier Family Care I, Inc","Cigna","Provider Load","Provider Load",null,null,null,"2022-12-12"]
["Hilary Cosby, RD","PE - Premier Family Care I, Inc","Superior","In Process","Pending PSV",null,null,null,"2022-12-22"]
["Lawrence A Wilson, MD","PE - Premier Family Care I, Inc","Ambetter","Participating","Enrollment Complete","2022-04-01",null,null,"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","PE - Premier Intensive Cardiac Rehabilitation","Cigna","Participating","Enrollment Complete","2020-12-01",9800227,null,"2021-08-03","8/3/2021 Per follow-up notes provider is link and Par  under the group and TIN# effective 12/1/2020 the physical location is on file.  Provider ID is 9800227.  DCannon"]
["Lawrence A Wilson, MD","PE - Premier Intensive Cardiac Rehabilitation","Aetna","Participating","Enrollment Complete","2021-04-01",null,null,"2021-06-28","6/28/2021 Received email response from aetnaproviderservices@aetna.com confirming provider is participating under group Tax ID and location effective 4/1/2021. KFrazier"]
["Lawrence A Wilson, MD","PE - Premier Family Care I, Inc","Omni PPO","Participating","Enrollment Complete","2021-01-07",null,null,"2021-04-01","2/2/2021 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","PE - Premier Intensive Cardiac Rehabilitation","Boon Chapman","Participating","Enrollment Complete","2021-01-07",null,null,"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"]
["Lawrence A Wilson, MD","PE - Premier Family Care I, Inc","Coventry Workers Comp","In House Enrollment","In House Enrollment",null,null,null,"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","PE - Premier Intensive Cardiac Rehabilitation","TriCare Standard","In Process","Payor Follow Up",null,null,null,"2022-03-28","3/28/2022 Location pending in portal, allow more time. Cbankston"]
["Lawrence A Wilson, MD","PE - Premier Family Care I, Inc","First Health Coventry","Participating","Enrollment Complete","2021-11-10",1103233,null,"2022-02-10","2/10/2022 Received email from dilikarA@aetna.com, provider enrollment is complete. Provider ID: 1103233 and Effective date is 11/01/2021. Cbankston"]
["Lawrence A Wilson, MD","PE - Premier Intensive Cardiac Rehabilitation","Multiplan","Participating","Enrollment Complete","2021-01-07",null,null,"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"]
["Lawrence A Wilson, MD","PE - Premier Family Care I, Inc","Triwest VA","Facility Enrollment","Application Submitted",null,null,null,"2022-11-15"," 08/19/2022 - Application submitted to Scarlett Abigail (Scarlett_Abigail@bcbstx.com) of TriWest VA"]
["Lawrence A Wilson, MD",null,"Triwest VA","Facility Enrollment","Application Submitted",null,null,null,"2022-11-15"," 08/19/2022 - Application submitted to Scarlett Abigail (Scarlett_Abigail@bcbstx.com) of TriWest VA"]
["Lawrence A Wilson, MD","PE - Premier Family Care I, Inc","Triwest VA","Facility Enrollment","Facility Enrollment",null,null,null,"2022-11-23","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",null,"Triwest VA","Facility Enrollment","Facility Enrollment",null,null,null,"2022-11-23","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","PE - Premier Family Care I, Inc","Coventry Workers Comp","Participating","Enrollment Complete","2021-08-01",null,null,"2021-10-08","10/8/21 Recevied email from CoventryProvider@cvty.us.com, provider effective 8/1/2021. Cbankston"]
["Lawrence A Wilson, MD","PE - Premier Intensive Cardiac Rehabilitation","Scott&White (First Care)","Participating","Enrollment Complete","2021-03-05",null,null,"2021-04-22","4/22/2021 Rcvd roster from S&W and provider is participating and linked to TIN effective 03/5/2021.  DCannon"]
["Lawrence A Wilson, MD","PE - Premier Family Care I, Inc","Rail Road Medicare","Participating","Enrollment Complete","2020-12-01","Q00021661","CE1588","2021-02-09","2/9/2021 - Rcvd RR Medicare Welcome letter.  DCannon"]
["Lawrence A Wilson, MD","PE - Premier Intensive Cardiac Rehabilitation","First Health Coventry","Participating","Enrollment Complete","2020-12-01",1103233,null,"2022-05-11","5/11/2022 Per First Health website provider is PAR and linked to group TIN/location effective 12/1/2020.  PID # 1103233.  DCannon"]
["Lawrence A Wilson, MD","PE - Premier Family Care I, Inc","Boon Chapman","Participating","Enrollment Complete","2021-01-07",null,null,"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"]
["Lawrence A Wilson, MD","PE - Premier Family Care I, Inc","IMS","Participating","Enrollment Complete","2021-01-07",null,null,"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","PE - Premier Intensive Cardiac Rehabilitation","Rail Road Medicare","Participating","Enrollment Complete","2020-12-01","Q00021661","CE1588","2021-06-25","6/24/2021 Provider is already enrolled with payor under Tax ID with asssigned RR PTAN Q00021661 effective 12/01/2020. KFrazier"]
["Lawrence A Wilson, MD","PE - Premier Intensive Cardiac Rehabilitation","Galaxy Health","Participating","Enrollment Complete","2021-01-07",null,null,"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","PE - Premier Family Care I, Inc","Superior","Participating","Enrollment Complete","2021-03-01",null,null,"2021-03-08","3/8/2021 Rcvd email from Superior confirming that the providers are PAR and loaded under TIN/locations effective 3/1/2021.  DCannon"]
["Lawrence A Wilson, MD","PE - Premier Intensive Cardiac Rehabilitation","Caprock (CapStar)","Participating","Enrollment Complete","2021-01-07",null,null,"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 1/7/2021.  DCannon"]
["Lawrence A Wilson, MD","PE - Premier Family Care I, Inc","HealthSmart PPO","Participating","Enrollment Complete","2002-04-01",null,null,"2021-04-09","4/9/2021 4/11/2021 Rcvd email from HealthSmart <mdipsupport@healthsmart.com> confirming participation of provider under TIN and location effective 4/1/2002.  DCannon"]
["Lawrence A Wilson, MD","PE - Premier Family Care I, 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","PE - Premier Intensive Cardiac Rehabilitation","HealthSmart PPO","Participating","Enrollment Complete","2021-01-07",null,null,"2021-06-03","6/1/2021 Per Healthsmart website provider is PAR and loaded under TIN/location effective 1/7/2021.  DCannon"]
["Lawrence A Wilson, MD","PE - Premier Intensive Cardiac Rehabilitation","United Health Care","Participating","Enrollment Complete","2021-05-18",2438204,null,"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 5/18/2021 and assigned provider ID 2438204. KFrazier"]
["Lawrence A Wilson, MD","PE - Premier Family Care I, Inc","USA PPO","Participating","Enrollment Complete","2021-01-07",946236,null,"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"]
["Lawrence A Wilson, MD","PE - Premier Family Care I, Inc","CAQH","Participating","CAQH Reattested","2022-11-26",null,null,"2022-11-26","11/26/2022 CAQH reviewed and re-attested.  DCannon"]
["Lawrence A Wilson, MD","PE - City of Midland Health Department","CAQH","Participating","CAQH Reattested","2022-11-26",null,null,"2022-11-26","11/26/2022 CAQH reviewed and re-attested.  DCannon"]
["Lawrence A Wilson, MD","PE - WesTex Urgent Care, PLLC","CAQH","Participating","CAQH Reattested","2022-11-26",null,null,"2022-11-26","11/26/2022 CAQH reviewed and re-attested.  DCannon"]
["Lawrence A Wilson, MD","PE - Premier Family Care I, Inc","Multiplan","Participating","Enrollment Complete","2021-01-07",null,null,"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"]
["Lawrence A Wilson, MD","PE - Premier Family Care I, Inc","United Health Care","Participating","Enrollment Complete","2021-05-18",null,null,"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","PE - Premier Family Care I, Inc","Galaxy Health","Participating","Enrollment Complete","2021-01-07",null,null,"2021-03-15","3/15/2021 Rcvd email from Michelle Monroe at Galaxy Health confirming provider is participating under TIN and at location effective 01/07/2021.  DCannon"]
["Lawrence A Wilson, MD","PE - Premier Intensive Cardiac Rehabilitation","USA PPO","Participating","Enrollment Complete","2021-01-07",null,null,"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 1/7/2021.  DCannon"]
["Lawrence A Wilson, MD","PE - Premier Family Care I, Inc","Cigna","Participating","Enrollment Complete","2020-12-01",9800227,null,"2021-07-08","7/1/2021- S/W Natalie of Cigna @  8008824462, NPI# is on file for the provider, shows link and Par  under the group and TIN# effective 12/1/2020 the physical location is on file.  Provider ID is 9800227, No call ref#- Herminia Gilongos"]
["Lawrence A Wilson, MD","PE - Premier Family Care I, Inc","Alliance WC","Participating","Enrollment Complete","2021-03-19",null,null,"2021-06-28","6/28/2021 Received an email from Rep Michelle Killough at michelle.killough@pswca.org confirming provider is participating effective 3/19/2021 under group Tax ID. KFrazier"]
["Lawrence A Wilson, MD","PE - Premier Intensive Cardiac Rehabilitation","Amerigroup","Participating","Enrollment Complete","2021-01-07",null,null,"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","PE - Premier Intensive Cardiac Rehabilitation","Omni PPO","Participating","Enrollment Complete","2021-01-07",null,null,"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 1/7/2021. DCannon"]
["Lawrence A Wilson, MD","PE - Premier Intensive Cardiac Rehabilitation","Medicare","Participating","No Enrollment Required","2020-12-01","1L5835","0008AH","2021-03-19","3/19/2021 There is no requirement to add additional location since provider is currently assigned PTAN under group. KFrazier"]
["Lawrence A Wilson, MD","PE - Premier Family Care I, Inc","Amerigroup","Participating","Enrollment Complete","2021-01-07",null,null,"2022-04-05","4/5/2022 Rcvd email from Joe Rodriguez at Amerigroup confirming provider is PAR and linked to group TIN/location effective 1/7/2021.  DCannon"]
["Lawrence A Wilson, MD","PE - Premier Intensive Cardiac Rehabilitation","Superior","Participating","Enrollment Complete","2021-05-01",null,null,"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"]
["Lawrence A Wilson, MD","PE - Premier Intensive Cardiac Rehabilitation","Ambetter","Participating","Enrollment Complete","2022-04-01",null,null,"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","PE - Premier Family Care I, Inc","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"]
["Lawrence A Wilson, MD","PE - Premier Intensive Cardiac Rehabilitation","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"]
["Lawrence A Wilson, MD","PE - Premier Family Care I, Inc","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"]
["Lawrence A Wilson, MD","PE - Premier Intensive Cardiac Rehabilitation","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"]
["Lawrence A Wilson, MD","PE - Premier Intensive Cardiac Rehabilitation","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"]
["Lawrence A Wilson, MD","PE - Premier Intensive Cardiac Rehabilitation","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"]
["Lawrence A Wilson, MD","PE - Premier Intensive Cardiac Rehabilitation","IMS","Participating","Enrollment Complete","2021-01-07",null,null,"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 1/7/2021. DCannon"]
["Lawrence A Wilson, MD","PE - Premier Family Care I, Inc","Medicaid","Participating","Enrollment Complete","2020-12-01","0429805-07","0798373-01","2021-03-12","3/12/2021 Received forwarded approval notice from Candace Wynne, and provider has been assigned TPI 0429805-07 effective 12/01/2020. KFrazier"]
["Lawrence A Wilson, MD","PE - Premier Family Care I, Inc","Aetna","Participating","Enrollment Complete","2007-03-15",7942472,null,"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"]
["Lawrence A Wilson, MD","PE - Premier Family Care I, Inc","Caprock (CapStar)","Participating","Enrollment Complete","2021-01-07",null,null,"2021-04-09","4/9/2020 Rcvd roster from Mary Rodriguez <mary.rodriguez@90degreebenefits.com> at Caprock listing provider as participating under TIN.  DCannon"]
["Lawrence A Wilson, MD","PE - Premier Intensive Cardiac Rehabilitation","Medicaid","In Process","Pending Other Enrollment",null,null,null,"2021-06-25","6/25/2021 Pending group location add approval with TMHP at this time, as we can only add one performing provider at a time when enrolling the group location. KFrazier"]
["Lawrence A Wilson, MD","PE - Premier Family Care I, Inc","Scott&White (First Care)","Participating","Enrollment Complete","2021-03-05",null,null,"2021-03-24","3/24/2021 Rcvd confirmation email from hpcredentialinggroup@BSWHealth.org that provider is participating with TIN and location effective 3/5/2021.  DCannon"]
["John W Foster, Jr, MD","PE - Premier Family Care I, Inc","Galaxy Health","Participating","Enrollment Complete","2019-09-01",1679568380,null,"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"]
["John W Foster, Jr, MD","PE - Premier Family Care I, Inc","TriCare Standard","Participating","Enrollment Complete","2020-06-01",null,null,"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","PE - Premier Family Care I, Inc","Medicare","Participating","Enrollment Complete","2020-06-01","1D5510","0008AH","2020-06-23","06/23/2020 - Rec'd email from the payer stating this provider is EFF 6-1-2020 under PTAN 1D5510 - Stacey Hudak"]
["John W Foster, Jr, MD","PE - Premier Family Care I, Inc","Triwest VA","Facility Enrollment","In House Enrollment",null,null,null,"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"]
["John W Foster, Jr, MD",null,"Triwest VA","Facility Enrollment","In House Enrollment",null,null,null,"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"]
["John W Foster, Jr, MD","PE - Premier Family Care I, Inc","Triwest VA","Facility Enrollment","Application Submitted",null,null,null,"2022-11-23","08/19/2022 - Submitted application to TriWest VA (sent to Scarlett Abigail, Scarlett_Abigail@bcbstx.com)"]
["John W Foster, Jr, MD",null,"Triwest VA","Facility Enrollment","Application Submitted",null,null,null,"2022-11-23","08/19/2022 - Submitted application to TriWest VA (sent to Scarlett Abigail, Scarlett_Abigail@bcbstx.com)"]
["John W Foster, Jr, MD","PE - Premier Family Care I, Inc","Triwest VA","Facility Enrollment","Facility Enrollment",null,null,null,"2022-11-23","10/17/2022 - Received roster from Scarlett of TriWest VA; provider status: \"No Action.  TIN is CCN participating under own DCN.\""]
["John W Foster, Jr, MD",null,"Triwest VA","Facility Enrollment","Facility Enrollment",null,null,null,"2022-11-23","10/17/2022 - Received roster from Scarlett of TriWest VA; provider status: \"No Action.  TIN is CCN participating under own DCN.\""]
["John W Foster, Jr, MD","PE - Premier Family Care I, Inc","Aetna","Participating","Enrollment Complete","2020-10-01",4403006,null,"2020-09-08","09/08/2020 - Rec'd email from the payer stating \"Welcome to the provider network effective 10/1/2020. Your Provider Identification Number (PIN) is: 4403006\" - Stacey Hudak"]
["John W Foster, Jr, MD","PE - Premier Family Care I, Inc","Humana","Participating","Enrollment Complete","2020-04-01",1679568380,null,"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"]
["John W Foster, Jr, MD","PE - Premier Family Care I, Inc","United Health Care","Participating","Enrollment Complete","2020-07-11",1679568380,null,"2020-08-24","8/24/2020 - moved to completed status after reviewing follow up complete note - Stacey Hudak"]
["John W Foster, Jr, MD","PE - Premier Family Care I, Inc","Tricare Prime","Panel Closed","Panel Closed",null,null,null,"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"]
["John W Foster, Jr, MD","PE - Premier Family Care I, Inc","Ambetter","Participating","Enrollment Complete","2022-06-01",null,null,"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","PE - Premier Family Care I, Inc","CAQH","Participating","CAQH Reattested","2023-01-17",10773285,null,"2023-01-17","1/17/2023 CAQH reviewed and re-attested.  DCannon"]
["John W Foster, Jr, MD","PE - Premier Family Care I, Inc","Amerigroup","Participating","Enrollment Complete","2020-04-03",null,null,"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"]
["John W Foster, Jr, MD","PE - Premier Family Care I, Inc","Rail Road Medicare","Participating","Enrollment Complete","2020-06-01","P02490186","CE1588","2020-08-28","08/28/2020 - found effective info through payer site - updated payer line - Stacey Hudak"]
["John W Foster, Jr, MD","PE - Premier Family Care I, Inc","Superior","Participating","Enrollment Complete","2020-08-01",1679568380,null,"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"]
["John W Foster, Jr, MD","PE - Premier Family Care I, Inc","First Health Coventry","Participating","Enrollment Complete","2020-09-01",1900818,null,"2020-12-17","12/17/2020 - Rcvd confirmation email from payor that credentialing has been completed.  CPID 1900818 effective 9/1/2020.  DCannon"]
["John W Foster, Jr, MD","PE - Premier Family Care I, Inc","IMS","Participating","Enrollment Complete","2019-09-01",1679568380,null,"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"]
["John W Foster, Jr, MD","PE - Premier Family Care I, Inc","Multiplan","Participating","Enrollment Complete","2020-04-22",null,null,"2021-06-29","6/29/2021 Rcvd roster from Multiplan confirming provider is PAR under TIN effective 4/22/2020.  DCannon"]
["John W Foster, Jr, MD","PE - Premier Family Care I, Inc","Scott&White (First Care)","Participating","Enrollment Complete","2021-02-05",1679568380,null,"2021-02-11","2/11/2021 Received email of provider approval from BSWHPEXPEDITES@BSWHealth.org with an effective date of 2/5/2021 and asks to allow 3-4 weeks before submitting claims so they may complete the configuration of provider load in their system. KFrazier"]
["John W Foster, Jr, MD","PE - Premier Family Care I, Inc","Caprock (CapStar)","Participating","Enrollment Complete","2019-09-01",1679568380,null,"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"]
["John W Foster, Jr, MD","PE - Premier Family Care I, Inc","Boon Chapman","Participating","Enrollment Complete","2020-04-22",null,null,"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 4/22/2020.  DCannon"]
["John W Foster, Jr, MD","PE - Premier Family Care I, Inc","HealthSmart PPO","Participating","Enrollment Complete","2011-02-01",1679568380,null,"2020-06-05","06/05/2020 - Rec'd email from the payer stating this provider is EFF - Stacey Hudak"]
["John W Foster, Jr, MD","PE - Premier Family Care I, Inc","Cigna","Participating","Enrollment Complete","2021-08-16",1208794,null,"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","PE - Premier Family Care I, Inc","Cigna","Terminated","Terminated","2020-04-01",1679568380,null,"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"]
["John W Foster, Jr, MD","PE - Premier Family Care I, Inc","Wellcare","Participating","Enrollment Complete","2021-11-01",null,null,"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 W Foster, Jr, MD","PE - Premier Family Care I, Inc","USA PPO","Participating","Enrollment Complete","2021-01-26",514205,null,"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"]
["John W Foster, Jr, MD","PE - Premier Family Care I, Inc","Medicaid","Participating","Enrollment Complete","2020-08-03",137278111,79837301,"2020-08-14","8/14/2020 - Rec'd notification that this enrollment has been completed. I corrected the SS# and the clinic must have uploaded the signed deficiency letter to assist completion. - Stacey Hudak"]
["Dario Beltran, MD","PE - Premier Family Care I, Inc","Humana","Participating","Enrollment Complete","2020-01-01",null,null,"2021-11-18","11/18/2021 Rcvd full roster from Humana listing provider as PAR and linked to group TIN/location effective 1/1/2020.  DCannon"]
["Dario Beltran, MD","PE - Premier Family Care I, Inc","CAQH","Participating","CAQH Reattested","2022-12-15",12019639,null,"2022-12-15","12/15/2022 CAQH reviewed and re-attested.  DCannon"]
["Dario Beltran, MD","PE - Premier Family Care I, Inc","TriCare Standard","Participating","Enrollment Complete","2011-03-03",1912100850,null,"2021-11-15","11/15/2021 Per confirm par statues note.   S/W Diana of Tricare @ 800-444-5445 Transferred to WPS Dept. S/w Maggie. Provider NPI# is on file for the provider and is participating effective 03/03/2011 under the group and TIN#.  No end date. Physical location is on file. Call ref# 14226448.  DCannon"]
["Dario Beltran, MD","PE - Premier Family Care I, Inc","Cigna","Participating","Enrollment Complete","2021-10-29",3531211,null,"2022-03-09","3/9/2022 Rcvd email from Cigna that provider is PAR and linked to group TIN/location effective 10/29/2021.  PID # 3531211.  DCannon"]
["Dario Beltran, MD","PE - Premier Family Care I, Inc","HealthSmart PPO","Enrollment Stopped","Enrollment Stopped","2019-07-18",1912100850,null,"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","PE - Premier Family Care I, Inc","Medicaid","Enrollment Stopped","Enrollment Stopped","2020-03-15",121276305,79837301,"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","PE - Premier Family Care I, Inc","United Health Care","Participating","Enrollment Complete","2020-04-03",null,null,"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 4/3/2020.  DCannon"]
["Dario Beltran, MD","PE - Premier Family Care I, Inc","Amerigroup","Participating","Enrollment Complete","2012-03-01",1448905,null,"2021-11-15","11/15/2021 Per Amerigroup roster provider is PAR and linked to group TIN/location effective 3/1/2012.  DCannon"]
["Dario Beltran, MD","PE - Premier Family Care I, Inc","First Health Coventry","In Process","Action Needed",null,1067924,null,"2023-03-06","03.06.2023 S/W Brenda of First Health @800-226-5116. Per rep, provider is no longer in the network since 01/31/2021. Since the TIN has delegated group which is PriMed Health Network, rep advised to contact them first because they're the one who terminated the provider with First Health and reinstate the provider back in First Health. Call ref# 564186. - Mary Rose Acebedo"]
["Dario Beltran, MD","PE - Premier Family Care I, Inc","Medicare","Participating","Enrollment Complete","2009-12-01","8L21655","0008AH","2021-11-15","11/15/2021 Per PECOS provider is PAR and linked to group PTAN/location.  PTAN 8L21655 effective 12/1/2009.  DCannon."]
["Dario Beltran, MD","PE - Premier Family Care I, Inc","Aetna","Participating","Enrollment Complete","2011-01-17",1912100850,null,"2021-11-15"," S/W Ella of Aetna @ 8003531232, NPI# for the provider is Linked and Par under group and TIN# effective 1/17/2011, the physical location is on file, Provider ID is 5175561. Call ref#6052978261."]
["Dario Beltran, MD","PE - Premier Family Care I, Inc","Multiplan","Enrollment Stopped","Enrollment Stopped","2016-07-13",1912100850,"52669: West Texas Physicians Alliance Group Cntrct","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","PE - Premier Family Care I, Inc","USA PPO","Participating","Enrollment Complete","2020-04-03",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 4/3/2020.  DCannon"]
["Dario Beltran, MD","PE - Premier Family Care I, Inc","Omni PPO","Enrollment Stopped","Enrollment Complete","2019-09-01",1912100850,null,"2020-07-27","IMS complete"]
["Dario Beltran, MD","PE - Premier Family Care I, Inc","Triwest VA","Facility Enrollment","In House Enrollment",null,null,null,"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"]
["Dario Beltran, MD",null,"Triwest VA","Facility Enrollment","In House Enrollment",null,null,null,"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"]
["Dario Beltran, MD","PE - Premier Family Care I, Inc","Triwest VA","Facility Enrollment","Application Submitted",null,null,null,"2022-11-23","08/19/2022 - Submitted application to TriWest VA (sent to Scarlett Abigail, Scarlett_Abigail@bcbstx.com)"]
["Dario Beltran, MD",null,"Triwest VA","Facility Enrollment","Application Submitted",null,null,null,"2022-11-23","08/19/2022 - Submitted application to TriWest VA (sent to Scarlett Abigail, Scarlett_Abigail@bcbstx.com)"]
["Dario Beltran, MD","PE - Premier Family Care I, Inc","Triwest VA","Facility Enrollment","Facility Enrollment",null,null,null,"2022-11-23","10/17/2022 - Received roster from Scarlett of TriWest VA; provider status: \"No Action.  TIN is CCN participating under own DCN.\""]
["Dario Beltran, MD",null,"Triwest VA","Facility Enrollment","Facility Enrollment",null,null,null,"2022-11-23","10/17/2022 - Received roster from Scarlett of TriWest VA; provider status: \"No Action.  TIN is CCN participating under own DCN.\""]
["Dario Beltran, MD","PE - Premier Family Care I, Inc","IMS","Enrollment Stopped","Enrollment Complete","2019-09-01",1922008234,null,"2020-07-27","07/27/2020 - enrollment was completed due to being submitted on July 2020 roster to the payer - Stacey Hduak"]
["Dario Beltran, MD","PE - Premier Family Care I, Inc","Wellcare","Participating","Enrollment Complete","2021-11-01",null,null,"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"]
["Dario Beltran, MD","PE - Premier Family Care I, Inc","Boon Chapman","Enrollment Stopped","Enrollment Stopped","2016-07-13",1912100850,null,"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","PE - Premier Family Care I, Inc","Scott&White (First Care)","Participating","Enrollment Complete","2022-09-13",null,null,"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"]
["Dario Beltran, MD","PE - Premier Family Care I, Inc","Caprock (CapStar)","Terminated","Enrollment Stopped","2016-07-06",1912100850,null,"2020-10-12"]
["Dario Beltran, MD","PE - Premier Family Care I, Inc","Galaxy Health","Enrollment Stopped","Enrollment Stopped","2019-05-18",1912100850,null,"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","PE - Premier Family Care I, Inc","Superior","Participating","Enrollment Complete","2021-12-01",1912100850,null,"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"]
["Dario Beltran, MD","PE - Premier Family Care I, Inc","Ambetter","Participating","Enrollment Complete","2022-06-01",null,null,"2022-06-13","6/13/2022 Per roster received from Superior provider is PAR and linked to group delegation roster effective 6/1/2022."]
