Your Information *

Name*

Phone*

E-mail*

Title

Preferred method of contact?

Email

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Postal-mail

Provider Type *

Medical Group

   

Specialty

Sub-specialty

Physician

   

Specialty

Sub-specialty

DME

ASC

Group Name / DBA

 

Physician Information

First*

Middle*

Last*

Credential*

   

State License Number*

Tax ID Number*

NPI Number*

DEA Number

Effective Date

Physician Locations

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Phone*

Fax

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Address*

City*

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Office Manager Contact Information

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Fax

Previously Nominated?

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• If Yes, referred by:

Name

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Please allow 6-8 weeks for your nomination to be processed and for contractual material to be issued.
* Denotes Required Field
 

 

To obtain a copy of any required MPN notifications, please call (855) 622-6474

The contact information for the Medical Access Assistant (MMA) is:
Toll Free Telephone Number: (855) 622-6474
Fax Number: (714) 892-4825
Email Address: LWPMAA@snp-plus.com
The contact for your MPN is:
Name: LWP Claims Solutions, Inc.
Telephone Number: (800) 565-5694

Date of Last Physician and Provider Listing Update: 11/15/2017