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["Providers Full Name","Providers NPI","Tax ID#","State","Practice Name","Payor Name","Enrollment Status","Current Status","Effective Date","Indv ID#","Grp ID#","Note Date","Notes","Symplr Rep","Enroll Type","Practice Address","Practice Address 2","Practice City","Practice Zip Code"]
["Douglas J Colson, MD","1790767119","75-2656723","TX","PE - Premier Family Care, Inc","TriCare Standard","Participating","Enrollment Complete","2023-10-17","","","2023-10-27","Ste. 102 and 103 effective 10/17/2023 has been approved. MD"]
["Douglas J Colson, MD","1790767119","75-2656723","TX","","TriCare Standard","Participating","Enrollment Complete","2023-10-17","","","2023-10-27","Ste. 102 and 103 effective 10/17/2023 has been approved. MD"]
["Douglas J Colson, MD","1790767119","75-2656723","TX","PE - Premier Family Care, Inc","TriCare Standard","Participating","Enrollment Stopped","2023-10-17","","","2023-11-06","Ste. 240, 205, and 107 have been confirmed as non current service addresses. Provider should only be linked to Ste. 103. MS"]
["Douglas J Colson, MD","1790767119","75-2656723","TX","","TriCare Standard","Participating","Enrollment Stopped","2023-10-17","","","2023-11-06","Ste. 240, 205, and 107 have been confirmed as non current service addresses. Provider should only be linked to Ste. 103. MS"]
["Douglas J Colson, MD","1790767119","75-2656723","TX","PE - Premier Family Care, Inc","Amerigroup","Participating","Enrollment Complete","2023-07-19","","","2023-11-09","11/9/2023 Per email received from Jessica Bess at  Multiplan provider is PAR with Amerigroup and linked to group TIN/locations thru Multiplan enrollment effective 7/19/2023.  DCannon"]
["Douglas J Colson, MD","1790767119","75-2656723","TX","PE - Premier Family Care, Inc","USA PPO","Participating","Enrollment Complete","2018-08-29","","","2023-11-22","11/22/2023 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 8/29/2018.  DCannon"]
["Douglas J Colson, MD","1790767119","75-2656723","TX","PE - Premier Family Care, Inc","Humana","Participating","Enrollment Complete","2023-07-19","","","2023-12-21","12/21/2023 Per Humana online directory provider is PAR and linked to group TIN and  all locations effective 7/19/2023.  DCannon"]
["Douglas J Colson, MD","1790767119","75-2656723","TX","PE - Premier Family Care, Inc","Galaxy Health","Participating","Enrollment Complete","2023-07-19","","","2023-11-07","11/7/2023 Per email received from Galaxy October delegated roster has been processed and provider is PAR and linked to group/location effective 7/19/2023.  DCannon"]
["Douglas J Colson, MD","1790767119","75-2656723","TX","PE - Premier Family Care, Inc","Cigna","Participating","Enrollment Complete","2023-07-19","6670877","","2023-11-08","Received confirmation of update. MS"]
["Douglas J Colson, MD","1790767119","75-2656723","TX","PE - Premier Family Care, Inc","Scott&White (First Care)","Participating","Enrollment Complete","2023-07-19","","","2024-01-29","1/29/2024 Rcvd confirmation from S&W that provider is PAR and linked to group TIN/location effective 7/19/2023.  DCannon"]
["Douglas J Colson, MD","1790767119","75-2656723","TX","PE - Premier Family Care, Inc","IMS","Participating","Enrollment Complete","2023-07-19","","","2024-01-02","1/2/2024 Rcvd email from German Avilies at IMS/OMNI that October delegation roster is complete.  Provider is PAR and linked to group TIN/location effective 7/19/2023.  DCannon"]
["Douglas J Colson, MD","1790767119","75-2656723","TX","PE - Premier Family Care, Inc","Aetna","Participating","Enrollment Complete","2023-07-19","5117734","","2023-11-19","11.29.2023 S/W PhilC of Aetna @ 1-800-353-1232. Per rep, Provider is in network with Aetna and linked to the group and TIN# effective 07/19/2023. Next recredentialing date is on 07/19/2026. PIN: 5117734. Servicing location is on file. Payer# 60054. Call ref# 6172179371. - Willie Ravas"]
["Douglas J Colson, MD","1790767119","75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","2023-10-17","","","2024-01-25","Confirmed provider is credentialed and in network with Tricare. MS"]
["Douglas J Colson, MD","1790767119","75-2656723","TX","PE - Premier Family Care, Inc","Superior","Participating","Enrollment Complete","2023-11-01","","","2023-11-06","11/6/2023 Rcvd email from Superior that provider is PAR and linked to group TIN/location effective 11/1/2023.  DCannon"]
["Douglas J Colson, MD","1790767119","75-2656723","TX","PE - Premier Family Care, Inc","Wellmed","Participating","Enrollment Complete","2022-01-01","","","2023-11-03","11/3/2023 Rcvd confirmation email from UHC/Wellmed that provider is PAR and linked to group TIN/location effective 1/1/2022.  DCannon"]
["Douglas J Colson, MD","1790767119","75-2656723","TX","PE - Premier Family Care, Inc","Boon Chapman","Participating","Enrollment Complete","2023-07-19","","","2023-11-09","11/9/2023 Rcvd email confirmation from Jessica Bess at Multiplan that October roster has been processed and provider is PAR w/ group effective 7/19/2023.  DCannon"]
["Douglas J Colson, MD","1790767119","75-2656723","TX","PE - Premier Family Care, Inc","Omni PPO","Participating","Enrollment Complete","2023-07-19","","","2024-01-02","1/2/2024 Rcvd email from German Avilies at IMS/OMNI that October delegation roster is complete.  Provider is PAR and linked to group TIN/location effective 7/19/2023.  DCannon"]
["Douglas J Colson, MD","1790767119","75-2656723","TX","PE - Premier Family Care, Inc","Medicare","Participating","Enrollment Complete","2023-10-01","679507","0008AH","2024-02-07","Location was added to group record eff 10/1/2023. MS"]
["Douglas J Colson, MD","1790767119","75-2656723","TX","PE - Premier Family Care, Inc","HealthSmart PPO","Participating","Enrollment Complete",45126,"","","2023-12-15","12/15/2023 Per email rcvd from Aleece Moerbe at Healthsmart provider is PAR and linked to group TIN/location effective 7/19/2023.  DCannon"]
["Douglas J Colson, MD","1790767119","75-2656723","TX","PE - Premier Family Care, Inc","First Health Coventry","Participating","Enrollment Complete","2023-07-19","1046218","","2023-12-06","12/6/2023 S/W Kim of First Health @ 800-226-5116 and transferred me over to Courtney. Per rep, Provider is in network with First Health and linked to the group and TIN# effective 7/19/2023.  PIN: 1046218. Servicing location is on file. No payer# available. DCannon"]
["Douglas J Colson, MD","1790767119","75-2656723","TX","PE - Premier Family Care, Inc","Caprock (CapStar)","Participating","Enrollment Complete","2023-07-19","","","2023-10-19","10/19/2023 Rcvd email  confirmation from Caprock that provider is PAR and linked to group TIN/locations effective 7/19/2023.  DCannon"]
["Douglas J Colson, MD","1790767119","75-2656723","TX","PE - Premier Family Care, Inc","Wellcare","Participating","Enrollment Complete","2023-11-01","","","2023-11-06","11/6/2023 Rcvd email from Superior that provider is PAR and linked to group TIN/location effective 11/1/2023.  DCannon"]
["Douglas J Colson, MD","1790767119","75-2656723","TX","PE - Premier Family Care, Inc","Medicaid","Participating","Enrollment Complete","2023-02-22","","","2024-03-20","Welcome ltr rcvd. Provider effective at this location 02/22/2023. Jen Videan"]
["Douglas J Colson, MD","1790767119","75-2656723","TX","PE - Premier Family Care, Inc","Multiplan","Participating","Enrollment Complete","2023-07-19","","","2023-11-09","11/9/2023 Rcvd email confirmation from Jessica Bess at Multiplan that October roster has been processed and provider is PAR w/ group effective 7/19/2023.  DCannon"]
["Douglas J Colson, MD","1790767119","75-2656723","TX","PE - Premier Family Care, Inc","Ambetter","Participating","Enrollment Complete","2023-11-01","","","2023-11-06","11/6/2023 Rcvd email from Superior that provider is PAR and linked to group TIN/location effective 11/1/2023.  DCannon"]
["Douglas J Colson, MD","1790767119","75-2656723","TX","PE - Premier Family Care, Inc","Triwest VA","In House Enrollment","In House Enrollment","","","","2023-10-13",""]
["Douglas J Colson, MD","1790767119","75-2656723","TX","PE - Premier Family Care, Inc","CAQH","Participating","CAQH Reattested",45532,"11483093","","2024-08-28","08/28/2024 CAQH Reattesed updated and uploaded COI wthompson"]
["Douglas J Colson, MD","1790767119","75-2656723","TX","PE - Premier Family Care, Inc","United Health Care","Participating","Enrollment Complete","2018-07-10","002539407","","2023-11-03","11/3/2023 Rcvd confirmation email from UHC that provider is PAR and linked to group TIN/location effective 7/10/2018.  MPIN # 002539407.  DCannon"]
["Lori Ann Reeves, APRN-FNP-BC","1023520830","75-2656723","TX","PE - Premier Family Care, Inc","USA PPO","Participating","Enrollment Complete","2013-12-27","1023520830","463131679","2020-08-18","Confirmed provider is participating under delegated agreement for PPO and H&W Networks (list of networks attached). Kim Frazier"]
["Lori Ann Reeves, APRN-FNP-BC","1023520830","75-2656723","TX","PE - Premier Family Care, Inc","Caprock (CapStar)","Participating","Enrollment Complete","2019-09-01","","","2020-09-11",""]
["Lori Ann Reeves, APRN-FNP-BC","1023520830","75-2656723","TX","PE - Premier Family Care, Inc","Wellmed","Participating","Enrollment Complete","2022-03-01","","","2023-03-23","3/23/2023 Rcvd roster from UHC w/ all Wellmed participating providers.  Provider is PAR effective 3/1/2022.  DCannon"]
["Lori Ann Reeves, APRN-FNP-BC","1023520830","75-2656723","TX","PE - Premier Family Care, 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, APRN-FNP-BC","1023520830","75-2656723","TX","PE - Premier Family Care, 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, APRN-FNP-BC","1023520830","75-2656723","TX","PE - Premier Family Care, Inc","IMS","Participating","Enrollment Complete","2019-09-01","1023520830","","2020-07-27","07/27/2020 - Rec'd roster response back from the payer regarding 7/15/2020 submission stating that all requested providers/service locations have been added to PriMed agreement - Stacey Hudak"]
["Lori Ann Reeves, APRN-FNP-BC","1023520830","75-2656723","TX","PE - Premier Family Care, Inc","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, APRN-FNP-BC","1023520830","75-2656723","TX","PE - Premier Family Care, 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, APRN-FNP-BC","1023520830","75-2656723","TX","PE - Premier Family Care, 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, APRN-FNP-BC","1023520830","75-2656723","TX","PE - Premier Family Care, 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, APRN-FNP-BC","1023520830","75-2656723","TX","PE - Premier Family Care, 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, APRN-FNP-BC","1023520830","75-2656723","TX","PE - Premier Family Care, Inc","Ambetter","Participating","Enrollment Complete","2022-06-01","","","2022-06-13","6/13/2022 Per roster received from Superior provider is PAR and linked to group delegation roster effective 6/1/2022."]
["Lori Ann Reeves, APRN-FNP-BC","1023520830","75-2656723","TX","PE - Premier Family Care, Inc","Medicaid","Participating","Enrollment Complete","2018-03-19","382485601","079837301","2023-05-10","5/10/2023 Rcvd TX Medicaid revalidation approval letter.  Provider is PAR and linked to group.  TPI # 1023520830 - effective 3/19/2018.  DCannon"]
["Lori Ann Reeves, APRN-FNP-BC","1023520830","75-2656723","TX","PE - Premier Family Care, Inc","Boon Chapman","Participating","Enrollment Complete","2018-06-15","1023520830","","2020-10-05","Enrolled thru PHCS"]
["Lori Ann Reeves, APRN-FNP-BC","1023520830","75-2656723","TX","PE - Premier Family Care, Inc","Scott&White (First Care)","Participating","Enrollment Complete","2018-07-11","1023520830","","2020-02-19","2/19/2020--Per payer roster received from Irma Henson, this provider is participating with this service location and TIN--tisha rader"]
["Lori Ann Reeves, APRN-FNP-BC","1023520830","75-2656723","TX","PE - Premier Family Care, Inc","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, APRN-FNP-BC","1023520830","75-2656723","TX","PE - Premier Family Care, 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, APRN-FNP-BC","1023520830","75-2656723","TX","PE - Premier Family Care, Inc","Multiplan","Participating","Enrollment Complete","2018-06-15","1023520830","52669: West Texas Physicians Alliance Group Cntrct","2020-03-11","03/11/2020 - Rec'd email response from the payer stating provider is effective with different networks/effective dates as follows:\n\"Network:  MPI \nNetwork Participation effective: 10/01/2019 Group contract through: West Texas Physicians Alliance\n\nNetwork:  PHCS\nNetwork Participation effective: 06/15/2018 Group contract through: West Texas Physicians Alliance\n\nNetwork:  Beech St.\nNetwork Participation effective: 11/27/2019 Group contract through: West Texas Physicians Alliance\"\n\nAll are linked to group TIN - Stacey Hudak"]
["Lori Ann Reeves, APRN-FNP-BC","1023520830","75-2656723","TX","PE - Premier Family Care, Inc","CAQH","Active","CAQH Reattested","2024-08-27","14145595","","2024-08-27","08/27/2024 CAQH Reattested updated and uploaded COI wthompson"]
["Lori Ann Reeves, APRN-FNP-BC","1023520830","75-2656723","TX","PE - Premier Family Care, 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, APRN-FNP-BC","1023520830","75-2656723","TX","","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, APRN-FNP-BC","1023520830","75-2656723","TX","PE - Premier Family Care, Inc","Amerigroup","Participating","Add Info Submitted","2020-06-29","1023520830","","2024-07-22","Submitted designation role to PCP in July roster via delegated roster. FC"]
["Lori Ann Reeves, APRN-FNP-BC","1023520830","75-2656723","TX","","Amerigroup","Participating","Add Info Submitted","2020-06-29","1023520830","","2024-07-22","Submitted designation role to PCP in July roster via delegated roster. FC"]
["Lori Ann Reeves, APRN-FNP-BC","1023520830","75-2656723","TX","PE - Premier Family Care, 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, APRN-FNP-BC","1023520830","75-2656723","TX","PE - Premier Family Care, Inc","Omni PPO","Participating","Enrollment Complete","2019-09-01","1023520830","","2020-07-27","IMS is complete"]
["Lori Ann Reeves, APRN-FNP-BC","1023520830","75-2656723","TX","PE - Premier Family Care, 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, APRN-FNP-BC","1023520830","75-2656723","TX","PE - Premier Family Care, Inc","Triwest VA","Participating","Enrollment Complete","2020-12-01","","","2023-03-24","03/17/2023- Per Triwest VA  email confirmation, provider participating under practice DCN, eff. 12/01/2020. PA"]
["Lori Ann Reeves, APRN-FNP-BC","1023520830","75-2656723","TX","PE - Premier Family Care, 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"]
["Angel A Tejada Mejia, MD","1982085205","47-5554737","TX","PE - Midland Inpatient Medical Association","Medicaid","Participating","Enrollment Complete","2019-08-01","","","2024-08-15","Provider is already enrolled and linked to group effective 08/01/2018. Jen Videan"]
["Angel A Tejada Mejia, MD","1982085205","47-5554737","TX","PE - Midland Inpatient Medical Association","Medicare","Participating","Enrollment Complete","2018-08-01","703171","519061","2024-08-15","Provider was already enrolled and linked to this TIN. MS"]
["Angel A Tejada Mejia, MD","1982085205","47-5554737","TX","PE - Midland Inpatient Medical Association","Cigna","Participating","Enrollment Complete","2024-07-01","0044767","","2024-08-23","Provider has been linked and is active under this TIN. MS"]
["Angel A Tejada Mejia, MD","1982085205","47-5554737","TX","PE - Midland Inpatient Medical Association","Rail Road Medicare","Participating","Enrollment Complete","2018-08-01","P02179380","DW7662","2024-08-15","Provider enrolled and active. MS"]
["Angel A Tejada Mejia, MD","1982085205","47-5554737","TX","PE - Midland Inpatient Medical Association","TriCare Standard","Participating","Enrollment Complete","2018-07-17","","","2024-08-15","Provider is active and linked to location. MS"]
["Angel A Tejada Mejia, MD","1982085205","47-5554737","TX","PE - Midland Inpatient Medical Association","CAQH","In Process","CAQH Reattested","2024-08-02","","","2024-08-02","8/2/24 - CAQH sweep completed by WT"]
["Angel A Tejada Mejia, MD","1982085205","47-5554737","TX","PE - Midland Inpatient Medical Association","Tricare Prime","Panel Closed","Panel Closed","","","","2024-08-13","location is not tricare credentialed, and the panel is currently closed. MS"]
["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","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",45526,"14218808","","2024-08-22","08/22/2024 CAQH Reattested updated and uploaded license wthompson"]
["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",43325,"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",43312,"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",43384,"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",42995,"1104237015","","2020-07-30","7/30/2020 - moved to completed status after reviewing follow up complete note - Stacey Hudak"]
["Anusha Ammu, MD","1386135713","75-2656723","TX","PE - Premier Family Care, Inc","Caprock (CapStar)","Participating","Enrollment Complete",45236,"","","2023-12-28","12/28/2023 Per email received from Caprock December delegated roster is complete.  Provider is PAR and linked to group TIN/locations effective 11/6/2023.  DCannon"]
["Anusha Ammu, MD","1386135713","75-2656723","TX","PE - Premier Family Care, Inc","IMS","Participating","Enrollment Complete",45236,"","","2024-01-02","1/2/2024 Rcvd email from German Avilies at IMS/OMNI that December delegation roster is complete.  Provider is PAR and linked to group TIN/location effective 11/6/2023.  DCannon"]
["Anusha Ammu, MD","1386135713","75-6000608","TX","PE - City of Midland Health Department","Humana","Participating","Enrollment Complete",45208,"","","2024-06-21","Received email confirmation from Marcus Wester, provider is par and linked to TIN/location, eff. 10/09/2023. PA."]
["Anusha Ammu, MD","1386135713","75-6000608","TX","PE - City of Midland Health Department","BCBSTX","Participating","Enrollment Complete",45391,"","","2024-04-08","Received email provider is now PAR and participating with the following networks, eff. 4/9/2024:\nBAV - Blue Advantage HMO\nBCA - BlueChoice PPO\nMCH - Medicare Advantage HMO\nSNP - Dual Eligible Special Needs Plan\nHME - Health Select\nHMO - Blue Essentials\nPMC - Medicare Advantage PPO\nWEL - WellMed MA HMO. PA."]
["Anusha Ammu, MD","1386135713","75-6000608","TX","PE - City of Midland Health Department","TriCare Standard","No Enrollment Required","No Enrollment Required","","","","2024-04-01","Enrollment is set up as an ambulatory enrollment and providers can not be added to it. MS"]
["Anusha Ammu, MD","1386135713","75-2656723","TX","PE - Premier Family Care, Inc","HealthSmart PPO","Participating","Enrollment Complete","","","","2024-02-29","Per roster received from Aleece Moerbe (Aleece.Moerbe@healthsmart.com) on 02/23/2024, provider is PAR, eff. 10/09/2023 and linked to 400 Rosalind Redfern, Suite 230. PA."]
["Anusha Ammu, MD","1386135713","75-6000608","TX","PE - City of Midland Health Department","Rail Road Medicare","No Enrollment Required","No Enrollment Required","","","","2024-04-25","Due to the type of Medicare enrollment, this enrollment is not required. MS"]
["Anusha Ammu, MD","1386135713","75-2656723","TX","PE - Premier Family Care, Inc","TriCare Standard","Participating","Enrollment Complete",45311,"","","2024-01-09","Received confirmation via self service portal. MS"]
["Anusha Ammu, MD","1386135713","75-6000608","TX","PE - City of Midland Health Department","USA PPO","In Process","Payor Follow Up","","","","2024-07-30","Sent email to payor requesting enrollment status update. PA."]
["Anusha Ammu, MD","1386135713","75-6000608","TX","PE - City of Midland Health Department","Wellmed","In Process","Payor Follow Up","","","","2024-07-08","Sent email to payor requesting status update. PA."]
["Anusha Ammu, MD","1386135713","75-2656723","TX","PE - Premier Family Care, Inc","Boon Chapman","Participating","Enrollment Complete","2023-11-06","","","2024-05-24","Par through Multiplan enrollment, eff. 11/06/2023. PA"]
["Anusha Ammu, MD","1386135713","75-2656723","TX","PE - Premier Family Care, Inc","Galaxy Health","Participating","Enrollment Complete",45236,"","","2024-01-11","1/11/2024 Per email rcvd from Karen Avalos at Galaxy December roster is complete.  Provider is PAR and linked to group TIN/locations effective 11/6/2023.  DCannon"]
["Anusha Ammu, MD","1386135713","75-6000608","TX","PE - City of Midland Health Department","Wellcare","Participating","Enrollment Complete","2024-04-01","","","2024-04-29","Per email from Sebastian Flores (sebastian.flores@superiorhealthplan.com), provider is PAR and linked to TIN/location, eff.  04/01/2024. PA."]
["Anusha Ammu, MD","1386135713","75-6000608","TX","PE - City of Midland Health Department","Medicare","No Enrollment Required","No Enrollment Required","","","","2024-04-08","Enrollment not required as the type of enrollment is unable to have providers reassigned. MS"]
["Anusha Ammu, MD","1386135713","75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete",45293,"","","2024-02-28","Re-Cred has been completed eff 1/2/2024. MS"]
["Anusha Ammu, MD","1386135713","75-6000608","TX","PE - City of Midland Health Department","IMS","Participating","Enrollment Complete","2024-02-06","","","2024-05-29","As per Kodi from IMS, provider participating as of 2/6/2024 received via email. FC"]
["Anusha Ammu, MD","1386135713","75-6000608","TX","PE - City of Midland Health Department","Omni PPO","Participating","Enrollment Complete","2024-02-06","","","2024-05-29","As per Kodi from IMS, provider participating as of 2/6/2024 received via email. FC"]
["Anusha Ammu, MD","1386135713","75-2656723","TX","PE - Premier Family Care, Inc","Superior","Participating","Enrollment Complete",45292,"","","2024-01-12","1/12/2024 Per email rcvd from Superior, December roster is complete provider is PAR and linked to group TIN/locations effective 1/1/2024.  DCannon"]
["Anusha Ammu, MD","1386135713","75-6000608","TX","PE - City of Midland Health Department","Galaxy Health","Participating","Enrollment Complete",45328,"","","2024-04-16","Received email from Karen Avalos confirming roster completed; provider is PAR under TIN: 75-6000608, eff. 2/06/2024. PA."]
["Anusha Ammu, MD","1386135713","75-2656723","TX","PE - Premier Family Care, Inc","Aetna","Participating","Enrollment Complete",45236,"","","2024-02-15","Per phone call, the provider is linked to TIN eff 11/6/2023. MS"]
["Anusha Ammu, MD","1386135713","75-6000608","TX","PE - City of Midland Health Department","Scott&White (First Care)","In Process","Payor Follow Up","","","","2024-07-26","Sent email to payor requesting enrollment status. PA."]
["Anusha Ammu, MD","1386135713","75-2656723","TX","PE - Premier Family Care, Inc","CAQH","Participating","CAQH Reattested",45532,"","","2024-08-28","08/28/2024 CAQH Reattested updated and uploaded COI wthompson"]
["Anusha Ammu, MD","1386135713","75-2656723","TX","PE - Premier Family Care, Inc","First Health Coventry","Participating","Enrollment Complete","2024-01-01","","","2024-08-09","Received notification via email Dr. Ammu par as of 1/1/2024. FC"]
["Anusha Ammu, MD","1386135713","75-6000608","TX","PE - City of Midland Health Department","Multiplan","Participating","Enrollment Complete",45328,"","","2024-07-11","7/11/2024 As per Marcie Eckhart provider participating as of 2/6/2024. FC"]
["Anusha Ammu, MD","1386135713","75-6000608","TX","PE - City of Midland Health Department","Ambetter","Participating","Enrollment Complete",45383,"","","2024-04-29","Per email from Sebastian Flores (sebastian.flores@superiorhealthplan.com), provider is PAR and linked to TIN/location, eff.  04/01/2024. PA."]