["Padmaja M Patel, MD","PE - Premier Family Care I, Inc","Aetna","Participating","Enrollment Complete","2020-10-15",null,null,"2020-10-21","10/21/2020 - SW Ann of Aetna @ 800 3531232, Provider is on file  and Participating under the group and TIN# effective 10/15/2020, Physical address on file.  call ref# 5631204512. - Herminia Gilongos"]
["Padmaja M Patel, MD","PE - Premier Family Care I, Inc","Superior","Participating","Enrollment Complete","2020-12-01",null,null,"2020-12-22","12/22/2020 Rcvd email from Superior confirming that the providers are PAR and loaded under TIN/locations effective 12/1/2020.  DCannon"]
["Padmaja M Patel, MD","PE - Premier Family Care I, Inc","Caprock (CapStar)","Participating","Enrollment Complete","2021-01-01",null,null,"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 1/1/2021.  DCannon"]
["Padmaja M Patel, MD","PE - Premier Intensive Cardiac Rehabilitation","First Health Coventry","Thru Other Payor","See Other Payor Line",null,null,null,"2021-03-18","3/18/2021 Please reference the Aetna payor line for the full update, as we submitted a demographic update for all lines of business to add provider under location as Medical Director. KFrazier"]
["Padmaja M Patel, MD","PE - Premier Intensive Cardiac Rehabilitation","Cigna","Participating","Enrollment Complete","2021-05-01",6008373,null,"2021-07-08","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 5/1/2021 the physical location is on file.  Provider ID is 6008373, No call ref#- Herminia Gilongos"]
["Padmaja M Patel, MD","PE - Premier Family Care I, Inc","Humana","Participating","Enrollment Complete","2020-01-01",null,null,"2021-11-18","11/18/2021 Rcvd full roster from Humana listing provider as PAR and linked to group TIN/location effective 1/1/2020.  DCannon"]
["Padmaja M Patel, MD","PE - Premier Family Care I, Inc","Omni PPO","Participating","Enrollment Complete","2020-10-01",null,null,"2020-11-25","11/25/2020 - Rcvd email confirmation that Nov monthly roster was processed and this provider was made effective with the requested eff date of 10/1/2020.  DCannon"]
["Padmaja M Patel, MD","PE - Premier Family Care I, Inc","Caprock (CapStar)","Participating","Enrollment Complete","2020-10-01",null,null,"2021-04-28","4/28/2021 Rcvd roster from payer with all participating providers listed.  Provider is PAR and linked to TIN/locations effective 10/1/2020."]
["Padmaja M Patel, MD","PE - Premier Intensive Cardiac Rehabilitation","Humana","Participating","Enrollment Complete","2020-01-01",null,null,"2021-11-18","11/18/2021 Rcvd full roster from Humana listing provider as PAR and linked to group TIN/location effective 1/1/2020.  DCannon"]
["Padmaja M Patel, MD","PE - Premier Family Care I, Inc","Medicare","Participating","Enrollment Complete","2019-04-01",774823,null,"2020-12-07","12/7/2020 - Verified provider's PTAN # 774823 via the PECOS website.  DCannon"]
["Padmaja M Patel, MD","PE - Premier Intensive Cardiac Rehabilitation","Scott&White (First Care)","Participating","Enrollment Complete","2019-06-06",null,null,"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 6/6/2019.  DCannon"]
["Padmaja M Patel, MD","PE - Premier Intensive Cardiac Rehabilitation","Rail Road Medicare","Participating","Enrollment Complete","2021-01-01","P02604011","CE1588","2021-08-06","8/6/2021 RR Medicare PTAN # was issued instantly PTAN # P02604011 - effective 1/1/2021.  DCannon"]
["Padmaja M Patel, MD","PE - Premier Family Care I, Inc","Galaxy Health","Participating","Enrollment Complete","2020-10-01",null,null,"2020-12-14","12/14/2020 - Rcvd email confirmation from Galaxy Health that the November Delegation Roster was completed. DCannon"]
["Padmaja M Patel, MD","PE - Premier Intensive Cardiac Rehabilitation","Multiplan","Participating","Enrollment Complete","2019-03-06",12037979,null,"2022-02-24","2/24/2022 Per follow-up note from 2/18/2022 - Provider NPI# is on file for the provider and participating effective 03/06/2019 under the group and TIN#. Provider ID#  12037979. Physical location is on file. Call ref# 7919804 -DCannon"]
["Padmaja M Patel, MD","PE - Premier Family Care I, Inc","Amerigroup","Participating","Enrollment Complete","2020-04-03",null,null,"2021-11-11","11/11/2021 Rcvd email from Marco Rodriguez @ Amerigroup confirming that provider is PAR under group TIN/location effective 4/3/2020.  DCannon"]
["Padmaja M Patel, MD","PE - Premier Intensive Cardiac Rehabilitation","Boon Chapman","Participating","Enrollment Complete","2019-03-06",null,null,"2022-02-24","2/18/2022 - Per follow-up note from 2/18/2022 - Provider NPI# is on file for the provider and participating effective 03/06/2019 under the group and TIN#. Provider ID#  12037979. Physical location is on file. Call ref# 7919804 -DCannon"]
["Padmaja M Patel, MD","PE - Premier Intensive Cardiac Rehabilitation","United Health Care","Participating","Enrollment Complete","2021-01-01",null,null,"2021-05-03","5/3/2021 Received an email from United_Healthcare_Provider_Operations@uhc.com confirming provider and location have been added as participating effective 1/1/2021 with MPIN 001888475 under reference number PR-5800110. KFrazier"]
["Padmaja M Patel, MD","PE - Premier Family Care I, Inc","Medicaid","Enrollment Stopped","Enrollment Denied",null,null,null,"2021-08-12","3/24/2021 Upon review of the TMHP portal, application for group and performing provider were denied. KFrazier"]
["Padmaja M Patel, MD","PE - Premier Family Care I, Inc","Scott&White (First Care)","Participating","Enrollment Complete","2019-06-06",null,null,"2021-01-21","1/20/2021 - Rcvd email from BSWHPEXPEDITES@BSWHealth.org that provider is participating and linked to TIN effectivre 6/6/2019"]
["Padmaja M Patel, MD","PE - Premier Family Care I, Inc","Medicare","Participating","Enrollment Complete","2019-04-01",774823,null,"2020-12-07","12/7/2020 - Verified provider's PTAN # 774823 via the PECOS website.  DCannon"]
["Padmaja M Patel, MD","PE - Premier Family Care I, Inc","First Health Coventry","Participating","Enrollment Complete","2020-09-01",1097226,null,"2021-01-18","1/18/2021 - Per follow-up notes provider is now on file and participating under group, location and TIN effective 9/1/2020 PID # 1097226.  DCannon"]
["Padmaja M Patel, MD","PE - Premier Family Care I, Inc","IMS","Participating","Enrollment Complete","2020-10-01",null,null,"2020-11-12","11/12/20 - Received email from payer 10/20/20 that provider has been loaded in their system as a participating provider effective 10/1/20.  DCannon"]
["Padmaja M Patel, MD","PE - Premier Intensive Cardiac Rehabilitation","Triwest VA","Facility Enrollment","In House Enrollment",null,null,null,"2021-03-18","3/18/2021 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"]
["Padmaja M Patel, MD",null,"Triwest VA","Facility Enrollment","In House Enrollment",null,null,null,"2021-03-18","3/18/2021 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"]
["Padmaja M Patel, MD","PE - Premier Intensive Cardiac Rehabilitation","Triwest VA","Facility Enrollment","Application Submitted",null,null,null,null,"08/19/2022 - Submitted application to TriWest VA (sent to Scarlett Abigail, Scarlett_Abigail@bcbstx.com)"]
["Padmaja M Patel, MD",null,"Triwest VA","Facility Enrollment","Application Submitted",null,null,null,null,"08/19/2022 - Submitted application to TriWest VA (sent to Scarlett Abigail, Scarlett_Abigail@bcbstx.com)"]
["Padmaja M Patel, MD","PE - Premier Intensive Cardiac Rehabilitation","Triwest VA","Facility Enrollment","Facility Enrollment",null,null,null,null,"10/17/2022 - Received roster from Scarlett; provider status: \"No Action.  TIN is CCN participating under own DCN.\""]
["Padmaja M Patel, MD",null,"Triwest VA","Facility Enrollment","Facility Enrollment",null,null,null,null,"10/17/2022 - Received roster from Scarlett; provider status: \"No Action.  TIN is CCN participating under own DCN.\""]
["Padmaja M Patel, MD","PE - Premier Family Care I, Inc","Triwest VA","Facility Enrollment","Payor Follow Up",null,null,null,null,"10/17/2022 - Received roster from Scarlett; provider status: \"No Action.  TIN is CCN participating under own DCN.\""]
["Padmaja M Patel, MD",null,"Triwest VA","Facility Enrollment","Payor Follow Up",null,null,null,null,"10/17/2022 - Received roster from Scarlett; provider status: \"No Action.  TIN is CCN participating under own DCN.\""]
["Padmaja M Patel, MD","PE - Premier Family Care I, Inc","Triwest VA","Facility Enrollment","Application Submitted",null,null,null,null,"08/19/2022 - Submitted application to TriWest VA (sent to Scarlett Abigail, Scarlett_Abigail@bcbstx.com)"]
["Padmaja M Patel, MD",null,"Triwest VA","Facility Enrollment","Application Submitted",null,null,null,null,"08/19/2022 - Submitted application to TriWest VA (sent to Scarlett Abigail, Scarlett_Abigail@bcbstx.com)"]
["Padmaja M Patel, MD","PE - Premier Family Care I, Inc","Tricare Prime","Participating","Enrollment Complete","2019-04-01",null,null,"2020-10-26","10/26/2020 Confirmed provider is participating under group Tax ID and location per self-service portal. Kimberly Frazier"]
["Padmaja M Patel, MD","PE - Premier Family Care I, Inc","USA PPO","Participating","Enrollment Complete","2021-01-26",823585,null,"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"]
["Padmaja M Patel, MD","PE - Premier Family Care I, Inc","First Health Coventry","Participating","Enrollment Complete","2020-09-01",1097226,null,"2021-01-18","1/18/2021 - Per follow-up notes provider is now on file and participating under group, location and TIN effective 09/1/2020 PID # 1097226.  DCannon"]
["Padmaja M Patel, MD","PE - Premier Family Care I, Inc","Scott&White (First Care)","Participating","Enrollment Complete","2019-06-06",null,null,"2021-01-21","1/20/2021 - Rcvd email from BSWHPEXPEDITES@BSWHealth.org that provider is participating and linked to TIN effectivre 6/6/2019"]
["Padmaja M Patel, MD","PE - Premier Intensive Cardiac Rehabilitation","Ambetter","Participating","Enrollment Complete","2022-04-01",null,null,"2022-06-13","6/13/2022 Per roster received from Superior provider is PAR and linked to group delegation roster effective 4/1/2022."]
["Padmaja M Patel, MD","PE - Premier Family Care I, Inc","Ambetter","Participating","Enrollment Complete","2022-04-01",null,null,"2022-06-13","6/13/2022 Per roster received from Superior provider is PAR and linked to group delegation roster effective 4/1/2022."]
["Padmaja M Patel, MD","PE - Premier Family Care I, Inc","Ambetter","Participating","Enrollment Complete","2022-04-01",null,null,"2022-06-13","6/13/2022 Per roster received from Superior provider is PAR and linked to group delegation roster effective 4/1/2022."]
["Padmaja M Patel, MD","PE - Premier Family Care I, Inc","Ambetter","Participating","Enrollment Complete","2022-04-01",null,null,"2022-06-13","6/13/2022 Per roster received from Superior provider is PAR and linked to group delegation roster effective 4/1/2022."]
["Padmaja M Patel, MD","PE - Premier Family Care I, Inc","Ambetter","Participating","Enrollment Complete","2022-04-01",null,null,"2022-06-13","6/13/2022 Per roster received from Superior provider is PAR and linked to group delegation roster effective 4/1/2022."]
["Padmaja M Patel, MD","PE - Premier Family Care I, Inc","Ambetter","Participating","Enrollment Complete","2022-04-01",null,null,"2022-06-13","6/13/2022 Per roster received from Superior provider is PAR and linked to group delegation roster effective 4/1/2022."]
["Padmaja M Patel, MD","PE - Premier Intensive Cardiac Rehabilitation","Medicaid","Enrollment Stopped","Enrollment Stopped",null,null,null,"2021-08-12","8/12/2021 Upon review of TMHP portal, application was closed 6/8/21 due to issue regarding same PTAN as group and specialty completely different. KFrazier"]
["Padmaja M Patel, MD","PE - Premier Family Care I, Inc","Galaxy Health","Participating","Enrollment Complete","2020-10-01",null,null,"2020-12-14","12/14/2020 - Rcvd email confirmation from Galaxy Health that the November Delegation Roster was completed. DCannon"]
["Padmaja M Patel, MD","PE - Premier Family Care I, Inc","Boon Chapman","Participating","Enrollment Complete","2019-03-06",null,null,"2021-09-15","9/15/2021 Rcvd roster from Multiplan listing provider PAR and linked to group TIN/location effective 3/6/2019.  DCannon"]
["Padmaja M Patel, MD","PE - Premier Family Care I, Inc","Medicaid","Enrollment Stopped","Enrollment Denied",null,null,null,"2021-08-12","3/24/2021 Upon review of the TMHP portal, application for group and performing provider were denied. KFrazier"]
["Padmaja M Patel, MD","PE - Premier Intensive Cardiac Rehabilitation","Superior","Participating","Enrollment Complete","2021-05-01",null,null,"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"]
["Padmaja M Patel, MD","PE - Premier Family Care I, Inc","Multiplan","Participating","Enrollment Complete","2019-03-06",null,null,"2021-06-29","6/29/2021 Rcvd roster from Multiplan confirming provider is PAR under TIN effective 03/06/2019.  DCannon"]
["Padmaja M Patel, MD","PE - Premier Family Care I, Inc","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"]
["Padmaja M Patel, MD","PE - Premier Family Care I, Inc","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"]
["Padmaja M Patel, MD","PE - Premier Intensive Cardiac Rehabilitation","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"]
["Padmaja M Patel, MD","PE - Premier Family Care I, Inc","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"]
["Padmaja M Patel, MD","PE - Premier Family Care I, Inc","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"]
["Padmaja M Patel, MD","PE - Premier Intensive Cardiac Rehabilitation","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"]
["Padmaja M Patel, MD","PE - Premier Intensive Cardiac Rehabilitation","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"]
["Padmaja M Patel, MD","PE - Premier Family Care I, Inc","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"]
["Padmaja M Patel, MD","PE - Premier Intensive Cardiac Rehabilitation","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"]
["Padmaja M Patel, MD","PE - Premier Intensive Cardiac Rehabilitation","IMS","Participating","Enrollment Complete","2021-01-01",null,null,"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 1/1/2021. DCannon"]
["Padmaja M Patel, MD","PE - Premier Family Care I, Inc","Superior","Participating","Enrollment Complete","2020-11-01",null,null,"2020-11-25","11/25/2020 -  Rcvd email confirmation that Oct monthly roster was processed and this provider was made effective with the requested eff date of 11/1/2020.  DCannon"]
["Padmaja M Patel, MD","PE - Premier Family Care I, Inc","Cigna","Participating","Enrollment Complete","2021-03-31",9355182,null,"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 9355182. KFrazier"]
["Padmaja M Patel, MD","PE - Premier Intensive Cardiac Rehabilitation","Aetna","Terminated","Terminated","2021-01-01",5777706,null,"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"]
["Padmaja M Patel, MD","PE - Premier Family Care I, Inc","Humana","Participating","Enrollment Complete","2020-01-01",null,null,"2021-11-18","11/18/2021 Rcvd full roster from Humana listing provider as PAR and linked to group TIN/location effective 1/1/2020.  DCannon"]
["Padmaja M Patel, MD","PE - Premier Family Care I, Inc","Triwest VA","Facility Enrollment","Application Submitted",null,null,null,"2022-11-28","08/19/2022 - Submitted application to TriWest VA (sent to Scarlett Abigail, Scarlett_Abigail@bcbstx.com)"]
["Padmaja M Patel, MD",null,"Triwest VA","Facility Enrollment","Application Submitted",null,null,null,"2022-11-28","08/19/2022 - Submitted application to TriWest VA (sent to Scarlett Abigail, Scarlett_Abigail@bcbstx.com)"]
["Padmaja M Patel, MD","PE - Premier Family Care I, Inc","Triwest VA","Facility Enrollment","Facility Enrollment",null,null,null,"2022-11-28","10/17/2022 - Received roster from Scarlett of TriWest VA; provider status: \"No Action.  TIN is CCN participating under own DCN.\""]
["Padmaja M Patel, MD",null,"Triwest VA","Facility Enrollment","Facility Enrollment",null,null,null,"2022-11-28","10/17/2022 - Received roster from Scarlett of TriWest VA; provider status: \"No Action.  TIN is CCN participating under own DCN.\""]
["Padmaja M Patel, MD","PE - Premier Family Care I, Inc","Galaxy Health","Participating","Enrollment Complete","2020-10-01",null,null,"2020-12-14","12/14/2020 - Rcvd email confirmation from Galaxy Health that the November Delegation Roster was completed. DCannon"]
["Padmaja M Patel, MD","PE - Premier Intensive Cardiac Rehabilitation","Caprock (CapStar)","Participating","Enrollment Complete","2021-01-01",null,null,"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 1/1/2021.  DCannon"]
["Padmaja M Patel, MD","PE - Premier Family Care I, Inc","United Health Care","Participating","Enrollment Complete","2020-10-24",null,null,"2021-05-03","5/3/2021 Received an email from United_Healthcare_Provider_Operations@uhc.com confirming provider and location have been added as participating effective 10/24/2020 with MPIN 001419429 under reference number PR-5800134. KFrazier"]
["Padmaja M Patel, MD","PE - Premier Intensive Cardiac Rehabilitation","Galaxy Health","Participating","Enrollment Complete","2021-01-01",null,null,"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 1/1/2021.  DCannon"]
["Padmaja M Patel, MD","PE - Premier Family Care I, Inc","IMS","Participating","Enrollment Complete","2020-10-01",null,null,"2020-11-25","11/25/2020 - Rcvd email confirmation that Nov monthly roster was processed and this provider was made effective with the requested eff date of 10/1/2020.  DCannon"]
["Padmaja M Patel, MD","PE - Premier Intensive Cardiac Rehabilitation","Omni PPO","Participating","Enrollment Complete","2021-01-01",null,null,"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 3/15/2021. DCannon"]
["Padmaja M Patel, MD","PE - Premier Family Care I, Inc","Cigna","Terminated","Terminated","2019-01-01",null,null,"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"]
["Padmaja M Patel, MD","PE - Premier Intensive Cardiac Rehabilitation","Amerigroup","Participating","Enrollment Complete","2020-04-03",null,null,"2021-11-11","11/11/2021 Rcvd email from Marco Rodriguez @ Amerigroup confirming that provider is PAR under group TIN/location effective 4/3/2020.  DCannon"]
["Padmaja M Patel, MD","PE - Premier Family Care I, Inc","HealthSmart PPO","Participating","Enrollment Complete","2019-03-06",null,null,"2021-01-27","1/27/2021 - Rcvd confirmation email that provider is participating and linked to location and TIN effective 3/6/2019.  DCannon"]
["Padmaja M Patel, MD","PE - Premier Intensive Cardiac Rehabilitation","Cigna","Terminated","Terminated","2021-01-01",9355182,null,"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"]
["Padmaja M Patel, MD","PE - Premier Intensive Cardiac Rehabilitation","TriCare Standard","Participating","Thru Other Payor",null,null,null,"2021-03-23","3/23/2021 Since group is already certified under Tax ID and is participating with Prime, a Roster was submitted for loading of group location and provider. KFrazier"]
["Padmaja M Patel, MD","PE - Premier Intensive Cardiac Rehabilitation","USA PPO","Participating","Enrollment Complete","2021-01-01",null,null,"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 1/1/2021.  DCannon"]
["Padmaja M Patel, MD","PE - Premier Family Care I, Inc","TriCare Standard","Participating","Enrollment Complete","2019-04-01",null,null,"2020-10-26","10/26/2020 Confirmed provider is certified as non-network provider under Group with location. Kimberly Frazier"]
["Padmaja M Patel, MD","PE - Premier Family Care I, Inc","Boon Chapman","Participating","Enrollment Complete","2019-03-06",null,null,"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"]
["Padmaja M Patel, MD","PE - Premier Family Care I, Inc","Multiplan","Participating","Enrollment Complete","2019-03-06",null,null,"2021-06-29","6/29/2021 Rcvd roster from Multiplan confirming provider is PAR under TIN effective 03/06/2019.  DCannon"]
["Padmaja M Patel, MD","PE - Premier Family Care I, Inc","USA PPO","Participating","Enrollment Complete","2021-01-26",823585,null,"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"]
["Padmaja M Patel, MD","PE - Premier Family Care I, Inc","Cigna","Participating","Enrollment Complete","2021-03-31",9355182,null,"2021-08-05","7/28/2021 Received an email from PDMCOGZ@cigna.com confirming provider is now participating under group Tax ID and location effective 3/31/2021 with assigned provider number 9355182. KFrazier"]
["Padmaja M Patel, MD","PE - Premier Family Care I, Inc","Amerigroup","Participating","Enrollment Complete","2020-04-03",null,null,"2021-11-11","11/11/2021 Rcvd email from Marco Rodriguez @ Amerigroup confirming that provider is PAR under group TIN/location effective 4/3/2020.  DCannon"]
["Padmaja M Patel, MD","PE - Premier Family Care I, Inc","HealthSmart PPO","Participating","Enrollment Complete","2019-03-06",null,null,"2021-01-27","1/27/2021 - Rcvd confirmation email that provider is participating and linked to location and TIN effective 3/6/2019.  DCannon"]
["Padmaja M Patel, MD","PE - Premier Intensive Cardiac Rehabilitation","HealthSmart PPO","Participating","Enrollment Complete","2021-01-01",null,null,"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"]
["Padmaja M Patel, MD","PE - Premier Family Care I, Inc","United Health Care","Participating","Enrollment Complete","2020-10-24",null,null,"2021-05-03","5/3/2021 Received an email from United_Healthcare_Provider_Operations@uhc.com confirming provider and location have been added as participating effective 10/24/2020 with MPIN 001888475 under reference number PR-5800134. KFrazier"]
["Padmaja M Patel, MD","PE - Premier Family Care I, Inc","Cigna","Terminated","Terminated","2019-01-01",null,null,"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"]
["Padmaja M Patel, MD","PE - Premier Family Care I, Inc","TriCare Standard","Participating","Enrollment Complete","2021-05-05",null,null,"2021-08-03","8/3/2021 - Per follow-up notes provider is linked and Par under the group and TIN# effective 5/5/2021 -11/30/2021 under this location. Provider ID is 75-2656723-79701-H002"]
["Padmaja M Patel, MD","PE - Premier Intensive Cardiac Rehabilitation","Medicare","Participating","Enrollment Complete","2021-01-01","1M6718","1K9664","2021-03-04","3/4/2021 Received email notification provider has been approved with assigned PTAN 1M6718 effective 1/1/2021. KFrazier"]
["Venus M Skeen, DNP","PE - Premier Family Care I, Inc","Triwest VA","Facility Enrollment","In House Enrollment",null,null,null,"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"]
["Venus M Skeen, DNP",null,"Triwest VA","Facility Enrollment","In House Enrollment",null,null,null,"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"]
["Venus M Skeen, DNP","PE - Premier Family Care I, Inc","Triwest VA","Facility Enrollment","Application Submitted",null,null,null,"2022-11-28","08/19/2022 - Submitted application to TriWest VA (sent to Scarlett Abigail, Scarlett_Abigail@bcbstx.com)"]
["Venus M Skeen, DNP",null,"Triwest VA","Facility Enrollment","Application Submitted",null,null,null,"2022-11-28","08/19/2022 - Submitted application to TriWest VA (sent to Scarlett Abigail, Scarlett_Abigail@bcbstx.com)"]
["Venus M Skeen, DNP","PE - Premier Family Care I, Inc","Triwest VA","Facility Enrollment","Facility Enrollment",null,null,null,"2022-11-28","10/17/2022 - Received roster from Scarlett of TriWest VA; provider status: \"No Action.  TIN is CCN participating under own DCN.\""]
["Venus M Skeen, DNP",null,"Triwest VA","Facility Enrollment","Facility Enrollment",null,null,null,"2022-11-28","10/17/2022 - Received roster from Scarlett of TriWest VA; provider status: \"No Action.  TIN is CCN participating under own DCN.\""]
["Venus M Skeen, DNP","PE - Premier Family Care I, Inc","Cigna","Participating","Enrollment Complete","2021-03-31",5102893,null,"2021-07-06","7/2/2021 Received email from PDMCOGZ@Cigna.com confirming provider is now participating under group Tax ID effective 3/31/2021 with provider ID 5102893. KFrazier"]
["Venus M Skeen, DNP","PE - Premier Family Care I, Inc","Medicaid","Participating","Enrollment Complete",null,357539103,79837301,"2020-01-29","01/29/2020 - Found provider PAR through payer portal. Provider is linked to the group TPI 079837301 with the following plans: \nTRADITIONAL MEDICAID, Amerigroup - MRSA West, Amerigroup Texas, Inc. - MRSA West - stacey Hudak"]
["Venus M Skeen, DNP","PE - Premier Family Care I, Inc","Caprock (CapStar)","Participating","Enrollment Complete","2019-09-18",1952865057,null,"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"]
["Venus M Skeen, DNP","PE - Premier Family Care I, Inc","Amerigroup","Participating","Enrollment Complete","2020-04-03",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 4/3/2020.  DCannon"]
["Venus M Skeen, DNP","PE - Premier Family Care I, Inc","TriCare Standard","Participating","Enrollment Complete","2020-08-26",null,null,"2020-09-24","09/24/2020 - moved to completed status after reviewing follow up complete - Stacey Hudak"]
["Venus M Skeen, DNP","PE - Premier Family Care I, Inc","Multiplan","Participating","Enrollment Complete","2019-10-07",1104229293,"52669: West Texas Physicians Alliance Group Cntrct","2020-02-13","02/13/2020 - **FOR PREMIER FAMILY CARE TIN** Rec'd roster stating this provider is linked to DIRECT GROUP CONTRACT as of 10-7-2019. Provider is networked with Beechstreet. - Stacey Hudak"]
["Venus M Skeen, DNP","PE - Premier Family Care I, Inc","Medicare","Participating","Enrollment Complete","2019-09-01",858626,"0008AH","2020-01-29","01/29/2020 - confirmed EFF through PECOS group enrollment - Stacey Hudak"]
["Venus M Skeen, DNP","PE - Premier Family Care I, Inc","Cigna","Terminated","Terminated","2019-12-02",1104229293,null,"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"]
["Venus M Skeen, DNP","PE - Premier Family Care I, Inc","USA PPO","Participating","Enrollment Complete","2019-09-30",1291209,null,"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"]
["Venus M Skeen, DNP","PE - Premier Family Care I, Inc","First Health Coventry","Participating","Enrollment Complete","2019-09-01",3309742,null,"2020-03-20","03/20/2020 - Rec'd email from the payer confirming this provider is effective under PID# 3309742  with this TIN - Stacey Hudak"]
["Venus M Skeen, DNP","PE - Premier Family Care I, Inc","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"]
["Venus M Skeen, DNP","PE - Premier Family Care I, Inc","Scott&White (First Care)","Participating","Enrollment Complete","2019-09-01",1104229293,null,"2020-10-02","10/02/2020 - moved to completed status after reviewing follow up complete - Stacey Hudak"]
["Venus M Skeen, DNP","PE - Premier Family Care I, Inc","Superior","Participating","Enrollment Complete","2020-08-01",1104229293,null,"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"]
["Venus M Skeen, DNP","PE - Premier Family Care I, Inc","Aetna","Participating","Enrollment Complete","2020-02-15",1104229293,null,"2020-04-23","04/23/2020--S/W Christine of Aetna @ 800-353-1232. Per rep the Provider is on file, linked & participating under the GRP & TIN effective 2/15/2020. Physical Location is on file. Provider ID #4170965. Call ref # 5234061830\ncopied note from spreadsheet-tisha rader"]
["Venus M Skeen, DNP","PE - Premier Family Care I, Inc","United Health Care","Participating","Enrollment Complete","2019-09-01",1104229293,null,"2020-07-30","7/30/2020 - moved to completed status after reviewing follow up complete note - Stacey Hudak"]
["Venus M Skeen, DNP","PE - Premier Family Care I, Inc","Galaxy Health","Participating","Enrollment Complete","2019-09-01",1104229293,null,"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"]
["Venus M Skeen, DNP","PE - Premier Family Care I, Inc","IMS","Participating","Enrollment Complete","2019-09-01",1104229293,null,"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"]
["Venus M Skeen, DNP","PE - Premier Family Care I, Inc","Omni PPO","Participating","Enrollment Complete","2019-09-01",1104229293,null,"2020-07-27","IMS completed"]
["Venus M Skeen, DNP","PE - Premier Family Care I, Inc","HealthSmart PPO","Participating","Enrollment Complete","2019-10-02",null,null,"2021-01-27","1/27/2021 - Rcvd confirmation email that provider is participating and linked to location and TIN effective 10/2/2019.  DCannon"]
["Venus M Skeen, DNP","PE - Premier Family Care I, Inc","Rail Road Medicare","Participating","Enrollment Complete","2019-09-01","P02428347","CE1588","2020-08-28","08/28/2020 - moved to completed status after confirming EFF info through payer site - Stacey Hudak"]
["Venus M Skeen, DNP","PE - Premier Family Care I, Inc","Humana","Participating","Enrollment Complete","2020-01-01",1104229293,null,"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"]
["Venus M Skeen, DNP","PE - Premier Family Care I, Inc","Boon Chapman","Participating","Enrollment Complete","2019-10-07",null,null,"2021-09-15","9/15/2021 Received roster from Multiplan listing provider as PAR under group TIN/location effective 10/7/2019.  DCannon"]
["Adenike T Esho, MD","PE - Premier Family Care I, Inc","Caprock (CapStar)","Participating","Enrollment Complete","2016-05-01",1467745240,null,"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"]
["Adenike T Esho, MD","PE - Premier Family Care I, Inc","Amerigroup","Participating","Enrollment Complete","2019-08-30",1467745240,null,"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","PE - Premier Family Care I, Inc","IMS","Participating","Enrollment Complete","2019-08-26",1467745240,null,"2020-06-22","06/22/2020- Rec'd email from the payer confirming this provider is PAR with this group/service location - Stacey Hudak"]
["Adenike T Esho, MD","PE - Premier Family Care I, Inc","HealthSmart PPO","Participating","Enrollment Complete","2019-06-12",13535050,null,"2020-07-21","07/21/2020 - Rec'd spreadsheet from the payer stating this provider is EFF at this service location - Stacey Hudak"]
["Adenike T Esho, MD","PE - Premier Family Care I, Inc","Superior","Participating","Enrollment Complete","2019-10-01",1467745240,null,"2020-07-14","07/14/2020 - Rec'd spreadsheet from the delegated team stating this provider has been linked to the PriMed contract since 10-1-2019 **see the other enrollment complete line to see details about when this provider became effective with various specific products** - stacey Hudak"]
["Adenike T Esho, MD","PE - Premier Family Care I, Inc","Galaxy Health","Participating","Enrollment Complete","2019-08-26",1467745240,null,"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","PE - Premier Family Care I, Inc","USA PPO","Participating","Enrollment Complete","2015-05-12",1467745240,752656723,"2020-08-24","Confirmed provider is participating with PPO and H&W networks (list of networks attached). Kimberly Frazier"]
["Adenike T Esho, MD","PE - Premier Family Care I, Inc","First Health Coventry","Participating","Enrollment Complete","2019-08-01",2739018,null,"2020-03-24","3/24/2020-receieved email with roster stating provider PAR 8/1/2019 PID # 2739018\ntisha rader"]
["Adenike T Esho, MD","PE - Premier Family Care I, Inc","Aetna","Participating","Enrollment Complete","2015-11-01",1467745240,null,"2020-02-03","02/03/2020 - Rec'd confirmation from the payer that this provider is EFF 11-1-2015 under a DIRECT CONTRACT. This service location is linked to the provider. - Stacey Hudak"]
["Adenike T Esho, MD","PE - Premier Family Care I, Inc","Multiplan","Participating","Enrollment Complete","2019-08-14",1467745240,null,"2020-02-13","02/13/2020 - Rec'd roster stating this provider is linked to DIRECT GROUP CONTRACT as of 8-14-2019. Provider is networked with Beechstreet. - Stacey Hudak"]
["Adenike T Esho, MD","PE - Premier Family Care I, Inc","TriCare Standard","Participating","Enrollment Complete","2015-03-28",null,null,"2020-12-24","12/24/2020 Confirmed via Self-Service chat provider is currently certified as non-network provider. KFrazier"]
["Adenike T Esho, MD","PE - Premier Family Care I, Inc","Ambetter","Participating","Enrollment Complete","2022-06-01",null,null,"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","PE - Premier Family Care I, Inc","Scott&White (First Care)","Participating","Enrollment Complete","2019-05-03",1467745240,null,"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"]
["Adenike T Esho, MD","PE - Premier Family Care I, Inc","Medicare","Participating","Enrollment Complete","2014-12-29","383114YPVD","0008AH","2020-01-29","01/29/2020 - confirmed EFF through PECOS group enrollment - Stacey Hudak"]
["Adenike T Esho, MD","PE - Premier Family Care I, Inc","Boon Chapman","Participating","Enrollment Complete","2019-08-14",null,null,"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 8/14/2019.  DCannon"]
["Adenike T Esho, MD","PE - Premier Family Care I, Inc","Wellcare","Participating","Enrollment Complete","2021-11-01",null,null,"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","PE - Premier Family Care I, Inc","Humana","Participating","Enrollment Complete","2020-01-01",1467745240,null,"2020-07-17","7/17/2020 - 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"]
["Adenike T Esho, MD","PE - Premier Family Care I, Inc","Cigna","Participating","Enrollment Complete","2019-08-28",1467745240,null,"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","PE - Premier Family Care I, Inc","Omni PPO","Participating","Enrollment Complete","2019-08-26",1467745240,null,"2020-06-25"]
["Adenike T Esho, MD","PE - Premier Family Care I, Inc","Medicaid","Participating","Enrollment Complete",null,341837801,79837301,"2020-01-29","01/29/2020 - Found provider PAR through payer portal. Provider is PAR with the following plans: SUPERIOR - FOSTER CARE, Superior HealthPlan - Lubbock, Superior HealthPlan - Lubbock, TRADITIONAL MEDICAID, 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"]
["Adenike T Esho, MD","PE - Premier Family Care I, Inc","Triwest VA","Facility Enrollment","Facility Enrollment",null,null,null,"2022-11-23","10/17/2022 - Received roster from Scarlett of TriWest VA; provider status: \"No Action.  TIN is CCN participating under own DCN.\""]
["Adenike T Esho, MD","PE - Premier Family Care I, Inc","CAQH","Participating","CAQH Reattested","2023-02-12",13510925,null,"2023-02-12","2/12/2023 CAQH reviewed and re-attested.  DCannon"]
["Adenike T Esho, MD","PE - Premier Family Care I, Inc","Tricare Prime","Participating","Enrollment Complete","2021-04-01",null,null,"2021-11-03","11/3/2021 Per follow-up notes.  NPI# for the provider is on file, shows Linked and Certified , In network  under the group and TIN# at this location,  effective 4/1/2021 -  no termination date, Provider ID is 75-2656723-79706-C006.  DCannon"]
["Haritha Bellam, MD","PE - Premier Family Care I, Inc","Boon Chapman","Participating","Enrollment Complete","2016-07-13",null,null,"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 7/13/2016.  DCannon"]
["Haritha Bellam, MD",null,"Boon Chapman","Participating","Enrollment Complete","2016-07-13",null,null,"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 7/13/2016.  DCannon"]
["Haritha Bellam, MD","PE - Premier Family Care I, Inc","Superior","Participating","Enrollment Complete","2017-01-01",1770883191,null,"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",null,"Superior","Participating","Enrollment Complete","2017-01-01",1770883191,null,"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","PE - Premier Family Care I, Inc","Scott&White (First Care)","Participating","Enrollment Complete","2018-04-13",1770883191,null,"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"]
["Haritha Bellam, MD",null,"Scott&White (First Care)","Participating","Enrollment Complete","2018-04-13",1770883191,null,"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"]
["Haritha Bellam, MD","PE - Premier Family Care I, Inc","First Health Coventry","Participating","Enrollment Complete","2015-10-01",2785559,null,"2020-03-20","3/20/2020-receieved email with roster stating provider PAR 10/1/2015 PID # --tisha rader"]
["Haritha Bellam, MD",null,"First Health Coventry","Participating","Enrollment Complete","2015-10-01",2785559,null,"2020-03-20","3/20/2020-receieved email with roster stating provider PAR 10/1/2015 PID # --tisha rader"]
["Haritha Bellam, MD","PE - Premier Family Care I, Inc","USA PPO","Participating","Enrollment Complete","2015-10-26",1770883191,752656723,"2020-08-24","Confirmed provider is participating with PPO and H&W networks (list of networks attached). Kimberly Frazier"]
["Haritha Bellam, MD",null,"USA PPO","Participating","Enrollment Complete","2015-10-26",1770883191,752656723,"2020-08-24","Confirmed provider is participating with PPO and H&W networks (list of networks attached). Kimberly Frazier"]
["Haritha Bellam, MD","PE - Premier Family Care I, Inc","Caprock (CapStar)","Participating","Enrollment Complete","2015-10-15",1770883191,null,"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",null,"Caprock (CapStar)","Participating","Enrollment Complete","2015-10-15",1770883191,null,"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","PE - Premier Family Care I, Inc","Humana","Participating","Enrollment Complete","2020-01-01",1770883191,null,"2020-07-17","7/17-2020 - Received email spreadsheet from the payor confirming that his provider is EFF at this service location and PAR with the PRIMED DELEGATED agreement - Pam Porter"]
["Haritha Bellam, MD",null,"Humana","Participating","Enrollment Complete","2020-01-01",1770883191,null,"2020-07-17","7/17-2020 - Received email spreadsheet from the payor confirming that his provider is EFF at this service location and PAR with the PRIMED DELEGATED agreement - Pam Porter"]
["Haritha Bellam, MD","PE - Premier Family Care I, Inc","Cigna","Participating","Enrollment Complete","2019-02-12",1770883191,null,"2020-02-20","02/20/2020 - Rec'd verification from the payer that this provider is EFF 2-12-2019 and linked to this service location under a DIRECT CONTRACT with this payer - Stacey Hudak"]
["Haritha Bellam, MD",null,"Cigna","Participating","Enrollment Complete","2019-02-12",1770883191,null,"2020-02-20","02/20/2020 - Rec'd verification from the payer that this provider is EFF 2-12-2019 and linked to this service location under a DIRECT CONTRACT with this payer - Stacey Hudak"]
["Haritha Bellam, MD","PE - Premier Family Care I, Inc","TriCare Standard","Participating","Enrollment Complete","2018-04-14",null,null,"2020-10-30","10/30/2020 Confirmed provider is certified as non-network with Tax ID and location effective 4/14/2018. Kimberly Frazier"]
["Haritha Bellam, MD",null,"TriCare Standard","Participating","Enrollment Complete","2018-04-14",null,null,"2020-10-30","10/30/2020 Confirmed provider is certified as non-network with Tax ID and location effective 4/14/2018. Kimberly Frazier"]
["Haritha Bellam, MD","PE - Premier Family Care I, Inc","HealthSmart PPO","Participating","Enrollment Complete","2018-08-10",1770883191,null,"2020-06-05","06/05/2020 - rec'd email from the payer stating provider is EFF - stacey Hudak"]
["Haritha Bellam, MD",null,"HealthSmart PPO","Participating","Enrollment Complete","2018-08-10",1770883191,null,"2020-06-05","06/05/2020 - rec'd email from the payer stating provider is EFF - stacey Hudak"]
["Haritha Bellam, MD","PE - Premier Family Care I, Inc","Ambetter","Participating","Enrollment Complete","2022-06-01",null,null,"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",null,"Ambetter","Participating","Enrollment Complete","2022-06-01",null,null,"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","PE - Premier Family Care I, Inc","Wellcare","Participating","Enrollment Complete","2022-09-01",null,null,"2022-11-15","11/15/2022 Per roster received from Wellcare provider is PAR and linked to group TIN/location effective 9/1/2022.  DCannon"]
["Haritha Bellam, MD",null,"Wellcare","Participating","Enrollment Complete","2022-09-01",null,null,"2022-11-15","11/15/2022 Per roster received from Wellcare provider is PAR and linked to group TIN/location effective 9/1/2022.  DCannon"]
["Haritha Bellam, MD","PE - Premier Family Care I, Inc","Amerigroup","Participating","Enrollment Complete","2015-12-01",1770883191,null,"2020-02-11","2/11/2020 – Received Roster from Amerigroup and provider is now PAR- Also showing 01/01/2020 and 11/1/16 and 1/1/17 as effective dates.  Tisha Rader"]
["Haritha Bellam, MD",null,"Amerigroup","Participating","Enrollment Complete","2015-12-01",1770883191,null,"2020-02-11","2/11/2020 – Received Roster from Amerigroup and provider is now PAR- Also showing 01/01/2020 and 11/1/16 and 1/1/17 as effective dates.  Tisha Rader"]
["Haritha Bellam, MD","PE - Premier Family Care I, Inc","IMS","Participating","Enrollment Complete","2015-10-26",1770883191,null,"2020-06-22","06/22/2020- Rec'd email from the payer confirming this provider is PAR with this group/service location - Stacey Hudak"]
["Haritha Bellam, MD",null,"IMS","Participating","Enrollment Complete","2015-10-26",1770883191,null,"2020-06-22","06/22/2020- Rec'd email from the payer confirming this provider is PAR with this group/service location - Stacey Hudak"]
["Haritha Bellam, MD","PE - Premier Family Care I, Inc","Medicaid","Participating","Enrollment Complete",null,347934701,79837301,"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",null,"Medicaid","Participating","Enrollment Complete",null,347934701,79837301,"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","PE - Premier Family Care I, Inc","Triwest VA","Facility Enrollment","Application Submitted",null,null,null,"2022-11-23","08/19/2022 - Submitted application to TriWest VA (sent to Scarlett Abigail, Scarlett_Abigail@bcbstx.com)"]
["Haritha Bellam, MD",null,"Triwest VA","Facility Enrollment","Application Submitted",null,null,null,"2022-11-23","08/19/2022 - Submitted application to TriWest VA (sent to Scarlett Abigail, Scarlett_Abigail@bcbstx.com)"]
["Haritha Bellam, MD","PE - Premier Family Care I, Inc","Triwest VA","Facility Enrollment","Facility Enrollment",null,null,null,"2022-11-23","10/17/2022 - Received roster from Scarlett of TriWest VA; provider status: \"No Action.  TIN is CCN participating under own DCN.\""]
["Haritha Bellam, MD",null,"Triwest VA","Facility Enrollment","Facility Enrollment",null,null,null,"2022-11-23","10/17/2022 - Received roster from Scarlett of TriWest VA; provider status: \"No Action.  TIN is CCN participating under own DCN.\""]
["Haritha Bellam, MD","PE - Premier Family Care I, Inc","Galaxy Health","Participating","Enrollment Complete","2015-11-19",1770883191,null,"2020-07-10","07/10/2020 - updated payer line to enrollment complete status instead of \"Delegated status\" for report running purposes - Stacey Hudak"]
["Haritha Bellam, MD",null,"Galaxy Health","Participating","Enrollment Complete","2015-11-19",1770883191,null,"2020-07-10","07/10/2020 - updated payer line to enrollment complete status instead of \"Delegated status\" for report running purposes - Stacey Hudak"]
["Haritha Bellam, MD","PE - Premier Family Care I, Inc","Tricare Prime","Participating","Enrollment Complete","2018-04-14",null,null,"2020-12-21","12/21/2020 Upon review of the Self-Service portal, provider has been fully re-credentialed as it's listed as 'complete'. KFrazier"]
["Haritha Bellam, MD",null,"Tricare Prime","Participating","Enrollment Complete","2018-04-14",null,null,"2020-12-21","12/21/2020 Upon review of the Self-Service portal, provider has been fully re-credentialed as it's listed as 'complete'. KFrazier"]
["Haritha Bellam, MD","PE - Premier Family Care I, Inc","Aetna","Participating","Enrollment Complete","2015-07-01",1770883191,null,"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",null,"Aetna","Participating","Enrollment Complete","2015-07-01",1770883191,null,"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","PE - Premier Family Care I, Inc","Omni PPO","Participating","Enrollment Complete","2015-10-26",1770883191,null,"2020-06-25"]
["Haritha Bellam, MD",null,"Omni PPO","Participating","Enrollment Complete","2015-10-26",1770883191,null,"2020-06-25"]
["Haritha Bellam, MD","PE - Premier Family Care I, Inc","Medicare","Participating","Enrollment Complete","2015-05-11","415412YPVD","0008AH","2020-01-29","01/29/2020 - confirmed EFF through PECOS group enrollment - Stacey Hudak"]
["Haritha Bellam, MD",null,"Medicare","Participating","Enrollment Complete","2015-05-11","415412YPVD","0008AH","2020-01-29","01/29/2020 - confirmed EFF through PECOS group enrollment - Stacey Hudak"]
["Haritha Bellam, MD","PE - Premier Family Care I, Inc","Multiplan","Participating","Enrollment Complete","2016-07-13",1770883191,"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 7-13-2016. Provider is networked with Beechstreet. - Stacey Hudak"]
["Haritha Bellam, MD",null,"Multiplan","Participating","Enrollment Complete","2016-07-13",1770883191,"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 7-13-2016. Provider is networked with Beechstreet. - Stacey Hudak"]
["Haritha Bellam, MD","PE - Premier Family Care I, Inc","CAQH","Participating","CAQH Reattested","2022-11-20",12284010,null,"2022-11-20","11/20/2022 CAQH reviewed and re-attested. DCannon"]
["Haritha Bellam, MD",null,"CAQH","Participating","CAQH Reattested","2022-11-20",12284010,null,"2022-11-20","11/20/2022 CAQH reviewed and re-attested. DCannon"]
["Haritha Bellam, MD","PE - Premier Family Care I, Inc","United Health Care","Participating","Enrollment Complete","2020-01-01",1770883191,null,"2020-08-31","08/31/2020 - moved to completed status after reviewing follow up completed note - Stacey Hudak"]
["Haritha Bellam, MD",null,"United Health Care","Participating","Enrollment Complete","2020-01-01",1770883191,null,"2020-08-31","08/31/2020 - moved to completed status after reviewing follow up completed note - Stacey Hudak"]
["Mini Gopalan, MD","PE - Premier Family Care I, Inc","First Health Coventry","Participating","Enrollment Complete","2014-02-01",1605744,null,"2020-03-20","3/20/2020-receieved email with roster stating provider PAR 2/1/2014 PID # 1605744-tisha rader"]
["Mini Gopalan, MD","PE - Premier Family Care I, Inc","IMS","Participating","Enrollment Complete","2014-02-01",1720060932,null,"2020-06-22","06/22/2020- Rec'd email from the payer confirming this provider is PAR with this group/service location - Stacey Hudak"]
["Mini Gopalan, MD","PE - Premier Family Care I, Inc","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"]
["Mini Gopalan, MD","PE - Premier Family Care I, Inc","Caprock (CapStar)","Participating","Enrollment Complete","2016-09-07",1720060932,null,"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"]
["Mini Gopalan, MD","PE - Premier Family Care I, Inc","Liberty Mutual","Participating","Enrollment Complete","2014-02-01",1720060932,"75-2656723","2020-08-26","Confirmed provider is participating with WIN networks, which includes this payor (list of networks attached). Kimberly Frazier"]
["Mini Gopalan, MD","PE - Premier Family Care I, Inc","Superior","Participating","Enrollment Complete","2017-01-01",1720060932,null,"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"]
["Mini Gopalan, MD","PE - Premier Family Care I, Inc","Humana","Participating","Enrollment Complete","2020-01-01",1720060932,null,"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"]
["Mini Gopalan, MD","PE - Premier Family Care I, Inc","Medicaid","Participating","Enrollment Complete",null,170594904,79837301,"2020-01-29","01/29/2020 - Found provider enrolled through group payer portal. Provider is linked to the following plans: SUPERIOR - FOSTER CARE, FirstCare - Lubbock, Superior HealthPlan - Lubbock, Superior HealthPlan - Lubbock, TRADITIONAL MEDICAID, Superior Health Plan - Lubbock, Superior Health Plan - MRSA West, Superior HealthPlan - MRSA West, FirstCare - MRSA West, Superior Health Plan - MRSA West - Stacey Hudak"]
["Mini Gopalan, MD","PE - Premier Family Care I, Inc","Triwest VA","Facility Enrollment","Application Submitted",null,null,null,"2022-11-25","08/19/2022 - Submitted application to TriWest VA (sent to Scarlett Abigail, Scarlett_Abigail@bcbstx.com)"]
["Mini Gopalan, MD",null,"Triwest VA","Facility Enrollment","Application Submitted",null,null,null,"2022-11-25","08/19/2022 - Submitted application to TriWest VA (sent to Scarlett Abigail, Scarlett_Abigail@bcbstx.com)"]
["Mini Gopalan, MD","PE - Premier Family Care I, Inc","Triwest VA","Facility Enrollment","Facility Enrollment",null,null,null,"2022-11-25","10/17/2022 - Received roster from Scarlett of TriWest VA; provider status: \"No Action.  TIN is CCN participating under own DCN.\""]
["Mini Gopalan, MD",null,"Triwest VA","Facility Enrollment","Facility Enrollment",null,null,null,"2022-11-25","10/17/2022 - Received roster from Scarlett of TriWest VA; provider status: \"No Action.  TIN is CCN participating under own DCN.\""]
["Mini Gopalan, MD","PE - Premier Family Care I, Inc","Ambetter","Participating","Enrollment Complete","2022-06-01",null,null,"2022-06-13","6/13/2022 Per roster received from Superior provider is PAR and linked to group delegation roster effective 6/1/2022."]