["Anusha Ammu, MD","1386135713","75-2656723","TX","PE - Premier Family Care, Inc","Scott&White (First Care)","Participating","Enrollment Complete","2023-11-06","","","2024-01-29","1/29/2024 Rcvd confirmation from S&W that provider is PAR and linked to group TIN/location effective 11/6/2023.  DCannon"]
["Anusha Ammu, MD","1386135713","75-2656723","TX","PE - Premier Family Care, Inc","Omni PPO","Participating","Enrollment Complete",45236,"","","2024-01-02","1/2/2024 Rcvd email from German Avilies at IMS/OMNI that December delegation roster is complete.  Provider is PAR and linked to group TIN/location effective 11/6/2023.  DCannon"]
["Anusha Ammu, MD","1386135713","75-6000608","TX","PE - City of Midland Health Department","Cigna","In Process","Pending Contracting","","","","2024-05-07","Resent application directly to the provider to sign. MS"]
["Anusha Ammu, MD","1386135713","75-2656723","TX","PE - Premier Family Care, Inc","Medicaid","Participating","Enrollment Complete",45231,"","","2023-12-19","Rcvd TMHP Welcome letter. Provider effective 11/01/2023. Jen Videan"]
["Anusha Ammu, MD","1386135713","75-6000608","TX","PE - City of Midland Health Department","HealthSmart PPO","Participating","Enrollment Complete",45328,"","","2024-07-04","7/4/2024 provider participating as of 2/6/2024 as per Aleece Moerbe from HealthSmart via email confirmation. FC"]
["Anusha Ammu, MD","1386135713","75-2656723","TX","PE - Premier Family Care, Inc","Multiplan","Participating","Enrollment Complete",45236,"","","2024-05-24","Received email confirmation from Multiplan rep Jessica Bess (jessica.bess@multiplan.com), provider is PAR, eff. 11/06/2023. PA."]
["Anusha Ammu, MD","1386135713","75-6000608","TX","PE - City of Midland Health Department","Cigna Healthspring","Panel Closed","Panel Closed","","","","2024-04-18","Received letter the panel is closed. MS"]
["Anusha Ammu, MD","1386135713","75-6000608","TX","PE - City of Midland Health Department","Tricare Prime","Panel Closed","Panel Closed","","","","2024-03-04","Location is not Tricare Credentialed. Panel is closed. MS"]
["Anusha Ammu, MD","1386135713","75-6000608","TX","PE - City of Midland Health Department","Medicaid","In Process","Application Resubmitted","","","","2024-09-03","Application resubmitted. Request ID# 20545397. Jen Videan"]
["Anusha Ammu, MD","1386135713","75-2656723","TX","PE - Premier Family Care, Inc","Wellmed","Participating","Enrollment Complete","2023-11-06","00920011605","","2024-01-29","1/29/2024 Per UHC provider portal provider is PAR and linked to group TIN/locations effective 11/6/2023. MPIN # 00920011605.  DCannon"]
["Anusha Ammu, MD","1386135713","75-6000608","TX","PE - City of Midland Health Department","Superior","Participating","Enrollment Complete",45383,"","","2024-04-29","Per email from Sebastian Flores (sebastian.flores@superiorhealthplan.com), provider is PAR and linked to TIN/location, eff.  04/01/2024. PA."]
["Anusha Ammu, MD","1386135713","75-6000608","TX","PE - City of Midland Health Department","United Health Care","In Process","Payor Follow Up","","","","2024-08-21","Per UHC Network Account Manager, enrollment request has been escalated, case # 04702429, to have provider loaded to existing contract for City of Midland's TIN, eff. 02/06/2024. PA."]
["Anusha Ammu, MD","1386135713","75-2656723","TX","PE - Premier Family Care, Inc","USA PPO","In Process","Payor Follow Up","","","","2024-07-30","Sent email to payor requesting enrollment status update. PA."]
["Anusha Ammu, MD","1386135713","75-2656723","TX","PE - Premier Family Care, Inc","Humana","Participating","Enrollment Complete","2023-10-09","","","2024-06-21","Received email confirmation from Marcus Wester, provider is par and linked to TIN/location, eff. 10/09/2023. PA"]
["Anusha Ammu, MD","1386135713","75-6000608","TX","PE - City of Midland Health Department","PPHP","Participating","Enrollment Complete","2024-04-25","","","2024-07-12","Received email confirmation from PPHP,  provider is PAR and linked to TIN/location, eff. 04/25/2024.  PA."]
["Anusha Ammu, MD","1386135713","75-2656723","TX","PE - Premier Family Care, Inc","PPHP","Participating","Enrollment Complete",45407,"","","2024-07-12","Received email confirmation from PPHP,  provider is PAR and linked to TIN/location, eff. 04/25/2024.  PA."]
["Anusha Ammu, MD","1386135713","75-6000608","TX","PE - City of Midland Health Department","First Health Coventry","Participating","Enrollment Complete","2024-04-01","","","2024-07-17","As per Ashanti call ref#1130732, provider participating as of 4/1/2024, listed as a SPEC. FC"]
["Anusha Ammu, MD","1386135713","75-2656723","TX","PE - Premier Family Care, Inc","United Health Care","Participating","Enrollment Complete","2023-11-06","008925217","","2024-01-23","1/23/2024  Rcvd confirmation email from UHC that provider is PAR and linked to group TIN/location effective 11/6/2023.  MPIN # 008925217.  DCannon"]
["Anusha Ammu, MD","1386135713","75-2656723","TX","PE - Premier Family Care, Inc","Medicare","Participating","Enrollment Complete","2023-11-01","6C4889","","2023-11-28","Provider is already enrolled with this group and locations. MS"]
["Anusha Ammu, MD","1386135713","75-6000608","TX","PE - City of Midland Health Department","Caprock (CapStar)","Participating","Enrollment Complete","2023-10-20","","","2024-06-07","Received confirmation via email  from Mary mary.rodriguez@90degreebenefit.com provider participating as of 10/9/2023. FC"]
["Anusha Ammu, MD","1386135713","75-6000608","TX","PE - City of Midland Health Department","Aetna","Participating","Enrollment Complete","2024-02-06","","","2024-05-20","5/20/2024- Spoke to Nica M call ref # 6192807041 provider participating as of 2/6/2026. FC"]
["Anusha Ammu, MD","1386135713","75-6000608","TX","","Aetna","Participating","Enrollment Complete","2024-02-06","","","2024-05-20","5/20/2024- Spoke to Nica M call ref # 6192807041 provider participating as of 2/6/2026. FC"]
["Anusha Ammu, MD","1386135713","75-6000608","TX","PE - City of Midland Health Department","Aetna","Participating","Payor Follow Up","2024-02-06","","","2024-07-17","As per Dennis R call ref#6198039875, suite number is not tied to TIN. I will fax a letter of intent to 859-455-8650 for demographic update to add suite 22. FC"]
["Anusha Ammu, MD","1386135713","75-6000608","TX","","Aetna","Participating","Payor Follow Up","2024-02-06","","","2024-07-17","As per Dennis R call ref#6198039875, suite number is not tied to TIN. I will fax a letter of intent to 859-455-8650 for demographic update to add suite 22. FC"]
["Anusha Ammu, MD","1386135713","75-6000608","TX","PE - City of Midland Health Department","Triwest VA","Thru Other Payor","Payor Follow Up","","","","2024-08-19","Requested status update on enrollment via email to Scarlett Abigail. PA."]
["Anusha Ammu, MD","1386135713","75-2656723","TX","PE - Premier Family Care, Inc","Cigna","Participating","Enrollment Complete","2023-12-01","0446524","","2023-12-04","Received approval email effective 12/01/23. MS"]
["Glen Allen Bennion, DO","1386132876","83-0358685","TX","PE - Midland Community Healthcare Services","CAQH","In House Enrollment","In House Enrollment","","","","2023-11-03","11/3/2023 CAQH profile maintained by practice.  DCannon"]
["Glen Allen Bennion, DO","1386132876","83-0358685","TX","PE - Midland Community Healthcare Services","Amerigroup","Participating","Enrollment Complete","2023-11-06","","","2024-04-11","4/11/2024 As per Cassandra (WellPoint rep) Dr. Bennion is par effective 11/6/2023. FC"]
["Glen Allen Bennion, DO","1386132876","83-0358685","TX","PE - Midland Community Healthcare Services","Tricare Prime","Panel Closed","Panel Closed","","","","2023-11-05","Panel is closed to new providers until further notice. MS"]
["Glen Allen Bennion, DO","1386132876","83-0358685","TX","PE - Midland Community Healthcare Services","IMS","Participating","Enrollment Complete","2023-11-06","","","2024-01-02","1/2/2024 Rcvd email from German Avilies at IMS/OMNI that November delegation roster is complete.  Provider is PAR and linked to group TIN/location effective 11/6/2023.  DCannon"]
["Glen Allen Bennion, DO","1386132876","83-0358685","TX","PE - Midland Community Healthcare Services","USA PPO","Participating","Enrollment Complete","2023-11-06","","","2024-01-11","1/11/2024 Per email from USA MCO - LaNetricia Myart provider is PAR and linked to group TIN/location effective 11/6/2023.  Provider is also listed on the online provider directory.  DCannon"]
["Glen Allen Bennion, DO","1386132876","83-0358685","TX","PE - Midland Community Healthcare Services","HealthSmart PPO","Participating","Enrollment Complete","","","","2024-02-29","Per roster received from Aleece Moerbe (Aleece.Moerbe@healthsmart.com) on 02/23/2024, provider is PAR, eff. 11/6/2023. PA."]
["Glen Allen Bennion, DO","1386132876","83-0358685","TX","PE - Midland Community Healthcare Services","Aetna","Participating","Enrollment Complete","2023-11-06","","","2023-12-28","12/28/2023 S/W Paul of Aetna @ 1-800-353-1232. Per rep, Provider is in network with Aetna for the state of TX and linked to the group TIN and location effective 11/06/2023.  DCannon"]
["Glen Allen Bennion, DO","1386132876","83-0358685","TX","PE - Midland Community Healthcare Services","Cigna","Participating","Enrollment Complete","2023-11-01","8096880","","2024-01-03","Received confirmation. MS"]
["Glen Allen Bennion, DO","1386132876","83-0358685","TX","PE - Midland Community Healthcare Services","Omni PPO","Participating","Enrollment Complete","2023-11-06","","","2024-01-02","1/2/2024 Rcvd email from German Avilies at IMS/OMNI that November delegation roster is complete.  Provider is PAR and linked to group TIN/location effective 11/6/2023.  DCannon"]
["Glen Allen Bennion, DO","1386132876","83-0358685","TX","PE - Midland Community Healthcare Services","Boon Chapman","Participating","Enrollment Complete","2023-11-06","","","2023-12-20","12/20/2023 Per email from Jessica Bess at Multiplan November delegated roster provider load is complete.  Provider is PAR and linked to group TIN/location effective 11/6/2023.  DCannon"]
["Glen Allen Bennion, DO","1386132876","83-0358685","TX","PE - Midland Community Healthcare Services","Humana","Participating","Enrollment Complete","2023-11-06","","","2023-12-21","12/21/2023 Per Humana online directory provider is PAR and linked to group TIN and  all locations effective 11/6/2023.  DCannon"]
["Glen Allen Bennion, DO","1386132876","83-0358685","TX","PE - Midland Community Healthcare Services","TriCare Standard","Participating","Enrollment Complete","2023-11-06","","","2023-12-07","Provider is linked to the group eff 11/6/23. MS"]
["Glen Allen Bennion, DO","1386132876","83-0358685","TX","PE - Midland Community Healthcare Services","Scott&White (First Care)","Participating","Enrollment Complete","2023-11-06","","","2024-01-11","1/11/2024 Per email from Scott & White November roster has been completed.  Provider is PAR and linked to group TIN/location effective 11/6/2023.  DCannon"]
["Glen Allen Bennion, DO","1386132876","83-0358685","TX","PE - Midland Community Healthcare Services","United Health Care","Participating","Enrollment Complete","2023-11-06","008167479","","2023-12-27","12/27/2023 Per email rcvd from UHC provider is PAR and linked to group TIN and locations effective 11/6/2023.  MPIN # 008167479.  DCannon"]
["Glen Allen Bennion, DO","1386132876","83-0358685","TX","PE - Midland Community Healthcare Services","Wellmed","Participating","Enrollment Complete",45236,"","","2023-12-27","12/27/2023 Per email rcvd from UHC provider is PAR and linked to group TIN and locations effective 11/6/2023.  MPIN # 008167479.  DCannon"]
["Glen Allen Bennion, DO","1386132876","83-0358685","TX","PE - Midland Community Healthcare Services","Multiplan","Participating","Enrollment Complete",45236,"","","2023-12-20","12/20/2023 Rcvd email confirmation from Jessica Bess at Multiplan that November roster has been processed and provider is PAR w/ group effective 11/6/2023.  DCannon"]
["Glen Allen Bennion, DO","1386132876","83-0358685","TX","PE - Midland Community Healthcare Services","Caprock (CapStar)","Participating","Enrollment Complete",45236,"","","2023-11-30","11/30/2023 Per email received from Caprock, November Delegated roster has been completed.  Provider is PAR and linked to group TIN effective 11/6/2023.  DCannon"]
["Bethany M Wood, PA","1225283963","46-3131679","TX","PE - Midland Texas Orthopedic Group Inc","USA PPO","Participating","Enrollment Complete",45047,"","","2023-05-19","Checked enrollment status via https://providersearch.usamco.com/wintprovsearch . Provider is enrolled with Group Health and Wellness PPO. MS"]
["Bethany M Wood, PA","1225283963","46-3131679","TX","PE - Midland Texas Orthopedic Group Inc","Texas Municipal League","Participating","Enrollment Complete",45065,"","","2023-07-18","Michelle Killough confirmed provider is effective 5/19/2023. MS See Alliance for enrollment note updates."]
["Bethany M Wood, PA","1225283963","46-3131679","TX","PE - Midland Texas Orthopedic Group Inc","Medicaid","Participating","Enrollment Complete",45047,"","","2023-08-02","Rcvd approval letter from TMHP. Jen Videan"]
["Bethany M Wood, PA","1225283963","46-3131679","TX","PE - Midland Texas Orthopedic Group Inc","Sedgwick","Participating","Enrollment Complete","2024-06-19","1225283963","","2024-06-28","Approval ltr rcvd. Provider effective 06/19/2024. Jen Videan"]
["Bethany M Wood, PA","1225283963","46-3131679","TX","PE - Midland Texas Orthopedic Group Inc","Amerigroup","Participating","Re-Credentialing","2023-04-14","","","2024-04-15","4/17/2024- Submitted recred status via delegated monthly roster on 4/15/2024. FC."]
["Bethany M Wood, PA","1225283963","46-3131679","TX","PE - Midland Texas Orthopedic Group Inc","Omni PPO","Participating","Re-Credentialing","2023-04-14","","","2024-04-15","4/17/2024- Submitted recred status via delegated monthly roster on 4/15/2024. FC."]
["Bethany M Wood, PA","1225283963","46-3131679","TX","PE - Midland Texas Orthopedic Group Inc","Corvel Healthcare Corp.","Participating","Enrollment Complete","2023-04-14","","","2023-07-12","Received confirmation email from rep. MS"]
["Bethany M Wood, PA","1225283963","46-3131679","TX","PE - Midland Texas Orthopedic Group Inc","Galaxy Health","Participating","Enrollment Complete","2023-04-14","","","2023-07-20","7/20/2023 Per email received from Galaxy April  delegated roster has been processed and provider is PAR and linked to group effective 4/14/2023.  DCannon"]
["Bethany M Wood, PA","1225283963","46-3131679","TX","PE - Midland Texas Orthopedic Group Inc","HealthSmart PPO","Participating","Re-Credentialing","2023-04-14","","","2024-04-15","4/17/2024- Submitted recred status via delegated monthly roster on 4/15/2024. FC."]
["Bethany M Wood, PA","1225283963","46-3131679","TX","PE - Midland Texas Orthopedic Group Inc","Zurich","Delegated - Third Party","Thru Other Payor","","","","2024-01-26","Not listed on Coventry portal. Please add to next delegated submission. MS"]
["Bethany M Wood, PA","1225283963","46-3131679","TX","","Zurich","Delegated - Third Party","Thru Other Payor","","","","2024-01-26","Not listed on Coventry portal. Please add to next delegated submission. MS"]
["Bethany M Wood, PA","1225283963","46-3131679","TX","PE - Midland Texas Orthopedic Group Inc","Zurich","Delegated - Third Party","Payor Follow Up","","","","2024-08-09","8/9/2024 Emailed cssupport@cvty.us.com for network status for Zurich. FC"]
["Bethany M Wood, PA","1225283963","46-3131679","TX","","Zurich","Delegated - Third Party","Payor Follow Up","","","","2024-08-09","8/9/2024 Emailed cssupport@cvty.us.com for network status for Zurich. FC"]
["Bethany M Wood, PA","1225283963","46-3131679","TX","PE - Midland Texas Orthopedic Group Inc","Aetna","Participating","Re-Credentialing","2023-04-14","","","2024-04-15","4/17/2024- Submitted recred status via delegated monthly roster on 4/15/2024. FC."]
["Bethany M Wood, PA","1225283963","46-3131679","TX","PE - Midland Texas Orthopedic Group Inc","Superior","Participating","Enrollment Complete","2023-05-01","","","2023-07-25","7/25/2023 Rcvd confirmation email from Superior that April delegation roster has been processed and provider has been loaded to delegation roster and PAR w/ group effective 5/1/2023.  DCannon"]
["Bethany M Wood, PA","1225283963","46-3131679","TX","PE - Midland Texas Orthopedic Group Inc","Broadspire Services Inc.","Participating","Enrollment Complete","2024-01-11","","","2024-07-08","Contract complete. Effective 01/11/2024. Provider was listed on par provider roster submitted with contract. Jen Videan"]
["Bethany M Wood, PA","1225283963","46-3131679","TX","PE - Midland Texas Orthopedic Group Inc","Liberty Mutual","Delegated - Third Party","Thru Other Payor","","","","2024-01-26","Not listed on Coventry portal. Please add to next roster submission. MS"]
["Bethany M Wood, PA","1225283963","46-3131679","TX","PE - Midland Texas Orthopedic Group Inc","Coventry Workers Comp","Participating","Enrollment Complete","2023-05-25","","","2024-04-25","4/25/2024 provider participating as of 5/25/2023 via roster. FC"]
["Bethany M Wood, PA","1225283963","46-3131679","TX","PE - Midland Texas Orthopedic Group Inc","Wellmed","Participating","Enrollment Complete","2023-05-01","","","2023-12-28","12/28/2023 Per UHC web portal provider is PAR and linked to group TIN/location effective 5/1/2023.  DCannon"]
["Bethany M Wood, PA","1225283963","46-3131679","TX","PE - Midland Texas Orthopedic Group Inc","TriCare Standard","Participating","Enrollment Complete","2023-04-25","","","2023-10-19","Received enrollment confirmation. MS"]
["Bethany M Wood, PA","1225283963","46-3131679","TX","PE - Midland Texas Orthopedic Group Inc","Rail Road Medicare","Participating","Enrollment Complete","2023-05-01","","","2023-08-21","Received confirmation. MS"]
["Bethany M Wood, PA","1225283963","46-3131679","TX","PE - Midland Texas Orthopedic Group Inc","Alliance WC","Participating","Enrollment Complete","2023-05-19","","","2023-05-22","Michelle Killough confirmed provider is effective 5/19/2023. MS"]
["Bethany M Wood, PA","1225283963","46-3131679","TX","PE - Midland Texas Orthopedic Group Inc","Medicare","Participating","Enrollment Complete","2023-05-01","2T0202","","2023-05-10","5/10/2023 Rcvd Medicare approval letter.  PTAN # 2T0202 - effective 5/1/2023.   DCannon"]
["Bethany M Wood, PA","1225283963","46-3131679","TX","PE - Midland Texas Orthopedic Group Inc","Cigna","Participating","Enrollment Complete","2023-07-01","","","2023-09-15","Received confirmation email with effective date. MS"]
["Bethany M Wood, PA","1225283963","46-3131679","TX","PE - Midland Texas Orthopedic Group Inc","Cigna Healthspring","Pending Other Enrollment","Pending Other Enrollment","","","","2024-07-23","Group letter of interest was submitted. They payer has received it and after reviewing if they want to contract, they will be reaching out to me for additional info and the roster. Nothing is needed until then. MS"]
["Bethany M Wood, PA","1225283963","46-3131679","TX","PE - Midland Texas Orthopedic Group Inc","Humana","Participating","Enrollment Complete","2023-04-14","","","2023-09-19","9/19/2023 - Received email that delegation roster has been completed.  Provider is PAR and linked to group TIN/location effective 4/14/2023.  DCannon"]
["Bethany M Wood, PA","1225283963","46-3131679","TX","PE - Midland Texas Orthopedic Group Inc","CAQH","Participating","CAQH Reattested","2024-07-05","","","2024-07-05","07/05/2024 CAQH Reattested all locations current and all expirables up to date wthompson"]
["Bethany M Wood, PA","1225283963","46-3131679","TX","PE - Midland Texas Orthopedic Group Inc","United Health Care","Participating","Enrollment Complete","2023-05-01","003614004","","2023-11-15","11/15/2023 Per email received from UHC provider is PAR and linked to group TIN effective 5/1/2023.  MPIN# 003614004.  DCannon"]
["Bethany M Wood, PA","1225283963","46-3131679","TX","PE - Midland Texas Orthopedic Group Inc","Gallagher","Delegated - Third Party","Thru Other Payor","","","","2024-01-26","Not listed on Coventry portal. Please add to next roster submission. MS"]
["Bethany M Wood, PA","1225283963","46-3131679","TX","PE - Midland Texas Orthopedic Group Inc","Tricare Prime","Participating","Enrollment Complete","2023-04-25","","","2024-01-26","Confirmed provider is credentialed and in network with Tricare. MS"]
["Bethany M Wood, PA","1225283963","46-3131679","TX","PE - Midland Texas Orthopedic Group Inc","Texas Mutual","Participating","Enrollment Complete","2023-08-01","","","2023-08-08","Rcvd approval letter. Effective 08/01/2023. Jen Videan"]
["Bethany M Wood, PA","1225283963","46-3131679","TX","PE - Midland Texas Orthopedic Group Inc","Multiplan","Participating","Re-Credentialing","2023-04-14","","","2024-04-15","4/17/2024- Submitted recred status via delegated monthly roster on 4/15/2024. FC."]
["Bethany M Wood, PA","1225283963","46-3131679","TX","PE - Midland Texas Orthopedic Group Inc","IMS","Participating","Re-Credentialing","2023-04-14","","","2024-04-15","4/17/2024- Submitted recred status via delegated monthly roster on 4/15/2024. FC."]
["Bethany M Wood, PA","1225283963","46-3131679","TX","PE - Midland Texas Orthopedic Group Inc","Caprock (CapStar)","Participating","Re-Credentialing","2023-04-14","","","2024-04-15","4/17/2024- Submitted recred status via delegated monthly roster on 4/15/2024. FC."]