["Mini Gopalan, MD","PE - Premier Family Care I, Inc","Medicare","Participating","Enrollment Complete","2014-02-01","338891YPVD","0008AH","2020-01-29","01/29/2020 - confirmed EFF through PECOS group enrollment - Stacey Hudak"]
["Mini Gopalan, MD","PE - Premier Family Care I, Inc","Aetna","Participating","Enrollment Complete","2008-01-01",1720060932,null,"2020-02-03","02/03/2020 - this provider is EFF 1-1-2008 under a DELEGATED AGREEMENT with Primed Health Network. No additional information was provided - Stacey Hudak"]
["Mini Gopalan, MD","PE - Premier Family Care I, Inc","Multiplan","Participating","Enrollment Complete","2016-09-13",1720060932,"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 9-13-2016. Provider is networked with Beechstreet. - Stacey Hudak"]
["Mini Gopalan, MD","PE - Premier Family Care I, Inc","TriCare Standard","Participating","Enrollment Complete","2005-01-01",1720060932,null,"2020-04-06","04/06/2020 - This provider is showing as effective at this service location, with this payer under a NON NETWORKED group. - stacey hudak"]
["Mini Gopalan, MD","PE - Premier Family Care I, Inc","CAQH","Participating","CAQH Reattested","2023-01-04",11448656,null,"2023-01-04","1/4/2023 CAQH reviewed and re-attested.  DCannon"]
["Mini Gopalan, MD","PE - Premier Family Care I, Inc","Cigna","Participating","Enrollment Complete","2021-04-01",9048323,null,"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 4/1/2021 and assigned provider ID 9048323. KFrazier"]
["Mini Gopalan, MD","PE - Premier Family Care I, Inc","United Health Care","Participating","Enrollment Complete","2017-10-31",1720060932,null,"2020-07-30","7/30/2020 - moved to completed status after reviewing follow up complete note - Stacey Hudak"]
["Mini Gopalan, MD","PE - Premier Family Care I, Inc","Boon Chapman","Participating","Enrollment Complete","2016-09-13",null,null,"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 9/13/2016.  DCannon"]
["Mini Gopalan, MD","PE - Premier Family Care I, Inc","USA PPO","Participating","Enrollment Complete","2014-02-01",1720060932,752656723,"2020-08-26","Confirmed provider is participating with PPO, H&W and WIN networks (list of networks attached). Kimbelry Frazier"]
["Mini Gopalan, MD","PE - Premier Family Care I, Inc","Amerigroup","Participating","Enrollment Complete","2015-09-15",1720060932,null,"2020-02-11","2/11/2020 – Received Roster from Amerigroup and provider is now PAR- Tisha Rader\n\n3/15/2020 - Rec'd email from the Multiplan/Texas True Choice stating this providers EFF info is true - Stacey Hudak"]
["Mini Gopalan, MD","PE - Premier Family Care I, Inc","Scott&White (First Care)","Participating","Enrollment Complete","2018-04-13",1720060932,null,"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"]
["Mini Gopalan, MD","PE - Premier Family Care I, Inc","Cigna","Terminated","Terminated","2013-03-01",1720060932,null,"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"]
["Mini Gopalan, MD","PE - Premier Family Care I, Inc","Omni PPO","Participating","Enrollment Complete","2014-02-01",1720060932,null,"2020-06-25"]
["Mini Gopalan, MD","PE - Premier Family Care I, Inc","Galaxy Health","Participating","Enrollment Complete","2014-02-01",1720060932,null,"2020-07-10","07/10/2020 - updated payer line to enrollment complete status instead of \"Delegated status\" for report running purposes - Stacey Hudak"]
["Mini Gopalan, MD","PE - Premier Family Care I, Inc","Sedgwick","Participating","Enrollment Complete","2014-02-01",1720060932,"75-2656723","2020-08-26","Confirmed provider is participating with WIN networks, which includes this payor (list of networks attached). Kimberly Frazier"]
["Mini Gopalan, MD","PE - Premier Family Care I, Inc","HealthSmart PPO","Participating","Enrollment Complete","2016-04-25",1720060932,null,"2020-06-05","06/05/2020 - Rec'd email from the payer stating this provider is EFF - Stacey Hudak"]
["Nanette R Paredes, PA-C","PE - Premier Family Care I, Inc","Caprock (CapStar)","Participating","Enrollment Complete","2018-10-03",1437175163,null,"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"]
["Nanette R Paredes, PA-C","PE - Premier Family Care I, Inc","HealthSmart PPO","Participating","Enrollment Complete","2018-11-27",1437175163,null,"2020-06-05","06/05/2020 - Rec'd email from the payer stating this provider is EFF - Stacey Hudak"]
["Nanette R Paredes, PA-C","PE - Premier Family Care I, Inc","Superior","Participating","Enrollment Complete","2019-08-01",1437175163,null,"2020-07-14","07/14/2020 - Rec'd spreadsheet from the delegated team stating this provider has been linked to the PriMed contract since 8-1-2019  **see the other enrollment complete line to see details about when this provider became effective with various specific products** - stacey Hudak"]
["Nanette R Paredes, PA-C","PE - Premier Family Care I, Inc","Cigna","Participating","Enrollment Complete","2021-07-07",3218941,null,"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-C","PE - Premier Family Care I, Inc","Amerigroup","Participating","Enrollment Complete","2018-11-30",1437175163,null,"2020-02-12","2/12/2020 – Received Roster from Amerigroup and provider is now PAR- Tisha Rader\n\n3/19/2020 - Rec'd email from multiplan/texas true choice stating that this provider is EFF at this service location - Stacey Hudak"]
["Nanette R Paredes, PA-C","PE - Premier Family Care I, Inc","Triwest VA","Facility Enrollment","In House Enrollment",null,null,null,"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"]
["Nanette R Paredes, PA-C",null,"Triwest VA","Facility Enrollment","In House Enrollment",null,null,null,"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"]
["Nanette R Paredes, PA-C","PE - Premier Family Care I, Inc","Triwest VA","Facility Enrollment","Application Submitted",null,null,null,"2022-11-28","08/19/2022 - Submitted application to TriWest VA (sent to Scarlett Abigail, Scarlett_Abigail@bcbstx.com)"]
["Nanette R Paredes, PA-C",null,"Triwest VA","Facility Enrollment","Application Submitted",null,null,null,"2022-11-28","08/19/2022 - Submitted application to TriWest VA (sent to Scarlett Abigail, Scarlett_Abigail@bcbstx.com)"]
["Nanette R Paredes, PA-C","PE - Premier Family Care I, Inc","Triwest VA","Facility Enrollment","Facility Enrollment",null,null,null,"2022-11-28","10/17/2022 - Received roster from Scarlett of TriWest VA; provider status: \"No Action.  TIN is CCN participating under own DCN.\""]
["Nanette R Paredes, PA-C",null,"Triwest VA","Facility Enrollment","Facility Enrollment",null,null,null,"2022-11-28","10/17/2022 - Received roster from Scarlett of TriWest VA; provider status: \"No Action.  TIN is CCN participating under own DCN.\""]
["Nanette R Paredes, PA-C","PE - Premier Family Care I, Inc","Medicaid","Participating","Enrollment Complete",null,389669801,79837301,"2020-01-29","01/29/2020 - found provider PAR thorugh payer portal. Provider is linked to the following plans: TRADITIONAL MEDICAID, Amerigroup - MRSA West, Amerigroup Texas, Inc. - MRSA West - Stacey Hudak"]
["Nanette R Paredes, PA-C","PE - Premier Family Care I, Inc","CAQH","Participating","CAQH Reattested","2023-02-12",12235547,null,"2023-02-12","2/12/2023 CAQH reviewed and re-attested.  DCannon"]
["Nanette R Paredes, PA-C","PE - Premier Family Care I, Inc","United Health Care","Participating","Enrollment Complete","2018-10-01",2485553,null,"2020-06-08","06/08/2020 - Rec'd email from the payer stating this provider/service locaiton is EFF - Stacey Hudak"]
["Nanette R Paredes, PA-C","PE - Premier Family Care I, Inc","Omni PPO","Participating","Enrollment Complete","2018-11-30",1437175163,null,"2020-06-25"]
["Nanette R Paredes, PA-C","PE - Premier Family Care I, Inc","Multiplan","Participating","Enrollment Complete","2018-10-29",1437175163,"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 10-29-2018. Provider is networked with Beechstreet. - Stacey Hudak"]
["Nanette R Paredes, PA-C","PE - Premier Family Care I, Inc","Cigna","Terminated","Terminated","2019-09-01",3218941,null,"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"]
["Nanette R Paredes, PA-C","PE - Premier Family Care I, Inc","USA PPO","Participating","Enrollment Complete","2021-01-26",959669,null,"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-C","PE - Premier Family Care I, Inc","Humana","Participating","Enrollment Complete","2018-10-03",1437175163,null,"2020-08-31","08/31/2020 - moved to completed status after reviewing follow up complete note - Stacey Hudak"]
["Nanette R Paredes, PA-C","PE - Premier Family Care I, Inc","Scott&White (First Care)","Participating","Enrollment Complete","2019-01-17",null,null,"2021-01-29","1/29/2021 - Rcvd roster from Scott&White (First Care) confirming participation of provider with TIN and location effective dates.  DCannon"]
["Nanette R Paredes, PA-C","PE - Premier Family Care I, Inc","Ambetter","Participating","Enrollment Complete","2022-06-01",null,null,"2022-06-13","6/13/2022 Per roster received from Superior provider is PAR and linked to group delegation roster effective 6/1/2022."]
["Nanette R Paredes, PA-C","PE - Premier Family Care I, Inc","TriCare Standard","Participating","Enrollment Complete","2019-02-11",1437175163,null,"2020-09-24","09/24/2020 - moved to completed status after reviewing follow up status - Stacey Hudak"]
["Nanette R Paredes, PA-C","PE - Premier Family Care I, Inc","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"]
["Nanette R Paredes, PA-C","PE - Premier Family Care I, Inc","IMS","Participating","Enrollment Complete","2018-11-30",1437175163,null,"2020-06-22","06/22/2020- Rec'd email from the payer confirming this provider is PAR with this group/service location - Stacey Hudak"]
["Nanette R Paredes, PA-C","PE - Premier Family Care I, Inc","Medicare","Participating","Enrollment Complete","2018-09-01",716134,"0008AH","2020-03-10","03/10/2020 - Signed into PECOS and confirmed that this provider is linked to Premier Family Care as an employee EFF 9-1-2018 - Stacey Hudak"]
["Nanette R Paredes, PA-C","PE - Premier Family Care I, Inc","Boon Chapman","Participating","Enrollment Complete","2018-10-29",null,null,"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"]
["Nanette R Paredes, PA-C","PE - Premier Family Care I, Inc","First Health Coventry","Participating","Enrollment Complete","2018-11-01",1104379,null,"2020-03-20","3/20/2020-receieved email with roster stating provider PAR 11/1/2018 PID # 1104379\ntisha rader"]
["Nanette R Paredes, PA-C","PE - Premier Family Care I, Inc","Galaxy Health","Participating","Enrollment Complete","2018-11-20",1437175163,null,"2020-07-17","07/17/2020 Received a spreadsheet from the payer stating this provider is effective as of 11/20/2018 – Archie Candiasan"]
["Nanette R Paredes, PA-C","PE - Premier Family Care I, Inc","Aetna","Participating","Enrollment Complete","2019-09-01",1437175163,null,"2020-03-26","3/26/2020--SW Sandra of Aetna @ 800-353-1232. NPI is on file for the provider and is participating effective 9/1/2019 under group and TIN. DIRECT CONTRACT with Aetna. Physical location is on file. Call ref# 5195894813.\ntisha rader"]
["Johnny L Flitton, PA-C","PE - Premier Family Care I, Inc","Superior","Participating","Enrollment Complete","2021-12-01",null,null,"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"]
["Johnny L Flitton, PA-C","PE - Premier Family Care I, Inc","IMS","Participating","Enrollment Complete","2021-11-01",null,null,"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","PE - Premier Family Care I, Inc","Medicare","Participating","Enrollment Complete","2008-11-10","8L9009","0008AH","2020-05-26","05/26/2020 - Signed onto Novitas application checker and used tracking# to find that this reval was approved - Stacey Hudak"]
["Johnny L Flitton, PA-C","PE - Premier Family Care I, Inc","Rail Road Medicare","Participating","Enrollment Complete","2008-11-10","P02124313","CE1588","2021-11-18","11/18/2021 Received RR Medicare PTAN approval letter instantly.  PTAN # P02124313 - effective 11/10/2008.  DCannon"]
["Johnny L Flitton, PA-C","PE - Premier Family Care I, Inc","Caprock (CapStar)","Participating","Enrollment Complete","2021-11-15",null,null,"2022-03-11","3/11/2022 Rcvd email from Caprock ProviderServices.T8@90degreebenefits.com that monthly delegated roster provider load is complete and provider is loaded under TIN at location effective 11/15/2021.  DCannon"]
["Johnny L Flitton, PA-C","PE - Premier Family Care I, Inc","Cigna","Participating","Enrollment Complete","2021-09-01",9560591,null,"2021-09-03","9/3/2021 Received an email from pdmcogz@cigna.com confirming provider is participating under group Tax ID effective 9/1/2021 with assigned provider ID number 9560591. KFrazier"]
["Johnny L Flitton, PA-C","PE - Premier Family Care I, Inc","Amerigroup","Participating","Enrollment Complete","2020-04-03",null,null,"2022-04-05","4/5/2022 Rcvd email from Joe Rodriguez at Amerigroup confirming provider is PAR and linked to group TIN/location effective 4/3/2020.  DCannon"]
["Johnny L Flitton, PA-C","PE - Premier Family Care I, Inc","Aetna","Participating","Enrollment Complete","2014-02-15",9326179,null,"2021-12-03","12/3/2021 Per f/u note:  S/W Mark of Aetna @ 800-353-1232. advised app sent on 11/15/2021 with Request ID is 00072104. Rep stated, Provider NPI# is on file for the provider and is participating effective 02/15/2014 under the group and TIN#. PIN: 9326179. Physical location is on file. Call ref# 6060911105.  DCannon"]
["Johnny L Flitton, PA-C","PE - Premier Family Care I, Inc","HealthSmart PPO","Participating","Enrollment Complete","2019-07-18",13403339,null,"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","PE - Premier Family Care I, Inc","USA PPO","Participating","Enrollment Complete","2015-09-03",1098037,null,"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"]
["Johnny L Flitton, PA-C","PE - Premier Family Care I, Inc","Cigna","Participating","Enrollment Complete","2021-11-01",9560591,null,"2022-02-22","2/22/2022 Received email from pdmcogz@cigna.com. Provider is par with location. Eff 11/01/2021.0PID: 9560591. Cbankston"]
["Johnny L Flitton, PA-C","PE - Premier Family Care I, Inc","Cigna","Terminated","Terminated","2015-03-31",1437356730,null,"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"]
["Johnny L Flitton, PA-C","PE - Premier Family Care I, Inc","Multiplan","Participating","Enrollment Complete","2015-03-04",1437356730,"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 3-4-2015. Provider is networked with Beechstreet. - Stacey Hudak"]
["Johnny L Flitton, PA-C","PE - Premier Family Care I, Inc","Caprock (CapStar)","Participating","Enrollment Complete","2014-02-05",1437356730,null,"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"]
["Johnny L Flitton, PA-C","PE - Premier Family Care I, Inc","United Health Care","Participating","Enrollment Complete","2019-11-01",1437356730,null,"2020-08-31","08/31/2020 - moved to completed status after reviewing follow up completed status - Stacey Hudak"]
["Johnny L Flitton, PA-C","PE - Premier Family Care I, Inc","HealthSmart PPO","Participating","Enrollment Complete","2021-11-01",null,null,"2021-12-30","12/30/2021 Per Healthsmart website provider is PAR and loaded under TIN/location effective 11/1/2021.  DCannon"]
["Johnny L Flitton, PA-C","PE - Premier Family Care I, Inc","Medicaid","Participating","Enrollment Complete","2008-04-02",190610903,79837301,"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","PE - Premier Family Care I, Inc","TriCare Standard","Participating","Enrollment Complete","2021-12-01",null,null,"2021-12-14","12/14/2021 Per portal, provider linked to location as of 12/1/2021. Cbankston"]
["Johnny L Flitton, PA-C","PE - Premier Family Care I, Inc","First Health Coventry","In Process","Enrollment Complete",null,null,null,"2023-01-18","01.18.2023: S/W Teresita of First Health @800-226-5116. Per rep, provider is participating, in network and linked under the group and TIN effective 02/01/2015. Provider ID# 1906310. Physical location is on file. Don't have payer#. Call Ref# 516478. - Mary Rose Acebedo"]
["Johnny L Flitton, PA-C","PE - Premier Family Care I, Inc","Wellcare","Participating","Enrollment Complete","2022-11-01",null,null,"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"]
["Johnny L Flitton, PA-C","PE - Premier Family Care I, Inc","Medicare","Participating","Enrollment Complete","2008-11-10","8L9009","0008AH","2021-11-18","11/18/2021 Per PECOS provider is PAR and linked to group/location.  PTAN # 8L9009 - effective 11/10/2008.  DCannon"]
["Johnny L Flitton, PA-C","PE - Premier Family Care I, Inc","Multiplan","Participating","Enrollment Complete","2021-11-15",null,null,"2021-12-13","12/13/2021 Rcvd Multiplan approval letter.  Provider is PAR effective 11/15/2021.  DCannon"]
["Johnny L Flitton, PA-C","PE - Premier Family Care I, Inc","Tricare Prime","Participating","Enrollment Complete","2021-12-01",null,null,"2021-12-14","12/14/2021 Provider added to location per portal, as of 12/01/2021. Cbankston"]
["Johnny L Flitton, PA-C","PE - Premier Family Care I, Inc","Scott&White (First Care)","Participating","Enrollment Complete","2018-05-14",1437356730,null,"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"]
["Johnny L Flitton, PA-C","PE - Premier Family Care I, Inc","Triwest VA","In House Enrollment","In House Enrollment",null,null,null,"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","PE - Premier Family Care I, Inc","Boon Chapman","Participating","Enrollment Complete","2015-03-04",null,null,"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 3/4/2015.  DCannon"]
["Johnny L Flitton, PA-C","PE - Premier Family Care I, Inc","Omni PPO","Participating","Enrollment Complete","2021-11-01",null,null,"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","PE - Premier Family Care I, Inc","Amerigroup","Participating","Enrollment Complete","2020-04-03",null,null,"2021-03-15","3/15/2021 - Per online verification of Amerigroup provider directory provider is participating at location.  Sending email to payor to obtain effective date.  DCannon"]
["Johnny L Flitton, PA-C","PE - Premier Family Care I, Inc","First Health Coventry","Participating","Enrollment Complete","2015-02-01",1906310,null,"2021-01-18","1/18/2021 - Per follow-up notes provider is now on file and participating under group, location and TIN effective 2/1/2015 PID # 1906310.  DCannon"]
["Johnny L Flitton, PA-C","PE - Premier Family Care I, Inc","Humana","Participating","Enrollment Complete","2015-03-17",null,null,"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","PE - Premier Family Care I, Inc","IMS","Participating","Enrollment Complete","2015-02-16",1437356730,null,"2020-06-22","06/22/2020- Rec'd email from the payer confirming this provider is PAR with this group/service location - Stacey Hudak"]
["Johnny L Flitton, PA-C","PE - Premier Family Care I, Inc","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"]
["Johnny L Flitton, PA-C","PE - Premier Family Care I, Inc","Humana","Participating","Enrollment Complete","2020-01-01",1437356730,null,"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"]
["Johnny L Flitton, PA-C","PE - Premier Family Care I, Inc","TriCare Standard","Participating","Enrollment Complete",null,null,null,"2022-02-13","2/13/2022 Per Tricare portal, provider is linked to location as of 12.14.2022. Cbankston"]
["Johnny L Flitton, PA-C","PE - Premier Family Care I, Inc","Galaxy Health","Participating","Enrollment Complete","2015-02-16",1437356730,null,"2020-07-10","07/10/2020 - updated payer line to enrollment complete status instead of \"Delegated status\" for report running purposes - Stacey Hudak"]
["Johnny L Flitton, PA-C","PE - Premier Family Care I, Inc","Galaxy Health","Participating","Enrollment Complete","2021-11-01",null,null,"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"]
["Johnny L Flitton, PA-C","PE - Premier Family Care I, Inc","Boon Chapman","Participating","Enrollment Complete","2021-11-15",12669221,null,"2022-02-24","2/24/2022 Per follow-up note from 2/18/2022 -  NPI# for the provider is on file, shows linked and Par under the group and TIN# effective 11/15/2021, the physical location is on file and the Provider ID is 12669221.   DCannon"]
["Johnny L Flitton, PA-C","PE - Premier Family Care I, Inc","Medicaid","Participating","Enrollment Complete","2008-04-02",1437356730,null,"2022-04-14","4/13/2022 Per TMHP portal provider is PAR and linked to group/location effective 4/2/2008.  Provider ID - 1437356730.  DCannon"]
["Johnny L Flitton, PA-C","PE - Premier Family Care I, Inc","Omni PPO","Participating","Enrollment Complete","2015-02-16",1437356730,null,"2020-06-25"]
["Johnny L Flitton, PA-C","PE - Premier Family Care I, Inc","Triwest VA","Facility Enrollment","In House Enrollment",null,null,null,"2021-11-18"]
["Johnny L Flitton, PA-C",null,"Triwest VA","Facility Enrollment","In House Enrollment",null,null,null,"2021-11-18"]
["Johnny L Flitton, PA-C","PE - Premier Family Care I, Inc","Triwest VA","Facility Enrollment","Application Submitted",null,null,null,"2022-11-23","08/19/2022 - Submitted application to TriWest VA (sent to Scarlett Abigail, Scarlett_Abigail@bcbstx.com)"]
["Johnny L Flitton, PA-C",null,"Triwest VA","Facility Enrollment","Application Submitted",null,null,null,"2022-11-23","08/19/2022 - Submitted application to TriWest VA (sent to Scarlett Abigail, Scarlett_Abigail@bcbstx.com)"]
["Johnny L Flitton, PA-C","PE - Premier Family Care I, Inc","Triwest VA","Facility Enrollment","Facility Enrollment",null,null,null,"2022-11-23","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",null,"Triwest VA","Facility Enrollment","Facility Enrollment",null,null,null,"2022-11-23","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","PE - Premier Family Care I, Inc","Aetna","Participating","Enrollment Complete","2019-03-01",1437356730,null,"2020-02-03","02/03/2020 - this provider is EFF 1-1-2008 under a DELEGATED AGREEMENT with Primed Health Network. No additional information was provided - Stacey Hudak"]
["Johnny L Flitton, PA-C","PE - Premier Family Care I, Inc","Superior","Participating","Enrollment Complete","2017-01-01",1437356730,null,"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"]
["Johnny L Flitton, PA-C","PE - Premier Family Care I, Inc","United Health Care","Participating","Enrollment Complete",null,2854139,null,"2022-04-08","4/8/2022 Received email from united_healthcare_provider_operations@uhc.com, provider complete. MPIN 002854139. Cbankston"]
["Johnny L Flitton, PA-C","PE - Premier Family Care I, Inc","CAQH","Participating","CAQH Reattested","2023-01-09",12235261,null,"2023-01-09","1/9/2023 CAQH reviewed and re-attested.  DCannon"]
["Gerardo M Catalasan, MD","PE - Premier Family Care I, Inc","United Health Care","Participating","Enrollment Complete","2020-01-01",1760501720,null,"2020-08-31","08/31/2020 - Moved to completed status after reviewing follow up completed note - Stacey Hudak"]
["Gerardo M Catalasan, MD",null,"United Health Care","Participating","Enrollment Complete","2020-01-01",1760501720,null,"2020-08-31","08/31/2020 - Moved to completed status after reviewing follow up completed note - Stacey Hudak"]
["Gerardo M Catalasan, MD",null,"United Health Care","Participating","Enrollment Complete","2020-01-01",1760501720,null,"2020-08-31","08/31/2020 - Moved to completed status after reviewing follow up completed note - Stacey Hudak"]
["Gerardo M Catalasan, MD","PE - Premier Family Care I, Inc","CAQH","Participating","CAQH Reattested","2023-03-10",13752595,null,"2023-03-10","3/10/2023 CAQH reviewed and re-attested.  DCannon"]
["Gerardo M Catalasan, MD",null,"CAQH","Participating","CAQH Reattested","2023-03-10",13752595,null,"2023-03-10","3/10/2023 CAQH reviewed and re-attested.  DCannon"]
["Gerardo M Catalasan, MD",null,"CAQH","Participating","CAQH Reattested","2023-03-10",13752595,null,"2023-03-10","3/10/2023 CAQH reviewed and re-attested.  DCannon"]