["Bethany M Wood, PA","1225283963","46-3131679","TX","PE - Midland Texas Orthopedic Group Inc","First Health Coventry","Participating","Payor Follow Up","2023-04-14","","","2024-05-16","5/16/2024 Payor has incorrect address, updated address submitted via delegated roster on 5/15/2024. FC"]
["Bethany M Wood, PA","1225283963","46-3131679","TX","PE - Midland Texas Orthopedic Group Inc","Triwest VA","In House Enrollment","In House Enrollment","","","","2023-04-18",""]
["Bethany M Wood, PA","1225283963","46-3131679","TX","PE - Midland Texas Orthopedic Group Inc","Scott&White (First Care)","Participating","Enrollment Complete","2023-04-14","","","2023-08-17","8/17/2023 Received email from Scott & White HPDELEGATION@BSWHealth.org that provider load from April has been completed and provider is PAR effective 4/14/2023.  DCannon"]
["Bethany M Wood, PA","1225283963","46-3131679","TX","PE - Midland Texas Orthopedic Group Inc","Molina","Pending Other Enrollment","Pending Contracting","","","","2024-08-07","Contract request form for the group and provider was submitted to mhtcontractrequest@molinahealthcare.com MS"]
["Bethany M Wood, PA","1225283963","46-3131679","TX","PE - Midland Texas Orthopedic Group Inc","Boon Chapman","Participating","Enrollment Complete","2023-04-14","","","2023-07-25","7/25/2023 Rcvd email from Jessica Bess at Multiplan with a full roster and provider is PAR w/ group effective 4/14/2023.  DCannon"]
["Bethany M Wood, PA","1225283963","46-3131679","TX","PE - Midland Texas Orthopedic Group Inc","Medicaid","Participating","Enrollment Complete","2023-05-01","","","2024-07-25","Revalidation approval ltr rcvd. Effective 05/01/2023. Jen Videan"]
["Bethany M Wood, PA","1225283963","46-3131679","TX","PE - Midland Texas Orthopedic Group Inc","Wellcare","Participating","Enrollment Complete","2023-05-01","","","2023-07-25","7/25/2023 Rcvd confirmation email from Superior that April delegation roster has been processed and provider has been loaded to delegation roster and PAR w/ group effective 5/1/2023.  DCannon"]
["Bethany M Wood, PA","1225283963","46-3131679","TX","PE - Midland Texas Orthopedic Group Inc","Ambetter","Participating","Enrollment Complete",45047,"","","2023-07-25","7/25/2023 Rcvd confirmation email from Superior that April delegation roster has been processed and provider has been loaded to delegation roster and PAR w/ group effective 5/1/2023.  DCannon"]
["Bethany M Wood, PA","1225283963","46-3131679","TX","PE - Midland Texas Orthopedic Group Inc","Hartford","Delegated - Third Party","Thru Other Payor","","","","2024-01-26","Not listed in Coventry portal. Please add to next roster submission. MS"]
["Bethany M Wood, PA","1225283963","46-3131679","TX","PE - Midland Texas Orthopedic Group Inc","Travelers WC","Delegated - Third Party","Thru Other Payor","","","","2024-01-26","Not listed in Coventry portal. Please add to next roster submission. MS"]
["Ryan S Rowland, MD","1740542034","46-0950925","TX","PE - Urgent Orthopedic Specialists, PLLC","USA PPO","Participating","Enrollment Complete",43312,"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",43363,"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",44713,"","","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","Coventry Workers Comp","In Process","Add Info Submitted","","","","2024-08-19","8/19/2024 Submitted via roster to Coventry. FC"]
["Ryan S Rowland, MD","1740542034","46-0950925","TX","PE - Urgent Orthopedic Specialists, PLLC","Galaxy Health","Participating","Enrollment Complete","2019-09-01","1740542034","","2020-08-24","08/21/2020 - Rec'd email confirmation that this roster was processed and this provider was made effective with the requested eff date of 9-1-2019 - Stacey Hudak"]
["Ryan S Rowland, MD","1740542034","46-0950925","TX","PE - Urgent Orthopedic Specialists, PLLC","CAQH","Participating","CAQH Reattested","2024-08-26","","","2024-08-26","08/26/2024 CAQH Reattested updated and uploaded COI and license wthompson"]
["Ryan S Rowland, MD","1740542034","46-0950925","TX","PE - Urgent Orthopedic Specialists, PLLC","IMS","Participating","Enrollment Complete",43305,"1740542034","","2020-06-22","06/22/2020- Rec'd email from the payer confirming this provider is PAR with this group/service location - Stacey Hudak"]
["Ryan S Rowland, MD","1740542034","46-0950925","TX","PE - Urgent Orthopedic Specialists, PLLC","Caprock (CapStar)","Participating","Enrollment Complete","2018-07-24","1740542034","","2020-06-02","06/02/2020 - rec'd spreadsheet back from the payer Mary Rodriguez <MRodriguez@caprockhp.com> confirming this provider/service location is EFF with this payer - Stacey Hudak"]
["Ryan S Rowland, MD","1740542034","46-0950925","TX","PE - Urgent Orthopedic Specialists, PLLC","Multiplan","Participating","Enrollment Complete","2018-08-16","1740542034","","2020-09-08","09/08/2020 - Found response from the payer stating \"Thank you for contacting our Service Department at MultiPlan. Here is the following information we have on file for Multiple providers listed below:\n\nNetwork: Beech St, MPI, & PHCS\nNetwork Participation effective: Please see below\nContract Source Group contract through: Please see below\nRyan S Rowland, MD NPI: 1740542034 – \n5026 – West Texas Physicians Alliance –  Beech St Eff Date 07/11/2018\n23655 – West Texas Physicians Alliance –  MPI Eff Date 08/16/2018\n52669 – West Texas Physicians Alliance – PHCS Eff Date 08/16/2018\" - Stacey Hudak"]
["Ryan S Rowland, MD","1740542034","46-0950925","TX","PE - Urgent Orthopedic Specialists, PLLC","Wellmed","Participating","Enrollment Complete","2022-01-01","","","2023-03-23","3/23/2023 Rcvd roster from UHC w/ all Wellmed participating providers.  Provider is PAR effective 1/1/2022.  DCannon"]
["Ryan S Rowland, MD","1740542034","46-0950925","TX","PE - Urgent Orthopedic Specialists, PLLC","United Health Care","Participating","Enrollment Complete","2018-07-24","1740542034","","2020-08-31","08/31/2020 - moved to completed status after reviewing follow up complete note from 8/28/2020 - Stacey Hudak"]
["Ryan S Rowland, MD","1740542034","46-0950925","TX","PE - Urgent Orthopedic Specialists, PLLC","Triwest VA","Participating","Enrollment Complete",44774,"","","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",43313,"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"]
["Ryan S Rowland, MD","1740542034","46-0950925","TX","PE - Urgent Orthopedic Specialists, PLLC","Medicaid","In Process","Payor Follow Up","","","","2024-08-21","Application in PE Review status. Jen Videan"]
["Pamela F Doughty, PA","1346807278","46-0950925","TX","PE - Urgent Orthopedic Specialists, PLLC","Ambetter","Participating","Enrollment Complete",44713,"","","2022-06-13","6/13/2022 Per roster received from Superior provider is PAR and linked to group delegation roster effective 6/1/2022."]
["Pamela F Doughty, PA","1346807278","46-0950925","TX","PE - Urgent Orthopedic Specialists, PLLC","Galaxy Health","Participating","Enrollment Complete",43709,"1346807278","","2020-08-24","08/21/2020 - Rec'd email confirmation that this roster was processed and this provider was made effective with the requested eff date of 9-1-2019 - Stacey Hudak"]
["Pamela F Doughty, PA","1346807278","46-0950925","TX","PE - Urgent Orthopedic Specialists, PLLC","Caprock (CapStar)","Participating","Enrollment Complete",43709,"1346807278","","2020-09-23","09/23/2020 - rec'd confirmation from the payer that this August 2020 roster was completed. This provider/service location was added to PriMed Agreement - OK to move to completed status. - Stacey Hudak"]
["Pamela F Doughty, PA","1346807278","46-0950925","TX","PE - Urgent Orthopedic Specialists, PLLC","United Health Care","Participating","Enrollment Complete",43971,"1346807278","","2020-08-31","08/31/2020 - moved to completed status after reviewing follow up completed status - Stacey Hudak"]
["Pamela F Doughty, PA","1346807278","46-0950925","TX","PE - Urgent Orthopedic Specialists, PLLC","CAQH","Participating","CAQH Reattested",45530,"","","2024-08-26","08/26/2024 CAQH Reattested updated and uploaded COI wthompson"]
["Pamela F Doughty, PA","1346807278","46-0950925","TX","PE - Urgent Orthopedic Specialists, PLLC","Superior","Participating","Enrollment Complete","2020-08-01","1346807278","","2020-08-06","8/6/2020 - Rec'd an email from the payer stating this provider was added to their database EFF: 8-1-2020 after receiving/processing the July roster - Stacey Hudak"]
["Pamela F Doughty, PA","1346807278","46-0950925","TX","PE - Urgent Orthopedic Specialists, PLLC","Wellmed","Participating","Enrollment Complete",44562,"","","2023-03-23","3/23/2023 Rcvd roster from UHC w/ all Wellmed participating providers.  Provider is PAR effective 1/1/2022.  DCannon"]
["Pamela F Doughty, PA","1346807278","46-0950925","TX","PE - Urgent Orthopedic Specialists, PLLC","Multiplan","Participating","Enrollment Complete",43964,"1346807278","","2020-09-08","09/08/2020 - Rec'd email response from the payer stating \" Network: Beech St, MPI, & PHCS\nNetwork Participation effective: Please see below\nContract Source Group contract through: Please see below:\n\nPamela F Doughty, PA NPI: 1346807278\n5026 – West Texas Physicians Alliance –Beech St Eff Date 05/06/2020\n23655 – West Texas Physicians Alliance – MPI Eff Date 05/13/2020\n52669 – West Texas Physicians Alliance – PHCS Eff Date 05/13/2020\"\n- Stacey Hudak"]
["Pamela F Doughty, PA","1346807278","46-0950925","TX","PE - Urgent Orthopedic Specialists, PLLC","Medicaid","Participating","In House Enrollment","2020-01-05","412587401","325373401","2020-08-13","8/13/2020 - rec'd effective letter from the clinic. HOwever, this is not a payer that they asked Symplr to maintain. Created a payer line to house effective info if needed by another payer for enrollment - Stacey Hudak"]
["Pamela F Doughty, PA","1346807278","46-0950925","TX","PE - Urgent Orthopedic Specialists, PLLC","Scott&White (First Care)","Participating","Enrollment Complete","2020-09-28","","","2021-01-29","1/29/2021 - Rcvd roster from Scott&White (First Care) confirming participation of provider with TIN and location effective dates.  DCannon"]
["Pamela F Doughty, PA","1346807278","46-0950925","TX","PE - Urgent Orthopedic Specialists, PLLC","First Health Coventry","Participating","Enrollment Complete","2020-09-01","","","2020-12-10","12/10/2020 - Per First Health provider is active and linked to practice location effective 9/1/2020.  DCannon"]
["Pamela F Doughty, PA","1346807278","46-0950925","TX","PE - Urgent Orthopedic Specialists, PLLC","Humana","Participating","Enrollment Complete","2017-05-01","","","2021-11-18","11/18/2021 Rcvd full roster from Humana listing provider as PAR and linked to group TIN/location effective 5/1/2017.  DCannon"]
["Pamela F Doughty, PA","1346807278","46-0950925","TX","PE - Urgent Orthopedic Specialists, PLLC","USA PPO","Participating","Enrollment Complete","2021-01-26","1312287","","2021-03-12","3/12/2021 Per verification on payor website USAMCO.com provider is loaded as participating.  Rcvd Roster LeNetrice Myart with provider numbers and effective dates for providers.  DCannon"]
["Pamela F Doughty, PA","1346807278","46-0950925","TX","PE - Urgent Orthopedic Specialists, PLLC","Wellcare","Participating","Enrollment Complete","2021-11-01","","","2022-11-15","11/15/2022 Per roster received from Wellcare provider is PAR and linked to group TIN/location effective 11/1/2021.  DCannon"]
["Pamela F Doughty, PA","1346807278","46-0950925","TX","PE - Urgent Orthopedic Specialists, PLLC","IMS","Participating","Enrollment Complete","2019-09-01","1346807278","","2020-07-27","07/27/2020 - Rec'd roster response back from the payer regarding 7/15/2020 submission stating that all requested providers/service locations have been added to PriMed agreement - Stacey Hudak"]
["Pamela F Doughty, PA","1346807278","46-0950925","TX","PE - Urgent Orthopedic Specialists, PLLC","HealthSmart PPO","Participating","Enrollment Complete","2020-05-06","13725946","","2020-07-21","07/21/2020 - rec'd email with a spreadsheet from the payer stating this provider/TIN/service location are all PAR with WEST TEXAS PHYSICIANS ALLIANCE Delegated - Stacey Hudak"]
["Pamela F Doughty, PA","1346807278","46-0950925","TX","PE - Urgent Orthopedic Specialists, PLLC","Coventry Workers Comp","In Process","Add Info Submitted","","","","2024-08-19","8/19/2024 Submitted via roster to Coventry. FC"]
["Pamela F Doughty, PA","1346807278","46-0950925","TX","PE - Urgent Orthopedic Specialists, PLLC","Triwest VA","In House Enrollment","In House Enrollment","","","","2021-01-13","01/06/2021 - MQA Team is working with Representatives at BCBS-TX to ensure all providers are enrolled and loaded to participate with the VACCN network in a timely manner. However, we are currently awaiting a full roster of providers currently participating and will update all records accordingly upon receipt. Kfrazier"]
["Pamela F Doughty, PA","1346807278","46-0950925","TX","PE - Urgent Orthopedic Specialists, PLLC","Amerigroup","Participating","Enrollment Complete",43936,"","","2024-08-29","Received confirmation from Cassandra Dunagon provider is participating with all products. FC"]
["Pamela F Doughty, PA","1346807278","46-0950925","TX","PE - Urgent Orthopedic Specialists, PLLC","Aetna","Participating","Enrollment Complete",44075,"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",43399,"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",45478,"","","2024-07-05","07/05/2024 CAQH Reattested all locations current and all expirables up to date wthompson"]
["Gautham S Gadiraju, MD","1649462987","47-5554737","TX","PE - Midland Inpatient Medical Association","Galaxy Health","Participating","Enrollment Complete",43399,"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","Medicaid","Participating","Enrollment Complete",43313,"387144401","364596201","2023-12-19","Revalidation approval letter rcvd. Effective 08/01/2018. Jen Videan"]
["Gautham S Gadiraju, MD","1649462987","47-5554737","TX","PE - Midland Inpatient Medical Association","United Health Care","Participating","Enrollment Complete",43313,"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",43374,"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","Wellmed","Participating","Enrollment Complete","2020-06-01","","","2023-03-23","3/23/2023 Rcvd roster from UHC w/ all Wellmed participating providers.  Provider is PAR effective 6/1/2020.  DCannon"]
["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",43508,"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","2024-08-29","","","2024-08-29","08/29/2024 CAQH Reattested updated and uploaded COI wthompson"]
["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",43434,"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",43374,"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",43313,"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",44501,"","","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",43399,"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",43399,"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",44652,"","","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",43435,"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",43344,"377470502","364596201","2023-08-22","Revalidation approval ltr rcvd via TMHP website. Effective 09/01/2018. Jen Videan"]
["Vamsi K Korrapati, MD","1407149883","47-5554737","TX","PE - Midland Inpatient Medical Association","Aetna","Participating","Enrollment Complete",43419,"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","83-0358685","TX","PE - Midland Community Healthcare Services","Wellcare","Participating","Enrollment Complete","2024-04-01","","","2024-04-29","Per email from Sebastian Flores (sebastian.flores@superiorhealthplan.com), provider is PAR and linked to TIN/location, eff.  04/01/2024. PA."]
["Kevin W Benson, MD","1326061086","83-0358685","TX","PE - Midland Community Healthcare Services","Aetna","Participating","Enrollment Complete","2024-03-11","","","2024-06-03","Per Aetna rep Irish G, 1-800-353-1232, reference #6194100173, provider is  PAR, effective 3/11/2024, linked to TIN and location. PA"]
["Kevin W Benson, MD","1326061086","83-0358685","TX","PE - Midland Community Healthcare Services","HealthSmart PPO","Participating","Enrollment Complete","2024-03-11","","","2024-08-30","Received confirmation via email from Aleece Moerbe provider participating as of 3/11/2024. FC"]
["Kevin W Benson, MD","1326061086","83-0358685","TX","PE - Midland Community Healthcare Services","Cigna","Participating","Enrollment Complete","2024-02-12","7487489","","2024-04-05","Received confirmation of enrollment via email. MS"]
["Kevin W Benson, MD","1326061086","83-0358685","TX","PE - Midland Community Healthcare Services","Humana","In Process","Payor Follow Up","","","","2024-08-27","Sent follow up email to Network Manager Erica Lee, requesting status. PA."]
["Kevin W Benson, MD","1326061086","83-0358685","TX","PE - Midland Community Healthcare Services","Scott&White (First Care)","In Process","Payor Follow Up","","","","2024-07-26","Sent email to payor requesting enrollment status. PA."]
["Kevin W Benson, MD","1326061086","83-0358685","TX","PE - Midland Community Healthcare Services","Superior","Participating","Enrollment Complete",45383,"","","2024-04-29","Per email from Sebastian Flores (sebastian.flores@superiorhealthplan.com), provider is PAR and linked to TIN/location, eff.  04/01/2024. PA."]
["Kevin W Benson, MD","1326061086","83-0358685","TX","PE - Midland Community Healthcare Services","Wellmed","Thru Other Payor","Thru Other Payor","","","","2024-03-19","Pending UHC enrollment. PA."]
["Kevin W Benson, MD","1326061086","83-0358685","TX","PE - Midland Community Healthcare Services","Amerigroup","Participating","Enrollment Complete",45364,"","","2024-08-08","Provider PAR with Star, Star kids, and Star + eff date 3/13/2024 as per roster received from Cassandra via email. FC"]
["Kevin W Benson, MD","1326061086","83-0358685","TX","PE - Midland Community Healthcare Services","Tricare Prime","Panel Closed","Panel Closed","","","","2024-03-12","Location is not Tricare Credentialed, panel is closed. MS"]
["Kevin W Benson, MD","1326061086","83-0358685","TX","PE - Midland Community Healthcare Services","First Health Coventry","Participating","Enrollment Complete",45383,"","","2024-08-08","Provider participating as of 4/1/2024 listed as Pediatrics, spoke to Tash call ref#11607782. FC"]
["Kevin W Benson, MD","1326061086","83-0358685","TX","PE - Midland Community Healthcare Services","TriCare Standard","Participating","Enrollment Complete",45363,"","","2024-04-29","Provider is linked to this location eff 3/12/24. MS"]
["Kevin W Benson, MD","1326061086","83-0358685","TX","PE - Midland Community Healthcare Services","Caprock (CapStar)","Participating","Enrollment Complete","2023-12-28","","","2024-08-16","Received confirmation from Mary Rodriguez via e,mail, provider participating as of 12/28/2023. FC"]
["Kevin W Benson, MD","1326061086","83-0358685","TX","PE - Midland Community Healthcare Services","Multiplan","Participating","Enrollment Complete",45362,"","","2024-08-16","Received confirmation from Jessica Bess via email provider participating as of 3/11/2024. FC"]
["Kevin W Benson, MD","1326061086","83-0358685","TX","PE - Midland Community Healthcare Services","Ambetter","Participating","Enrollment Complete","2024-04-01","","","2024-04-29","Per email from Sebastian Flores (sebastian.flores@superiorhealthplan.com), provider is PAR and linked to TIN/location, eff.  04/01/2024. PA."]
["Kevin W Benson, MD","1326061086","83-0358685","TX","PE - Midland Community Healthcare Services","United Health Care","Participating","Enrollment Complete",45362,"","","2024-08-08","Received confirmation provider is PAR and linked to TIN/location, eff. 3/11/2024. Product roster uploaded. PA."]
["John W Mathewson, MD","1588857874","46-3131679","TX","PE - Midland Texas Orthopedic Group Inc","Cigna Healthspring","Pending Other Enrollment","Pending Other Enrollment","","","","2024-07-23","Group letter of interest was submitted. They payer has received it and after reviewing if they want to contract, they will be reaching out to me for additional info and the roster. Nothing is needed until then. MS"]
["John W Mathewson, MD","1588857874","46-3131679","TX","PE - Midland Texas Orthopedic Group Inc","Medicare","Participating","Enrollment Complete","2019-03-01","774291","320497","2021-09-10","9/10/2021 Received written revalidation approval for provider under provider PTAN 774291. KFrazier"]
["John W Mathewson, MD","1588857874","46-3131679","TX","PE - Midland Texas Orthopedic Group Inc","Ambetter","Participating","Enrollment Complete","2022-04-01","","","2022-06-13","6/13/2022 Per roster received from Superior provider is PAR and linked to group delegation roster effective 4/1/2022."]
["John W Mathewson, MD","1588857874","46-3131679","TX","PE - Midland Texas Orthopedic Group Inc","Wellmed","Participating","Enrollment Complete","2022-01-01","","","2023-03-23","3/23/2023 Rcvd roster from UHC w/ all Wellmed participating providers.  Provider is PAR effective 1/1/2022.  DCannon"]
["John W Mathewson, MD","1588857874","46-3131679","TX","PE - Midland Texas Orthopedic Group Inc","Alliance WC","Participating","Enrollment Complete","2019-05-10","","","2024-07-24","Approval Ltr rcvd. Effective 05/10/2019. Jen Videan"]
["John W Mathewson, MD","1588857874","46-3131679","TX","PE - Midland Texas Orthopedic Group Inc","Multiplan","Participating","Re-Credentialing","2020-05-21","1588857874","","2024-04-19","4/19/2024- Submitted recred status via delegated monthly roster on 4/15/2024. FC"]
["John W Mathewson, MD","1588857874","46-3131679","TX","PE - Midland Texas Orthopedic Group Inc","Caprock (CapStar)","Participating","Re-Credentialing",43559,"1588857874","","2024-04-19","4/19/2024- Submitted recred status via delegated monthly roster on 4/15/2024. FC"]
["John W Mathewson, MD","1588857874","46-3131679","TX","PE - Midland Texas Orthopedic Group Inc","CAQH","Participating","CAQH Reattested","2024-07-05","","","2024-07-05","07/05/2024 CAQH Reattested all locations current and all expirables up to date wthompson"]
["John W Mathewson, MD","1588857874","46-3131679","TX","PE - Midland Texas Orthopedic Group Inc","Omni PPO","Participating","Re-Credentialing","2019-05-21","1588857874","","2024-04-19","4/19/2024- Submitted recred status via delegated monthly roster on 4/15/2024. FC"]
["John W Mathewson, MD","1588857874","46-3131679","TX","PE - Midland Texas Orthopedic Group Inc","Medicaid","Participating","Enrollment Complete","","","","2024-08-22","Revalidation approval ltr rcvd. Jen Videan"]
["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",43616,"","","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","Sedgwick","Participating","Enrollment Complete","2024-06-19","1588857874","","2024-06-28","Approval ltr rcvd. Provider effective 06/19/2024. Jen Videan"]
["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","Re-Credentialing","2019-05-21","1588857874","","2024-04-19","4/19/2024- Submitted recred status via delegated monthly roster on 4/15/2024. FC"]
["John W Mathewson, MD","1588857874","46-3131679","TX","PE - Midland Texas Orthopedic Group Inc","Molina","Pending Other Enrollment","Pending Contracting","","","","2024-08-07","Contract request form for the group and provider was submitted to mhtcontractrequest@molinahealthcare.com MS"]
["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","Re-Credentialing",43586,"2650428","","2024-04-19","4/19/2024- Submitted recred status via delegated monthly roster on 4/15/2024. FC"]
["John W Mathewson, MD","1588857874","46-3131679","TX","PE - Midland Texas Orthopedic Group Inc","Texas Municipal League","Participating","Enrollment Complete",43595,"","","2024-07-24","Please see status updates under Alliance WC payor line. Jen Videan"]
["John W Mathewson, MD","1588857874","46-3131679","TX","PE - Midland Texas Orthopedic Group Inc","Triwest VA","Participating","Enrollment Complete",44774,"","","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","Tricare Prime","Participating","Enrollment Complete",43574,"","","2024-01-26","Confirmed provider is credentialed and in network with Tricare. MS"]
["John W Mathewson, MD","1588857874","46-3131679","TX","PE - Midland Texas Orthopedic Group Inc","Boon Chapman","Participating","Enrollment Complete",43952,"","","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",43525,"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",43831,"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","Corvel Healthcare Corp.","Participating","Enrollment Complete",44313,"1588857874","","2024-05-07","Provider active with Corvel. Jen Videan"]
["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","Re-Credentialing","2019-05-21","1588857874","","2024-04-19","4/19/2024- Submitted recred status via delegated monthly roster on 4/15/2024. FC"]
["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","Re-Credentialing","2021-02-12","1588857874","","2024-04-19","4/19/2024- Submitted recred status via delegated monthly roster on 4/15/2024. FC"]
["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","Re-Credentialing","2019-05-31","1588857874","","2024-04-19","4/19/2024- Submitted recred status via delegated monthly roster on 4/15/2024. FC"]
["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"]
["John W Mathewson, MD","1588857874","46-3131679","TX","PE - Midland Texas Orthopedic Group Inc","Coventry Workers Comp","In Process","Add Info Submitted","","","","2024-08-19","8/19/2024 Submitted via roster to Coventry. FC"]
["John W Mathewson, MD","1588857874","46-3131679","TX","PE - Midland Texas Orthopedic Group Inc","Broadspire Services Inc.","Participating","Enrollment Complete",45302,"","","2024-07-08","Contract complete. Effective 01/11/2024. Provider was listed on par provider roster submitted with contract. Jen Videan"]
["Kristin L Rettig, PA","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","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","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","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","1164778767","46-3131679","TX","PE - Midland Texas Orthopedic Group Inc","Amerigroup","Participating","Re-Credentialing","2021-02-12","1164778767","","2024-04-19","4/19/2024- Submitted recred status via delegated monthly roster on 4/15/2024. FC"]
["Kristin L Rettig, PA","1164778767","46-3131679","TX","PE - Midland Texas Orthopedic Group Inc","IMS","Participating","Re-Credentialing",43606,"1164778767","","2024-04-19","4/19/2024- Submitted recred status via delegated monthly roster on 4/15/2024. FC"]
["Kristin L Rettig, PA","1164778767","46-3131679","TX","PE - Midland Texas Orthopedic Group Inc","Sedgwick","Participating","Enrollment Complete",45462,"1164778767","","2024-06-28","Approval ltr rcvd. Provider effective 06/19/2024. Jen Videan"]
["Kristin L Rettig, PA","1164778767","46-3131679","TX","PE - Midland Texas Orthopedic Group Inc","CAQH","Participating","CAQH Reattested",45478,"","","2024-07-05","07/05/2024 CAQH Reattested all locations current and all expirables up to date"]
["Kristin L Rettig, PA","1164778767","46-3131679","TX","PE - Midland Texas Orthopedic Group Inc","Texas Municipal League","Thru Other Payor","Thru Other Payor","","","","2024-08-13","Please see status updates under Alliance WC payor line. Jen Videan"]
["Kristin L Rettig, PA","1164778767","46-3131679","TX","PE - Midland Texas Orthopedic Group Inc","Cigna Healthspring","Pending Other Enrollment","Pending Other Enrollment","","","","2024-07-23","Group letter of interest was submitted. They payer has received it and after reviewing if they want to contract, they will be reaching out to me for additional info and the roster. Nothing is needed until then. MS"]
["Kristin L Rettig, PA","1164778767","46-3131679","TX","PE - Midland Texas Orthopedic Group Inc","Wellmed","Participating","Enrollment Complete","2022-01-01","","","2023-03-23","3/23/2023 Rcvd roster from UHC w/ all Wellmed participating providers.  Provider is PAR effective 1/1/2022.  DCannon"]
["Kristin L Rettig, PA","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","1164778767","46-3131679","TX","PE - Midland Texas Orthopedic Group Inc","Alliance WC","In Process","Payor Follow Up","","","","2024-08-13","Per michelle.killough@pswca.org, provider has been approved to join network. Submit Provider Data Form with license, DEA, Cert, COI and W9. \nEmailed above to michelle.killough@pswca.org. Jen Videan"]
["Kristin L Rettig, PA","1164778767","46-3131679","TX","PE - Midland Texas Orthopedic Group Inc","Caprock (CapStar)","Participating","Re-Credentialing","2019-05-21","1164778767","","2024-04-19","4/19/2024- Submitted recred status via delegated monthly roster on 4/15/2024. FC"]
["Kristin L Rettig, PA","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","1164778767","46-3131679","TX","PE - Midland Texas Orthopedic Group Inc","Medicaid","Participating","Enrollment Complete","2019-02-18","362149203","331090601","2024-02-21","Rcvd revalidation approval ltr. Jen Videan"]
["Kristin L Rettig, PA","1164778767","46-3131679","TX","PE - Midland Texas Orthopedic Group Inc","Corvel Healthcare Corp.","In Process","Payor Follow Up","","","","2024-08-13","Allow up to 180 days for processing. Roster just submitted 07/29/2024. Allow more time. Jen Videan"]
["Kristin L Rettig, PA","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","1164778767","46-3131679","TX","PE - Midland Texas Orthopedic Group Inc","First Health Coventry","Participating","Re-Credentialing","2019-05-01","3039403","","2024-04-19","4/19/2024- Submitted recred status via delegated monthly roster on 4/15/2024. FC"]
["Kristin L Rettig, PA","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","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","1164778767","46-3131679","TX","PE - Midland Texas Orthopedic Group Inc","Superior","Participating","Enrollment Complete",43934,"","","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","1164778767","46-3131679","TX","PE - Midland Texas Orthopedic Group Inc","USA PPO","Participating","Enrollment Complete",43616,"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","1164778767","46-3131679","TX","PE - Midland Texas Orthopedic Group Inc","HealthSmart PPO","Participating","Re-Credentialing",43616,"1164778767","","2024-04-19","4/19/2024- Submitted recred status via delegated monthly roster on 4/15/2024. FC"]
["Kristin L Rettig, PA","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","1164778767","46-3131679","TX","PE - Midland Texas Orthopedic Group Inc","Tricare Prime","Participating","Enrollment Complete",43622,"","","2024-01-26","Confirmed provider is credentialed and in network with Tricare. MS"]
["Kristin L Rettig, PA","1164778767","46-3131679","TX","PE - Midland Texas Orthopedic Group Inc","Boon Chapman","Participating","Enrollment Complete",43952,"","","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","1164778767","46-3131679","TX","PE - Midland Texas Orthopedic Group Inc","TriCare Standard","Participating","Enrollment Complete",43622,"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","1164778767","46-3131679","TX","PE - Midland Texas Orthopedic Group Inc","Liberty Mutual","Participating","Enrollment Complete",43770,"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","1164778767","46-3131679","TX","PE - Midland Texas Orthopedic Group Inc","Broadspire Services Inc.","Participating","Enrollment Complete","2024-01-11","","","2024-07-08","Contract complete. Effective 01/11/2024. Provider was listed on par provider roster submitted with contract. Jen Videan"]
["Kristin L Rettig, PA","1164778767","46-3131679","TX","PE - Midland Texas Orthopedic Group Inc","Aetna","Participating","Enrollment Complete","2024-04-05","","","2024-08-27","Provider participating as of 4/5/2024 listed as a SPEC received via roster from Brandy Smith. FC"]
["Kristin L Rettig, PA","1164778767","46-3131679","TX","PE - Midland Texas Orthopedic Group Inc","Multiplan","Participating","Re-Credentialing","2020-05-21","1164778767","","2024-04-19","4/19/2024- Submitted recred status via delegated monthly roster on 4/15/2024. FC"]
["Kristin L Rettig, PA","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","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","1164778767","46-3131679","TX","PE - Midland Texas Orthopedic Group Inc","Coventry Workers Comp","In Process","Add Info Submitted","","","","2024-08-19","8/19/2024 Submitted via roster to Coventry. FC"]
["Kristin L Rettig, PA","1164778767","46-3131679","TX","PE - Midland Texas Orthopedic Group Inc","United Health Care","Participating","Enrollment Complete",43770,"1164778767","","2020-08-31","08/31/2020 - moved to completed status after reviewing follow up complete status - Stacey Hudak"]
["Kristin L Rettig, PA","1164778767","46-3131679","TX","PE - Midland Texas Orthopedic Group Inc","Molina","Pending Other Enrollment","Pending Contracting","","","","2024-08-07","Contract request form for the group and provider was submitted to mhtcontractrequest@molinahealthcare.com MS"]
["Rachel K Longacre, APRN-FNP-BC","1639524861","75-2656723","TX","PE - Premier Family Care, Inc","Multiplan","Participating","Enrollment Complete",43571,"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, APRN-FNP-BC","1639524861","75-2656723","TX","","Multiplan","Participating","Enrollment Complete",43571,"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, APRN-FNP-BC","1639524861","75-2656723","TX","PE - Premier Family Care, Inc","Multiplan","Participating","Application Resubmitted",43571,"1639524861","52669: West Texas Physicians Alliance Group Cntrct","2024-07-18","Submitted reapplication via delegated roster on 7/15/2024. FC"]
["Rachel K Longacre, APRN-FNP-BC","1639524861","75-2656723","TX","","Multiplan","Participating","Application Resubmitted",43571,"1639524861","52669: West Texas Physicians Alliance Group Cntrct","2024-07-18","Submitted reapplication via delegated roster on 7/15/2024. FC"]
["Rachel K Longacre, APRN-FNP-BC","1639524861","75-2656723","TX","PE - Premier Family Care, Inc","Omni PPO","Participating","Enrollment Complete","2019-05-21","1639524861","","2020-06-25",""]
["Rachel K Longacre, APRN-FNP-BC","1639524861","75-2656723","TX","","Omni PPO","Participating","Enrollment Complete","2019-05-21","1639524861","","2020-06-25",""]
["Rachel K Longacre, APRN-FNP-BC","1639524861","75-2656723","TX","PE - Premier Family Care, Inc","Omni PPO","Participating","Application Resubmitted","2019-05-21","1639524861","","2024-07-18","Submitted reapplication via delegated roster on 7/15/2024. FC"]
["Rachel K Longacre, APRN-FNP-BC","1639524861","75-2656723","TX","","Omni PPO","Participating","Application Resubmitted","2019-05-21","1639524861","","2024-07-18","Submitted reapplication via delegated roster on 7/15/2024. FC"]
["Rachel K Longacre, APRN-FNP-BC","1639524861","75-2656723","TX","PE - Premier Family Care, Inc","Medicare","Participating","Enrollment Complete","2019-05-01","793339","0008AH","2023-07-17","7/17/2023 Per PECOS - Medicare provider is PAR and linked to group/location.  PTAN# 793339.  DCannon"]
["Rachel K Longacre, APRN-FNP-BC","1639524861","75-2656723","TX","PE - Premier Family Care, Inc","Medicare","Participating","Enrollment Complete","2019-05-01","793339","0008AH","2023-07-17","7/17/2023 Per PECOS - Medicare provider is PAR and linked to group/location.  PTAN# 793339.  DCannon"]
["Rachel K Longacre, APRN-FNP-BC","1639524861","75-2656723","TX","PE - Premier Family Care, Inc","Medicare","Participating","Enrollment Complete","2019-05-01","793339","0008AH","2023-07-17","7/17/2023 Per PECOS - Medicare provider is PAR and linked to group/location.  PTAN# 793339.  DCannon"]
["Rachel K Longacre, APRN-FNP-BC","1639524861","75-2656723","TX","PE - Premier Family Care, Inc","Medicare","Participating","Enrollment Complete","2019-05-01","793339","0008AH","2023-07-17","7/17/2023 Per PECOS - Medicare provider is PAR and linked to group/location.  PTAN# 793339.  DCannon"]
["Rachel K Longacre, APRN-FNP-BC","1639524861","75-2656723","TX","PE - Premier Family Care, Inc","CAQH","Participating","CAQH Reattested","2024-08-27","13859704","","2024-08-27","08/27/2024 CAQH Reattesed updated and uploaded COI wthompson"]
["Rachel K Longacre, APRN-FNP-BC","1639524861","75-2656723","TX","PE - Premier Family Care, Inc","United Health Care","Participating","Enrollment Complete","2023-07-19","","","2023-09-07","9/7/2023 Per email response from UHC June delegated roster is provider load is complete.  Provider is PAR and linked to group TIN/location effective 7/19/2023.  DCannon"]
["Rachel K Longacre, APRN-FNP-BC","1639524861","75-2656723","TX","PE - Premier Family Care, 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, APRN-FNP-BC","1639524861","75-2656723","TX","PE - Premier Family Care, Inc","Wellmed","Participating","Enrollment Complete","2022-01-01","","","2023-03-23","3/23/2023 Rcvd roster from UHC w/ all Wellmed participating providers.  Provider is PAR effective 1/1/2022.  DCannon"]
["Rachel K Longacre, APRN-FNP-BC","1639524861","75-2656723","TX","PE - Premier Family Care, Inc","Omni PPO","Participating","Enrollment Complete","2023-07-19","","","2023-07-18","7/18/2023 Per email received from IMS/OMNI June delegated roster has been processed and provider is PAR and linked to group effective 7/19/2023.  DCannon"]
["Rachel K Longacre, APRN-FNP-BC","1639524861","75-2656723","TX","PE - Premier Family Care, Inc","Amerigroup","Participating","Enrollment Complete","2023-07-19","","","2023-10-19","10/19/2023 Per email received from Jessica Bess at  Multiplan provider is PAR with Amerigroup and linked to group TIN/locations thru Multiplan enrollment effective 7/19/2023.  DCannon"]
["Rachel K Longacre, APRN-FNP-BC","1639524861","75-2656723","TX","PE - Premier Family Care, 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, APRN-FNP-BC","1639524861","75-2656723","TX","PE - Premier Family Care, 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, APRN-FNP-BC","1639524861","75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","Panel Closed","Panel Closed","","","","2024-03-06","Location added under group record, but is not a Tricare Credentialed location. MS"]
["Rachel K Longacre, APRN-FNP-BC","1639524861","75-2656723","TX","PE - Premier Family Care, 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, APRN-FNP-BC","1639524861","75-2656723","TX","PE - Premier Family Care, Inc","Aetna","Participating","Enrollment Complete","2020-09-15","","","2023-08-18","8/18/2023 Per email from Priscilla Albertine at MQA she received confirmation that provider is PAR and linked to group TIN/location effective 7/19/2023.  DCannon"]
["Rachel K Longacre, APRN-FNP-BC","1639524861","75-2656723","TX","PE - Premier Family Care, Inc","Superior","Participating","Enrollment Complete","2023-07-01","","","2023-07-24","7/24/2023 Rcvd email from Superior that provider is PAR and linked group via delegated roster effective 7/1/2023.  DCannon"]
["Rachel K Longacre, APRN-FNP-BC","1639524861","75-2656723","TX","PE - Premier Family Care, Inc","USA PPO","Participating","Enrollment Complete",43616,"1639524861","752656723","2020-08-18","Confirmed provider is participating with PPO and H&W networks (list of networks attached). Kimberly Frazier"]
["Rachel K Longacre, APRN-FNP-BC","1639524861","75-2656723","TX","PE - Premier Family Care, Inc","Caprock (CapStar)","Participating","Enrollment Complete","2019-05-21","1639524861","","2020-06-02","06/02/2020 - rec'd spreadsheet back from the payer Mary Rodriguez <MRodriguez@caprockhp.com> confirming this provider/service location is EFF with this payer - Stacey Hudak"]
["Rachel K Longacre, APRN-FNP-BC","1639524861","75-2656723","TX","","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, APRN-FNP-BC","1639524861","75-2656723","TX","PE - Premier Family Care, Inc","Caprock (CapStar)","Participating","Application Resubmitted","2019-05-21","1639524861","","2024-07-18","Submitted reapplication via delegated roster on 6/14/2024. FC"]
["Rachel K Longacre, APRN-FNP-BC","1639524861","75-2656723","TX","","Caprock (CapStar)","Participating","Application Resubmitted","2019-05-21","1639524861","","2024-07-18","Submitted reapplication via delegated roster on 6/14/2024. FC"]
["Rachel K Longacre, APRN-FNP-BC","1639524861","75-2656723","TX","PE - Premier Family Care, Inc","Wellmed","Participating","Enrollment Complete","2023-07-19","","","2023-09-07","9/7/2023 Per email response from UHC June delegated roster is provider load is complete.  Provider is PAR and linked to group TIN/location effective 7/19/2023.  DCannon"]
["Rachel K Longacre, APRN-FNP-BC","1639524861","75-2656723","TX","PE - Premier Family Care, Inc","Humana","Participating","Enrollment Complete",43831,"","","2024-06-21","Received email confirmation from Marcus Wester, provider is par and linked to TIN/location, eff. 01/01/2020. PA."]
["Rachel K Longacre, APRN-FNP-BC","1639524861","75-2656723","TX","PE - Premier Family Care, Inc","Wellcare","Participating","Enrollment Complete","2023-07-01","","","2023-07-24","7/24/2023 Rcvd email from Superior that provider is PAR and linked group via delegated roster effective 7/1/2023.  DCannon"]
["Rachel K Longacre, APRN-FNP-BC","1639524861","75-2656723","TX","PE - Premier Family Care, Inc","Cigna","Participating","Enrollment Complete","2023-04-17","","","2023-09-13","Received confirmation of enrollment via email. MS"]
["Rachel K Longacre, APRN-FNP-BC","1639524861","75-2656723","TX","PE - Premier Family Care, Inc","IMS","Participating","Enrollment Complete",43606,"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, APRN-FNP-BC","1639524861","75-2656723","TX","","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, APRN-FNP-BC","1639524861","75-2656723","TX","PE - Premier Family Care, Inc","IMS","Participating","Application Resubmitted","2019-05-21","1639524861","","2024-07-18","Submitted reapplication via delegated roster on 6/14/2024. FC"]
["Rachel K Longacre, APRN-FNP-BC","1639524861","75-2656723","TX","","IMS","Participating","Application Resubmitted","2019-05-21","1639524861","","2024-07-18","Submitted reapplication via delegated roster on 6/14/2024. FC"]
["Rachel K Longacre, APRN-FNP-BC","1639524861","75-2656723","TX","PE - Premier Family Care, Inc","USA PPO","Participating","Enrollment Complete","2023-07-19","","","2023-08-23","8/23/2023 In following up with USAMCO (800-872-3860) I was told that you can confirm participating via the USA MCO website  https://providersearch.usamco.com/hwprovsearch.  Provider is PAR and linked to location/TIN effective 7/19/2023.  DCannon"]
["Rachel K Longacre, APRN-FNP-BC","1639524861","75-2656723","TX","PE - Premier Family Care, Inc","Boon Chapman","Participating","Enrollment Complete",43571,"","","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, APRN-FNP-BC","1639524861","75-2656723","TX","PE - Premier Family Care, Inc","HealthSmart PPO","Participating","Enrollment Complete",43616,"1639524861","","2020-06-05","06/05/2020 - Rec'd email from the payer stating this provider is EFF - Stacey Hudak"]
["Rachel K Longacre, APRN-FNP-BC","1639524861","75-2656723","TX","","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, APRN-FNP-BC","1639524861","75-2656723","TX","PE - Premier Family Care, Inc","HealthSmart PPO","Participating","Application Resubmitted","2019-05-31","1639524861","","2024-07-18","Submitted reapplication via delegated roster on 6/14/2024. FC"]
["Rachel K Longacre, APRN-FNP-BC","1639524861","75-2656723","TX","","HealthSmart PPO","Participating","Application Resubmitted","2019-05-31","1639524861","","2024-07-18","Submitted reapplication via delegated roster on 6/14/2024. FC"]
["Rachel K Longacre, APRN-FNP-BC","1639524861","75-2656723","TX","PE - Premier Family Care, Inc","IMS","Participating","Enrollment Complete","2023-07-19","","","2023-07-18","7/18/2023 Per email received from IMS/OMNI June delegated roster has been processed and provider is PAR and linked to group effective 7/19/2023.  DCannon"]
["Rachel K Longacre, APRN-FNP-BC","1639524861","75-2656723","TX","PE - Premier Family Care, Inc","Multiplan","Participating","Enrollment Complete","2023-07-19","","","2023-07-25","7/25/2023 Rcvd email from Jessica Bess at Multiplan with a full roster and provider is PAR w/ group and location effective 7/19/2023.  DCannon"]
["Rachel K Longacre, APRN-FNP-BC","1639524861","75-2656723","TX","PE - Premier Family Care, Inc","Galaxy Health","Participating","Enrollment Complete","2023-07-19","","","2023-07-20","7/20/2023 Per email received from Galaxy June delegated roster has been processed and provider is PAR and linked to group effective 7/19/2023.  DCannon"]
["Rachel K Longacre, APRN-FNP-BC","1639524861","75-2656723","TX","PE - Premier Family Care, Inc","Medicaid","Participating","Enrollment Complete","","360348204","079837301","2020-01-29","01/29/2020 - found provider through payer portal. Provider is linked to the following plans: TRADITIONAL MEDICAID, Texas Children's Health Plan - MRSA Northeast, Amerigroup - MRSA West, Amerigroup Texas, Inc. - MRSA West - Stacey Hudak"]
["Rachel K Longacre, APRN-FNP-BC","1639524861","75-2656723","TX","PE - Premier Family Care, 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, APRN-FNP-BC","1639524861","75-2656723","TX","PE - Premier Family Care, Inc","Aetna","Participating","Enrollment Complete","2020-09-15","1639524861","","2020-09-22","09/22/2020 - Called 800-872-3862 but routed to Aetna Corporate Center and unable to reach live rep. Called Aetna @ 800-353-1232 S/W Mark. Provider NPI# is on file for the provider and is participating effective 09/15/2020 under the group and TIN#. Physical location is on file.Call Ref# 5560576876. - Archie Candiasan"]
["Rachel K Longacre, APRN-FNP-BC","1639524861","75-2656723","TX","PE - Premier Family Care, Inc","First Health Coventry","Participating","Enrollment Complete","2019-05-01","","","2023-08-25","Confirmation of location being added via provider directory. MS"]
["Rachel K Longacre, APRN-FNP-BC","1639524861","75-2656723","TX","PE - Premier Family Care, 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, APRN-FNP-BC","1639524861","75-2656723","TX","PE - Premier Family Care, Inc","TriCare Standard","Participating","Enrollment Complete","2024-03-07","","","2024-03-13","Provider is linked to Ste. 240. MS"]
["Rachel K Longacre, APRN-FNP-BC","1639524861","75-2656723","TX","PE - Premier Family Care, Inc","Wellcare","Participating","Enrollment Complete",44501,"","","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, APRN-FNP-BC","1639524861","75-2656723","TX","PE - Premier Family Care, Inc","Cigna","Participating","Enrollment Complete","2021-03-31","2017791","","2021-08-04","8/4/2021 Received an email from PDMCOGZ@cigna.com with confirmation provider is now participating under group Tax ID effective 3/31/2021 with assigned provider ID number 2017791. KFrazier"]
["Rachel K Longacre, APRN-FNP-BC","1639524861","75-2656723","TX","PE - Premier Family Care, Inc","Caprock (CapStar)","Participating","Enrollment Complete","2023-07-19","","","2023-07-26","7/26/2023 Rcvd email  confirmation from Caprock that provider is PAR and linked to group TIN/locations effective 7/19/2023.  DCannon"]
["Rachel K Longacre, APRN-FNP-BC","1639524861","75-2656723","TX","PE - Premier Family Care, 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, APRN-FNP-BC","1639524861","75-2656723","TX","PE - Premier Family Care, Inc","Medicaid","Participating","Enrollment Complete","2022-08-04","","","2023-08-21","Per TMHP website provider is active at 4214 Andrews Hwy Ste 107. Effective 08/04/2022. Jen Videan"]
["Rachel K Longacre, APRN-FNP-BC","1639524861","75-2656723","TX","PE - Premier Family Care, Inc","Scott&White (First Care)","Participating","Enrollment Complete",43753,"","","2023-08-24","8/24/2023 Per email rcvd from Scott & White provider is PAR and linked to group TIN/location effective 10/15/2019.  DCannon"]
["Rachel K Longacre, APRN-FNP-BC","1639524861","75-2656723","TX","PE - Premier Family Care, 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, APRN-FNP-BC","1639524861","75-2656723","TX","PE - Premier Family Care, Inc","Boon Chapman","Participating","Enrollment Complete","2023-07-19","","","2023-07-25","7/25/2023 Rcvd email from Jessica Bess at Multiplan with a full roster and provider is PAR w/ group and location effective 7/19/2023.  DCannon"]
["Rachel K Longacre, APRN-FNP-BC","1639524861","75-2656723","TX","PE - Premier Family Care, 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",43703,"1144665233","","2020-06-26",""]
["William Gage Liesman, MD","1144665233","46-0950925","TX","PE - Urgent Orthopedic Specialists, PLLC","Wellcare","Participating","Enrollment Complete",44501,"","","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","Medicaid","Participating","Enrollment Complete","2019-09-01","","","2024-07-08","Revalidation approved. Effective 09/01/2019. Jen Videan"]
["William Gage Liesman, MD","1144665233","46-0950925","TX","PE - Urgent Orthopedic Specialists, PLLC","Multiplan","Participating","Enrollment Complete","2019-09-01","1144665233","","2020-09-08","09/08/2020 - Rec'd email from the payer stating:\n\"Network: Beech St, MPI, & PHCS\nNetwork Participation effective: Please see below\nContract Source Group contract through: Please see below\n\nW Gage Liesman, MD NPI: 1144665233\n5026 – West Texas Physicians Alliance – Eff Date 09/01/2019\n23655 – West Texas Physicians Alliance – Eff Date 09/01/2019\n52669 – West Texas Physicians Alliance – Eff Date 09/01/2019\" - Stacey Hudak"]
["William Gage Liesman, MD","1144665233","46-0950925","TX","PE - Urgent Orthopedic Specialists, PLLC","Ambetter","Participating","Enrollment Complete","2022-06-01","","","2022-06-13","6/13/2022 Per roster received from Superior provider is PAR and linked to group delegation roster effective 6/1/2022."]