["Gerardo M Catalasan, MD","PE - Premier Family Care I, Inc","Sedgwick","Participating","Enrollment Complete","2009-10-23",1760501720,752656723,"2020-08-26","Confirmed provider is participating with WIN networks, which includes this payor (list of networks attached). Kimberly Frazier"]
["Gerardo M Catalasan, MD",null,"Sedgwick","Participating","Enrollment Complete","2009-10-23",1760501720,752656723,"2020-08-26","Confirmed provider is participating with WIN networks, which includes this payor (list of networks attached). Kimberly Frazier"]
["Gerardo M Catalasan, MD",null,"Sedgwick","Participating","Enrollment Complete","2009-10-23",1760501720,752656723,"2020-08-26","Confirmed provider is participating with WIN networks, which includes this payor (list of networks attached). Kimberly Frazier"]
["Gerardo M Catalasan, MD","PE - Premier Family Care I, Inc","Aetna","Participating","Enrollment Complete","2020-12-01",null,null,"2020-11-07","11/6/2020 Received email from ProviderCommunications@aetna.cpe.messages2.com confirming provider is participating under group Tax ID effective 12/1/2020 and assigned PIN number 9631791. Kimberly Frazier"]
["Gerardo M Catalasan, MD",null,"Aetna","Participating","Enrollment Complete","2020-12-01",null,null,"2020-11-07","11/6/2020 Received email from ProviderCommunications@aetna.cpe.messages2.com confirming provider is participating under group Tax ID effective 12/1/2020 and assigned PIN number 9631791. Kimberly Frazier"]
["Gerardo M Catalasan, MD",null,"Aetna","Participating","Enrollment Complete","2020-12-01",null,null,"2020-11-07","11/6/2020 Received email from ProviderCommunications@aetna.cpe.messages2.com confirming provider is participating under group Tax ID effective 12/1/2020 and assigned PIN number 9631791. Kimberly Frazier"]
["Gerardo M Catalasan, MD","PE - Premier Family Care I, Inc","Liberty Mutual","Participating","Enrollment Complete","2009-10-23",1760501720,752656723,"2020-08-26","Confirmed provider is participating with WIN networks, which includes this payor (list of networks attached). Kimberly Frazier"]
["Gerardo M Catalasan, MD",null,"Liberty Mutual","Participating","Enrollment Complete","2009-10-23",1760501720,752656723,"2020-08-26","Confirmed provider is participating with WIN networks, which includes this payor (list of networks attached). Kimberly Frazier"]
["Gerardo M Catalasan, MD",null,"Liberty Mutual","Participating","Enrollment Complete","2009-10-23",1760501720,752656723,"2020-08-26","Confirmed provider is participating with WIN networks, which includes this payor (list of networks attached). Kimberly Frazier"]
["Gerardo M Catalasan, MD","PE - Premier Family Care I, Inc","Boon Chapman","Participating","Enrollment Complete","2020-04-03",null,null,"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",null,"Boon Chapman","Participating","Enrollment Complete","2020-04-03",null,null,"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",null,"Boon Chapman","Participating","Enrollment Complete","2020-04-03",null,null,"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","PE - Premier Family Care I, Inc","Medicaid","Participating","Enrollment Complete","2020-03-29",194527101,79837301,"2020-08-13","8/13/2020 - confirmed that this provider is now affiliated with the proper service location through TMHP portal - Stacey Hudak"]
["Gerardo M Catalasan, MD",null,"Medicaid","Participating","Enrollment Complete","2020-03-29",194527101,79837301,"2020-08-13","8/13/2020 - confirmed that this provider is now affiliated with the proper service location through TMHP portal - Stacey Hudak"]
["Gerardo M Catalasan, MD",null,"Medicaid","Participating","Enrollment Complete","2020-03-29",194527101,79837301,"2020-08-13","8/13/2020 - confirmed that this provider is now affiliated with the proper service location through TMHP portal - Stacey Hudak"]
["Gerardo M Catalasan, MD","PE - Premier Family Care I, Inc","Multiplan","Participating","Enrollment Complete","2020-04-03",null,null,"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",null,"Multiplan","Participating","Enrollment Complete","2020-04-03",null,null,"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",null,"Multiplan","Participating","Enrollment Complete","2020-04-03",null,null,"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","PE - Premier Family Care I, Inc","Omni PPO","Participating","Enrollment Complete","2008-05-13",1760501720,null,"2020-06-25"]
["Gerardo M Catalasan, MD",null,"Omni PPO","Participating","Enrollment Complete","2008-05-13",1760501720,null,"2020-06-25"]
["Gerardo M Catalasan, MD",null,"Omni PPO","Participating","Enrollment Complete","2008-05-13",1760501720,null,"2020-06-25"]
["Gerardo M Catalasan, MD","PE - Premier Family Care I, Inc","Wellcare","Participating","Enrollment Complete","2021-11-01",null,null,"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",null,"Wellcare","Participating","Enrollment Complete","2021-11-01",null,null,"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",null,"Wellcare","Participating","Enrollment Complete","2021-11-01",null,null,"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","PE - Premier Family Care I, Inc","Amerigroup","Participating","Enrollment Complete","2012-03-01",1760501720,null,"2020-02-11","2/11/2020 – Received Roster from Amerigroup and provider is now PAR- Additional effective dates on roster are:\n11/1/16,  8/1/12,  1/1/20, and 1/1/17---Tisha Rader"]
["Gerardo M Catalasan, MD",null,"Amerigroup","Participating","Enrollment Complete","2012-03-01",1760501720,null,"2020-02-11","2/11/2020 – Received Roster from Amerigroup and provider is now PAR- Additional effective dates on roster are:\n11/1/16,  8/1/12,  1/1/20, and 1/1/17---Tisha Rader"]
["Gerardo M Catalasan, MD",null,"Amerigroup","Participating","Enrollment Complete","2012-03-01",1760501720,null,"2020-02-11","2/11/2020 – Received Roster from Amerigroup and provider is now PAR- Additional effective dates on roster are:\n11/1/16,  8/1/12,  1/1/20, and 1/1/17---Tisha Rader"]
["Gerardo M Catalasan, MD","PE - Premier Family Care I, Inc","Scott&White (First Care)","Participating","Enrollment Complete","2018-04-20",1760501720,null,"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"]
["Gerardo M Catalasan, MD",null,"Scott&White (First Care)","Participating","Enrollment Complete","2018-04-20",1760501720,null,"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"]
["Gerardo M Catalasan, MD",null,"Scott&White (First Care)","Participating","Enrollment Complete","2018-04-20",1760501720,null,"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"]
["Gerardo M Catalasan, MD","PE - Premier Family Care I, Inc","HealthSmart PPO","Participating","Enrollment Complete","2011-02-01",1760501720,null,"2020-06-05","06/05/2020 - rec'd email from the payer stating this provider is EFF - Stacey Hudak"]
["Gerardo M Catalasan, MD",null,"HealthSmart PPO","Participating","Enrollment Complete","2011-02-01",1760501720,null,"2020-06-05","06/05/2020 - rec'd email from the payer stating this provider is EFF - Stacey Hudak"]
["Gerardo M Catalasan, MD",null,"HealthSmart PPO","Participating","Enrollment Complete","2011-02-01",1760501720,null,"2020-06-05","06/05/2020 - rec'd email from the payer stating this provider is EFF - Stacey Hudak"]
["Gerardo M Catalasan, MD","PE - Premier Family Care I, Inc","Triwest VA","Facility Enrollment","Application Submitted",null,null,null,"2022-11-23","08/19/2022 - Submitted application to TriWest VA (sent to Scarlett Abigail, Scarlett_Abigail@bcbstx.com)"]
["Gerardo M Catalasan, MD",null,"Triwest VA","Facility Enrollment","Application Submitted",null,null,null,"2022-11-23","08/19/2022 - Submitted application to TriWest VA (sent to Scarlett Abigail, Scarlett_Abigail@bcbstx.com)"]
["Gerardo M Catalasan, MD",null,"Triwest VA","Facility Enrollment","Application Submitted",null,null,null,"2022-11-23","08/19/2022 - Submitted application to TriWest VA (sent to Scarlett Abigail, Scarlett_Abigail@bcbstx.com)"]
["Gerardo M Catalasan, MD","PE - Premier Family Care I, Inc","Triwest VA","Facility Enrollment","Facility Enrollment",null,null,null,"2022-11-23","10/17/2022 - Received roster from Scarlett of TriWest VA; provider status: \"No Action.  TIN is CCN participating under own DCN.\""]
["Gerardo M Catalasan, MD",null,"Triwest VA","Facility Enrollment","Facility Enrollment",null,null,null,"2022-11-23","10/17/2022 - Received roster from Scarlett of TriWest VA; provider status: \"No Action.  TIN is CCN participating under own DCN.\""]
["Gerardo M Catalasan, MD",null,"Triwest VA","Facility Enrollment","Facility Enrollment",null,null,null,"2022-11-23","10/17/2022 - Received roster from Scarlett of TriWest VA; provider status: \"No Action.  TIN is CCN participating under own DCN.\""]
["Gerardo M Catalasan, MD","PE - Premier Family Care I, Inc","Superior","Participating","Enrollment Complete","2017-01-01",1760501720,null,"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"]
["Gerardo M Catalasan, MD",null,"Superior","Participating","Enrollment Complete","2017-01-01",1760501720,null,"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"]
["Gerardo M Catalasan, MD",null,"Superior","Participating","Enrollment Complete","2017-01-01",1760501720,null,"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"]
["Gerardo M Catalasan, MD","PE - Premier Family Care I, Inc","First Health Coventry","Participating","Enrollment Complete","2008-09-01",1901802,null,"2020-03-20","3/20/2020-receieved email with roster stating provider PAR 9/1/2008 PID # 1901802\ntisha rader"]
["Gerardo M Catalasan, MD",null,"First Health Coventry","Participating","Enrollment Complete","2008-09-01",1901802,null,"2020-03-20","3/20/2020-receieved email with roster stating provider PAR 9/1/2008 PID # 1901802\ntisha rader"]
["Gerardo M Catalasan, MD",null,"First Health Coventry","Participating","Enrollment Complete","2008-09-01",1901802,null,"2020-03-20","3/20/2020-receieved email with roster stating provider PAR 9/1/2008 PID # 1901802\ntisha rader"]
["Gerardo M Catalasan, MD","PE - Premier Family Care I, Inc","TriCare Standard","Participating","Enrollment Complete","2014-11-08",1760501720,null,"2020-09-21","09/21/2020 - Moved to completed status after reviewing follow up complete note - Stacey Hudak"]
["Gerardo M Catalasan, MD",null,"TriCare Standard","Participating","Enrollment Complete","2014-11-08",1760501720,null,"2020-09-21","09/21/2020 - Moved to completed status after reviewing follow up complete note - Stacey Hudak"]
["Gerardo M Catalasan, MD",null,"TriCare Standard","Participating","Enrollment Complete","2014-11-08",1760501720,null,"2020-09-21","09/21/2020 - Moved to completed status after reviewing follow up complete note - Stacey Hudak"]
["Gerardo M Catalasan, MD","PE - Premier Family Care I, Inc","Cigna","Participating","Enrollment Complete","2010-09-20",1760501720,null,"2020-02-20","02/20/2020 - Rec'd verification from the payer that this provider is EFF 9-20-2010 and linked to this service location under a DIRECT CONTRACT with this payer - Stacey Hudak"]
["Gerardo M Catalasan, MD",null,"Cigna","Participating","Enrollment Complete","2010-09-20",1760501720,null,"2020-02-20","02/20/2020 - Rec'd verification from the payer that this provider is EFF 9-20-2010 and linked to this service location under a DIRECT CONTRACT with this payer - Stacey Hudak"]
["Gerardo M Catalasan, MD",null,"Cigna","Participating","Enrollment Complete","2010-09-20",1760501720,null,"2020-02-20","02/20/2020 - Rec'd verification from the payer that this provider is EFF 9-20-2010 and linked to this service location under a DIRECT CONTRACT with this payer - Stacey Hudak"]
["Gerardo M Catalasan, MD","PE - Premier Family Care I, Inc","Ambetter","Participating","Enrollment Complete","2022-06-01",null,null,"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",null,"Ambetter","Participating","Enrollment Complete","2022-06-01",null,null,"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",null,"Ambetter","Participating","Enrollment Complete","2022-06-01",null,null,"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","PE - Premier Family Care I, Inc","IMS","Participating","Enrollment Complete","2008-05-13",1760501720,null,"2020-06-22","06/22/2020- Rec'd email from the payer confirming this provider is PAR with this group/service location - Stacey Hudak"]
["Gerardo M Catalasan, MD",null,"IMS","Participating","Enrollment Complete","2008-05-13",1760501720,null,"2020-06-22","06/22/2020- Rec'd email from the payer confirming this provider is PAR with this group/service location - Stacey Hudak"]
["Gerardo M Catalasan, MD",null,"IMS","Participating","Enrollment Complete","2008-05-13",1760501720,null,"2020-06-22","06/22/2020- Rec'd email from the payer confirming this provider is PAR with this group/service location - Stacey Hudak"]
["Gerardo M Catalasan, MD","PE - Premier Family Care I, Inc","Galaxy Health","Participating","Enrollment Complete","2014-05-12",1760501720,null,"2020-07-10","07/10/2020 - updated payer line to enrollment complete status instead of \"Delegated status\" for report running purposes - Stacey Hudak"]
["Gerardo M Catalasan, MD",null,"Galaxy Health","Participating","Enrollment Complete","2014-05-12",1760501720,null,"2020-07-10","07/10/2020 - updated payer line to enrollment complete status instead of \"Delegated status\" for report running purposes - Stacey Hudak"]
["Gerardo M Catalasan, MD",null,"Galaxy Health","Participating","Enrollment Complete","2014-05-12",1760501720,null,"2020-07-10","07/10/2020 - updated payer line to enrollment complete status instead of \"Delegated status\" for report running purposes - Stacey Hudak"]
["Gerardo M Catalasan, MD","PE - Premier Family Care I, Inc","Medicare","Participating","Enrollment Complete","2008-01-01","8K8025","0008AH","2020-01-29","01/29/2020 - confirmed EFF through PECOS group enrollment - Stacey Hudak"]
["Gerardo M Catalasan, MD",null,"Medicare","Participating","Enrollment Complete","2008-01-01","8K8025","0008AH","2020-01-29","01/29/2020 - confirmed EFF through PECOS group enrollment - Stacey Hudak"]
["Gerardo M Catalasan, MD",null,"Medicare","Participating","Enrollment Complete","2008-01-01","8K8025","0008AH","2020-01-29","01/29/2020 - confirmed EFF through PECOS group enrollment - Stacey Hudak"]
["Gerardo M Catalasan, MD","PE - Premier Family Care I, Inc","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"]
["Gerardo M Catalasan, MD",null,"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"]
["Gerardo M Catalasan, MD",null,"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"]
["Gerardo M Catalasan, MD","PE - Premier Family Care I, Inc","Humana","Participating","Enrollment Complete","2020-01-01",null,null,"2021-11-18","11/18/2021 Rcvd full roster from Humana listing provider as PAR and linked to group TIN/location effective 1/1/2020.  DCannon"]
["Gerardo M Catalasan, MD",null,"Humana","Participating","Enrollment Complete","2020-01-01",null,null,"2021-11-18","11/18/2021 Rcvd full roster from Humana listing provider as PAR and linked to group TIN/location effective 1/1/2020.  DCannon"]
["Gerardo M Catalasan, MD",null,"Humana","Participating","Enrollment Complete","2020-01-01",null,null,"2021-11-18","11/18/2021 Rcvd full roster from Humana listing provider as PAR and linked to group TIN/location effective 1/1/2020.  DCannon"]
["Jeffrey Limbacher, PA-C","PE - Premier Family Care I, Inc","Cigna","Participating","Enrollment Complete","2020-05-13",8867748,null,"2020-05-14","05/14/2020 - Rec'd email from the payer stating \"Congratulations! Your application to participate in the Cigna network has been approved. Your effective date is 05/13/2020. Your provider identification number is 8867748. \" - Stacey Hudak"]
["Jeffrey Limbacher, PA-C",null,"Cigna","Participating","Enrollment Complete","2020-05-13",8867748,null,"2020-05-14","05/14/2020 - Rec'd email from the payer stating \"Congratulations! Your application to participate in the Cigna network has been approved. Your effective date is 05/13/2020. Your provider identification number is 8867748. \" - Stacey Hudak"]
["Jeffrey Limbacher, PA-C","PE - Premier Family Care I, Inc","Amerigroup","Participating","Enrollment Complete","2014-11-28",1376723361,null,"2020-02-11","2/11/2020 – Received Roster from Amerigroup and provider is now PAR- Tisha Rader"]
["Jeffrey Limbacher, PA-C",null,"Amerigroup","Participating","Enrollment Complete","2014-11-28",1376723361,null,"2020-02-11","2/11/2020 – Received Roster from Amerigroup and provider is now PAR- Tisha Rader"]
["Jeffrey Limbacher, PA-C","PE - Premier Family Care I, Inc","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",null,"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","PE - Premier Family Care I, Inc","Humana","Participating","Enrollment Complete","2020-01-01",1376723361,null,"2020-07-17","7/17/2020 - 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"]
["Jeffrey Limbacher, PA-C",null,"Humana","Participating","Enrollment Complete","2020-01-01",1376723361,null,"2020-07-17","7/17/2020 - 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"]
["Jeffrey Limbacher, PA-C","PE - Premier Family Care I, Inc","Triwest VA","Facility Enrollment","In House Enrollment",null,null,null,"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"]
["Jeffrey Limbacher, PA-C",null,"Triwest VA","Facility Enrollment","In House Enrollment",null,null,null,"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"]
["Jeffrey Limbacher, PA-C",null,"Triwest VA","Facility Enrollment","In House Enrollment",null,null,null,"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"]
["Jeffrey Limbacher, PA-C","PE - Premier Family Care I, Inc","Triwest VA","Facility Enrollment","Application Submitted",null,null,null,"2022-11-23","08/19/2022 - Submitted application to TriWest VA (sent to Scarlett Abigail, Scarlett_Abigail@bcbstx.com)"]
["Jeffrey Limbacher, PA-C",null,"Triwest VA","Facility Enrollment","Application Submitted",null,null,null,"2022-11-23","08/19/2022 - Submitted application to TriWest VA (sent to Scarlett Abigail, Scarlett_Abigail@bcbstx.com)"]
["Jeffrey Limbacher, PA-C",null,"Triwest VA","Facility Enrollment","Application Submitted",null,null,null,"2022-11-23","08/19/2022 - Submitted application to TriWest VA (sent to Scarlett Abigail, Scarlett_Abigail@bcbstx.com)"]
["Jeffrey Limbacher, PA-C","PE - Premier Family Care I, Inc","Triwest VA","Facility Enrollment","Facility Enrollment",null,null,null,"2022-11-23","10/17/2022 - Received roster from Scarlett of TriWest VA; provider status: \"No Action.  TIN is CCN participating under own DCN.\""]
["Jeffrey Limbacher, PA-C",null,"Triwest VA","Facility Enrollment","Facility Enrollment",null,null,null,"2022-11-23","10/17/2022 - Received roster from Scarlett of TriWest VA; provider status: \"No Action.  TIN is CCN participating under own DCN.\""]
["Jeffrey Limbacher, PA-C",null,"Triwest VA","Facility Enrollment","Facility Enrollment",null,null,null,"2022-11-23","10/17/2022 - Received roster from Scarlett of TriWest VA; provider status: \"No Action.  TIN is CCN participating under own DCN.\""]
["Jeffrey Limbacher, PA-C","PE - Premier Family Care I, Inc","Superior","Participating","Enrollment Complete","2017-01-01",1376723361,null,"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",null,"Superior","Participating","Enrollment Complete","2017-01-01",1376723361,null,"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","PE - Premier Family Care I, Inc","Aetna","Participating","Enrollment Complete","2019-03-01",1376723361,null,"2020-02-03","02/03/2020 - Confirmed that this provider is enrolled with a DIRECT CONTRACT EFF 3-1-2019 - Stacey Hudak"]
["Jeffrey Limbacher, PA-C",null,"Aetna","Participating","Enrollment Complete","2019-03-01",1376723361,null,"2020-02-03","02/03/2020 - Confirmed that this provider is enrolled with a DIRECT CONTRACT EFF 3-1-2019 - Stacey Hudak"]
["Jeffrey Limbacher, PA-C","PE - Premier Family Care I, Inc","Scott&White (First Care)","Participating","Enrollment Complete","2018-05-11",1376723361,null,"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",null,"Scott&White (First Care)","Participating","Enrollment Complete","2018-05-11",1376723361,null,"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","PE - Premier Family Care I, Inc","TriCare Standard","Participating","Enrollment Complete","2018-11-30",1376723361,null,"2020-03-03","03/03/2020 - Rec'd confirmation of provider enrollment through payer portal.  - Stacey Hudak"]
["Jeffrey Limbacher, PA-C",null,"TriCare Standard","Participating","Enrollment Complete","2018-11-30",1376723361,null,"2020-03-03","03/03/2020 - Rec'd confirmation of provider enrollment through payer portal.  - Stacey Hudak"]
["Jeffrey Limbacher, PA-C","PE - Premier Family Care I, Inc","CAQH","Participating","CAQH Reattested","2022-08-24",13780299,null,"2022-11-26","11/26/2022 CAQH reviewed and re-attested.  DCannon"]
["Jeffrey Limbacher, PA-C",null,"CAQH","Participating","CAQH Reattested","2022-08-24",13780299,null,"2022-11-26","11/26/2022 CAQH reviewed and re-attested.  DCannon"]
["Jeffrey Limbacher, PA-C","PE - Premier Family Care I, Inc","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"]
["Jeffrey Limbacher, PA-C",null,"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"]
["Jeffrey Limbacher, PA-C","PE - Premier Family Care I, Inc","Multiplan","Participating","Enrollment Complete","2022-01-03",null,null,"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",null,"Multiplan","Participating","Enrollment Complete","2022-01-03",null,null,"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","PE - Premier Family Care I, Inc","Caprock (CapStar)","Participating","Enrollment Complete","2014-12-01",1376723361,null,"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 Limbacher, PA-C",null,"Caprock (CapStar)","Participating","Enrollment Complete","2014-12-01",1376723361,null,"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 Limbacher, PA-C","PE - Premier Family Care I, Inc","United Health Care","Participating","Enrollment Complete","2020-01-01",1376723361,null,"2020-08-31","08/31/2020 - moved to completed status after reviewing follow up completed note - Stacey Hudak"]
["Jeffrey Limbacher, PA-C",null,"United Health Care","Participating","Enrollment Complete","2020-01-01",1376723361,null,"2020-08-31","08/31/2020 - moved to completed status after reviewing follow up completed note - Stacey Hudak"]
["Jeffrey Limbacher, PA-C","PE - Premier Family Care I, Inc","Medicaid","Participating","Enrollment Complete","2017-02-01",190978001,79837301,"2021-02-08","2/8/2021 - Per f/u notes provider is participating at location  and under TIN effective 2/1/2017 TIP # 190978001.  DCannon"]
["Jeffrey Limbacher, PA-C",null,"Medicaid","Participating","Enrollment Complete","2017-02-01",190978001,79837301,"2021-02-08","2/8/2021 - Per f/u notes provider is participating at location  and under TIN effective 2/1/2017 TIP # 190978001.  DCannon"]
["Jeffrey Limbacher, PA-C","PE - Premier Family Care I, Inc","USA PPO","Participating","Enrollment Complete","2014-11-28",null,null,"2020-09-09","Confirmed provider is participating with PPO and H&W networks (list of networks attached). Kimberly Frazier"]
["Jeffrey Limbacher, PA-C",null,"USA PPO","Participating","Enrollment Complete","2014-11-28",null,null,"2020-09-09","Confirmed provider is participating with PPO and H&W networks (list of networks attached). Kimberly Frazier"]
["Jeffrey Limbacher, PA-C","PE - Premier Family Care I, Inc","Ambetter","Participating","Enrollment Complete","2022-04-01",null,null,"2022-06-13","6/13/2022 Per roster received from Superior provider is PAR for Ambetter product and linked to group delegation roster effective 4/1/2022."]
["Jeffrey Limbacher, PA-C",null,"Ambetter","Participating","Enrollment Complete","2022-04-01",null,null,"2022-06-13","6/13/2022 Per roster received from Superior provider is PAR for Ambetter product and linked to group delegation roster effective 4/1/2022."]