["William Gage Liesman, MD","1144665233","46-0950925","TX","PE - Urgent Orthopedic Specialists, PLLC","Scott&White (First Care)","Participating","Enrollment Complete","2019-09-30","1144665233","","2020-08-20","08/20/2020 - rec'd email from the payer stating this provider is affilliated with the PRIMED DELEGATED AGREEMENT under this TIN/Service Location. \nThis provider is networked with:\nFirstCare MyChoice PPO\nCHIP\nFirstCare Select Benefit Network\nHMO Enhanced Benefit Network\nMedicaid (FC)\nMedicare (FC)\nPPO Limited Benefit Network\n- Stacey Hudak"]
["William Gage Liesman, MD","1144665233","46-0950925","TX","PE - Urgent Orthopedic Specialists, PLLC","CAQH","Participating","CAQH Reattested","2024-08-26","","","2024-08-26","08/26/2024 CAQH Reattested updated and uploaded COI wthompson"]
["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","Coventry Workers Comp","In Process","Add Info Submitted","","","","2024-08-19","8/19/2024 Submitted via roster to Coventry. FC"]
["William Gage Liesman, MD","1144665233","46-0950925","TX","PE - Urgent Orthopedic Specialists, PLLC","USA PPO","Participating","Enrollment Complete","2019-08-30","1144665233","460950925","2020-08-18","Confirmed provider is participating with PPO and H&W networks (list of networks attached). Kimberly Frazier"]
["William Gage Liesman, MD","1144665233","46-0950925","TX","PE - Urgent Orthopedic Specialists, PLLC","Amerigroup","Participating","Enrollment Complete","2020-04-15","","","2021-02-13","2/13/2021 - Rcvd complete roster from Amerigroup provider is participating and linked to TIN and location for the following plans STAR, CHIP_PERINATAL, STAR_PLUS, CHIP.  DCannon"]
["William Gage Liesman, MD","1144665233","46-0950925","TX","PE - Urgent Orthopedic Specialists, PLLC","United Health Care","Participating","Enrollment Complete","2020-01-01","1144665233","","2020-08-31","08/31/2020 - moved to completed status after reviewing August follow up complete note - Stacey Hudak"]
["William Gage Liesman, MD","1144665233","46-0950925","TX","PE - Urgent Orthopedic Specialists, PLLC","Aetna","Participating","Enrollment Complete","2020-09-01","6694913","","2020-11-24","11/24/2020 - Per f/u report provider NPI# is on file for the provider is linked and is participating effective 09/01/2020 under the group and TIN#. Provider ID 6694913. Group ID 4907135.  DCannon"]
["William Gage Liesman, MD","1144665233","46-0950925","TX","PE - Urgent Orthopedic Specialists, PLLC","IMS","Participating","Enrollment Complete","2019-08-26","1144665233","","2020-06-22","06/22/2020- Rec'd email from the payer confirming this provider is PAR with this group/service location - Stacey Hudak"]
["William Gage Liesman, MD","1144665233","46-0950925","TX","PE - Urgent Orthopedic Specialists, PLLC","Wellmed","Participating","Enrollment Complete","2020-06-01","","","2023-03-23","3/23/2023 Rcvd roster from UHC w/ all Wellmed participating providers.  Provider is PAR effective 6/1/2020.  DCannon"]
["William Gage Liesman, MD","1144665233","46-0950925","TX","PE - Urgent Orthopedic Specialists, PLLC","Medicaid","Participating","In House Enrollment","2019-09-01","404183201","","2020-06-29","06/29/2020 - client supplied us with copy of MEDICAID EFF letter for other payer enrollments, if needed. Symplr does not need to maintain this enrollment.  Stacey Hudak"]
["William Gage Liesman, MD","1144665233","46-0950925","TX","PE - Urgent Orthopedic Specialists, PLLC","Humana","Participating","Enrollment Complete","2017-05-01","","","2021-11-18","11/18/2021 Rcvd full roster from Humana listing provider as PAR and linked to group TIN/location effective 5/1/2017.  DCannon"]
["William Gage Liesman, MD","1144665233","46-0950925","TX","PE - Urgent Orthopedic Specialists, PLLC","Superior","Participating","Enrollment Complete","2019-10-01","1144665233","","2020-07-14","07/14/2020 - Rec'd email from the payer stating this provider is EFF under PRIMED DELEGATED agreement - Stacey Hudak"]
["Madhavi Gadiraju, MD","1932541406","75-2656723","TX","PE - Premier Family Care, Inc","Wellmed","Participating","Enrollment Complete","2023-06-05","","","2023-09-07","9/7/2023 Per email response from UHC June delegated roster is provider load is complete.  Provider is PAR and linked to group TIN/location effective 6/5/2023.  DCannon"]
["Madhavi Gadiraju, MD","1932541406","75-2656723","TX","PE - Premier Family Care, Inc","Amerigroup","Participating","Enrollment Complete","2023-06-05","","","2023-10-19","10/19/2023 Per email received from Jessica Bess at  Multiplan provider is PAR with Amerigroup and linked to group TIN/locations thru Multiplan enrollment effective 6/5/2023.  DCannon"]
["Madhavi Gadiraju, MD","1932541406","75-2656723","TX","","Amerigroup","Participating","Enrollment Complete","2023-06-05","","","2023-10-19","10/19/2023 Per email received from Jessica Bess at  Multiplan provider is PAR with Amerigroup and linked to group TIN/locations thru Multiplan enrollment effective 6/5/2023.  DCannon"]
["Madhavi Gadiraju, MD","1932541406","75-2656723","TX","PE - Premier Family Care, Inc","Amerigroup","Participating","Add Info Submitted","2023-06-05","","","2024-08-19","Submitted reapplication via delegated roster on 8/15/2024. FC"]
["Madhavi Gadiraju, MD","1932541406","75-2656723","TX","","Amerigroup","Participating","Add Info Submitted","2023-06-05","","","2024-08-19","Submitted reapplication via delegated roster on 8/15/2024. FC"]
["Madhavi Gadiraju, MD","1932541406","75-2656723","TX","PE - Premier Family Care, Inc","Superior","Participating","Enrollment Complete","2019-11-01","1932541406","","2023-07-17","7/17/2023 Rcvd email from Superior that provider is PAR and linked to new location via group delegated roster effective 6/1/2023.  DCannon"]
["Madhavi Gadiraju, MD","1932541406","75-2656723","TX","PE - Premier Family Care, Inc","Ambetter","Participating","Enrollment Complete","2022-06-01","","","2022-06-13","6/13/2022 Per roster received from Superior provider is PAR and linked to group delegation roster effective 6/1/2022."]
["Madhavi Gadiraju, MD","1932541406","75-2656723","TX","PE - Premier Family Care, Inc","CAQH","Participating","CAQH Reattested","2024-07-05","13876531","","2024-07-05","07/05/2024 CAQH Reattested all locations current and all expirables up to date wthompson"]
["Madhavi Gadiraju, MD","1932541406","75-2656723","TX","PE - Premier Family Care, Inc","CAQH","Participating","CAQH Reattested","2024-07-05","13876531","","2024-07-05","07/05/2024 CAQH Reattested all locations current and all expirables up to date wthompson"]
["Madhavi Gadiraju, MD","1932541406","75-2656723","TX","PE - Premier Family Care, Inc","CAQH","Participating","CAQH Reattested","2024-07-05","13876531","","2024-07-05","07/05/2024 CAQH Reattested all locations current and all expirables up to date wthompson"]
["Madhavi Gadiraju, MD","1932541406","75-2656723","TX","PE - Premier Family Care, Inc","CAQH","Participating","CAQH Reattested","2024-07-05","13876531","","2024-07-05","07/05/2024 CAQH Reattested all locations current and all expirables up to date wthompson"]
["Madhavi Gadiraju, MD","1932541406","75-2656723","TX","PE - Premier Family Care, 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, Inc","Superior","Participating","Enrollment Complete","2023-06-01","","","2023-07-17","7/17/2023 Rcvd email from Superior that provider is PAR and linked to new location via group delegated roster effective 6/1/2023.  DCannon"]
["Madhavi Gadiraju, MD","1932541406","75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","2019-07-02","","","2024-01-26","Confirmed provider is credentialed and in network with Tricare. MS"]
["Madhavi Gadiraju, MD","1932541406","75-2656723","TX","PE - Premier Family Care, Inc.","IMS","Participating","Enrollment Complete","2023-06-05","","","2023-07-18","7/18/2023 Per email received from IMS/OMNI June delegated roster has been processed and provider is PAR and linked to group effective 6/5/2023.  DCannon"]
["Madhavi Gadiraju, MD","1932541406","75-2656723","TX","","IMS","Participating","Enrollment Complete",45082,"","","2023-07-18","7/18/2023 Per email received from IMS/OMNI June delegated roster has been processed and provider is PAR and linked to group effective 6/5/2023.  DCannon"]
["Madhavi Gadiraju, MD","1932541406","75-2656723","TX","PE - Premier Family Care, Inc.","IMS","Participating","Add Info Submitted","2023-06-05","","","2024-08-19","Submitted reapplication via delegated roster on 8/15/2024. FC"]
["Madhavi Gadiraju, MD","1932541406","75-2656723","TX","","IMS","Participating","Add Info Submitted","2023-06-05","","","2024-08-19","Submitted reapplication via delegated roster on 8/15/2024. FC"]
["Madhavi Gadiraju, MD","1932541406","75-2656723","TX","PE - Premier Family Care, Inc","Triwest VA","Participating","Enrollment Complete","2020-12-01","","","2023-03-24","03/17/2023- Per Triwest VA  email confirmation, provider participating under practice DCN, eff. 12/01/2020. PA"]
["Madhavi Gadiraju, MD","1932541406","75-2656723","TX","PE - Premier Family Care, Inc","United Health Care","Participating","Enrollment Complete","2023-06-05","","","2023-09-07","9/7/2023 Per email response from UHC June delegated roster is provider load is complete.  Provider is PAR and linked to group TIN/location effective 6/5/2023.  DCannon"]
["Madhavi Gadiraju, MD","1932541406","75-2656723","TX","PE - Premier Family Care, Inc","First Health Coventry","Participating","Enrollment Complete","2023-06-01","","","2023-08-17","8/17/2023 Per First Health web portal provider is PAR and linked to group TIN/location effective 6/1/2023.  PID # 3002056.  DCannon"]
["Madhavi Gadiraju, MD","1932541406","75-2656723","TX","PE - Premier Family Care, Inc","Aetna","Participating","Enrollment Complete","2019-07-01","5258891","","2023-08-16","8/16/2023 Per follow-up note - provider NPI# is on file for the provider and is participating effective 07/01/19 under the group and TIN#. Location address is on file. PIN# 5258891. DCannon"]
["Madhavi Gadiraju, MD","1932541406","75-2656723","TX","PE - Premier Family Care, 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, Inc","Wellmed","Participating","Enrollment Complete","2022-01-01","","","2023-03-23","3/23/2023 Rcvd roster from UHC w/ all Wellmed participating providers.  Provider is PAR effective 1/1/2022.  DCannon"]
["Madhavi Gadiraju, MD","1932541406","75-2656723","TX","PE - Premier Family Care, Inc","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, 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","","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, Inc","Amerigroup","Participating","Add Info Submitted","2019-09-30","1932541406","","2024-08-19","Submitted reapplication via delegated roster on 8/15/2024. FC"]
["Madhavi Gadiraju, MD","1932541406","75-2656723","TX","","Amerigroup","Participating","Add Info Submitted","2019-09-30","1932541406","","2024-08-19","Submitted reapplication via delegated roster on 8/15/2024. FC"]
["Madhavi Gadiraju, MD","1932541406","75-2656723","TX","PE - Premier Family Care, Inc","USA PPO","Participating","Enrollment Complete","2023-06-05","","","2023-10-20","10/20/2023 In following up with USAMCO (800-872-3860) I was told that you can confirm participating via the USA MCO website  https://providersearch.usamco.com/hwprovsearch.  Provider is PAR and linked to location/TIN effective 6/5/2023.  DCannon"]
["Madhavi Gadiraju, MD","1932541406","75-2656723","TX","PE - Premier Family Care, 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, Inc","Medicare","Participating","Enrollment Complete","2019-05-01","804641","0008AH","2023-07-17","7/17/2023 Per PECOS - Medicare provider is PAR and linked to group/location.  PTAN# 804641.  DCannon"]
["Madhavi Gadiraju, MD","1932541406","75-2656723","TX","PE - Premier Family Care, Inc","Medicare","Participating","Enrollment Complete","2019-05-01","804641","0008AH","2023-07-17","7/17/2023 Per PECOS - Medicare provider is PAR and linked to group/location.  PTAN# 804641.  DCannon"]
["Madhavi Gadiraju, MD","1932541406","75-2656723","TX","PE - Premier Family Care, Inc","Medicare","Participating","Enrollment Complete","2019-05-01","804641","0008AH","2023-07-17","7/17/2023 Per PECOS - Medicare provider is PAR and linked to group/location.  PTAN# 804641.  DCannon"]
["Madhavi Gadiraju, MD","1932541406","75-2656723","TX","PE - Premier Family Care, Inc","Medicare","Participating","Enrollment Complete","2019-05-01","804641","0008AH","2023-07-17","7/17/2023 Per PECOS - Medicare provider is PAR and linked to group/location.  PTAN# 804641.  DCannon"]
["Madhavi Gadiraju, MD","1932541406","75-2656723","TX","PE - Premier Family Care, Inc","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, Inc","Boon Chapman","Participating","Enrollment Complete","2023-06-05","","","2023-07-25","7/25/2023 Rcvd email from Jessica Bess at Multiplan with a full roster and provider is PAR w/ group and location effective 6/5/2023.  DCannon"]
["Madhavi Gadiraju, MD","1932541406","75-2656723","TX","PE - Premier Family Care, Inc","Cigna","Participating","Enrollment Complete","2023-06-05","","","2023-08-01","8/1/2023 Rcvd email confirmation that provider is PAR and linked to group/location effective 6/5/2023.  PID # 7585417.  DCannon"]
["Madhavi Gadiraju, MD","1932541406","75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete",45149,"","",45316,"Confirmed provider is credentialed and in network with Tricare. MS"]
["Madhavi Gadiraju, MD","1932541406","75-2656723","TX","PE - Premier Family Care, Inc","Galaxy Health","Participating","Enrollment Complete","2023-06-01","","","2023-07-20","7/20/2023 Per email received from Galaxy May delegated roster has been processed and provider is PAR and linked to group effective 5/1/2023.  DCannon"]
["Madhavi Gadiraju, MD","1932541406","75-2656723","TX","PE - Premier Family Care, Inc","Caprock (CapStar)","Participating","Enrollment Complete","2023-06-05","","","2023-07-26","7/26/2023 Rcvd email  confirmation from Caprock that provider is PAR and linked to group TIN/locations effective 6/5/2023.  DCannon"]
["Madhavi Gadiraju, MD","1932541406","75-2656723","TX","","Caprock (CapStar)","Participating","Enrollment Complete","2023-06-05","","","2023-07-26","7/26/2023 Rcvd email  confirmation from Caprock that provider is PAR and linked to group TIN/locations effective 6/5/2023.  DCannon"]
["Madhavi Gadiraju, MD","1932541406","75-2656723","TX","PE - Premier Family Care, Inc","Caprock (CapStar)","Participating","Add Info Submitted","2023-06-05","","","2024-08-19","Submitted reapplication via delegated roster on 8/15/2024. FC"]
["Madhavi Gadiraju, MD","1932541406","75-2656723","TX","","Caprock (CapStar)","Participating","Add Info Submitted","2023-06-05","","","2024-08-19","Submitted reapplication via delegated roster on 8/15/2024. FC"]
["Madhavi Gadiraju, MD","1932541406","75-2656723","TX","PE - Premier Family Care, Inc","TriCare Standard","Participating","Enrollment Complete","2023-08-11","","","2023-08-23","8/23/2023 Per Tricare portal provider is PAR and linked to group/location effective 8/11/2023."]
["Madhavi Gadiraju, MD","1932541406","75-2656723","TX","PE - Premier Family Care, Inc","Ambetter","Participating","Enrollment Complete","2023-06-01","","","2023-07-17","7/17/2023 Rcvd email from Superior that provider is PAR and linked to new location via group delegated roster effective 6/1/2023.  DCannon"]
["Madhavi Gadiraju, MD","1932541406","75-2656723","TX","PE - Premier Family Care, Inc","Scott&White (First Care)","Participating","Enrollment Complete","2023-07-20","","","2023-09-07","9/7/2023 Per email rcvd from Scott & White delegated roster for June has been completed.  Provider is PAR and linked to group TIN/location effective 7/20/2023.  DCannon"]
["Madhavi Gadiraju, MD","1932541406","75-2656723","TX","PE - Premier Family Care, 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","","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, Inc","Multiplan","Participating","Add Info Submitted","2019-07-20","1932541406","52669: West Texas Physicians Alliance Group Cntrct","2024-08-19","Submitted reapplication via delegated roster on 8/15/2024. FC"]
["Madhavi Gadiraju, MD","1932541406","75-2656723","TX","","Multiplan","Participating","Add Info Submitted","2019-07-20","1932541406","52669: West Texas Physicians Alliance Group Cntrct","2024-08-19","Submitted reapplication via delegated roster on 8/15/2024. FC"]
["Madhavi Gadiraju, MD","1932541406","75-2656723","TX","PE - Premier Family Care, 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, Inc.","Omni PPO","Participating","Enrollment Complete","2023-06-05","","","2023-07-18","7/18/2023 Per email received from IMS/OMNI June delegated roster has been processed and provider is PAR and linked to group effective 6/5/2023.  DCannon"]
["Madhavi Gadiraju, MD","1932541406","75-2656723","TX","","Omni PPO","Participating","Enrollment Complete","2023-06-05","","","2023-07-18","7/18/2023 Per email received from IMS/OMNI June delegated roster has been processed and provider is PAR and linked to group effective 6/5/2023.  DCannon"]
["Madhavi Gadiraju, MD","1932541406","75-2656723","TX","PE - Premier Family Care, Inc.","Omni PPO","Participating","Add Info Submitted","2023-06-05","","","2024-08-19","Submitted reapplication via delegated roster on 8/15/2024. FC"]
["Madhavi Gadiraju, MD","1932541406","75-2656723","TX","","Omni PPO","Participating","Add Info Submitted","2023-06-05","","","2024-08-19","Submitted reapplication via delegated roster on 8/15/2024. FC"]
["Madhavi Gadiraju, MD","1932541406","75-2656723","TX","PE - Premier Family Care, Inc","Multiplan","Participating","Enrollment Complete","2023-06-05","","","2023-07-25","7/25/2023 Rcvd email from Jessica Bess at Multiplan with a full roster and provider is PAR w/ group and location effective 6/5/2023.  DCannon"]
["Madhavi Gadiraju, MD","1932541406","75-2656723","TX","","Multiplan","Participating","Enrollment Complete","2023-06-05","","","2023-07-25","7/25/2023 Rcvd email from Jessica Bess at Multiplan with a full roster and provider is PAR w/ group and location effective 6/5/2023.  DCannon"]
["Madhavi Gadiraju, MD","1932541406","75-2656723","TX","PE - Premier Family Care, Inc","Multiplan","Participating","Add Info Submitted",45082,"","","2024-08-19","Submitted reapplication via delegated roster on 8/15/2024. FC"]
["Madhavi Gadiraju, MD","1932541406","75-2656723","TX","","Multiplan","Participating","Add Info Submitted",45082,"","","2024-08-19","Submitted reapplication via delegated roster on 8/15/2024. FC"]
["Madhavi Gadiraju, MD","1932541406","75-2656723","TX","PE - Premier Family Care, 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","","Caprock (CapStar)","Participating","Enrollment Complete",43628,"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, Inc","Caprock (CapStar)","Participating","Add Info Submitted",43628,"1932541406","","2024-08-19","Submitted reapplication via delegated roster on 8/15/2024. FC"]
["Madhavi Gadiraju, MD","1932541406","75-2656723","TX","","Caprock (CapStar)","Participating","Add Info Submitted",43628,"1932541406","","2024-08-19","Submitted reapplication via delegated roster on 8/15/2024. FC"]
["Madhavi Gadiraju, MD","1932541406","75-2656723","TX","PE - Premier Family Care, Inc","Scott&White (First Care)","Participating","Enrollment Complete",43586,"1932541406","","2020-02-19","2/19/2020--Per payer roster received from Irma Henson, this provider is participating with this service location and TIN--tisha rader"]
["Madhavi Gadiraju, MD","1932541406","75-2656723","TX","PE - Premier Family Care, Inc","Scott&White (First Care)","Participating","Enrollment Complete",43586,"1932541406","","2020-02-19","2/19/2020--Per payer roster received from Irma Henson, this provider is participating with this service location and TIN--tisha rader"]
["Madhavi Gadiraju, MD","1932541406","75-2656723","TX","PE - Premier Family Care, Inc","Scott&White (First Care)","Participating","Enrollment Complete",43586,"1932541406","","2020-02-19","2/19/2020--Per payer roster received from Irma Henson, this provider is participating with this service location and TIN--tisha rader"]
["Madhavi Gadiraju, MD","1932541406","75-2656723","TX","PE - Premier Family Care, Inc","Scott&White (First Care)","Participating","Enrollment Complete","2019-05-01","1932541406","","2020-02-19","2/19/2020--Per payer roster received from Irma Henson, this provider is participating with this service location and TIN--tisha rader"]
["Madhavi Gadiraju, MD","1932541406","75-2656723","TX","PE - Premier Family Care, Inc","Humana","Participating","Enrollment Complete","2020-01-01","","","2023-09-15","9/15/2023 Per email received from Humana provider is PAR and linked to group TIN/locations effective 1/1/2020.  DCannon"]
["Madhavi Gadiraju, MD","1932541406","75-2656723","TX","PE - Premier Family Care, Inc","Medicaid","Participating","Enrollment Complete","2022-08-21","","","2023-09-06","Downloaded approval letter from TMHP website. Effective 08/21/2022. Jen Videan"]
["Madhavi Gadiraju, MD","1932541406","75-2656723","TX","PE - Premier Family Care, Inc","HealthSmart PPO","Participating","Enrollment Complete","2019-06-12","1932541406","","2020-09-23","09/23/2020 - moved to completed status after reviewing follow up complete - Stacey Hudak"]
["Madhavi Gadiraju, MD","1932541406","75-2656723","TX","","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, Inc","HealthSmart PPO","Participating","Add Info Submitted","2019-06-12","1932541406","","","Submitted reapplication via delegated roster on 8/15/2024. FC"]
["Madhavi Gadiraju, MD","1932541406","75-2656723","TX","","HealthSmart PPO","Participating","Add Info Submitted","2019-06-12","1932541406","","","Submitted reapplication via delegated roster on 8/15/2024. FC"]
["Madhavi Gadiraju, MD","1932541406","75-2656723","TX","PE - Premier Family Care, Inc","Medicaid","Participating","Enrollment Complete","","","","2024-04-03","Rcvd revalidation approval ltr.  2402 W Wall effective 03/22/2023 and 4214 Andrews Hwy Ste 107 effective 08/21/2022. Jen Videan"]
["Madhavi Gadiraju, MD","1932541406","75-2656723","TX","PE - Premier Family Care, Inc","Medicaid","Participating","Enrollment Complete","","","","2024-04-03","Rcvd revalidation approval ltr.  2402 W Wall effective 03/22/2023 and 4214 Andrews Hwy Ste 107 effective 08/21/2022. Jen Videan"]
["Madhavi Gadiraju, MD","1932541406","75-2656723","TX","PE - Premier Family Care, Inc","Medicaid","Participating","Enrollment Complete","","","","2024-04-03","Rcvd revalidation approval ltr.  2402 W Wall effective 03/22/2023 and 4214 Andrews Hwy Ste 107 effective 08/21/2022. Jen Videan"]
["Madhavi Gadiraju, MD","1932541406","75-2656723","TX","PE - Premier Family Care, Inc","Medicaid","Participating","Enrollment Complete","","","","2024-04-03","Rcvd revalidation approval ltr.  2402 W Wall effective 03/22/2023 and 4214 Andrews Hwy Ste 107 effective 08/21/2022. Jen Videan"]
["Madhavi Gadiraju, MD","1932541406","75-2656723","TX","PE - Premier Family Care, 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, Inc","Triwest VA","In House Enrollment","In House Enrollment","","","","2023-06-14",""]
["Madhavi Gadiraju, MD","1932541406","75-2656723","TX","PE - Premier Family Care, Inc","HealthSmart PPO","Participating","Enrollment Complete","2023-06-05","","","2023-12-15","12/15/2023 Per email rcvd from Aleece Moerbe at Healthsmart provider is PAR and linked to group TIN/location effective 6/5/2023.  DCannon"]
["Madhavi Gadiraju, MD","1932541406","75-2656723","TX","PE - Premier Family Care, Inc","Omni PPO","Participating","Enrollment Complete","2019-09-30","1932541406","","2020-06-25",""]
["Madhavi Gadiraju, MD","1932541406","75-2656723","TX","","Omni PPO","Participating","Enrollment Complete","2019-09-30","1932541406","","2020-06-25",""]
["Madhavi Gadiraju, MD","1932541406","75-2656723","TX","PE - Premier Family Care, Inc","Omni PPO","Participating","Add Info Submitted","2019-09-30","1932541406","","2024-08-19","Submitted reapplication via delegated roster on 8/15/2024. FC"]
["Madhavi Gadiraju, MD","1932541406","75-2656723","TX","","Omni PPO","Participating","Add Info Submitted","2019-09-30","1932541406","","2024-08-19","Submitted reapplication via delegated roster on 8/15/2024. FC"]
["Megan Casselman, NP-C","1528619525","75-2656723","TX","PE - Premier Family Care, Inc","CAQH","Participating","CAQH Reattested","2024-08-28","14530139","","2024-08-28","08/28/2024 CAQH Reattested updated and uploaded COI wthompson"]
["Megan Casselman, NP-C","1528619525","75-2656723","TX","PE - Premier Family Care, 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, 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, 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, Inc","Medicaid","Participating","Enrollment Complete","","","","2024-08-21","Revalidation Approval Ltr rcvd. Jen Videan"]
["Megan Casselman, NP-C","1528619525","75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","2020-04-02","","","2024-01-26","Confirmed provider is credentialed and in network with Tricare. MS"]
["Megan Casselman, NP-C","1528619525","75-2656723","TX","PE - Premier Family Care, 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, 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, Inc","Medicaid","Participating","Enrollment Complete","","","","2024-03-25","Reactivation complete. Approval ltr rcvd. 2402 W Wall Street effective 02/26/2023. 4214 Andrews Hwy Ste. 240 Effective 10/01/2019. Jen Videan"]
["Megan Casselman, NP-C","1528619525","75-2656723","TX","PE - Premier Family Care, Inc","Medicaid","Participating","Enrollment Complete","","","","2024-03-25","Reactivation complete. Approval ltr rcvd. 2402 W Wall Street effective 02/26/2023. 4214 Andrews Hwy Ste. 240 Effective 10/01/2019. Jen Videan"]
["Megan Casselman, NP-C","1528619525","75-2656723","TX","PE - Premier Family Care, Inc","Medicaid","Participating","Enrollment Complete","","","","2024-03-25","Reactivation complete. Approval ltr rcvd. 2402 W Wall Street effective 02/26/2023. 4214 Andrews Hwy Ste. 240 Effective 10/01/2019. Jen Videan"]
["Megan Casselman, NP-C","1528619525","75-2656723","TX","PE - Premier Family Care, Inc","Medicaid","Participating","Enrollment Complete","","","","2024-03-25","Reactivation complete. Approval ltr rcvd. 2402 W Wall Street effective 02/26/2023. 4214 Andrews Hwy Ste. 240 Effective 10/01/2019. Jen Videan"]
["Megan Casselman, NP-C","1528619525","75-2656723","TX","PE - Premier Family Care, 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, Inc","Aetna","Participating","Enrollment Complete",44013,"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","","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, Inc","Aetna","Participating","Application Submitted","2020-07-01","6345073","","2024-06-27","Request submitted via fax to update providers specialty. MS"]
["Megan Casselman, NP-C","1528619525","75-2656723","TX","","Aetna","Participating","Application Submitted","2020-07-01","6345073","","2024-06-27","Request submitted via fax to update providers specialty. MS"]
["Megan Casselman, NP-C","1528619525","75-2656723","TX","PE - Premier Family Care, 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, Inc","United Health Care","Participating","Enrollment Complete",43739,"1528619525","","2020-08-31","08/31/2020 - moved to completed status after reviewing follow up complete note - stacey Hudak"]
["Megan Casselman, NP-C","1528619525","75-2656723","TX","PE - Premier Family Care, Inc","First Health Coventry","Participating","Enrollment Complete","2020-09-01","1528619525","","2020-10-01","10/01/2020 - Rec'd an email from the payer stating this enrollment has been completed  - Stacey Hudak"]
["Megan Casselman, NP-C","1528619525","75-2656723","TX","PE - Premier Family Care, Inc","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, 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, 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, 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, Inc","Wellmed","Participating","Enrollment Complete","2022-03-01","","","2023-03-23","3/23/2023 Rcvd roster from UHC w/ all Wellmed participating providers.  Provider is PAR effective 3/1/2022.  DCannon"]
["Megan Casselman, NP-C","1528619525","75-2656723","TX","PE - Premier Family Care, 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, Inc","Triwest VA","Facility Enrollment","Facility Enrollment","","","","2022-10-17","10/17/2022 - Received roster from Scarlett of TriWest VA; provider status: \"No Action.  TIN is CCN participating under own DCN.\""]
["Megan Casselman, NP-C","1528619525","75-2656723","TX","PE - Premier Family Care, 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, 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, Inc","TriCare Standard","Participating","Enrollment Complete","2020-04-02","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, 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, 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, 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 R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","PE - Premier Family Care, Inc","TriCare Standard","Participating","Enrollment Complete","2024-06-17","","","2024-07-02"," Provider linked to all locations effective 6/17/2024. MS"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","PE - Premier Family Care, Inc","TriCare Standard","Participating","Enrollment Complete","2024-06-17","","","2024-07-02"," Provider linked to all locations effective 6/17/2024. MS"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","PE - Premier Family Care, Inc","TriCare Standard","Participating","Enrollment Complete",45460,"","","2024-07-02"," Provider linked to all locations effective 6/17/2024. MS"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","PE - Premier Family Care, Inc","TriCare Standard","Participating","Enrollment Complete","2024-06-17","","","2024-07-02"," Provider linked to all locations effective 6/17/2024. MS"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","PE - Premier Family Care, Inc","TriCare Standard","Participating","Enrollment Complete","2024-06-17","","","2024-07-02"," Provider linked to all locations effective 6/17/2024. MS"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","PE - Premier Family Care, Inc","TriCare Standard","Participating","Enrollment Complete","2024-06-17","","","2024-07-02"," Provider linked to all locations effective 6/17/2024. MS"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","PE - Premier Family Care, Inc","TriCare Standard","Participating","Enrollment Complete","2024-06-17","","","2024-07-02"," Provider linked to all locations effective 6/17/2024. MS"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","PE - Premier Family Care, Inc","TriCare Standard","Participating","Enrollment Complete","2024-06-17","","","2024-07-02"," Provider linked to all locations effective 6/17/2024. MS"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","PE - Premier Family Care, Inc","Medicaid","In Process","Payor Follow Up","2024-06-06","","","2024-08-21","Application in PE Review status. Jen Videan"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","PE - Premier Family Care, Inc","Medicaid","In Process","Payor Follow Up","2024-06-06","","","2024-08-21","Application in PE Review status. Jen Videan"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","PE - Premier Family Care, Inc","Medicaid","In Process","Payor Follow Up","2024-06-06","","","2024-08-21","Application in PE Review status. Jen Videan"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","PE - Premier Family Care, Inc","Medicaid","In Process","Payor Follow Up","2024-06-06","","","2024-08-21","Application in PE Review status. Jen Videan"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","PE - Premier Family Care, Inc","Medicaid","In Process","Payor Follow Up",45449,"","","2024-08-21","Application in PE Review status. Jen Videan"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","PE - Premier Family Care, Inc","Medicaid","In Process","Payor Follow Up","2024-06-06","","","2024-08-21","Application in PE Review status. Jen Videan"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","PE - Premier Family Care, Inc","Medicaid","In Process","Payor Follow Up","2024-06-06","","","2024-08-21","Application in PE Review status. Jen Videan"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","PE - Premier Family Care, Inc","Medicaid","In Process","Payor Follow Up","2024-06-06","","","2024-08-21","Application in PE Review status. Jen Videan"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","PE - Premier Family Care, Inc","First Health Coventry","Participating","Enrollment Complete","2022-11-15","","","2023-02-28","2/28/2023 Per First Health web portal provider is PAR and linked to group TIN/location effective 11/15/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","PE - Premier Family Care, Inc","First Health Coventry","Participating","Enrollment Complete","2022-11-15","","","2023-02-28","2/28/2023 Per First Health web portal provider is PAR and linked to group TIN/location effective 11/15/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","PE - Premier Family Care, Inc","First Health Coventry","Participating","Enrollment Complete","2022-11-15","","","2023-02-28","2/28/2023 Per First Health web portal provider is PAR and linked to group TIN/location effective 11/15/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","PE - Premier Family Care, Inc","First Health Coventry","Participating","Enrollment Complete","2022-11-15","","","2023-02-28","2/28/2023 Per First Health web portal provider is PAR and linked to group TIN/location effective 11/15/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","PE - Premier Family Care, Inc","First Health Coventry","Participating","Enrollment Complete","2022-11-15","","","2023-02-28","2/28/2023 Per First Health web portal provider is PAR and linked to group TIN/location effective 11/15/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","PE - Premier Family Care, Inc","First Health Coventry","Participating","Enrollment Complete","2022-11-15","","","2023-02-28","2/28/2023 Per First Health web portal provider is PAR and linked to group TIN/location effective 11/15/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","PE - Premier Family Care, Inc","First Health Coventry","Participating","Enrollment Complete","2022-11-15","","","2023-02-28","2/28/2023 Per First Health web portal provider is PAR and linked to group TIN/location effective 11/15/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","PE - Premier Family Care, Inc","First Health Coventry","Participating","Enrollment Complete","2022-11-15","","","2023-02-28","2/28/2023 Per First Health web portal provider is PAR and linked to group TIN/location effective 11/15/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","PE - Premier Family Care, Inc","First Health Coventry","Participating","Enrollment Complete","2022-11-15","","","2023-02-28","2/28/2023 Per First Health web portal provider is PAR and linked to group TIN/location effective 11/15/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","PE - Premier Family Care, Inc","First Health Coventry","Participating","Enrollment Complete","2022-11-15","","","2023-02-28","2/28/2023 Per First Health web portal provider is PAR and linked to group TIN/location effective 11/15/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","PE - Premier Family Care, Inc","First Health Coventry","Participating","Enrollment Complete",44880,"","","2023-02-28","2/28/2023 Per First Health web portal provider is PAR and linked to group TIN/location effective 11/15/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","PE - Premier Family Care, Inc","First Health Coventry","Participating","Enrollment Complete","2022-11-15","","","2023-02-28","2/28/2023 Per First Health web portal provider is PAR and linked to group TIN/location effective 11/15/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","PE - Premier Family Care, Inc","First Health Coventry","Participating","Enrollment Complete","2022-11-15","","","2023-02-28","2/28/2023 Per First Health web portal provider is PAR and linked to group TIN/location effective 11/15/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","PE - Premier Family Care, Inc","First Health Coventry","Participating","Enrollment Complete","2022-11-15","","","2023-02-28","2/28/2023 Per First Health web portal provider is PAR and linked to group TIN/location effective 11/15/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","PE - Premier Family Care, Inc","First Health Coventry","Participating","Enrollment Complete","2022-11-15","","","2023-02-28","2/28/2023 Per First Health web portal provider is PAR and linked to group TIN/location effective 11/15/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","PE - Premier Family Care, Inc","First Health Coventry","Participating","Enrollment Complete","2022-11-15","","","2023-02-28","2/28/2023 Per First Health web portal provider is PAR and linked to group TIN/location effective 11/15/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","PE - Premier Family Care, Inc","First Health Coventry","Participating","Enrollment Complete","2022-11-15","","","2023-02-28","2/28/2023 Per First Health web portal provider is PAR and linked to group TIN/location effective 11/15/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","PE - Premier Family Care, Inc","First Health Coventry","Participating","Enrollment Complete","2022-11-15","","","2023-02-28","2/28/2023 Per First Health web portal provider is PAR and linked to group TIN/location effective 11/15/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","PE - Premier Family Care, Inc","First Health Coventry","Participating","Enrollment Complete","2022-11-15","","","2023-02-28","2/28/2023 Per First Health web portal provider is PAR and linked to group TIN/location effective 11/15/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","PE - Premier Family Care, Inc","First Health Coventry","Participating","Enrollment Complete",44880,"","","2023-02-28","2/28/2023 Per First Health web portal provider is PAR and linked to group TIN/location effective 11/15/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","PE - Premier Family Care, Inc","First Health Coventry","Participating","Enrollment Complete","2022-11-15","","","2023-02-28","2/28/2023 Per First Health web portal provider is PAR and linked to group TIN/location effective 11/15/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","PE - Premier Family Care, Inc","First Health Coventry","Participating","Enrollment Complete","2022-11-15","","","2023-02-28","2/28/2023 Per First Health web portal provider is PAR and linked to group TIN/location effective 11/15/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","PE - Premier Family Care, Inc","First Health Coventry","Participating","Enrollment Complete","2022-11-15","","","2023-02-28","2/28/2023 Per First Health web portal provider is PAR and linked to group TIN/location effective 11/15/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","PE - Premier Family Care, Inc","First Health Coventry","Participating","Enrollment Complete","2022-11-15","","","2023-02-28","2/28/2023 Per First Health web portal provider is PAR and linked to group TIN/location effective 11/15/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","PE - Premier Family Care, Inc","First Health Coventry","Participating","Enrollment Complete","2022-11-15","","","2023-02-28","2/28/2023 Per First Health web portal provider is PAR and linked to group TIN/location effective 11/15/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","PE - Premier Family Care, Inc","First Health Coventry","Participating","Enrollment Complete","2022-11-15","","","2023-02-28","2/28/2023 Per First Health web portal provider is PAR and linked to group TIN/location effective 11/15/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","PE - Premier Family Care, Inc","First Health Coventry","Participating","Enrollment Complete","2022-11-15","","","2023-02-28","2/28/2023 Per First Health web portal provider is PAR and linked to group TIN/location effective 11/15/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","PE - Premier Family Care, Inc","First Health Coventry","Participating","Enrollment Complete","2022-11-15","","","2023-02-28","2/28/2023 Per First Health web portal provider is PAR and linked to group TIN/location effective 11/15/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","PE - Premier Family Care, Inc","Wellcare","Participating","Enrollment Complete","2022-09-01","","","2022-09-08","9/8/2022 Per roster received from Superior August monthly delegated submission is complete and provider is PAR and linked to group TIN/locations effective  9/1/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","PE - Premier Family Care, Inc","Wellcare","Participating","Enrollment Complete",44805,"","","2022-09-08","9/8/2022 Per roster received from Superior August monthly delegated submission is complete and provider is PAR and linked to group TIN/locations effective  9/1/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","PE - Premier Family Care, Inc","Wellcare","Participating","Enrollment Complete","2022-09-01","","","2022-09-08","9/8/2022 Per roster received from Superior August monthly delegated submission is complete and provider is PAR and linked to group TIN/locations effective  9/1/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","PE - Premier Family Care, Inc","Wellcare","Participating","Enrollment Complete","2022-09-01","","","2022-09-08","9/8/2022 Per roster received from Superior August monthly delegated submission is complete and provider is PAR and linked to group TIN/locations effective  9/1/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","PE - Premier Family Care, Inc","Wellcare","Participating","Enrollment Complete","2022-09-01","","","2022-09-08","9/8/2022 Per roster received from Superior August monthly delegated submission is complete and provider is PAR and linked to group TIN/locations effective  9/1/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","PE - Premier Family Care, Inc","Wellcare","Participating","Enrollment Complete","2022-09-01","","","2022-09-08","9/8/2022 Per roster received from Superior August monthly delegated submission is complete and provider is PAR and linked to group TIN/locations effective  9/1/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","PE - Premier Family Care, Inc","Wellcare","Participating","Enrollment Complete","2022-09-01","","","2022-09-08","9/8/2022 Per roster received from Superior August monthly delegated submission is complete and provider is PAR and linked to group TIN/locations effective  9/1/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","PE - Premier Family Care, Inc","Wellcare","Participating","Enrollment Complete","2022-09-01","","","2022-09-08","9/8/2022 Per roster received from Superior August monthly delegated submission is complete and provider is PAR and linked to group TIN/locations effective  9/1/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","PE - Premier Family Care, Inc","Wellcare","Participating","Enrollment Complete","2022-09-01","","","2022-09-08","9/8/2022 Per roster received from Superior August monthly delegated submission is complete and provider is PAR and linked to group TIN/locations effective  9/1/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","PE - Premier Family Care, Inc","Wellcare","Participating","Enrollment Complete","2022-09-01","","","2022-09-08","9/8/2022 Per roster received from Superior August monthly delegated submission is complete and provider is PAR and linked to group TIN/locations effective  9/1/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","PE - Premier Family Care, Inc","Wellcare","Participating","Enrollment Complete","2022-09-01","","","2022-09-08","9/8/2022 Per roster received from Superior August monthly delegated submission is complete and provider is PAR and linked to group TIN/locations effective  9/1/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","PE - Premier Family Care, Inc","Wellcare","Participating","Enrollment Complete","2022-09-01","","","2022-09-08","9/8/2022 Per roster received from Superior August monthly delegated submission is complete and provider is PAR and linked to group TIN/locations effective  9/1/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","PE - Premier Family Care, Inc","Wellcare","Participating","Enrollment Complete","2022-09-01","","","2022-09-08","9/8/2022 Per roster received from Superior August monthly delegated submission is complete and provider is PAR and linked to group TIN/locations effective  9/1/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","PE - Premier Family Care, Inc","Wellcare","Participating","Enrollment Complete","2022-09-01","","","2022-09-08","9/8/2022 Per roster received from Superior August monthly delegated submission is complete and provider is PAR and linked to group TIN/locations effective  9/1/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","PE - Premier Family Care, Inc","Wellcare","Participating","Enrollment Complete","2022-09-01","","","2022-09-08","9/8/2022 Per roster received from Superior August monthly delegated submission is complete and provider is PAR and linked to group TIN/locations effective  9/1/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","PE - Premier Family Care, Inc","Wellcare","Participating","Enrollment Complete","2022-09-01","","","2022-09-08","9/8/2022 Per roster received from Superior August monthly delegated submission is complete and provider is PAR and linked to group TIN/locations effective  9/1/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","PE - Premier Family Care, Inc","Wellcare","Participating","Enrollment Complete","2022-09-01","","","2022-09-08","9/8/2022 Per roster received from Superior August monthly delegated submission is complete and provider is PAR and linked to group TIN/locations effective  9/1/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","PE - Premier Family Care, Inc","Wellcare","Participating","Enrollment Complete","2022-09-01","","","2022-09-08","9/8/2022 Per roster received from Superior August monthly delegated submission is complete and provider is PAR and linked to group TIN/locations effective  9/1/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","PE - Premier Family Care, Inc","Wellcare","Participating","Enrollment Complete","2022-09-01","","","2022-09-08","9/8/2022 Per roster received from Superior August monthly delegated submission is complete and provider is PAR and linked to group TIN/locations effective  9/1/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","PE - Premier Family Care, Inc","Wellcare","Participating","Enrollment Complete","2022-09-01","","","2022-09-08","9/8/2022 Per roster received from Superior August monthly delegated submission is complete and provider is PAR and linked to group TIN/locations effective  9/1/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","PE - Premier Family Care, Inc","Wellcare","Participating","Enrollment Complete","2022-09-01","","","2022-09-08","9/8/2022 Per roster received from Superior August monthly delegated submission is complete and provider is PAR and linked to group TIN/locations effective  9/1/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","PE - Premier Family Care, Inc","Wellcare","Participating","Enrollment Complete","2022-09-01","","","2022-09-08","9/8/2022 Per roster received from Superior August monthly delegated submission is complete and provider is PAR and linked to group TIN/locations effective  9/1/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","PE - Premier Family Care, Inc","Wellcare","Participating","Enrollment Complete","2022-09-01","","","2022-09-08","9/8/2022 Per roster received from Superior August monthly delegated submission is complete and provider is PAR and linked to group TIN/locations effective  9/1/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","PE - Premier Family Care, Inc","Wellcare","Participating","Enrollment Complete","2022-09-01","","","2022-09-08","9/8/2022 Per roster received from Superior August monthly delegated submission is complete and provider is PAR and linked to group TIN/locations effective  9/1/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","PE - Premier Family Care, Inc","Wellcare","Participating","Enrollment Complete","2022-09-01","","","2022-09-08","9/8/2022 Per roster received from Superior August monthly delegated submission is complete and provider is PAR and linked to group TIN/locations effective  9/1/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","PE - Premier Family Care, Inc","Wellcare","Participating","Enrollment Complete","2022-09-01","","","2022-09-08","9/8/2022 Per roster received from Superior August monthly delegated submission is complete and provider is PAR and linked to group TIN/locations effective  9/1/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","PE - Premier Family Care, Inc","Wellcare","Participating","Enrollment Complete","2022-09-01","","","2022-09-08","9/8/2022 Per roster received from Superior August monthly delegated submission is complete and provider is PAR and linked to group TIN/locations effective  9/1/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","PE - Premier Family Care, Inc","Wellcare","Participating","Enrollment Complete","2022-09-01","","","2022-09-08","9/8/2022 Per roster received from Superior August monthly delegated submission is complete and provider is PAR and linked to group TIN/locations effective  9/1/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","PE - Premier Family Care, Inc","Galaxy Health","Participating","Enrollment Complete","2022-08-12","","","2022-10-15","10/15/2022 Per follow-up email from KAvalos at Galaxy August delegation roster has been completed and provider is PAR and linked to group effective 8/12/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","PE - Premier Family Care, Inc","Galaxy Health","Participating","Enrollment Complete","2022-08-12","","","2022-10-15","10/15/2022 Per follow-up email from KAvalos at Galaxy August delegation roster has been completed and provider is PAR and linked to group effective 8/12/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","PE - Premier Family Care, Inc","Galaxy Health","Participating","Enrollment Complete","2022-08-12","","","2022-10-15","10/15/2022 Per follow-up email from KAvalos at Galaxy August delegation roster has been completed and provider is PAR and linked to group effective 8/12/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","PE - Premier Family Care, Inc","Galaxy Health","Participating","Enrollment Complete","2022-08-12","","","2022-10-15","10/15/2022 Per follow-up email from KAvalos at Galaxy August delegation roster has been completed and provider is PAR and linked to group effective 8/12/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","PE - Premier Family Care, Inc","Galaxy Health","Participating","Enrollment Complete","2022-08-12","","","2022-10-15","10/15/2022 Per follow-up email from KAvalos at Galaxy August delegation roster has been completed and provider is PAR and linked to group effective 8/12/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","PE - Premier Family Care, Inc","Galaxy Health","Participating","Enrollment Complete","2022-08-12","","","2022-10-15","10/15/2022 Per follow-up email from KAvalos at Galaxy August delegation roster has been completed and provider is PAR and linked to group effective 8/12/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","PE - Premier Family Care, Inc","Galaxy Health","Participating","Enrollment Complete","2022-08-12","","","2022-10-15","10/15/2022 Per follow-up email from KAvalos at Galaxy August delegation roster has been completed and provider is PAR and linked to group effective 8/12/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","PE - Premier Family Care, Inc","Galaxy Health","Participating","Enrollment Complete","2022-08-12","","","2022-10-15","10/15/2022 Per follow-up email from KAvalos at Galaxy August delegation roster has been completed and provider is PAR and linked to group effective 8/12/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","PE - Premier Family Care, Inc","Galaxy Health","Participating","Enrollment Complete","2022-08-12","","","2022-10-15","10/15/2022 Per follow-up email from KAvalos at Galaxy August delegation roster has been completed and provider is PAR and linked to group effective 8/12/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","PE - Premier Family Care, Inc","Galaxy Health","Participating","Enrollment Complete","2022-08-12","","","2022-10-15","10/15/2022 Per follow-up email from KAvalos at Galaxy August delegation roster has been completed and provider is PAR and linked to group effective 8/12/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","PE - Premier Family Care, Inc","Galaxy Health","Participating","Enrollment Complete","2022-08-12","","","2022-10-15","10/15/2022 Per follow-up email from KAvalos at Galaxy August delegation roster has been completed and provider is PAR and linked to group effective 8/12/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","PE - Premier Family Care, Inc","Galaxy Health","Participating","Enrollment Complete","2022-08-12","","","2022-10-15","10/15/2022 Per follow-up email from KAvalos at Galaxy August delegation roster has been completed and provider is PAR and linked to group effective 8/12/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","PE - Premier Family Care, Inc","Galaxy Health","Participating","Enrollment Complete","2022-08-12","","","2022-10-15","10/15/2022 Per follow-up email from KAvalos at Galaxy August delegation roster has been completed and provider is PAR and linked to group effective 8/12/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","PE - Premier Family Care, Inc","Galaxy Health","Participating","Enrollment Complete","2022-08-12","","","2022-10-15","10/15/2022 Per follow-up email from KAvalos at Galaxy August delegation roster has been completed and provider is PAR and linked to group effective 8/12/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","PE - Premier Family Care, Inc","Galaxy Health","Participating","Enrollment Complete","2022-08-12","","","2022-10-15","10/15/2022 Per follow-up email from KAvalos at Galaxy August delegation roster has been completed and provider is PAR and linked to group effective 8/12/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","PE - Premier Family Care, Inc","Galaxy Health","Participating","Enrollment Complete","2022-08-12","","","2022-10-15","10/15/2022 Per follow-up email from KAvalos at Galaxy August delegation roster has been completed and provider is PAR and linked to group effective 8/12/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","PE - Premier Family Care, Inc","Galaxy Health","Participating","Enrollment Complete","2022-08-12","","","2022-10-15","10/15/2022 Per follow-up email from KAvalos at Galaxy August delegation roster has been completed and provider is PAR and linked to group effective 8/12/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","PE - Premier Family Care, Inc","Galaxy Health","Participating","Enrollment Complete","2022-08-12","","","2022-10-15","10/15/2022 Per follow-up email from KAvalos at Galaxy August delegation roster has been completed and provider is PAR and linked to group effective 8/12/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","PE - Premier Family Care, Inc","Galaxy Health","Participating","Enrollment Complete","2022-08-12","","","2022-10-15","10/15/2022 Per follow-up email from KAvalos at Galaxy August delegation roster has been completed and provider is PAR and linked to group effective 8/12/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","PE - Premier Family Care, Inc","Galaxy Health","Participating","Enrollment Complete","2022-08-12","","","2022-10-15","10/15/2022 Per follow-up email from KAvalos at Galaxy August delegation roster has been completed and provider is PAR and linked to group effective 8/12/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","PE - Premier Family Care, Inc","Galaxy Health","Participating","Enrollment Complete","2022-08-12","","","2022-10-15","10/15/2022 Per follow-up email from KAvalos at Galaxy August delegation roster has been completed and provider is PAR and