["Jeffrey Limbacher, PA-C","PE - Premier Family Care I, Inc","HealthSmart PPO","Participating","Enrollment Complete","2016-07-25",13512484,null,"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",null,"HealthSmart PPO","Participating","Enrollment Complete","2016-07-25",13512484,null,"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","PE - Premier Family Care I, Inc","Omni PPO","Participating","Enrollment Complete","2017-11-28",1376723361,null,"2020-06-25"]
["Jeffrey Limbacher, PA-C",null,"Omni PPO","Participating","Enrollment Complete","2017-11-28",1376723361,null,"2020-06-25"]
["Jeffrey Limbacher, PA-C","PE - Premier Family Care I, Inc","Boon Chapman","Participating","Enrollment Complete","2022-01-03",null,null,null,"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",null,"Boon Chapman","Participating","Enrollment Complete","2022-01-03",null,null,null,"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","PE - Premier Family Care I, Inc","IMS","Participating","Enrollment Complete","2017-11-28",1376723361,null,"2020-06-22","06/22/2020- Rec'd email from the payer confirming this provider is PAR with this group/service location - Stacey Hudak"]
["Jeffrey Limbacher, PA-C",null,"IMS","Participating","Enrollment Complete","2017-11-28",1376723361,null,"2020-06-22","06/22/2020- Rec'd email from the payer confirming this provider is PAR with this group/service location - Stacey Hudak"]
["Jeffrey Limbacher, PA-C","PE - Premier Family Care I, Inc","Galaxy Health","Participating","Enrollment Complete","2016-05-18",1376723361,null,"2020-07-10","07/10/2020 - updated payer line to enrollment complete status instead of \"Delegated status\" for report running purposes - Stacey Hudak"]
["Jeffrey Limbacher, PA-C",null,"Galaxy Health","Participating","Enrollment Complete","2016-05-18",1376723361,null,"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","PE - Premier Family Care I, Inc","Boon Chapman","Participating","Enrollment Complete","2020-05-01",null,null,"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","PE - Premier Family Care I, Inc","Cigna","Participating","Enrollment Complete","2019-01-01",8553905,null,"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","PE - Premier Family Care I, Inc","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"]
["Adriana E Nur, MD","PE - Premier Family Care I, Inc","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"]
["Adriana E Nur, MD","PE - Premier Family Care I, Inc","Amerigroup","Participating","Enrollment Complete","2017-11-29",1619982584,null,"2020-02-11","2/11/2020 – Received Roster from Amerigroup and provider is now PAR- Tisha Rader"]
["Adriana E Nur, MD","PE - Premier Family Care I, Inc","Medicaid","Participating","Enrollment Complete","2020-08-09",1877169102,79837301,"2020-11-23","11/23/2020 Received email confirmation revalidation is complete for provider and confirmed next revalidation date for this TPI is 8/9/2025. Kimberly Frazier"]
["Adriana E Nur, MD","PE - Premier Family Care I, Inc","Ambetter","Participating","Enrollment Complete","2022-06-01",null,null,"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","PE - Premier Family Care I, Inc","Omni PPO","Participating","Enrollment Complete","2017-11-29",1619982584,null,"2020-06-25"]
["Adriana E Nur, MD","PE - Premier Family Care I, Inc","CAQH","Participating","CAQH Reattested","2023-03-13",10740365,null,"2023-03-13","3/13/2023 CAQH reviewed and re-attested.  DCannon"]
["Adriana E Nur, MD","PE - Premier Family Care I, Inc","Scott&White (First Care)","Participating","Enrollment Complete","2018-12-01",1619982584,null,"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"]
["Adriana E Nur, MD","PE - Premier Family Care I, Inc","Caprock (CapStar)","Participating","Enrollment Complete","2017-11-29",1619982584,null,"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"]
["Adriana E Nur, MD","PE - Premier Family Care I, Inc","Humana","Participating","Enrollment Complete","2020-01-01",null,null,"2021-11-18","11/18/2021 Rcvd full roster from Humana listing provider as PAR and linked to group TIN/location effective 1/1/2020.  DCannon"]
["Adriana E Nur, MD","PE - Premier Family Care I, Inc","Multiplan","Participating","Enrollment Complete","2020-05-01",null,null,"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","PE - Premier Family Care I, Inc","United Health Care","Participating","Enrollment Complete","2017-10-31",3110523,null,"2020-07-28","7-28-2020 - Moved to completed status after reviewing follow up complete note - Stacey Hudak"]
["Adriana E Nur, MD","PE - Premier Family Care I, Inc","IMS","Participating","Enrollment Complete","2017-11-29",1619982584,null,"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","PE - Premier Family Care I, Inc","Galaxy Health","Participating","Enrollment Complete","2017-11-29",1619982584,null,"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","PE - Premier Family Care I, Inc","TriCare Standard","Participating","Enrollment Complete","2018-11-30",1619982584,null,"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"]
["Adriana E Nur, MD","PE - Premier Family Care I, Inc","Rail Road Medicare","Participating","Enrollment Complete","2017-08-01","P02450595","CE1588","2020-06-11","06/11/2020 - found EFF info through payer portal - Stacey Hudak"]
["Adriana E Nur, MD","PE - Premier Family Care I, Inc","USA PPO","Participating","Enrollment Complete","2021-01-26",1082395,null,"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","PE - Premier Family Care I, Inc","Triwest VA","Facility Enrollment","Facility Enrollment",null,null,null,"2022-11-23","10/17/2022 - Received roster from Scarlett of TriWest VA; provider status: \"No Action.  TIN is CCN participating under own DCN.\""]
["Adriana E Nur, MD","PE - Premier Family Care I, Inc","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","PE - Premier Family Care I, Inc","Superior","Participating","Enrollment Complete","2020-08-01",1619982584,null,"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"]
["Adriana E Nur, MD","PE - Premier Family Care I, Inc","HealthSmart PPO","Participating","Enrollment Complete","2019-03-27",null,null,"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","PE - Premier Family Care I, Inc","Aetna","Participating","Enrollment Complete","2019-03-01",1619982584,null,"2020-02-03","02/03/2020 - Rec'd confirmation from the payer that this provider is EFF 3-1-2019 under a DIRECT CONTRACT. This service location is on file - Stacey Hudak"]
["Adriana E Nur, MD","PE - Premier Family Care I, Inc","First Health Coventry","Participating","Enrollment Complete","2017-12-01",1950288,null,"2020-03-20","03/20/2020 - Rec'd email with roster from payor stating provider PAR 12/1/2017 PID # 1950288-tisha rader"]
["Juan C Gil, MD","PE - Premier Family Care I, Inc","Multiplan","Participating","Enrollment Complete","2016-06-01",1558392779,"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 6-13-2016. Provider is networked with Beechstreet. - Stacey Hudak"]
["Juan C Gil, MD","PE - Premier Family Care I, Inc","Scott&White (First Care)","Participating","Enrollment Complete","2018-05-04",1558392779,null,"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","PE - Premier Family Care I, Inc","Galaxy Health","Participating","Enrollment Complete","2013-09-28",1558392779,null,"2020-07-10","07/10/2020 - updated payer line to enrollment complete status instead of \"Delegated status\" for report running purposes - Stacey Hudak"]
["Juan C Gil, MD","PE - Premier Family Care I, Inc","Amerigroup","Participating","Enrollment Complete","2020-06-29",1558392779,null,"2020-07-09","07/09/2020 - Rec'd welcome letter stating this provider is EFF with amerigroup STAR, STAR PLUS, Star Kids products through Texas True Choice - Stacey Hudak"]
["Juan C Gil, MD","PE - Premier Family Care I, Inc","USA PPO","Participating","Enrollment Complete","2010-04-16",null,null,"2020-09-09","Confirmed provider is participating with PPO and H&W networks (list of networks attached). Kimberly Frazier"]
["Juan C Gil, MD","PE - Premier Family Care I, Inc","CAQH","Participating","CAQH Reattested","2023-01-03",12024587,null,"2023-01-03","1/3/2022 CAQH reviewed and re-attested.  DCannon"]
["Juan C Gil, MD","PE - Premier Family Care I, Inc","TriCare Standard","Participating","Enrollment Complete","2018-11-30",1558392779,null,"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"]
["Juan C Gil, MD","PE - Premier Family Care I, Inc","First Health Coventry","Participating","Enrollment Complete","2011-06-01",1958740,null,"2020-03-20","3/20/2020-receieved email with roster stating provider PAR 6/1/2011 PID # 1958740\ntisha rader"]
["Juan C Gil, MD","PE - Premier Family Care I, Inc","Caprock (CapStar)","Participating","Enrollment Complete","2012-01-01",1558392779,null,"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"]
["Juan C Gil, MD","PE - Premier Family Care I, Inc","Humana","Participating","Enrollment Complete","2020-01-01",1558392779,null,"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"]
["Juan C Gil, MD","PE - Premier Family Care I, Inc","Triwest VA","Facility Enrollment","In House Enrollment",null,null,null,"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"]
["Juan C Gil, MD",null,"Triwest VA","Facility Enrollment","In House Enrollment",null,null,null,"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"]
["Juan C Gil, MD","PE - Premier Family Care I, Inc","Triwest VA","Facility Enrollment","Application Submitted",null,null,null,"2022-11-23","08/19/2022 - Submitted application to TriWest VA (sent to Scarlett Abigail, Scarlett_Abigail@bcbstx.com)"]
["Juan C Gil, MD",null,"Triwest VA","Facility Enrollment","Application Submitted",null,null,null,"2022-11-23","08/19/2022 - Submitted application to TriWest VA (sent to Scarlett Abigail, Scarlett_Abigail@bcbstx.com)"]
["Juan C Gil, MD","PE - Premier Family Care I, Inc","Triwest VA","Facility Enrollment","Facility Enrollment",null,null,null,"2022-11-23","10/17/2022 - Received roster from Scarlett of TriWest VA; provider status: \"No Action.  TIN is CCN participating under own DCN.\""]
["Juan C Gil, MD",null,"Triwest VA","Facility Enrollment","Facility Enrollment",null,null,null,"2022-11-23","10/17/2022 - Received roster from Scarlett of TriWest VA; provider status: \"No Action.  TIN is CCN participating under own DCN.\""]
["Juan C Gil, MD","PE - Premier Family Care I, Inc","Medicaid","Participating","Enrollment Complete",null,187586602,79837301,"2021-03-25","3/25/2021 Per TMHP Provider Portal provider revalidation has been completed.  Revalidation date 2/25/2026.  DCannon"]
["Juan C Gil, MD","PE - Premier Family Care I, Inc","Omni PPO","Participating","Enrollment Complete","2010-02-26",1558392779,null,"2020-08-13","IMS Complete"]
["Juan C Gil, MD","PE - Premier Family Care I, Inc","Cigna","Participating","Enrollment Complete","2010-08-01",1558392779,null,"2020-02-20","02/20/2020 - This provider is EFF 8-1-2010 and linked to our group TIN, but the provider is linked to a DELEGATED Group. Cigna could not determine what delegated entity - Stacey Hudak"]
["Juan C Gil, MD","PE - Premier Family Care I, Inc","HealthSmart PPO","Participating","Enrollment Complete","2011-02-01",1558392779,null,"2020-06-10","06/10/2020 - Rec'd email from the payer stating this provider is EFF - Stacey Hudak"]
["Juan C Gil, MD","PE - Premier Family Care I, Inc","Boon Chapman","Participating","Enrollment Complete","2016-06-01",null,null,"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","PE - Premier Family Care I, Inc","Medicare","Participating","Enrollment Complete","2010-01-04","8L22951","0008AH","2020-01-29","01/29/2020 - confirmed EFF through PECOS group enrollment - Stacey Hudak"]
["Juan C Gil, MD","PE - Premier Family Care I, Inc","United Health Care","Participating","Enrollment Complete","2010-06-06",3015766,null,"2020-06-08","06/08/2020 - rec'd email from the payer stating this provider is EFF - Stacey Hudak"]
["Juan C Gil, MD","PE - Premier Family Care I, Inc","Superior","Participating","Enrollment Complete","2017-01-01",1558392779,null,"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"]
["Juan C Gil, MD","PE - Premier Family Care I, Inc","IMS","Participating","Enrollment Complete","2010-02-26",1558392779,null,"2020-06-22","06/22/2020- Rec'd email from the payer confirming this provider is PAR with this group/service location - Stacey Hudak"]
["Juan C Gil, MD","PE - Premier Family Care I, Inc","Aetna","Participating","Enrollment Complete","2012-02-23",1558392779,null,"2020-03-26","3/26/2020--SW Jona of Aetna @ 800-353-1232. NPI is on file for the provider 2/23/2012 under group and TIN. Directly contracted with Aetna. Directly contracted with Aetna. Physcal location is on file. Call ref# 5196144885.\ntisha rader"]
["Rosanna Y Catalasan, MD","PE - Premier Family Care I, Inc","Multiplan","Delegated - Third Party","Delegated - Third Party","2006-06-01",1487837712,"West Texas Physicians Alliance","2020-09-28","09/28/2020 - Rec'd spreadsheet from the payer stating this provider is EFF under that West Texas Physicians Alliance delegation. This provider is networked with: Multiplan/PHCS/BeechStreet - Stacey Hudak"]
["Rosanna Y Catalasan, MD","PE - Premier Family Care I, Inc","Amerigroup","Participating","Enrollment Complete","2012-03-01",1487837712,null,"2020-02-11","2/11/2020 – Received Roster from Amerigroup and provider is now PAR- dditional effective dates listed on roster are:\n11/1/16,  8/1/12,  1/1/20,  and 1/1/17---Tisha Rader"]
["Rosanna Y Catalasan, MD","PE - Premier Family Care I, Inc","Scott&White (First Care)","Participating","Enrollment Complete","2018-04-13",1487837712,null,"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"]
["Rosanna Y Catalasan, MD","PE - Premier Family Care I, Inc","Omni PPO","Participating","Enrollment Complete","2010-02-26",1487837712,null,"2020-06-25"]
["Rosanna Y Catalasan, MD","PE - Premier Family Care I, Inc","CAQH","Participating","CAQH Reattested","2023-02-12",12038216,null,"2023-02-12","2/12/2023 CAQH reviewed and re-attested.  DCannon"]
["Rosanna Y Catalasan, MD","PE - Premier Family Care I, Inc","United Health Care","Participating","Enrollment Complete","2020-01-01",1487837712,null,"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"]
["Rosanna Y Catalasan, MD","PE - Premier Family Care I, Inc","IMS","Participating","Enrollment Complete","2010-02-26",1487837712,null,"2020-06-22","06/22/2020- Rec'd email from the payer confirming this provider is PAR with this group/service location - Stacey Hudak"]
["Rosanna Y Catalasan, MD","PE - Premier Family Care I, Inc","Aetna","Participating","Enrollment Complete","2010-04-15",null,null,"2020-02-03","02/03/2020 - Confirmed with the payer that this provider is EFF 4-15-2010 under a DIRECT CONTRACT. Next recred is 1-26-2021 and this service location is linked to the provider - Stacey Hudak"]
["Rosanna Y Catalasan, MD","PE - Premier Family Care I, Inc","Superior","Participating","Enrollment Complete","2017-01-01",1487837712,null,"2020-07-14","07/14/2020 - Rec'd email from the payer stating this provider is EFF under PRIMED DELEGATED agreement - Stacey Hudak"]
["Rosanna Y Catalasan, MD","PE - Premier Family Care I, Inc","Galaxy Health","Participating","Enrollment Complete","2012-02-23",1487837712,null,"2020-07-10","07/10/2020 - updated payer line to enrollment complete status instead of \"Delegated status\" for report running purposes - Stacey Hudak"]
["Rosanna Y Catalasan, MD","PE - Premier Family Care I, Inc","Ambetter","Participating","Enrollment Complete","2022-06-01",null,null,"2022-06-13","6/13/2022 Per roster received from Superior provider is PAR and linked to group delegation roster effective 6/1/2022."]
["Rosanna Y Catalasan, MD","PE - Premier Family Care I, Inc","Humana","Participating","Enrollment Complete","2020-01-01",1487837712,null,"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"]
["Rosanna Y Catalasan, MD","PE - Premier Family Care I, Inc","Cigna","Participating","Enrollment Complete","2012-07-01",1487837712,null,"2020-02-20","02/20/2020 - Rec'd verification from the payer that this provider is EFF 7-1-2012 and linked to this service location under a DIRECT CONTRACT with this payer - Stacey Hudak"]
["Rosanna Y Catalasan, MD","PE - Premier Family Care I, Inc","TriCare Standard","Participating","Enrollment Complete","2018-11-30",1487837712,null,"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","PE - Premier Family Care I, Inc","Medicare","Participating","Enrollment Complete","2010-01-01","8L23968","0008AH","2020-01-29","01/29/2020 - confirmed EFF through PECOS group enrollment - Stacey Hudak"]
["Rosanna Y Catalasan, MD","PE - Premier Family Care I, Inc","First Health Coventry","Participating","Enrollment Complete","2020-04-01",2122957,null,"2020-03-20","3/20/2020-receieved email with roster stating provider PAR 4/1/2020 PID # 2122957\ntisha rader"]
["Rosanna Y Catalasan, MD","PE - Premier Family Care I, Inc","Triwest VA","Facility Enrollment","Application Submitted",null,null,null,"2022-11-28","08/19/2022 - Submitted application to TriWest VA (sent to Scarlett Abigail, Scarlett_Abigail@bcbstx.com)"]
["Rosanna Y Catalasan, MD",null,"Triwest VA","Facility Enrollment","Application Submitted",null,null,null,"2022-11-28","08/19/2022 - Submitted application to TriWest VA (sent to Scarlett Abigail, Scarlett_Abigail@bcbstx.com)"]
["Rosanna Y Catalasan, MD","PE - Premier Family Care I, Inc","Triwest VA","Facility Enrollment","Facility Enrollment",null,null,null,"2022-11-28","10/17/2022 - Received roster from Scarlett of TriWest VA; provider status: \"No Action.  TIN is CCN participating under own DCN.\""]
["Rosanna Y Catalasan, MD",null,"Triwest VA","Facility Enrollment","Facility Enrollment",null,null,null,"2022-11-28","10/17/2022 - Received roster from Scarlett of TriWest VA; provider status: \"No Action.  TIN is CCN participating under own DCN.\""]
["Rosanna Y Catalasan, MD","PE - Premier Family Care I, Inc","Boon Chapman","Participating","Enrollment Complete","2006-06-01",null,null,"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 6/1/2006.  DCannon"]
["Rosanna Y Catalasan, MD","PE - Premier Family Care I, Inc","USA PPO","Participating","Enrollment Complete","2010-06-25",null,null,"2020-09-09","Confirmed provider is participating with PPO and H&W networks (list of networks attached). Kimberly Frazier"]
["Rosanna Y Catalasan, MD","PE - Premier Family Care I, Inc","HealthSmart PPO","Participating","Enrollment Complete","2019-07-18",1487837712,null,"2020-06-10","06/10/2020 - Rec'd a spreadsheet from the payer stating this provider is EFF - Stacey Hudak"]
["Rosanna Y Catalasan, MD","PE - Premier Family Care I, Inc","Wellcare","Participating","Enrollment Complete","2021-11-01",null,null,"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"]
["Rosanna Y Catalasan, MD","PE - Premier Family Care I, Inc","Medicaid","Participating","Enrollment Complete",null,209024301,79837301,"2021-10-06","10/6/2021 Confirmed license update complete via TMHP Portal.  DCannon"]
["Matthew A Sanchez, NP-C","PE - Premier Family Care I, Inc","USA PPO","Participating","Enrollment Complete","2016-10-26",null,null,"2020-09-09","Confirmed provider is participating with PPO and H&W networks (list of networks attached). Kimberly Frazier"]
["Matthew A Sanchez, NP-C","PE - Premier Family Care I, Inc","Medicaid","Participating","Enrollment Complete",null,352749103,79837301,"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, NP-C","PE - Premier Family Care I, Inc","Omni PPO","Participating","Enrollment Complete","2016-07-08",1437402278,null,"2020-06-25"]
["Matthew A Sanchez, NP-C","PE - Premier Family Care I, Inc","IMS","Participating","Enrollment Complete","2016-07-08",1437402278,null,"2020-06-22","06/22/2020- Rec'd email from the payer confirming this provider is PAR with this group/service location - Stacey Hudak"]
["Matthew A Sanchez, NP-C","PE - Premier Family Care I, Inc","First Health Coventry","Participating","Enrollment Complete","2016-07-01",2876013,null,"2020-03-20","3/20/2020-receieved email with roster stating provider PAR 7/1/2016 PID # 2876013"]
["Matthew A Sanchez, NP-C","PE - Premier Family Care I, 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, NP-C","PE - Premier Family Care I, Inc","Scott&White (First Care)","Participating","Enrollment Complete","2018-05-11",1437402278,null,"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"]
["Matthew A Sanchez, NP-C","PE - Premier Family Care I, Inc","Amerigroup","Participating","Enrollment Complete","2016-07-08",1437402278,null,"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, NP-C","PE - Premier Family Care I, Inc","Caprock (CapStar)","Participating","Enrollment Complete","2016-07-08",1437402278,null,"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"]
["Matthew A Sanchez, NP-C","PE - Premier Family Care I, Inc","Aetna","Participating","Enrollment Complete","2015-12-15",4689558,null,"2020-02-03","02/03/2020 - Confirmed with the payer that this provider is EFF 12-15-2015 under a DIRECT CONTRACT. Midlevels dont require recred. This service location is linked to the provider profile - Stacey Hudak"]
["Matthew A Sanchez, NP-C","PE - Premier Family Care I, Inc","Superior","Participating","Enrollment Complete","2016-08-01",1437402278,null,"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, NP-C","PE - Premier Family Care I, Inc","Ambetter","Participating","Enrollment Complete","2022-04-01",null,null,"2022-06-13","6/13/2022 Per roster received from Superior provider is PAR and linked to group delegation roster effective 4/1/2022."]
["Matthew A Sanchez, NP-C","PE - Premier Family Care I, Inc","Boon Chapman","Participating","Enrollment Complete","2016-01-27",null,null,"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 1/27/2016.  DCannon"]
["Matthew A Sanchez, NP-C","PE - Premier Family Care I, Inc","Humana","Participating","Enrollment Complete","2020-01-01",1437402278,null,"2020-07-17","7/17/2020 - Received email spreadsheet from the payor confirming that this provider is EFF atthis service location and PAR with the PRIMED DELEGATED agreement - Pam Porter"]
["Matthew A Sanchez, NP-C","PE - Premier Family Care I, Inc","TriCare Standard","Participating","Enrollment Complete","2019-05-07",null,null,"2021-07-09","7/2/2021- S/W Joel OF TRICARE Standard @ 8004445445, call was transferred to WPS for further assistance, Spoke to Stacy, as per Rep, NPI#is on file for the provider, shows link and Par under the group and TIN# effective 5/7/2019 w/ no term date under this location. Provider ID is 75-2656723-79701-P015. Call ref#13096127.- Herminia Gilongos"]
["Matthew A Sanchez, NP-C","PE - Premier Family Care I, Inc","Cigna","Participating","Enrollment Complete","2019-06-01",1437402278,null,"2020-02-20","02/20/2020 - Rec'd confirmation from the payer that this provider is EFF as of 6-1-2019 and linked to this locaiton - However, the provider is affiliated with a DELEGATED group. Cigna could not identify the delegated entity - Stacey Hudak"]
["Matthew A Sanchez, NP-C","PE - Premier Family Care I, Inc","Tricare Prime","Participating","Enrollment Complete","2016-05-07",null,null,"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, NP-C","PE - Premier Family Care I, Inc","Galaxy Health","Participating","Enrollment Complete","2016-07-08",1437402278,null,"2020-07-10","07/10/2020 - updated payer line to enrollment complete status instead of \"Delegated status\" for report running purposes - Stacey Hudak"]
["Matthew A Sanchez, NP-C","PE - Premier Family Care I, Inc","Multiplan","Delegated - Third Party","Delegated - Third Party","2016-01-27",1437402278,"Permian Basin Healthcare Network","2020-09-28","09/28/2020 - Rec'd spreadsheet from the payer stating this provider is EFF through: Permian Basin Healthcare Network with the following networks: Multiplan/PHCS/BeechStreet - Stacey Hudak"]
["Matthew A Sanchez, NP-C","PE - Premier Family Care I, Inc","CAQH","Participating","CAQH Reattested","2023-03-13",12567903,null,"2023-03-13","3/13/2023 CAQH reviewed and re-attested.  DCannon"]
["Matthew A Sanchez, NP-C","PE - Premier Family Care I, Inc","United Health Care","Participating","Enrollment Complete","2018-09-25",1437402278,null,"2020-07-30","7/30/2020 - moved to completed status after reviewing follow up complete note - Stacey Hudak"]
["Matthew A Sanchez, NP-C","PE - Premier Family Care I, Inc","HealthSmart PPO","Participating","Enrollment Complete","2019-07-18",1437402278,null,"2020-06-10","06/10/2020 - Rec'd email from the payer stating this provider is EFF - Stacey Hduak"]
["Matthew A Sanchez, NP-C","PE - Premier Family Care I, Inc","Triwest VA","Facility Enrollment","In House Enrollment",null,null,null,"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"]
["Matthew A Sanchez, NP-C",null,"Triwest VA","Facility Enrollment","In House Enrollment",null,null,null,"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"]
["Matthew A Sanchez, NP-C","PE - Premier Family Care I, Inc","Triwest VA","Facility Enrollment","Application Submitted",null,null,null,"2022-11-23","08/19/2022 - Submitted application to TriWest VA (sent to Scarlett Abigail, Scarlett_Abigail@bcbstx.com)"]
["Matthew A Sanchez, NP-C",null,"Triwest VA","Facility Enrollment","Application Submitted",null,null,null,"2022-11-23","08/19/2022 - Submitted application to TriWest VA (sent to Scarlett Abigail, Scarlett_Abigail@bcbstx.com)"]
["Matthew A Sanchez, NP-C","PE - Premier Family Care I, Inc","Triwest VA","Facility Enrollment","Facility Enrollment",null,null,null,"2022-11-23","10/17/2022 - Received roster from Scarlett of TriWest VA; provider status: \"No Action.  TIN is CCN participating under own DCN.\""]
["Matthew A Sanchez, NP-C",null,"Triwest VA","Facility Enrollment","Facility Enrollment",null,null,null,"2022-11-23","10/17/2022 - Received roster from Scarlett of TriWest VA; provider status: \"No Action.  TIN is CCN participating under own DCN.\""]
["Joan S R Petalcorin, MD","PE - Premier Family Care I, Inc","HealthSmart PPO","Participating","Enrollment Complete","2016-10-05",1619008141,null,"2020-06-10","06/10/2020 - Rec'd email from the payer stating this provider is EFF - Stacey Hudak"]
["Joan S R Petalcorin, MD","PE - Premier Family Care I, Inc","Superior","Participating","Enrollment Complete","2020-08-01",1619008141,null,"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"]
["Joan S R Petalcorin, MD","PE - Premier Family Care I, Inc","Multiplan","Participating","Enrollment Complete","2016-10-12",1619008141,"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 10-12-2016. Provider is networked with Beechstreet. - Stacey Hudak"]
["Joan S R Petalcorin, MD","PE - Premier Family Care I, Inc","Amerigroup","Participating","Enrollment Complete","2016-10-05",1619008141,null,"2020-02-12","2/12/2020 – Received Roster from Amerigroup and provider is now PAR- Tisha Rader\n\n03/20/2020 - Rec'd confirmation from Multiplan/Texas True Choice is EFF for this provider/service location. - stacey Hudak"]
["Joan S R Petalcorin, MD","PE - Premier Family Care I, Inc","Omni PPO","Participating","Enrollment Complete","2016-10-05",1619008141,null,"2020-06-25"]
["Joan S R Petalcorin, MD","PE - Premier Family Care I, Inc","Cigna","Terminated","Terminated","2016-07-20",1619008141,null,"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","PE - Premier Family Care I, Inc","Galaxy Health","Participating","Enrollment Complete","2016-10-05",1619008141,null,"2020-07-10","07/10/2020 - updated payer line to enrollment complete status instead of \"Delegated status\" for report running purposes - Stacey Hudak"]
["Joan S R Petalcorin, MD","PE - Premier Family Care I, Inc","IMS","Participating","Enrollment Complete","2016-10-05",1619008141,null,"2020-06-22","06/22/2020- Rec'd email from the payer confirming this provider is PAR with this group/service location - Stacey Hudak"]
["Joan S R Petalcorin, MD","PE - Premier Family Care I, Inc","Ambetter","Participating","Enrollment Complete","2022-06-01",null,null,"2022-06-13","6/13/2022 Per roster received from Superior provider is PAR and linked to group delegation roster effective 6/1/2022."]