linked to group effective 8/12/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","PE - Premier Family Care, Inc","Galaxy Health","Participating","Enrollment Complete","2022-08-12","","","2022-10-15","10/15/2022 Per follow-up email from KAvalos at Galaxy August delegation roster has been completed and provider is PAR and linked to group effective 8/12/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","PE - Premier Family Care, Inc","Galaxy Health","Participating","Enrollment Complete","2022-08-12","","","2022-10-15","10/15/2022 Per follow-up email from KAvalos at Galaxy August delegation roster has been completed and provider is PAR and linked to group effective 8/12/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","PE - Premier Family Care, Inc","Galaxy Health","Participating","Enrollment Complete","2022-08-12","","","2022-10-15","10/15/2022 Per follow-up email from KAvalos at Galaxy August delegation roster has been completed and provider is PAR and linked to group effective 8/12/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","PE - Premier Family Care, Inc","Galaxy Health","Participating","Enrollment Complete","2022-08-12","","","2022-10-15","10/15/2022 Per follow-up email from KAvalos at Galaxy August delegation roster has been completed and provider is PAR and linked to group effective 8/12/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","PE - Premier Family Care, Inc","Galaxy Health","Participating","Enrollment Complete","2022-08-12","","","2022-10-15","10/15/2022 Per follow-up email from KAvalos at Galaxy August delegation roster has been completed and provider is PAR and linked to group effective 8/12/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","PE - Premier Family Care, Inc","Galaxy Health","Participating","Enrollment Complete","2022-08-12","","","2022-10-15","10/15/2022 Per follow-up email from KAvalos at Galaxy August delegation roster has been completed and provider is PAR and linked to group effective 8/12/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","PE - Premier Family Care, Inc","Galaxy Health","Participating","Enrollment Complete","2022-08-12","","","2022-10-15","10/15/2022 Per follow-up email from KAvalos at Galaxy August delegation roster has been completed and provider is PAR and linked to group effective 8/12/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","PE - Premier Family Care, Inc","Medicare","Participating","Enrollment Complete","","","","2024-07-01","Locations are already listed in the group record, so the provider is already linked to them.MS"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","PE - Premier Family Care, Inc","Medicare","Participating","Enrollment Complete","","","","2024-07-01","Locations are already listed in the group record, so the provider is already linked to them.MS"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","PE - Premier Family Care, Inc","Medicare","Participating","Enrollment Complete","","","","2024-07-01","Locations are already listed in the group record, so the provider is already linked to them.MS"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","PE - Premier Family Care, Inc","Medicare","Participating","Enrollment Complete","","","","2024-07-01","Locations are already listed in the group record, so the provider is already linked to them.MS"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","PE - Premier Family Care, Inc","Medicare","Participating","Enrollment Complete","","","","2024-07-01","Locations are already listed in the group record, so the provider is already linked to them.MS"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","PE - Premier Family Care, Inc","Medicare","Participating","Enrollment Complete","","","","2024-07-01","Locations are already listed in the group record, so the provider is already linked to them.MS"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","PE - Premier Family Care, Inc","Medicare","Participating","Enrollment Complete","","","","2024-07-01","Locations are already listed in the group record, so the provider is already linked to them.MS"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","PE - Premier Family Care, Inc","Medicare","Participating","Enrollment Complete","","","","2024-07-01","Locations are already listed in the group record, so the provider is already linked to them.MS"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","PE - Premier Family Care, Inc","Superior","Participating","Enrollment Complete","2022-09-01","","","2022-09-08","9/8/2022 Per roster received from Superior August monthly delegated submission is complete and provider is PAR and linked to group TIN/locations effective  9/1/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","PE - Premier Family Care, Inc","Superior","Participating","Enrollment Complete","2022-09-01","","","2022-09-08","9/8/2022 Per roster received from Superior August monthly delegated submission is complete and provider is PAR and linked to group TIN/locations effective  9/1/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","PE - Premier Family Care, Inc","Superior","Participating","Enrollment Complete","2022-09-01","","","2022-09-08","9/8/2022 Per roster received from Superior August monthly delegated submission is complete and provider is PAR and linked to group TIN/locations effective  9/1/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","PE - Premier Family Care, Inc","Superior","Participating","Enrollment Complete","2022-09-01","","","2022-09-08","9/8/2022 Per roster received from Superior August monthly delegated submission is complete and provider is PAR and linked to group TIN/locations effective  9/1/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","PE - Premier Family Care, Inc","Superior","Participating","Enrollment Complete","2022-09-01","","","2022-09-08","9/8/2022 Per roster received from Superior August monthly delegated submission is complete and provider is PAR and linked to group TIN/locations effective  9/1/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","PE - Premier Family Care, Inc","Superior","Participating","Enrollment Complete","2022-09-01","","","2022-09-08","9/8/2022 Per roster received from Superior August monthly delegated submission is complete and provider is PAR and linked to group TIN/locations effective  9/1/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","PE - Premier Family Care, Inc","Superior","Participating","Enrollment Complete","2022-09-01","","","2022-09-08","9/8/2022 Per roster received from Superior August monthly delegated submission is complete and provider is PAR and linked to group TIN/locations effective  9/1/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","PE - Premier Family Care, Inc","Superior","Participating","Enrollment Complete","2022-09-01","","","2022-09-08","9/8/2022 Per roster received from Superior August monthly delegated submission is complete and provider is PAR and linked to group TIN/locations effective  9/1/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","PE - Premier Family Care, Inc","Superior","Participating","Enrollment Complete","2022-09-01","","","2022-09-08","9/8/2022 Per roster received from Superior August monthly delegated submission is complete and provider is PAR and linked to group TIN/locations effective  9/1/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","PE - Premier Family Care, Inc","Superior","Participating","Enrollment Complete","2022-09-01","","","2022-09-08","9/8/2022 Per roster received from Superior August monthly delegated submission is complete and provider is PAR and linked to group TIN/locations effective  9/1/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","PE - Premier Family Care, Inc","Superior","Participating","Enrollment Complete","2022-09-01","","","2022-09-08","9/8/2022 Per roster received from Superior August monthly delegated submission is complete and provider is PAR and linked to group TIN/locations effective  9/1/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","PE - Premier Family Care, Inc","Superior","Participating","Enrollment Complete","2022-09-01","","","2022-09-08","9/8/2022 Per roster received from Superior August monthly delegated submission is complete and provider is PAR and linked to group TIN/locations effective  9/1/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","PE - Premier Family Care, Inc","Superior","Participating","Enrollment Complete","2022-09-01","","","2022-09-08","9/8/2022 Per roster received from Superior August monthly delegated submission is complete and provider is PAR and linked to group TIN/locations effective  9/1/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","PE - Premier Family Care, Inc","Superior","Participating","Enrollment Complete","2022-09-01","","","2022-09-08","9/8/2022 Per roster received from Superior August monthly delegated submission is complete and provider is PAR and linked to group TIN/locations effective  9/1/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","PE - Premier Family Care, Inc","Superior","Participating","Enrollment Complete","2022-09-01","","","2022-09-08","9/8/2022 Per roster received from Superior August monthly delegated submission is complete and provider is PAR and linked to group TIN/locations effective  9/1/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","PE - Premier Family Care, Inc","Superior","Participating","Enrollment Complete","2022-09-01","","","2022-09-08","9/8/2022 Per roster received from Superior August monthly delegated submission is complete and provider is PAR and linked to group TIN/locations effective  9/1/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","PE - Premier Family Care, Inc","Superior","Participating","Enrollment Complete",44805,"","","2022-09-08","9/8/2022 Per roster received from Superior August monthly delegated submission is complete and provider is PAR and linked to group TIN/locations effective  9/1/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","PE - Premier Family Care, Inc","Superior","Participating","Enrollment Complete",44805,"","","2022-09-08","9/8/2022 Per roster received from Superior August monthly delegated submission is complete and provider is PAR and linked to group TIN/locations effective  9/1/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","PE - Premier Family Care, Inc","Superior","Participating","Enrollment Complete",44805,"","","2022-09-08","9/8/2022 Per roster received from Superior August monthly delegated submission is complete and provider is PAR and linked to group TIN/locations effective  9/1/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","PE - Premier Family Care, Inc","Superior","Participating","Enrollment Complete",44805,"","","2022-09-08","9/8/2022 Per roster received from Superior August monthly delegated submission is complete and provider is PAR and linked to group TIN/locations effective  9/1/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","PE - Premier Family Care, Inc","Superior","Participating","Enrollment Complete","2022-09-01","","","2022-09-08","9/8/2022 Per roster received from Superior August monthly delegated submission is complete and provider is PAR and linked to group TIN/locations effective  9/1/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","PE - Premier Family Care, Inc","Superior","Participating","Enrollment Complete","2022-09-01","","","2022-09-08","9/8/2022 Per roster received from Superior August monthly delegated submission is complete and provider is PAR and linked to group TIN/locations effective  9/1/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","PE - Premier Family Care, Inc","Superior","Participating","Enrollment Complete","2022-09-01","","","2022-09-08","9/8/2022 Per roster received from Superior August monthly delegated submission is complete and provider is PAR and linked to group TIN/locations effective  9/1/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","PE - Premier Family Care, Inc","Superior","Participating","Enrollment Complete","2022-09-01","","","2022-09-08","9/8/2022 Per roster received from Superior August monthly delegated submission is complete and provider is PAR and linked to group TIN/locations effective  9/1/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","PE - Premier Family Care, Inc","Superior","Participating","Enrollment Complete",44805,"","","2022-09-08","9/8/2022 Per roster received from Superior August monthly delegated submission is complete and provider is PAR and linked to group TIN/locations effective  9/1/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","PE - Premier Family Care, Inc","Superior","Participating","Enrollment Complete","2022-09-01","","","2022-09-08","9/8/2022 Per roster received from Superior August monthly delegated submission is complete and provider is PAR and linked to group TIN/locations effective  9/1/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","PE - Premier Family Care, Inc","Superior","Participating","Enrollment Complete",44805,"","","2022-09-08","9/8/2022 Per roster received from Superior August monthly delegated submission is complete and provider is PAR and linked to group TIN/locations effective  9/1/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","PE - Premier Family Care, Inc","Superior","Participating","Enrollment Complete","2022-09-01","","","2022-09-08","9/8/2022 Per roster received from Superior August monthly delegated submission is complete and provider is PAR and linked to group TIN/locations effective  9/1/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","PE - Premier Family Care, Inc","Ambetter","Participating","Enrollment Complete","2022-09-01","","","2022-09-08","9/8/2022 Per roster received from Superior August monthly delegated submission is complete and provider is PAR and linked to group TIN/locations effective  9/1/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","PE - Premier Family Care, Inc","Ambetter","Participating","Enrollment Complete","2022-09-01","","","2022-09-08","9/8/2022 Per roster received from Superior August monthly delegated submission is complete and provider is PAR and linked to group TIN/locations effective  9/1/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","PE - Premier Family Care, Inc","Ambetter","Participating","Enrollment Complete","2022-09-01","","","2022-09-08","9/8/2022 Per roster received from Superior August monthly delegated submission is complete and provider is PAR and linked to group TIN/locations effective  9/1/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","PE - Premier Family Care, Inc","Ambetter","Participating","Enrollment Complete","2022-09-01","","","2022-09-08","9/8/2022 Per roster received from Superior August monthly delegated submission is complete and provider is PAR and linked to group TIN/locations effective  9/1/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","PE - Premier Family Care, Inc","Ambetter","Participating","Enrollment Complete","2022-09-01","","","2022-09-08","9/8/2022 Per roster received from Superior August monthly delegated submission is complete and provider is PAR and linked to group TIN/locations effective  9/1/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","PE - Premier Family Care, Inc","Ambetter","Participating","Enrollment Complete","2022-09-01","","","2022-09-08","9/8/2022 Per roster received from Superior August monthly delegated submission is complete and provider is PAR and linked to group TIN/locations effective  9/1/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","PE - Premier Family Care, Inc","Ambetter","Participating","Enrollment Complete","2022-09-01","","","2022-09-08","9/8/2022 Per roster received from Superior August monthly delegated submission is complete and provider is PAR and linked to group TIN/locations effective  9/1/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","PE - Premier Family Care, Inc","Ambetter","Participating","Enrollment Complete","2022-09-01","","","2022-09-08","9/8/2022 Per roster received from Superior August monthly delegated submission is complete and provider is PAR and linked to group TIN/locations effective  9/1/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","PE - Premier Family Care, Inc","Ambetter","Participating","Enrollment Complete","2022-09-01","","","2022-09-08","9/8/2022 Per roster received from Superior August monthly delegated submission is complete and provider is PAR and linked to group TIN/locations effective  9/1/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","PE - Premier Family Care, Inc","Ambetter","Participating","Enrollment Complete","2022-09-01","","","2022-09-08","9/8/2022 Per roster received from Superior August monthly delegated submission is complete and provider is PAR and linked to group TIN/locations effective  9/1/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","PE - Premier Family Care, Inc","Ambetter","Participating","Enrollment Complete","2022-09-01","","","2022-09-08","9/8/2022 Per roster received from Superior August monthly delegated submission is complete and provider is PAR and linked to group TIN/locations effective  9/1/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","PE - Premier Family Care, Inc","Ambetter","Participating","Enrollment Complete","2022-09-01","","","2022-09-08","9/8/2022 Per roster received from Superior August monthly delegated submission is complete and provider is PAR and linked to group TIN/locations effective  9/1/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","PE - Premier Family Care, Inc","Ambetter","Participating","Enrollment Complete","2022-09-01","","","2022-09-08","9/8/2022 Per roster received from Superior August monthly delegated submission is complete and provider is PAR and linked to group TIN/locations effective  9/1/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","PE - Premier Family Care, Inc","Ambetter","Participating","Enrollment Complete","2022-09-01","","","2022-09-08","9/8/2022 Per roster received from Superior August monthly delegated submission is complete and provider is PAR and linked to group TIN/locations effective  9/1/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","PE - Premier Family Care, Inc","Ambetter","Participating","Enrollment Complete","2022-09-01","","","2022-09-08","9/8/2022 Per roster received from Superior August monthly delegated submission is complete and provider is PAR and linked to group TIN/locations effective  9/1/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","PE - Premier Family Care, Inc","Ambetter","Participating","Enrollment Complete","2022-09-01","","","2022-09-08","9/8/2022 Per roster received from Superior August monthly delegated submission is complete and provider is PAR and linked to group TIN/locations effective  9/1/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","PE - Premier Family Care, Inc","Ambetter","Participating","Enrollment Complete","2022-09-01","","","2022-09-08","9/8/2022 Per roster received from Superior August monthly delegated submission is complete and provider is PAR and linked to group TIN/locations effective  9/1/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","PE - Premier Family Care, Inc","Ambetter","Participating","Enrollment Complete","2022-09-01","","","2022-09-08","9/8/2022 Per roster received from Superior August monthly delegated submission is complete and provider is PAR and linked to group TIN/locations effective  9/1/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","PE - Premier Family Care, Inc","Ambetter","Participating","Enrollment Complete","2022-09-01","","","2022-09-08","9/8/2022 Per roster received from Superior August monthly delegated submission is complete and provider is PAR and linked to group TIN/locations effective  9/1/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","PE - Premier Family Care, Inc","Ambetter","Participating","Enrollment Complete",44805,"","","2022-09-08","9/8/2022 Per roster received from Superior August monthly delegated submission is complete and provider is PAR and linked to group TIN/locations effective  9/1/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","PE - Premier Family Care, Inc","Amerigroup","Participating","Enrollment Complete","2022-08-12","","","2022-10-28","10/28/2022 Per follow-up note from 10.21.2022 S/W Gloria of Amerigroup @ 800-454-3730. Per rep, provider is on file and participating. Link under the group and TIN effective 8/12/2022. Location is on file. Provider ID is 14387628. No recredentialing date. Dcannon"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","PE - Premier Family Care, Inc","Amerigroup","Participating","Enrollment Complete","2022-08-12","","","2022-10-28","10/28/2022 Per follow-up note from 10.21.2022 S/W Gloria of Amerigroup @ 800-454-3730. Per rep, provider is on file and participating. Link under the group and TIN effective 8/12/2022. Location is on file. Provider ID is 14387628. No recredentialing date. Dcannon"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","PE - Premier Family Care, Inc","Amerigroup","Participating","Enrollment Complete","2022-08-12","","","2022-10-28","10/28/2022 Per follow-up note from 10.21.2022 S/W Gloria of Amerigroup @ 800-454-3730. Per rep, provider is on file and participating. Link under the group and TIN effective 8/12/2022. Location is on file. Provider ID is 14387628. No recredentialing date. Dcannon"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","PE - Premier Family Care, Inc","Amerigroup","Participating","Enrollment Complete",44785,"","","2022-10-28","10/28/2022 Per follow-up note from 10.21.2022 S/W Gloria of Amerigroup @ 800-454-3730. Per rep, provider is on file and participating. Link under the group and TIN effective 8/12/2022. Location is on file. Provider ID is 14387628. No recredentialing date. Dcannon"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","PE - Premier Family Care, Inc","Amerigroup","Participating","Enrollment Complete","2022-08-12","","","2022-10-28","10/28/2022 Per follow-up note from 10.21.2022 S/W Gloria of Amerigroup @ 800-454-3730. Per rep, provider is on file and participating. Link under the group and TIN effective 8/12/2022. Location is on file. Provider ID is 14387628. No recredentialing date. Dcannon"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","PE - Premier Family Care, Inc","Amerigroup","Participating","Enrollment Complete","2022-08-12","","","2022-10-28","10/28/2022 Per follow-up note from 10.21.2022 S/W Gloria of Amerigroup @ 800-454-3730. Per rep, provider is on file and participating. Link under the group and TIN effective 8/12/2022. Location is on file. Provider ID is 14387628. No recredentialing date. Dcannon"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","PE - Premier Family Care, Inc","Amerigroup","Participating","Enrollment Complete","2022-08-12","","","2022-10-28","10/28/2022 Per follow-up note from 10.21.2022 S/W Gloria of Amerigroup @ 800-454-3730. Per rep, provider is on file and participating. Link under the group and TIN effective 8/12/2022. Location is on file. Provider ID is 14387628. No recredentialing date. Dcannon"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","PE - Premier Family Care, Inc","Amerigroup","Participating","Enrollment Complete","2022-08-12","","","2022-10-28","10/28/2022 Per follow-up note from 10.21.2022 S/W Gloria of Amerigroup @ 800-454-3730. Per rep, provider is on file and participating. Link under the group and TIN effective 8/12/2022. Location is on file. Provider ID is 14387628. No recredentialing date. Dcannon"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","PE - Premier Family Care, Inc","Amerigroup","Participating","Enrollment Complete","2022-08-12","","","2022-10-28","10/28/2022 Per follow-up note from 10.21.2022 S/W Gloria of Amerigroup @ 800-454-3730. Per rep, provider is on file and participating. Link under the group and TIN effective 8/12/2022. Location is on file. Provider ID is 14387628. No recredentialing date. Dcannon"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","PE - Premier Family Care, Inc","Amerigroup","Participating","Enrollment Complete","2022-08-12","","","2022-10-28","10/28/2022 Per follow-up note from 10.21.2022 S/W Gloria of Amerigroup @ 800-454-3730. Per rep, provider is on file and participating. Link under the group and TIN effective 8/12/2022. Location is on file. Provider ID is 14387628. No recredentialing date. Dcannon"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","PE - Premier Family Care, Inc","Amerigroup","Participating","Enrollment Complete","2022-08-12","","","2022-10-28","10/28/2022 Per follow-up note from 10.21.2022 S/W Gloria of Amerigroup @ 800-454-3730. Per rep, provider is on file and participating. Link under the group and TIN effective 8/12/2022. Location is on file. Provider ID is 14387628. No recredentialing date. Dcannon"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","PE - Premier Family Care, Inc","Amerigroup","Participating","Enrollment Complete","2022-08-12","","","2022-10-28","10/28/2022 Per follow-up note from 10.21.2022 S/W Gloria of Amerigroup @ 800-454-3730. Per rep, provider is on file and participating. Link under the group and TIN effective 8/12/2022. Location is on file. Provider ID is 14387628. No recredentialing date. Dcannon"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","PE - Premier Family Care, Inc","Amerigroup","Participating","Enrollment Complete","2022-08-12","","","2022-10-28","10/28/2022 Per follow-up note from 10.21.2022 S/W Gloria of Amerigroup @ 800-454-3730. Per rep, provider is on file and participating. Link under the group and TIN effective 8/12/2022. Location is on file. Provider ID is 14387628. No recredentialing date. Dcannon"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","PE - Premier Family Care, Inc","Amerigroup","Participating","Enrollment Complete","2022-08-12","","","2022-10-28","10/28/2022 Per follow-up note from 10.21.2022 S/W Gloria of Amerigroup @ 800-454-3730. Per rep, provider is on file and participating. Link under the group and TIN effective 8/12/2022. Location is on file. Provider ID is 14387628. No recredentialing date. Dcannon"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","PE - Premier Family Care, Inc","Amerigroup","Participating","Enrollment Complete","2022-08-12","","","2022-10-28","10/28/2022 Per follow-up note from 10.21.2022 S/W Gloria of Amerigroup @ 800-454-3730. Per rep, provider is on file and participating. Link under the group and TIN effective 8/12/2022. Location is on file. Provider ID is 14387628. No recredentialing date. Dcannon"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","PE - Premier Family Care, Inc","Amerigroup","Participating","Enrollment Complete","2022-08-12","","","2022-10-28","10/28/2022 Per follow-up note from 10.21.2022 S/W Gloria of Amerigroup @ 800-454-3730. Per rep, provider is on file and participating. Link under the group and TIN effective 8/12/2022. Location is on file. Provider ID is 14387628. No recredentialing date. Dcannon"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","PE - Premier Family Care, Inc","Amerigroup","Participating","Enrollment Complete","2022-08-12","","","2022-10-28","10/28/2022 Per follow-up note from 10.21.2022 S/W Gloria of Amerigroup @ 800-454-3730. Per rep, provider is on file and participating. Link under the group and TIN effective 8/12/2022. Location is on file. Provider ID is 14387628. No recredentialing date. Dcannon"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","PE - Premier Family Care, Inc","Amerigroup","Participating","Enrollment Complete","2022-08-12","","","2022-10-28","10/28/2022 Per follow-up note from 10.21.2022 S/W Gloria of Amerigroup @ 800-454-3730. Per rep, provider is on file and participating. Link under the group and TIN effective 8/12/2022. Location is on file. Provider ID is 14387628. No recredentialing date. Dcannon"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","PE - Premier Family Care, Inc","Amerigroup","Participating","Enrollment Complete",44785,"","",44862,"10/28/2022 Per follow-up note from 10.21.2022 S/W Gloria of Amerigroup @ 800-454-3730. Per rep, provider is on file and participating. Link under the group and TIN effective 8/12/2022. Location is on file. Provider