["Joan S R Petalcorin, MD","PE - Premier Family Care I, Inc","USA PPO","Participating","Enrollment Complete","2016-10-26",null,null,"2020-09-09","Confirmed provider is participating with PPO and H&W networks (list of networks attached). Kimberly Frazier"]
["Joan S R Petalcorin, MD","PE - Premier Family Care I, Inc","Caprock (CapStar)","Participating","Enrollment Complete","2016-10-05",1619008141,null,"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","PE - Premier Family Care I, Inc","Cigna","Participating","Enrollment Complete","2021-03-31",9223693,null,"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 9223693. KFrazier"]
["Joan S R Petalcorin, MD","PE - Premier Family Care I, Inc","TriCare Standard","Participating","Enrollment Complete","2016-09-24",1619008141,null,"2020-09-09","09/09/2020 - moved to completed status after reviewing last note - Stacey Hudak"]
["Joan S R Petalcorin, MD","PE - Premier Family Care I, Inc","Triwest VA","Facility Enrollment","Application Submitted",null,null,null,"2022-11-23","08/19/2022 - Submitted application to TriWest VA (sent to Scarlett Abigail, Scarlett_Abigail@bcbstx.com)"]
["Joan S R Petalcorin, MD",null,"Triwest VA","Facility Enrollment","Application Submitted",null,null,null,"2022-11-23","08/19/2022 - Submitted application to TriWest VA (sent to Scarlett Abigail, Scarlett_Abigail@bcbstx.com)"]
["Joan S R Petalcorin, MD","PE - Premier Family Care I, Inc","Triwest VA","Facility Enrollment","Facility Enrollment",null,null,null,"2022-11-23","10/17/2022 - Received roster from Scarlett of TriWest VA; provider status: \"No Action.  TIN is CCN participating under own DCN.\""]
["Joan S R Petalcorin, MD",null,"Triwest VA","Facility Enrollment","Facility Enrollment",null,null,null,"2022-11-23","10/17/2022 - Received roster from Scarlett of TriWest VA; provider status: \"No Action.  TIN is CCN participating under own DCN.\""]
["Joan S R Petalcorin, MD","PE - Premier Family Care I, Inc","Aetna","Participating","Enrollment Complete","2019-05-10",1619008141,null,"2020-02-03","02/03/2020 - Confirmed with the payer that this provider is EFF 5-10-2019 under a DIRECT CONTRACT. This service location is on file and recred will be \" On or before 05/10/2022 (reval/recred every 3 years)\" - Stacey Hudak"]
["Joan S R Petalcorin, MD","PE - Premier Family Care I, Inc","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"]
["Joan S R Petalcorin, MD","PE - Premier Family Care I, Inc","Boon Chapman","Participating","Enrollment Complete","2016-10-12",null,null,"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 10/12/2016.  DCannon"]
["Joan S R Petalcorin, MD","PE - Premier Family Care I, Inc","Medicare","Participating","Enrollment Complete","2016-08-01","518857YPVD","0008AH","2020-01-29","01/29/2020 - confirmed EFF through PECOS group enrollment - Stacey Hudak"]
["Joan S R Petalcorin, MD","PE - Premier Family Care I, Inc","Scott&White (First Care)","Participating","Enrollment Complete","2018-01-01",1619008141,null,"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"]
["Joan S R Petalcorin, MD","PE - Premier Family Care I, Inc","United Health Care","Participating","Enrollment Complete","2017-01-09",2907601,null,"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","PE - Premier Family Care I, Inc","CAQH","Participating","CAQH Reattested","2023-01-17",11857339,null,"2023-01-17","1/17/2023 CAQH reviewed and re-attested.  DCannon"]
["Joan S R Petalcorin, MD","PE - Premier Family Care I, Inc","Humana","Participating","Enrollment Complete","2020-01-01",1619008141,null,"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"]
["Joan S R Petalcorin, MD","PE - Premier Family Care I, Inc","Medicaid","Participating","Enrollment Complete",null,361391101,79837301,"2020-08-13","8/13/2020 - signed into TMHP to find that the next recred date has been pushed out to 2025. Recred approved - Stacey Hudak"]
["Joan S R Petalcorin, MD","PE - Premier Family Care I, Inc","First Health Coventry","Participating","Enrollment Complete","2016-10-01",1903184,null,"2020-03-20","3/20/2020-receieved email with roster stating provider PAR 10/1/2016 PID # 1903184\ntisha rader"]
["Tiffany D Cossey, MD","PE - Premier Family Care I, Inc","TriCare Standard","Participating","Enrollment Complete","2020-05-01",null,null,"2020-09-21","Confirmed via self-service portal provider is participating under group at this location as of 5/1/2020. Kimberly Frazier"]
["Tiffany D Cossey, MD","PE - Premier Family Care I, Inc","Cigna","Terminated","Terminated","2019-01-01",1053601344,null,"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"]
["Tiffany D Cossey, MD","PE - Premier Family Care I, Inc","Humana","Participating","Enrollment Complete","2019-04-01",null,null,"2021-11-18","11/18/2021 Rcvd full roster from Humana listing provider as PAR and linked to group TIN/location effective 4/1/2019.  DCannon"]
["Tiffany D Cossey, MD","PE - Premier Family Care I, Inc","Scott&White (First Care)","Participating","Enrollment Complete","2019-02-01",1053601344,null,"2020-10-02","10/02/2020- moved to the completed status after reviewing follow up note - Stacey Hudak"]
["Tiffany D Cossey, MD","PE - Premier Family Care I, Inc","Aetna","Participating","Enrollment Complete","2019-05-21",1053601344,null,"2020-04-23","04/23/2020--S/W Christine of Aetna @ 800-353-1232. Per rep the Provider is on file, linked & participating under the GRP & TIN effective 1/31/2019. Physical Location is on file. Provider ID #5535943. Call ref # 5234061830\ncopied note from spreadsheet-tisha rader"]
["Tiffany D Cossey, MD","PE - Premier Family Care I, Inc","Superior","Participating","Enrollment Complete","2020-08-01",1053601344,null,"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","PE - Premier Family Care I, Inc","Galaxy Health","Participating","Enrollment Complete","2019-05-21",1053601344,null,"2020-07-17","7/17/2020 - Received a spreadsheet from the payer stating this provider is effective as of 5/21/2019 - Jesriel Segovia"]
["Tiffany D Cossey, MD","PE - Premier Family Care I, Inc","Medicaid","Participating","Enrollment Complete",null,365597905,79837301,"2020-01-29","01/29/2020 - Found provider through payer portal. Provider is linked to the following plans: Texas Children's Health Plan - Harris, Texas Children's Health Plan - Jefferson, TRADITIONAL MEDICAID, Texas Children's Health Plan - Harris, Texas Children's Health Plan - Jefferson, Texas Children's Health Plan - MRSA Northeast, Amerigroup - MRSA West, Amerigroup Texas, Inc. - MRSA West - Stacey Hudak"]
["Tiffany D Cossey, MD","PE - Premier Family Care I, Inc","Wellcare","Participating","Enrollment Complete","2021-11-01",null,null,"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"]
["Tiffany D Cossey, MD","PE - Premier Family Care I, Inc","IMS","Participating","Enrollment Complete","2019-05-21",1053601344,null,"2020-06-22","06/22/2020- Rec'd email from the payer confirming this provider is PAR with this group/service location - Stacey Hudak"]
["Tiffany D Cossey, MD","PE - Premier Family Care I, Inc","United Health Care","Delegated","Delegated - Third Party","2019-03-03",1053601344,null,"2020-09-24","Delegated Entity Name: UT PHYSICIANS (PREV. UCP)\n\n*Primed Delegation termed with UHC on 1/1/2020"]
["Tiffany D Cossey, MD","PE - Premier Family Care I, Inc","Cigna","Participating","Enrollment Complete","2021-07-06",6423215,null,"2021-07-07","7/7/2021 Received an email from discovercigna@information.cigna.com confirming provider is participating under group Tax ID effective 7/6/2021 with assigned provider number 6423215. KFrazier"]
["Tiffany D Cossey, MD","PE - Premier Family Care I, Inc","HealthSmart PPO","Participating","Enrollment Complete","2019-05-31",1053601344,null,"2020-06-10","06/10/2020 - rec'd email from the payer stating this provider is EFF - Stacey Hudak"]
["Tiffany D Cossey, MD","PE - Premier Family Care I, Inc","Ambetter","Participating","Enrollment Complete","2022-06-01",null,null,"2022-06-13","6/13/2022 Per roster received from Superior provider is PAR and linked to group delegation roster effective 6/1/2022."]
["Tiffany D Cossey, MD","PE - Premier Family Care I, Inc","Triwest VA","Facility Enrollment","Application Submitted",null,null,null,"2022-11-28","08/19/2022 - Submitted application to TriWest VA (sent to Scarlett Abigail, Scarlett_Abigail@bcbstx.com)"]
["Tiffany D Cossey, MD",null,"Triwest VA","Facility Enrollment","Application Submitted",null,null,null,"2022-11-28","08/19/2022 - Submitted application to TriWest VA (sent to Scarlett Abigail, Scarlett_Abigail@bcbstx.com)"]
["Tiffany D Cossey, MD","PE - Premier Family Care I, Inc","Triwest VA","Facility Enrollment","Facility Enrollment",null,null,null,"2022-11-28","10/17/2022 - Received roster from Scarlett of TriWest VA; provider status: \"No Action.  TIN is CCN participating under own DCN.\""]
["Tiffany D Cossey, MD",null,"Triwest VA","Facility Enrollment","Facility Enrollment",null,null,null,"2022-11-28","10/17/2022 - Received roster from Scarlett of TriWest VA; provider status: \"No Action.  TIN is CCN participating under own DCN.\""]
["Tiffany D Cossey, MD","PE - Premier Family Care I, Inc","Omni PPO","Participating","Enrollment Complete","2019-05-21",1053601344,null,"2020-06-26"]
["Tiffany D Cossey, MD","PE - Premier Family Care I, Inc","Caprock (CapStar)","Participating","Enrollment Complete","2019-04-04",1053601344,null,"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"]
["Tiffany D Cossey, MD","PE - Premier Family Care I, Inc","USA PPO","Participating","Enrollment Complete","2019-05-31",null,null,"2020-09-09","Confirmed provider is participating with PPO, H&W and GEN networks (GEN is behavioral health) (list of networks attached). Kimberly Frazier"]
["Tiffany D Cossey, MD","PE - Premier Family Care I, Inc","Boon Chapman","Participating","Enrollment Complete","2019-04-04",null,null,"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 4/4/2019.  DCannon"]
["Tiffany D Cossey, MD","PE - Premier Family Care I, Inc","Multiplan","Participating","Enrollment Complete","2019-04-04",1053601344,"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 4-4-2019. Provider is networked with Beechstreet. - Stacey Hudak"]
["Tiffany D Cossey, MD","PE - Premier Family Care I, Inc","Amerigroup","Participating","Enrollment Complete","2019-05-31",1053601344,null,"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"]
["Raceli L Gibson, APRN-FNP-BC","PE - Premier Family Care I, Inc","First Health Coventry","Participating","Enrollment Complete","2021-04-01",null,null,"2021-08-06","8/6/2021 Moved to enrollment complete per notes from Aetna. Provider is effective 4.1.2021. KFrazier"]
["Raceli L Gibson, APRN-FNP-BC","PE - Premier Family Care I, Inc","Scott&White (First Care)","Participating","Enrollment Complete","2021-03-12",null,null,"2021-03-18","3/18/2021 Received email from BSWHPEXPEDITES@BSWHealth.org confirming provider has been approved and is participating under group effective 3/12/3021. KFrazier"]
["Raceli L Gibson, APRN-FNP-BC","PE - Premier Family Care I, Inc","USA PPO","Participating","Enrollment Complete","2021-01-26",null,null,"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"]
["Raceli L Gibson, APRN-FNP-BC","PE - Premier Family Care I, Inc","Omni PPO","Participating","Enrollment Complete","2020-10-13",null,null,"2020-11-25","11/25/2020 - Rcvd email confirmation that Nov monthly roster was processed and this provider was made effective with the requested eff date of 10/13/2020.  DCannon"]
["Raceli L Gibson, APRN-FNP-BC","PE - Premier Family Care I, Inc","Superior","Participating","Enrollment Complete","2020-12-01",null,null,"2020-12-07","12/7/21020 - Rcvd confirmation email from Superior that provider has been loaded effective 12/1/2020.  DCannon"]
["Raceli L Gibson, APRN-FNP-BC","PE - Premier Family Care I, Inc","Medicaid","Participating","Enrollment Complete","2020-10-01",349962604,79837301,"2020-12-07","12/7/2020 Upon review of TMHP portal, provider has been approved with assigned TPI 349962604. KFrazier"]
["Raceli L Gibson, APRN-FNP-BC","PE - Premier Family Care I, Inc","HealthSmart PPO","Participating","Enrollment Complete","2020-10-13",null,null,"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"]
["Raceli L Gibson, APRN-FNP-BC","PE - Premier Family Care I, Inc","Ambetter","Participating","Enrollment Complete","2022-06-01",null,null,"2022-06-13","6/13/2022 Per roster received from Superior provider is PAR and linked to group delegation roster effective 6/1/2022."]
["Raceli L Gibson, APRN-FNP-BC","PE - Premier Family Care I, Inc","Aetna","Participating","Enrollment Complete","2021-04-01",null,null,"2021-03-24","3/22/21 Called Atena SW Hazel Call ref# 6008361154. Provider will be eff 4/1/21. The demographics team still has to load the application in the system, so there isn't a provider ID yet. You can call back in a couple weeks for the provider ID. Tracking # PVB-1179465.  DCannon"]
["Raceli L Gibson, APRN-FNP-BC","PE - Premier Family Care I, Inc","Medicare","Participating","Enrollment Complete","2020-10-01","355114YPVD",null,"2020-11-10","11/10/2020 Confirmed provider remains active with Premier under group PTAN with assigned PTAN 355114YPVD, which was initially effective 8/1/2014. Kimberly Frazier"]
["Raceli L Gibson, APRN-FNP-BC","PE - Premier Family Care I, Inc","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"]
["Raceli L Gibson, APRN-FNP-BC","PE - Premier Family Care I, Inc","IMS","Participating","Enrollment Complete","2020-10-13",null,null,"2020-11-25","11/25/2020 - Rcvd email confirmation that Nov monthly roster was processed and this provider was made effective with the requested eff date of 10/13/2020.  DCannon"]
["Raceli L Gibson, APRN-FNP-BC","PE - Premier Family Care I, Inc","Cigna","Participating","Enrollment Complete","2021-02-12",3519149,null,"2021-02-20","2/20/2021 - Rcvd email from Cigna that provider has been approved effective 2/12/2021 PIN # 3519149.  DCannon"]
["Raceli L Gibson, APRN-FNP-BC","PE - Premier Family Care I, Inc","United Health Care","Participating","Enrollment Complete","2020-11-18",5256394,null,"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 11/18/2020 and assigned provider ID 5256394. KFrazier"]
["Raceli L Gibson, APRN-FNP-BC","PE - Premier Family Care I, Inc","Humana","In Process","Payor Follow Up",null,null,null,"2022-04-01","4/1/2022 Sent email to VThomas at Humana to check status of January delegated roster provider load.  DCannon"]
["Raceli L Gibson, APRN-FNP-BC","PE - Premier Family Care I, Inc","TriCare Standard","Participating","Enrollment Complete","2020-10-01",null,null,"2020-10-16","10/16/2020 Upon review of non-network link, provider is certified as a non-network provider and confirmed correct location on file. Kimberly Frazier"]
["Raceli L Gibson, APRN-FNP-BC","PE - Premier Family Care I, Inc","Caprock (CapStar)","Participating","Enrollment Complete","2020-10-13",null,null,"2021-04-07","4/7/2021 Rcvd roster from Mary Rodriguez 4/5/2021 listing provider as participating.  DCannon"]
["Raceli L Gibson, APRN-FNP-BC","PE - Premier Family Care I, Inc","Galaxy Health","Participating","Enrollment Complete","2020-10-13",null,null,"2020-12-14","12/14/2020 - Rcvd email confirmation from Galaxy Health that the November Delegation Roster was completed. DCannon"]
["Raceli L Gibson, APRN-FNP-BC","PE - Premier Family Care I, Inc","Triwest VA","Facility Enrollment","Application Submitted",null,null,null,"2022-11-28","08/19/2022 - Submitted application to TriWest VA (sent to Scarlett Abigail, Scarlett_Abigail@bcbstx.com)"]
["Raceli L Gibson, APRN-FNP-BC",null,"Triwest VA","Facility Enrollment","Application Submitted",null,null,null,"2022-11-28","08/19/2022 - Submitted application to TriWest VA (sent to Scarlett Abigail, Scarlett_Abigail@bcbstx.com)"]
["Raceli L Gibson, APRN-FNP-BC","PE - Premier Family Care I, Inc","Triwest VA","Facility Enrollment","Facility Enrollment",null,null,null,"2022-11-28","10/17/2022 - Received roster from Scarlett of TriWest VA; provider status: \"No Action.  TIN is CCN participating under own DCN.\""]
["Raceli L Gibson, APRN-FNP-BC",null,"Triwest VA","Facility Enrollment","Facility Enrollment",null,null,null,"2022-11-28","10/17/2022 - Received roster from Scarlett of TriWest VA; provider status: \"No Action.  TIN is CCN participating under own DCN.\""]
["Raceli L Gibson, APRN-FNP-BC","PE - Premier Family Care I, Inc","Amerigroup","Participating","Enrollment Complete","2020-10-13",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 10/13/2020.  DCannon"]
["Casey Mraz, MD","PE - Premier Family Care I, Inc","Superior","Participating","Enrollment Complete","2019-08-01",1659728855,null,"2020-07-14","07/14/2020 - Rec'd spreadsheet from the delegated team stating this provider has been linked to the PriMed contract since 8-1-2019 **see the other enrollment complete line to see details about when this provider became effective with various specific products** - stacey Hudak"]
["Casey Mraz, MD","PE - Premier Family Care I, Inc","Multiplan","Participating","Enrollment Complete","2019-08-07",1659728855,"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 8-7-2019. Provider is networked with Beechstreet. - Stacey Hudak"]
["Casey Mraz, MD","PE - Premier Family Care I, Inc","HealthSmart PPO","Participating","Enrollment Complete","2019-06-12",13681723,null,"2020-07-21","07/21/2020 - rec'd spreadsheet from the payer stating this provider is EFF with this TIN/service location as of 6-12-2019 under the WEST TEXAS PHYSICIANS ALLIANCE MDDO delegation - Stacey Hudak"]
["Casey Mraz, MD","PE - Premier Family Care I, Inc","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"]
["Casey Mraz, MD","PE - Premier Family Care I, Inc","IMS","Participating","Enrollment Complete","2019-06-14",1659728855,null,"2020-06-22","06/22/2020- Rec'd email from the payer confirming this provider is PAR with this group/service location - Stacey Hudak"]
["Casey Mraz, MD","PE - Premier Family Care I, Inc","Aetna","Participating","Enrollment Complete","2019-10-04",1659728855,null,"2020-02-03","02/03/2020 - Confirmed with the payer that this provider is EFF 10-4-2019 under a DIRECT CONTRACT. Next recred is 10-4-2022 and service location is on file and linked to provider - Stacey  Hudak"]
["Casey Mraz, MD","PE - Premier Family Care I, Inc","Ambetter","Participating","Enrollment Complete","2022-06-01",null,null,"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","PE - Premier Family Care I, Inc","USA PPO","Participating","Enrollment Complete","2019-06-16",null,null,"2020-09-09","Confirmed provider is participating with PPO and H&W networks (list of networks attached). Kimberly Frazier"]
["Casey Mraz, MD","PE - Premier Family Care I, Inc","Medicaid","Participating","Enrollment Complete",null,396567501,79837301,"2020-01-29","01/29/2020 - Provider is linked to group. Provider is only PAR with traditional medicaid - stacey Hudak"]
["Casey Mraz, MD","PE - Premier Family Care I, Inc","Amerigroup","Participating","Enrollment Complete","2019-10-21",1659728855,null,"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 the payer (Multiplan/Texas True Choice) confirming that this EFF info is true - Stacey Hudak"]
["Casey Mraz, MD","PE - Premier Family Care I, Inc","United Health Care","Participating","Enrollment Complete","2019-05-29",7093824,null,"2020-07-30"]
["Casey Mraz, MD","PE - Premier Family Care I, Inc","Boon Chapman","Participating","Enrollment Complete","2019-08-07",null,null,"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 8/7/2019.  DCannon"]
["Casey Mraz, MD","PE - Premier Family Care I, Inc","Triwest VA","Facility Enrollment","Application Submitted",null,null,null,"2022-11-23","08/19/2022 - Submitted application to TriWest VA (sent to Scarlett Abigail, Scarlett_Abigail@bcbstx.com)"]
["Casey Mraz, MD",null,"Triwest VA","Facility Enrollment","Application Submitted",null,null,null,"2022-11-23","08/19/2022 - Submitted application to TriWest VA (sent to Scarlett Abigail, Scarlett_Abigail@bcbstx.com)"]
["Casey Mraz, MD","PE - Premier Family Care I, Inc","Triwest VA","Facility Enrollment","Facility Enrollment",null,null,null,"2022-11-23","10/17/2022 - Received roster from Scarlett of TriWest VA; provider status: \"No Action.  TIN is CCN participating under own DCN.\""]
["Casey Mraz, MD",null,"Triwest VA","Facility Enrollment","Facility Enrollment",null,null,null,"2022-11-23","10/17/2022 - Received roster from Scarlett of TriWest VA; provider status: \"No Action.  TIN is CCN participating under own DCN.\""]
["Casey Mraz, MD","PE - Premier Family Care I, Inc","CAQH","Participating","CAQH Reattested","2023-03-13",14428752,null,"2023-03-13","3/13/2023 CAQH reviewed and re-attested.  DCannon"]
["Casey Mraz, MD","PE - Premier Family Care I, Inc","First Health Coventry","Participating","Enrollment Complete","2019-06-01",3278559,null,"2020-03-20","3/20/2020-receieved email with roster stating provider PAR  6/1/2019 PID # 3278559\ntisha rader"]
["Casey Mraz, MD","PE - Premier Family Care I, Inc","Scott&White (First Care)","Participating","Enrollment Complete","2019-05-31",1659728855,null,"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"]
["Casey Mraz, MD","PE - Premier Family Care I, Inc","Humana","Participating","Enrollment Complete","2020-01-01",1659728855,null,"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"]
["Casey Mraz, MD","PE - Premier Family Care I, Inc","Galaxy Health","Participating","Enrollment Complete","2019-06-12",1659728855,null,"2020-07-10","07/10/2020 - updated payer line to enrollment complete status instead of \"Delegated status\" for report running purposes - Stacey Hudak"]
["Casey Mraz, MD","PE - Premier Family Care I, Inc","Omni PPO","Participating","Enrollment Complete","2019-06-14",1659728855,null,"2020-06-25"]
["Casey Mraz, MD","PE - Premier Family Care I, Inc","Caprock (CapStar)","Participating","Enrollment Complete","2019-06-12",1659728855,null,"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"]
["Casey Mraz, MD","PE - Premier Family Care I, Inc","Medicare","Participating","Enrollment Complete","2019-04-01",786679,"0008AH","2020-01-29","01/29/2020 - confirmed EFF through PECOS group enrollment - Stacey Hudak"]
["Casey Mraz, MD","PE - Premier Family Care I, Inc","TriCare Standard","Participating","Enrollment Complete","2021-01-08",null,null,"2021-03-31","3/31/2021 Confirmed provider certified at location via Humana-Military portal effective 1/8/2021.  DCannon"]
["Casey Mraz, MD","PE - Premier Family Care I, Inc","Cigna","Participating","Enrollment Complete","2019-09-20",1659728855,null,"2020-02-20","02/20/2020 - Rec'd verification from the payer that this provider is EFF 9-20-2019 and linked to this service location under a DIRECT CONTRACT with this payer - Stacey Hudak"]
["Saranya Rajasekar, MD","PE - Premier Family Care I, Inc","Triwest VA","Facility Enrollment","Application Submitted",null,null,null,"2022-11-28","08/19/2022 - Submitted application to TriWest VA (sent to Scarlett Abigail, Scarlett_Abigail@bcbstx.com)"]
["Saranya Rajasekar, MD",null,"Triwest VA","Facility Enrollment","Application Submitted",null,null,null,"2022-11-28","08/19/2022 - Submitted application to TriWest VA (sent to Scarlett Abigail, Scarlett_Abigail@bcbstx.com)"]
["Saranya Rajasekar, MD",null,"Triwest VA","Facility Enrollment","Application Submitted",null,null,null,"2022-11-28","08/19/2022 - Submitted application to TriWest VA (sent to Scarlett Abigail, Scarlett_Abigail@bcbstx.com)"]
["Saranya Rajasekar, MD","PE - Premier Family Care I, Inc","Triwest VA","Facility Enrollment","Facility Enrollment",null,null,null,"2022-11-28","10/17/2022 - Received roster from Scarlett of TriWest VA; provider status: \"No Action.  TIN is CCN participating under own DCN.\""]
["Saranya Rajasekar, MD",null,"Triwest VA","Facility Enrollment","Facility Enrollment",null,null,null,"2022-11-28","10/17/2022 - Received roster from Scarlett of TriWest VA; provider status: \"No Action.  TIN is CCN participating under own DCN.\""]
["Saranya Rajasekar, MD",null,"Triwest VA","Facility Enrollment","Facility Enrollment",null,null,null,"2022-11-28","10/17/2022 - Received roster from Scarlett of TriWest VA; provider status: \"No Action.  TIN is CCN participating under own DCN.\""]
["Saranya Rajasekar, MD","PE - Premier Family Care I, Inc","Boon Chapman","Participating","Enrollment Complete","2022-04-11",null,null,"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",null,"Boon Chapman","Participating","Enrollment Complete","2022-04-11",null,null,"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",null,"Boon Chapman","Participating","Enrollment Complete","2022-04-11",null,null,"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","PE - Premier Family Care I, Inc","IMS","Participating","Enrollment Complete","2022-04-11",null,null,"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"]
["Saranya Rajasekar, MD",null,"IMS","Participating","Enrollment Complete","2022-04-11",null,null,"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"]
["Saranya Rajasekar, MD",null,"IMS","Participating","Enrollment Complete","2022-04-11",null,null,"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"]
["Saranya Rajasekar, MD","PE - Premier Family Care I, Inc","HealthSmart PPO","Participating","Enrollment Complete","2022-04-11",null,null,"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",null,"HealthSmart PPO","Participating","Enrollment Complete","2022-04-11",null,null,"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",null,"HealthSmart PPO","Participating","Enrollment Complete","2022-04-11",null,null,"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","PE - Premier Family Care I, Inc","CAQH","Participating","CAQH Reattested","2023-01-17",null,null,"2023-01-17","1/17/2023 CAQH reviewed and re-attested.  DCannon"]
["Saranya Rajasekar, MD",null,"CAQH","Participating","CAQH Reattested","2023-01-17",null,null,"2023-01-17","1/17/2023 CAQH reviewed and re-attested.  DCannon"]
["Saranya Rajasekar, MD",null,"CAQH","Participating","CAQH Reattested","2023-01-17",null,null,"2023-01-17","1/17/2023 CAQH reviewed and re-attested.  DCannon"]
["Saranya Rajasekar, MD","PE - Premier Family Care I, 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",null,"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",null,"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","PE - Premier Family Care I, Inc","Cigna","Participating","Enrollment Complete","2022-07-01",7352247,null,"2022-04-18","4/18/2022 Received email from pdmcogz@cigna.com, PID- 7352247. Request has been completed  under Cigna internal reference #  “W202204052277847 \" Eff 7.1.2022. Cbankston"]
["Saranya Rajasekar, MD",null,"Cigna","Participating","Enrollment Complete","2022-07-01",7352247,null,"2022-04-18","4/18/2022 Received email from pdmcogz@cigna.com, PID- 7352247. Request has been completed  under Cigna internal reference #  “W202204052277847 \" Eff 7.1.2022. Cbankston"]
["Saranya Rajasekar, MD",null,"Cigna","Participating","Enrollment Complete","2022-07-01",7352247,null,"2022-04-18","4/18/2022 Received email from pdmcogz@cigna.com, PID- 7352247. Request has been completed  under Cigna internal reference #  “W202204052277847 \" Eff 7.1.2022. Cbankston"]
["Saranya Rajasekar, MD","PE - Premier Family Care I, Inc","First Health Coventry","In Process","Enrollment Complete",null,null,null,"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",null,"First Health Coventry","In Process","Enrollment Complete",null,null,null,"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",null,"First Health Coventry","In Process","Enrollment Complete",null,null,null,"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","PE - Premier Family Care I, Inc","Wellcare","Participating","Enrollment Complete","2022-05-01",null,null,"2022-07-01","7/1/2022 Received May Monthly Validation roster from Superior and provider is PAR and linked effective 5/1/2022.  DCannon"]
["Saranya Rajasekar, MD",null,"Wellcare","Participating","Enrollment Complete","2022-05-01",null,null,"2022-07-01","7/1/2022 Received May Monthly Validation roster from Superior and provider is PAR and linked effective 5/1/2022.  DCannon"]
["Saranya Rajasekar, MD",null,"Wellcare","Participating","Enrollment Complete","2022-05-01",null,null,"2022-07-01","7/1/2022 Received May Monthly Validation roster from Superior and provider is PAR and linked effective 5/1/2022.  DCannon"]
["Saranya Rajasekar, MD","PE - Premier Family Care I, Inc","United Health Care","Participating","Enrollment Complete","2022-04-11",8166209,null,"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",null,"United Health Care","Participating","Enrollment Complete","2022-04-11",8166209,null,"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",null,"United Health Care","Participating","Enrollment Complete","2022-04-11",8166209,null,"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","PE - Premier Family Care I, Inc","Amerigroup","Participating","Enrollment Complete","2022-04-11",null,null,"2022-10-11","10/11/2022 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 4/11/2022.  DCannon"]
["Saranya Rajasekar, MD",null,"Amerigroup","Participating","Enrollment Complete","2022-04-11",null,null,"2022-10-11","10/11/2022 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 4/11/2022.  DCannon"]
["Saranya Rajasekar, MD",null,"Amerigroup","Participating","Enrollment Complete","2022-04-11",null,null,"2022-10-11","10/11/2022 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 4/11/2022.  DCannon"]
["Saranya Rajasekar, MD","PE - Premier Family Care I, Inc","Humana","Participating","Enrollment Complete","2022-04-11",null,null,"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",null,"Humana","Participating","Enrollment Complete","2022-04-11",null,null,"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",null,"Humana","Participating","Enrollment Complete","2022-04-11",null,null,"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","PE - Premier Family Care I, Inc","USA PPO","Participating","Enrollment Complete","2022-04-11",null,null,"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 4/11/2022.  DCannon"]
["Saranya Rajasekar, MD",null,"USA PPO","Participating","Enrollment Complete","2022-04-11",null,null,"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 4/11/2022.  DCannon"]
["Saranya Rajasekar, MD",null,"USA PPO","Participating","Enrollment Complete","2022-04-11",null,null,"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 4/11/2022.  DCannon"]
["Saranya Rajasekar, MD","PE - Premier Family Care I, Inc","Ambetter","Participating","Enrollment Complete","2022-05-01",null,null,"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",null,"Ambetter","Participating","Enrollment Complete","2022-05-01",null,null,"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",null,"Ambetter","Participating","Enrollment Complete","2022-05-01",null,null,"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","PE - Premier Family Care I, Inc","Multiplan","Participating","Enrollment Complete","2022-04-11",null,null,"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",null,"Multiplan","Participating","Enrollment Complete","2022-04-11",null,null,"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",null,"Multiplan","Participating","Enrollment Complete","2022-04-11",null,null,"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","PE - Premier Family Care I, 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",null,"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",null,"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","PE - Premier Family Care I, Inc","Caprock (CapStar)","Participating","Enrollment Complete","2022-04-11",null,null,"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"]
["Saranya Rajasekar, MD",null,"Caprock (CapStar)","Participating","Enrollment Complete","2022-04-11",null,null,"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"]
["Saranya Rajasekar, MD",null,"Caprock (CapStar)","Participating","Enrollment Complete","2022-04-11",null,null,"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"]
["Saranya Rajasekar, MD","PE - Premier Family Care I, Inc","Aetna","Participating","Enrollment Complete","2022-11-01",6655255,null,"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",null,"Aetna","Participating","Enrollment Complete","2022-11-01",6655255,null,"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",null,"Aetna","Participating","Enrollment Complete","2022-11-01",6655255,null,"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","PE - Premier Family Care I, Inc","Galaxy Health","Participating","Enrollment Complete","2022-04-11",null,null,"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  4/11/2022.  DCannon"]
["Saranya Rajasekar, MD",null,"Galaxy Health","Participating","Enrollment Complete","2022-04-11",null,null,"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  4/11/2022.  DCannon"]
["Saranya Rajasekar, MD",null,"Galaxy Health","Participating","Enrollment Complete","2022-04-11",null,null,"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  4/11/2022.  DCannon"]
["Saranya Rajasekar, MD","PE - Premier Family Care I, Inc","Superior","Participating","Enrollment Complete","2022-05-01",null,null,"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"]
["Saranya Rajasekar, MD",null,"Superior","Participating","Enrollment Complete","2022-05-01",null,null,"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"]
["Saranya Rajasekar, MD",null,"Superior","Participating","Enrollment Complete","2022-05-01",null,null,"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"]
["Saranya Rajasekar, MD","PE - Premier Family Care I, Inc","Omni PPO","Participating","Enrollment Complete","2022-04-11",null,null,"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"]
["Saranya Rajasekar, MD",null,"Omni PPO","Participating","Enrollment Complete","2022-04-11",null,null,"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"]
["Saranya Rajasekar, MD",null,"Omni PPO","Participating","Enrollment Complete","2022-04-11",null,null,"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"]
["Saranya Rajasekar, MD","PE - Premier Family Care I, Inc","Scott&White (First Care)","Participating","Enrollment Complete","2022-05-10",null,null,"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",null,"Scott&White (First Care)","Participating","Enrollment Complete","2022-05-10",null,null,"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",null,"Scott&White (First Care)","Participating","Enrollment Complete","2022-05-10",null,null,"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","PE - Premier Family Care I, Inc","Medicare","Participating","Enrollment Complete","2022-06-01","2D4132","0008AH","2022-05-18","5/18/2022 Per PECOS provider is PAR and linked to group/location effective 6/1/2022.  PTAN # 2D4132.  DCannon"]
["Saranya Rajasekar, MD",null,"Medicare","Participating","Enrollment Complete","2022-06-01","2D4132","0008AH","2022-05-18","5/18/2022 Per PECOS provider is PAR and linked to group/location effective 6/1/2022.  PTAN # 2D4132.  DCannon"]
["Saranya Rajasekar, MD",null,"Medicare","Participating","Enrollment Complete","2022-06-01","2D4132","0008AH","2022-05-18","5/18/2022 Per PECOS provider is PAR and linked to group/location effective 6/1/2022.  PTAN # 2D4132.  DCannon"]
["Tzu-Ching Wu, MD","PE - Premier Family Care I, Inc","Cigna","Terminated","Terminated","2019-01-01",1396930426,null,"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"]
["Tzu-Ching Wu, MD","PE - Premier Family Care I, Inc","Caprock (CapStar)","Participating","Enrollment Complete","2019-05-21",1396930426,null,"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"]
["Tzu-Ching Wu, MD","PE - Premier Family Care I, Inc","Triwest VA","Facility Enrollment","Application Submitted",null,null,null,"2022-11-28","08/19/2022 - Submitted application to TriWest VA (sent to Scarlett Abigail, Scarlett_Abigail@bcbstx.com)"]
["Tzu-Ching Wu, MD",null,"Triwest VA","Facility Enrollment","Application Submitted",null,null,null,"2022-11-28","08/19/2022 - Submitted application to TriWest VA (sent to Scarlett Abigail, Scarlett_Abigail@bcbstx.com)"]
["Tzu-Ching Wu, MD","PE - Premier Family Care I, Inc","Triwest VA","Facility Enrollment","Facility Enrollment",null,null,null,"2022-11-28","10/17/2022 - Received roster from Scarlett of TriWest VA; provider status: \"No Action.  TIN is CCN participating under own DCN.\""]
["Tzu-Ching Wu, MD",null,"Triwest VA","Facility Enrollment","Facility Enrollment",null,null,null,"2022-11-28","10/17/2022 - Received roster from Scarlett of TriWest VA; provider status: \"No Action.  TIN is CCN participating under own DCN.\""]
["Tzu-Ching Wu, MD","PE - Premier Family Care I, Inc","Multiplan","Delegated - Third Party","Delegated - Third Party","2019-04-05",1396930426,"West Texas Physicians Alliance","2020-09-28","09/28/2020 - moved to completed status after receiving a spreadsheet from the payer stating this provider is EFF with West Texas Physicians Alliance under the following networks: Multiplan/PHCS/BeechStreet - Stacey Hudak"]
["Tzu-Ching Wu, MD","PE - Premier Family Care I, Inc","United Health Care","Participating","Enrollment Complete","2019-01-01",3382000,null,"2020-06-08","06/8/2020 - Rec'd email from the payer stating this provider/address is EFF - Stacey Hudak"]
["Tzu-Ching Wu, MD","PE - Premier Family Care I, Inc","Medicare","Participating","Enrollment Complete","2019-01-07",761311,"0008AH","2020-04-27","04/27/2020 - Confirmed enrollment through GROUP PECOS enrollment - Stacey Hudak"]
["Tzu-Ching Wu, MD","PE - Premier Family Care I, Inc","Cigna","Participating","Enrollment Complete","2021-03-31",669817,null,"2021-07-06","7/6/2021 Received an email from PDMCOGZ@cigna.com confirming provider is participating under group Tax ID effective 3/31/2021, with assigned ID 0669817. KFrazier"]
["Tzu-Ching Wu, MD","PE - Premier Family Care I, Inc","Boon Chapman","Participating","Enrollment Complete","2019-04-05",null,null,"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 4/5/2019.  DCannon"]
["Tzu-Ching Wu, MD","PE - Premier Family Care I, Inc","Omni PPO","Participating","Enrollment Complete","2019-05-21",1396930426,null,"2020-06-26"]
["Tzu-Ching Wu, MD","PE - Premier Family Care I, Inc","Galaxy Health","Participating","Enrollment Complete","2019-05-21",1396930426,null,"2020-07-17","7/17/2020 - Received a spreadsheet from the payer stating this provider is effective as of 5/21/2019 - Jesriel Segovia"]
["Tzu-Ching Wu, MD","PE - Premier Family Care I, Inc","IMS","Participating","Enrollment Complete","2019-05-21",1396930426,null,"2020-06-22","06/22/2020- Rec'd email from the payer confirming this provider is PAR with this group/service location - Stacey Hudak"]
["Tzu-Ching Wu, MD","PE - Premier Family Care I, Inc","Aetna","Participating","Enrollment Complete","2019-01-31",1396930426,null,"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 1/31/2019. Physical Location is on file. Provider ID #9109842. Call ref # 5234162545\ncopied note from spreadsheet-tisha rader"]
["Tzu-Ching Wu, MD","PE - Premier Family Care I, Inc","TriCare Standard","Participating","Enrollment Complete","2020-05-01",null,null,"2021-04-02","4/2/2021 Per Humana Military Portal provider is certified and linked to group TIN and location effective 5/1/2020.  DCannon"]
["Tzu-Ching Wu, MD","PE - Premier Family Care I, Inc","First Health Coventry","Participating","Enrollment Complete","2019-05-01",2323463,null,"2020-03-20","3/20/2020-receieved email with roster stating provider PAR 5/1/2019 PID # 2323463\ntisha rader"]
["Tzu-Ching Wu, MD","PE - Premier Family Care I, Inc","HealthSmart PPO","Participating","Enrollment Complete","2019-05-31",1396930426,null,"2020-06-10","06/10/2020 - Rec'd email from the payer stating this provider is EFF - Stacey Hudak"]
["Tzu-Ching Wu, MD","PE - Premier Family Care I, Inc","Amerigroup","Participating","Enrollment Complete","2019-05-31",1396930426,null,"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","PE - Premier Family Care I, Inc","USA PPO","Participating","Enrollment Complete","2019-05-31",null,null,"2020-09-09","Confirmed provider is participating with PPO and H&W networks (list of networks attached). Kimberly Frazier"]
["Tzu-Ching Wu, MD","PE - Premier Family Care I, Inc","Medicaid","Participating","Enrollment Complete",null,283737907,79837301,"2020-01-29","01/29/2020 - found provider PAR through Medicaid portal. Provider is linked to the following plans: Texas Children's Health Plan - Harris, UnitedHealthcare Community Plan - Harris, UnitedHealthCare Community Plan - Harris - Mmp, Texas Children's Health Plan - Jefferson, UnitedHealthcare Community Plan - Jefferson, TRADITIONAL MEDICAID, Texas Children's Health Plan - Harris, Texas Children's Health Plan - Jefferson, Texas Children's Health Plan - MRSA Northeast, United Healthcare - Texas - Harris, United Healthcare - Texas - Jefferson, Amerigroup - MRSA West, Amerigroup Texas, Inc. - MRSA West - Stacey Hudak"]
["Tzu-Ching Wu, MD","PE - Premier Family Care I, Inc","Tricare Prime","Participating","Enrollment Complete","2020-05-01",null,null,"2020-10-08","10/8/2020 Confirmed via Self-Service Portal provider is participating under Tax ID and location. Kimberly Frazier"]
["Tzu-Ching Wu, MD","PE - Premier Family Care I, Inc","Superior","Participating","Enrollment Complete","2020-11-01",null,null,"2020-11-25","11/25/2020 -  Rcvd email confirmation that Oct monthly roster was processed and this provider was made effective with the requested eff date of 11/1/2020.  DCannon"]
["Tzu-Ching Wu, MD","PE - Premier Family Care I, Inc","Humana","Participating","Enrollment Complete","2019-04-04",1396930426,null,"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"]
["Tzu-Ching Wu, MD","PE - Premier Family Care I, Inc","First Health Coventry","Participating","Enrollment Complete","2019-05-01",2323463,null,"2020-03-20","3/20/2020-receieved email with roster stating provider PAR 5/1/2019 PID # 2323463\ntisha rader"]

{"sheet":"NPISearch","index":3,"n_rows":29,"n_cols":11,"rows_kept":29,"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"]
["Douglas J Colson, MD","PE - Premier Family Care I, Inc","Caprock (CapStar)","Participating","Enrollment Complete","2018-08-30",1790767119,null,"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"]
["Douglas J Colson, MD","PE - Premier Family Care I, Inc","Cigna","Terminated","Terminated","2018-08-31",1790767119,null,"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"]
["Douglas J Colson, MD","PE - Premier Family Care I, Inc","Superior","Participating","Enrollment Complete","2018-10-01",1790767119,null,"2020-07-14","07/14/2020 - Rec'd email from the payer stating this provider is EFF under PRIMED DELEGATED agreement - Stacey Hudak"]
["Douglas J Colson, MD","PE - Premier Family Care I, Inc","Ambetter","Participating","Enrollment Complete","2022-06-01",null,null,"2022-06-13","6/13/2022 Per roster received from Superior provider is PAR and linked to group delegation roster effective 6/1/2022."]
["Douglas J Colson, MD","PE - Premier Family Care I, Inc","Cigna","Participating","Enrollment Complete","2021-03-31",null,null,"2021-08-25","8/25/2021 Received an email from PDMCOGZ@cigna.com confirming provider is now participating under group Tax ID and location effective 3/31/2021 with assigned provider ID 6670877. KFrazier"]
["Douglas J Colson, MD","PE - Premier Family Care I, Inc","Aetna","Participating","Enrollment Complete","2018-09-01",1790767119,null,"2020-02-03","02/03/2020 - Rec'd confirmation from the payer that this provider is EFF 9-1-2018 with a DIRECT CONTRACT. The proper service location is in file - Stacey Hudak"]
["Douglas J Colson, MD","PE - Premier Family Care I, Inc","Tricare Prime","Participating","Enrollment Complete","2018-07-14",null,null,"2020-10-08","10/8/2020 Confirmed via Self-Service Portal provider is participating under Tax ID and location. Kimberly Frazier"]
["Douglas J Colson, MD","PE - Premier Family Care I, Inc","United Health Care","Participating","Enrollment Complete","2018-07-10",1790767119,null,"2020-07-30","7/30/2020 - moved to completed status after reviewing follow up complete note - Stacey Hudak"]
["Douglas J Colson, MD","PE - Premier Family Care I, Inc","Boon Chapman","Participating","Enrollment Complete","2018-08-01",null,null,"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 8/1/2018.  DCannon"]
["Douglas J Colson, MD","PE - Premier Family Care I, Inc","Scott&White (First Care)","Participating","Enrollment Complete","2019-01-11",1790767119,null,"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\n\n**Rec'd confirmation from the payer that this provider is tied to this TIN/Service location and networked with: \nFirstCare MyChoice PPO\nCHIP\nFirstCare Select Benefit Network\nHMO Enhanced Benefit Network\nMedicaid (FC)\nMedicare (FC)\nPPO Limited Benefit Network"]
["Douglas J Colson, MD","PE - Premier Family Care I, Inc","Triwest VA","Facility Enrollment","Application Submitted",null,null,null,"2022-11-23","08/19/2022 - Submitted application to TriWest VA (sent to Scarlett Abigail, Scarlett_Abigail@bcbstx.com)"]
["Douglas J Colson, MD",null,"Triwest VA","Facility Enrollment","Application Submitted",null,null,null,"2022-11-23","08/19/2022 - Submitted application to TriWest VA (sent to Scarlett Abigail, Scarlett_Abigail@bcbstx.com)"]
["Douglas J Colson, MD","PE - Premier Family Care I, Inc","Triwest VA","Facility Enrollment","Facility Enrollment",null,null,null,"2022-11-23","10/17/2022 - Received roster from Scarlett of TriWest VA; provider status: \"No Action.  TIN is CCN participating under own DCN.\""]
["Douglas J Colson, MD",null,"Triwest VA","Facility Enrollment","Facility Enrollment",null,null,null,"2022-11-23","10/17/2022 - Received roster from Scarlett of TriWest VA; provider status: \"No Action.  TIN is CCN participating under own DCN.\""]
["Douglas J Colson, MD","PE - Premier Family Care I, Inc","Amerigroup","Participating","Enrollment Complete","2018-08-29",1790767119,null,"2020-02-11","2/11/2020 – Received Roster from Amerigroup and provider is now PAR- Tisha Rader\n\n3/18/2020 - rec'd confirmation from Multiplan/Texas True Choice that this is correct - Stacey Hudak"]
["Douglas J Colson, MD","PE - Premier Family Care I, Inc","Medicare","Participating","Enrollment Complete","2018-07-01",679507,"0008AH","2020-01-29","01/29/2020 - confirmed EFF through PECOS group enrollment - Stacey Hudak"]
["Douglas J Colson, MD","PE - Premier Family Care I, Inc","First Health Coventry","Participating","Enrollment Complete","2018-08-01",1046218,null,"2020-03-24","3/24/2020-received email with roster from payor stating provider is PAR 8/1/2018 PID # 1046218\ntisha rader"]
["Douglas J Colson, MD","PE - Premier Family Care I, Inc","Omni PPO","Participating","Enrollment Complete","2018-08-30",1790767119,null,"2020-07-14"]
["Douglas J Colson, MD","PE - Premier Family Care I, Inc","Medicaid","Participating","Enrollment Complete",null,386238501,79837301,"2020-01-29","01/29/2020 - Found provider PAR through payer portal. This provider is linked to the following plans: FirstCare - Lubbock, TRADITIONAL MEDICAID, Amerigroup - MRSA West, FirstCare - MRSA West, Amerigroup Texas, Inc. - MRSA West - Stacey Hudak"]
["Douglas J Colson, MD","PE - Premier Family Care I, Inc","Multiplan","Participating","Enrollment Complete","2018-08-01",1790767119,null,"2020-02-12","02/12/2020 - this provider has been confirmed to be effective through the payer portal. EFF 8-1-2018 THROUGH WEST TEXAS PHYSICIANS ALLIANCE DELEGATED PARTY - networked to MPI. - Stacey Hudak"]
["Douglas J Colson, MD","PE - Premier Family Care I, Inc","TriCare Standard","Participating","Enrollment Complete","2018-07-14",null,null,"2020-11-03","11/3/2020 Upon review of the self-service portal provider reflects as 'complete'. Kimberly Frazier"]
["Douglas J Colson, MD","PE - Premier Family Care I, Inc","Humana","Participating","Enrollment Complete","2020-01-01",1790767119,null,"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"]
["Douglas J Colson, MD","PE - Premier Family Care I, Inc","USA PPO","Participating","Enrollment Complete","2018-08-29",1790767119,752656723,"2020-08-18","Confirmed provider is enrolled and participating under delegated agreement with the PPO and H&W networks (list attached in images). Kimberly Frazier"]
["Douglas J Colson, MD","PE - Premier Family Care I, Inc","Galaxy Health","Participating","Enrollment Complete","2018-08-01",1790767119,null,"2020-07-10","07/10/2020 - updated payer line to enrollment complete status instead of \"Delegated status\" for report running purposes - Stacey Hudak"]
["Douglas J Colson, MD","PE - Premier Family Care I, Inc","HealthSmart PPO","Participating","Enrollment Complete","2018-08-28",1790767119,null,"2020-06-05","06/05/2020 - Rec'd email from the payer stating this provider is EFF - Stacey Hudak"]
["Douglas J Colson, MD","PE - Premier Family Care I, Inc","Wellcare","Participating","Enrollment Complete","2021-11-01",null,null,"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"]
["Douglas J Colson, MD","PE - Premier Family Care I, Inc","IMS","Participating","Enrollment Complete","2018-08-30",1790767119,null,"2020-06-22","06/22/2020 0- Rec'd email from the payer confirming this provider is PAR with this group/service location - Stacey Hudak"]
["Douglas J Colson, MD","PE - Premier Family Care I, Inc","CAQH","Participating","CAQH Reattested","2023-01-25",11483093,null,"2022-10-18","10/18/2022 CAQH reviewed and re-attested.  Uploaded current malpractice COI.  DCannon"]