ID is 14387628. No recredentialing date. Dcannon"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","PE - Premier Family Care, Inc","Amerigroup","Participating","Enrollment Complete","2022-08-12","","","2022-10-28","10/28/2022 Per follow-up note from 10.21.2022 S/W Gloria of Amerigroup @ 800-454-3730. Per rep, provider is on file and participating. Link under the group and TIN effective 8/12/2022. Location is on file. Provider ID is 14387628. No recredentialing date. Dcannon"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","PE - Premier Family Care, Inc","Amerigroup","Participating","Enrollment Complete","2022-08-12","","","2022-10-28","10/28/2022 Per follow-up note from 10.21.2022 S/W Gloria of Amerigroup @ 800-454-3730. Per rep, provider is on file and participating. Link under the group and TIN effective 8/12/2022. Location is on file. Provider ID is 14387628. No recredentialing date. Dcannon"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","PE - Premier Family Care, Inc","Amerigroup","Participating","Enrollment Complete","2022-08-12","","","2022-10-28","10/28/2022 Per follow-up note from 10.21.2022 S/W Gloria of Amerigroup @ 800-454-3730. Per rep, provider is on file and participating. Link under the group and TIN effective 8/12/2022. Location is on file. Provider ID is 14387628. No recredentialing date. Dcannon"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","PE - Premier Family Care, Inc","Amerigroup","Participating","Enrollment Complete","2022-08-12","","","2022-10-28","10/28/2022 Per follow-up note from 10.21.2022 S/W Gloria of Amerigroup @ 800-454-3730. Per rep, provider is on file and participating. Link under the group and TIN effective 8/12/2022. Location is on file. Provider ID is 14387628. No recredentialing date. Dcannon"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","PE - Premier Family Care, Inc","Amerigroup","Participating","Enrollment Complete","2022-08-12","","","2022-10-28","10/28/2022 Per follow-up note from 10.21.2022 S/W Gloria of Amerigroup @ 800-454-3730. Per rep, provider is on file and participating. Link under the group and TIN effective 8/12/2022. Location is on file. Provider ID is 14387628. No recredentialing date. Dcannon"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","PE - Premier Family Care, Inc","Amerigroup","Participating","Enrollment Complete","2022-08-12","","","2022-10-28","10/28/2022 Per follow-up note from 10.21.2022 S/W Gloria of Amerigroup @ 800-454-3730. Per rep, provider is on file and participating. Link under the group and TIN effective 8/12/2022. Location is on file. Provider ID is 14387628. No recredentialing date. Dcannon"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","PE - Premier Family Care, Inc","Amerigroup","Participating","Enrollment Complete","2022-08-12","","","2022-10-28","10/28/2022 Per follow-up note from 10.21.2022 S/W Gloria of Amerigroup @ 800-454-3730. Per rep, provider is on file and participating. Link under the group and TIN effective 8/12/2022. Location is on file. Provider ID is 14387628. No recredentialing date. Dcannon"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","PE - Premier Family Care, Inc","Amerigroup","Participating","Enrollment Complete","2022-08-12","","","2022-10-28","10/28/2022 Per follow-up note from 10.21.2022 S/W Gloria of Amerigroup @ 800-454-3730. Per rep, provider is on file and participating. Link under the group and TIN effective 8/12/2022. Location is on file. Provider ID is 14387628. No recredentialing date. Dcannon"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","PE - Premier Family Care, Inc","Amerigroup","Participating","Enrollment Complete","2022-08-12","","","2022-10-28","10/28/2022 Per follow-up note from 10.21.2022 S/W Gloria of Amerigroup @ 800-454-3730. Per rep, provider is on file and participating. Link under the group and TIN effective 8/12/2022. Location is on file. Provider ID is 14387628. No recredentialing date. Dcannon"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","PE - Premier Family Care, Inc","Rail Road Medicare","Participating","Enrollment Complete","2022-08-28","","","2024-06-27","provider is already linked to group record and all locations are confirmed. MS"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","PE - Premier Family Care, Inc","Rail Road Medicare","Participating","Enrollment Complete","2022-08-28","","","2024-06-27","provider is already linked to group record and all locations are confirmed. MS"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","PE - Premier Family Care, Inc","Rail Road Medicare","Participating","Enrollment Complete","2022-08-28","","","2024-06-27","provider is already linked to group record and all locations are confirmed. MS"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","PE - Premier Family Care, Inc","Rail Road Medicare","Participating","Enrollment Complete",44801,"","","2024-06-27","provider is already linked to group record and all locations are confirmed. MS"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","PE - Premier Family Care, Inc","Rail Road Medicare","Participating","Enrollment Complete","2022-08-28","","","2024-06-27","provider is already linked to group record and all locations are confirmed. MS"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","PE - Premier Family Care, Inc","Rail Road Medicare","Participating","Enrollment Complete","2022-08-28","","","2024-06-27","provider is already linked to group record and all locations are confirmed. MS"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","PE - Premier Family Care, Inc","Rail Road Medicare","Participating","Enrollment Complete","2022-08-28","","","2024-06-27","provider is already linked to group record and all locations are confirmed. MS"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","PE - Premier Family Care, Inc","Rail Road Medicare","Participating","Enrollment Complete","2022-08-28","","","2024-06-27","provider is already linked to group record and all locations are confirmed. MS"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","PE - Premier Family Care, Inc","Rail Road Medicare","Participating","Enrollment Complete","2022-08-28","","","2022-09-08","9/8/2022 Rcvd RR Medicare approval letter.  PTAN # Q00322530 - effective 8/28/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","PE - Premier Family Care, Inc","Rail Road Medicare","Participating","Enrollment Complete","2022-08-28","","","2022-09-08","9/8/2022 Rcvd RR Medicare approval letter.  PTAN # Q00322530 - effective 8/28/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","PE - Premier Family Care, Inc","Rail Road Medicare","Participating","Enrollment Complete",44801,"","","2022-09-08","9/8/2022 Rcvd RR Medicare approval letter.  PTAN # Q00322530 - effective 8/28/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","PE - Premier Family Care, Inc","Rail Road Medicare","Participating","Enrollment Complete",44801,"","","2022-09-08","9/8/2022 Rcvd RR Medicare approval letter.  PTAN # Q00322530 - effective 8/28/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","PE - Premier Family Care, Inc","Rail Road Medicare","Participating","Enrollment Complete",44801,"","","2022-09-08","9/8/2022 Rcvd RR Medicare approval letter.  PTAN # Q00322530 - effective 8/28/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","PE - Premier Family Care, Inc","Rail Road Medicare","Participating","Enrollment Complete",44801,"","","2022-09-08","9/8/2022 Rcvd RR Medicare approval letter.  PTAN # Q00322530 - effective 8/28/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","PE - Premier Family Care, Inc","Rail Road Medicare","Participating","Enrollment Complete","2022-08-28","","","2022-09-08","9/8/2022 Rcvd RR Medicare approval letter.  PTAN # Q00322530 - effective 8/28/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","PE - Premier Family Care, Inc","Rail Road Medicare","Participating","Enrollment Complete","2022-08-28","","","2022-09-08","9/8/2022 Rcvd RR Medicare approval letter.  PTAN # Q00322530 - effective 8/28/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","PE - Premier Family Care, Inc","Rail Road Medicare","Participating","Enrollment Complete","2022-08-28","","","2022-09-08","9/8/2022 Rcvd RR Medicare approval letter.  PTAN # Q00322530 - effective 8/28/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","PE - Premier Family Care, Inc","Rail Road Medicare","Participating","Enrollment Complete","2022-08-28","","","2022-09-08","9/8/2022 Rcvd RR Medicare approval letter.  PTAN # Q00322530 - effective 8/28/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","PE - Premier Family Care, Inc","Rail Road Medicare","Participating","Enrollment Complete","2022-08-28","","","2022-09-08","9/8/2022 Rcvd RR Medicare approval letter.  PTAN # Q00322530 - effective 8/28/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","PE - Premier Family Care, Inc","Rail Road Medicare","Participating","Enrollment Complete","2022-08-28","","","2022-09-08","9/8/2022 Rcvd RR Medicare approval letter.  PTAN # Q00322530 - effective 8/28/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","PE - Premier Family Care, Inc","Rail Road Medicare","Participating","Enrollment Complete","2022-08-28","","","2022-09-08","9/8/2022 Rcvd RR Medicare approval letter.  PTAN # Q00322530 - effective 8/28/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","PE - Premier Family Care, Inc","Rail Road Medicare","Participating","Enrollment Complete","2022-08-28","","","2022-09-08","9/8/2022 Rcvd RR Medicare approval letter.  PTAN # Q00322530 - effective 8/28/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","PE - Premier Family Care, Inc","Rail Road Medicare","Participating","Enrollment Complete","2022-08-28","","","2022-09-08","9/8/2022 Rcvd RR Medicare approval letter.  PTAN # Q00322530 - effective 8/28/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","PE - Premier Family Care, Inc","Rail Road Medicare","Participating","Enrollment Complete",44801,"","","2022-09-08","9/8/2022 Rcvd RR Medicare approval letter.  PTAN # Q00322530 - effective 8/28/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","PE - Premier Family Care, Inc","Rail Road Medicare","Participating","Enrollment Complete","2022-08-28","","","2022-09-08","9/8/2022 Rcvd RR Medicare approval letter.  PTAN # Q00322530 - effective 8/28/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","PE - Premier Family Care, Inc","Rail Road Medicare","Participating","Enrollment Complete","2022-08-28","","","2022-09-08","9/8/2022 Rcvd RR Medicare approval letter.  PTAN # Q00322530 - effective 8/28/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","PE - Premier Family Care, Inc","Rail Road Medicare","Participating","Enrollment Complete","2022-08-28","","","2022-09-08","9/8/2022 Rcvd RR Medicare approval letter.  PTAN # Q00322530 - effective 8/28/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","PE - Premier Family Care, Inc","Rail Road Medicare","Participating","Enrollment Complete","2022-08-28","","","2022-09-08","9/8/2022 Rcvd RR Medicare approval letter.  PTAN # Q00322530 - effective 8/28/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","PE - Premier Family Care, Inc","Rail Road Medicare","Participating","Enrollment Complete","2022-08-28","","","2022-09-08","9/8/2022 Rcvd RR Medicare approval letter.  PTAN # Q00322530 - effective 8/28/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","PE - Premier Family Care, Inc","Rail Road Medicare","Participating","Enrollment Complete","2022-08-28","","","2022-09-08","9/8/2022 Rcvd RR Medicare approval letter.  PTAN # Q00322530 - effective 8/28/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","PE - Premier Family Care, Inc","Rail Road Medicare","Participating","Enrollment Complete","2022-08-28","","","2022-09-08","9/8/2022 Rcvd RR Medicare approval letter.  PTAN # Q00322530 - effective 8/28/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","PE - Premier Family Care, Inc","Rail Road Medicare","Participating","Enrollment Complete","2022-08-28","","","2022-09-08","9/8/2022 Rcvd RR Medicare approval letter.  PTAN # Q00322530 - effective 8/28/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","PE - Premier Family Care, Inc","Rail Road Medicare","Participating","Enrollment Complete","2022-08-28","","","2022-09-08","9/8/2022 Rcvd RR Medicare approval letter.  PTAN # Q00322530 - effective 8/28/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","PE - Premier Family Care, Inc","Rail Road Medicare","Participating","Enrollment Complete","2022-08-28","","","2022-09-08","9/8/2022 Rcvd RR Medicare approval letter.  PTAN # Q00322530 - effective 8/28/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","PE - Premier Family Care, Inc","Rail Road Medicare","Participating","Enrollment Complete","2022-08-28","","","2022-09-08","9/8/2022 Rcvd RR Medicare approval letter.  PTAN # Q00322530 - effective 8/28/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","PE - Premier Family Care, Inc","Rail Road Medicare","Participating","Enrollment Complete","2022-08-28","","","2022-09-08","9/8/2022 Rcvd RR Medicare approval letter.  PTAN # Q00322530 - effective 8/28/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","PE - Premier Family Care, Inc","CAQH","Participating","CAQH Reattested","2024-08-27","","","2024-08-27","08/27/2024 CAQH Reattested updated and uploaded COI wthompson"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","PE - Premier Family Care, Inc","CAQH","Participating","CAQH Reattested","2024-08-27","","","2024-08-27","08/27/2024 CAQH Reattested updated and uploaded COI wthompson"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","PE - Premier Family Care, Inc","CAQH","Participating","CAQH Reattested","2024-08-27","","","2024-08-27","08/27/2024 CAQH Reattested updated and uploaded COI wthompson"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","PE - Premier Family Care, Inc","CAQH","Participating","CAQH Reattested","2024-08-27","","","2024-08-27","08/27/2024 CAQH Reattested updated and uploaded COI wthompson"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","PE - Premier Family Care, Inc","CAQH","Participating","CAQH Reattested","2024-08-27","","","2024-08-27","08/27/2024 CAQH Reattested updated and uploaded COI wthompson"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","PE - Premier Family Care, Inc","CAQH","Participating","CAQH Reattested","2024-08-27","","","2024-08-27","08/27/2024 CAQH Reattested updated and uploaded COI wthompson"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","PE - Premier Family Care, Inc","CAQH","Participating","CAQH Reattested","2024-08-27","","","2024-08-27","08/27/2024 CAQH Reattested updated and uploaded COI wthompson"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","PE - Premier Family Care, Inc","CAQH","Participating","CAQH Reattested","2024-08-27","","","2024-08-27","08/27/2024 CAQH Reattested updated and uploaded COI wthompson"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","PE - Premier Family Care, Inc","CAQH","Participating","CAQH Reattested","2024-08-27","","","2024-08-27","08/27/2024 CAQH Reattested updated and uploaded COI wthompson"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","PE - Premier Family Care, Inc","CAQH","Participating","CAQH Reattested","2024-08-27","","","2024-08-27","08/27/2024 CAQH Reattested updated and uploaded COI wthompson"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","PE - Premier Family Care, Inc","CAQH","Participating","CAQH Reattested","2024-08-27","","","2024-08-27","08/27/2024 CAQH Reattested updated and uploaded COI wthompson"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","PE - Premier Family Care, Inc","CAQH","Participating","CAQH Reattested","2024-08-27","","","2024-08-27","08/27/2024 CAQH Reattested updated and uploaded COI wthompson"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","PE - Premier Family Care, Inc","CAQH","Participating","CAQH Reattested","2024-08-27","","","2024-08-27","08/27/2024 CAQH Reattested updated and uploaded COI wthompson"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","PE - Premier Family Care, Inc","CAQH","Participating","CAQH Reattested","2024-08-27","","","2024-08-27","08/27/2024 CAQH Reattested updated and uploaded COI wthompson"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","PE - Premier Family Care, Inc","CAQH","Participating","CAQH Reattested","2024-08-27","","","2024-08-27","08/27/2024 CAQH Reattested updated and uploaded COI wthompson"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","PE - Premier Family Care, Inc","CAQH","Participating","CAQH Reattested","2024-08-27","","","2024-08-27","08/27/2024 CAQH Reattested updated and uploaded COI wthompson"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","PE - Premier Family Care, Inc","CAQH","Participating","CAQH Reattested","2024-08-27","","","2024-08-27","08/27/2024 CAQH Reattested updated and uploaded COI wthompson"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","PE - Premier Family Care, Inc","CAQH","Participating","CAQH Reattested","2024-08-27","","","2024-08-27","08/27/2024 CAQH Reattested updated and uploaded COI wthompson"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","PE - Premier Family Care, Inc","CAQH","Participating","CAQH Reattested",45531,"","","2024-08-27","08/27/2024 CAQH Reattested updated and uploaded COI wthompson"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","PE - Premier Family Care, Inc","CAQH","Participating","CAQH Reattested",45531,"","","2024-08-27","08/27/2024 CAQH Reattested updated and uploaded COI wthompson"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","PE - Premier Family Care, Inc","CAQH","Participating","CAQH Reattested","2024-08-27","","","2024-08-27","08/27/2024 CAQH Reattested updated and uploaded COI wthompson"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","PE - Premier Family Care, Inc","CAQH","Participating","CAQH Reattested","2024-08-27","","","2024-08-27","08/27/2024 CAQH Reattested updated and uploaded COI wthompson"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","PE - Premier Family Care, Inc","CAQH","Participating","CAQH Reattested","2024-08-27","","","2024-08-27","08/27/2024 CAQH Reattested updated and uploaded COI wthompson"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","PE - Premier Family Care, Inc","CAQH","Participating","CAQH Reattested","2024-08-27","","","2024-08-27","08/27/2024 CAQH Reattested updated and uploaded COI wthompson"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","PE - Premier Family Care, Inc","CAQH","Participating","CAQH Reattested","2024-08-27","","","2024-08-27","08/27/2024 CAQH Reattested updated and uploaded COI wthompson"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","PE - Premier Family Care, Inc","CAQH","Participating","CAQH Reattested","2024-08-27","","","2024-08-27","08/27/2024 CAQH Reattested updated and uploaded COI wthompson"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","PE - Premier Family Care, Inc","CAQH","Participating","CAQH Reattested","2024-08-27","","","2024-08-27","08/27/2024 CAQH Reattested updated and uploaded COI wthompson"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","PE - Premier Family Care, Inc","CAQH","Participating","CAQH Reattested","2024-08-27","","","2024-08-27","08/27/2024 CAQH Reattested updated and uploaded COI wthompson"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","PE - Premier Family Care, Inc","First Health Coventry","Pending Other Enrollment","Pending Other Enrollment","","","","2024-06-28","Pending Aetna approval. MS"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","PE - Premier Family Care, Inc","First Health Coventry","Pending Other Enrollment","Pending Other Enrollment","","","","2024-06-28","Pending Aetna approval. MS"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","PE - Premier Family Care, Inc","First Health Coventry","Pending Other Enrollment","Pending Other Enrollment","","","","2024-06-28","Pending Aetna approval. MS"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","PE - Premier Family Care, Inc","First Health Coventry","Pending Other Enrollment","Pending Other Enrollment","","","","2024-06-28","Pending Aetna approval. MS"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","PE - Premier Family Care, Inc","First Health Coventry","Pending Other Enrollment","Pending Other Enrollment","","","","2024-06-28","Pending Aetna approval. MS"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","PE - Premier Family Care, Inc","First Health Coventry","Pending Other Enrollment","Pending Other Enrollment","","","","2024-06-28","Pending Aetna approval. MS"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","PE - Premier Family Care, Inc","First Health Coventry","Pending Other Enrollment","Pending Other Enrollment","","","","2024-06-28","Pending Aetna approval. MS"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","PE - Premier Family Care, Inc","First Health Coventry","Pending Other Enrollment","Pending Other Enrollment","","","","2024-06-28","Pending Aetna approval. MS"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","PE - Premier Family Care, Inc","Humana","Participating","Enrollment Complete","2022-09-12","","","2022-11-15","11/15/2022 Per email rcvd from Vernita Young at Humana delegated roster provider load for August is complete.  Provider is PAR and linked to group TIN/locations effective 9/12/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","PE - Premier Family Care, Inc","Humana","Participating","Enrollment Complete","2022-09-12","","","2022-11-15","11/15/2022 Per email rcvd from Vernita Young at Humana delegated roster provider load for August is complete.  Provider is PAR and linked to group TIN/locations effective 9/12/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","PE - Premier Family Care, Inc","Humana","Participating","Enrollment Complete","2022-09-12","","","2022-11-15","11/15/2022 Per email rcvd from Vernita Young at Humana delegated roster provider load for August is complete.  Provider is PAR and linked to group TIN/locations effective 9/12/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","PE - Premier Family Care, Inc","Humana","Participating","Enrollment Complete","2022-09-12","","","2022-11-15","11/15/2022 Per email rcvd from Vernita Young at Humana delegated roster provider load for August is complete.  Provider is PAR and linked to group TIN/locations effective 9/12/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","PE - Premier Family Care, Inc","Humana","Participating","Enrollment Complete","2022-09-12","","","2022-11-15","11/15/2022 Per email rcvd from Vernita Young at Humana delegated roster provider load for August is complete.  Provider is PAR and linked to group TIN/locations effective 9/12/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","PE - Premier Family Care, Inc","Humana","Participating","Enrollment Complete","2022-09-12","","","2022-11-15","11/15/2022 Per email rcvd from Vernita Young at Humana delegated roster provider load for August is complete.  Provider is PAR and linked to group TIN/locations effective 9/12/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","PE - Premier Family Care, Inc","Humana","Participating","Enrollment Complete","2022-09-12","","","2022-11-15","11/15/2022 Per email rcvd from Vernita Young at Humana delegated roster provider load for August is complete.  Provider is PAR and linked to group TIN/locations effective 9/12/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","PE - Premier Family Care, Inc","Humana","Participating","Enrollment Complete","2022-09-12","","","2022-11-15","11/15/2022 Per email rcvd from Vernita Young at Humana delegated roster provider load for August is complete.  Provider is PAR and linked to group TIN/locations effective 9/12/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","PE - Premier Family Care, Inc","Humana","Participating","Enrollment Complete","2022-09-12","","","2022-11-15","11/15/2022 Per email rcvd from Vernita Young at Humana delegated roster provider load for August is complete.  Provider is PAR and linked to group TIN/locations effective 9/12/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","PE - Premier Family Care, Inc","Humana","Participating","Enrollment Complete","2022-09-12","","","2022-11-15","11/15/2022 Per email rcvd from Vernita Young at Humana delegated roster provider load for August is complete.  Provider is PAR and linked to group TIN/locations effective 9/12/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","PE - Premier Family Care, Inc","Humana","Participating","Enrollment Complete","2022-09-12","","","2022-11-15","11/15/2022 Per email rcvd from Vernita Young at Humana delegated roster provider load for August is complete.  Provider is PAR and linked to group TIN/locations effective 9/12/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","PE - Premier Family Care, Inc","Humana","Participating","Enrollment Complete","2022-09-12","","","2022-11-15","11/15/2022 Per email rcvd from Vernita Young at Humana delegated roster provider load for August is complete.  Provider is PAR and linked to group TIN/locations effective 9/12/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","PE - Premier Family Care, Inc","Humana","Participating","Enrollment Complete","2022-09-12","","","2022-11-15","11/15/2022 Per email rcvd from Vernita Young at Humana delegated roster provider load for August is complete.  Provider is PAR and linked to group TIN/locations effective 9/12/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","PE - Premier Family Care, Inc","Humana","Participating","Enrollment Complete","2022-09-12","","","2022-11-15","11/15/2022 Per email rcvd from Vernita Young at Humana delegated roster provider load for August is complete.  Provider is PAR and linked to group TIN/locations effective 9/12/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","PE - Premier Family Care, Inc","Humana","Participating","Enrollment Complete","2022-09-12","","","2022-11-15","11/15/2022 Per email rcvd from Vernita Young at Humana delegated roster provider load for August is complete.  Provider is PAR and linked to group TIN/locations effective 9/12/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","PE - Premier Family Care, Inc","Humana","Participating","Enrollment Complete","2022-09-12","","","2022-11-15","11/15/2022 Per email rcvd from Vernita Young at Humana delegated roster provider load for August is complete.  Provider is PAR and linked to group TIN/locations effective 9/12/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","PE - Premier Family Care, Inc","Humana","Participating","Enrollment Complete","2022-09-12","","","2022-11-15","11/15/2022 Per email rcvd from Vernita Young at Humana delegated roster provider load for August is complete.  Provider is PAR and linked to group TIN/locations effective 9/12/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","PE - Premier Family Care, Inc","Humana","Participating","Enrollment Complete","2022-09-12","","","2022-11-15","11/15/2022 Per email rcvd from Vernita Young at Humana delegated roster provider load for August is complete.  Provider is PAR and linked to group TIN/locations effective 9/12/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","PE - Premier Family Care, Inc","Humana","Participating","Enrollment Complete","2022-09-12","","","2022-11-15","11/15/2022 Per email rcvd from Vernita Young at Humana delegated roster provider load for August is complete.  Provider is PAR and linked to group TIN/locations effective 9/12/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","PE - Premier Family Care, Inc","Humana","Participating","Enrollment Complete","2022-09-12","","","2022-11-15","11/15/2022 Per email rcvd from Vernita Young at Humana delegated roster provider load for August is complete.  Provider is PAR and linked to group TIN/locations effective 9/12/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","PE - Premier Family Care, Inc","Humana","Participating","Enrollment Complete","2022-09-12","","","2022-11-15","11/15/2022 Per email rcvd from Vernita Young at Humana delegated roster provider load for August is complete.  Provider is PAR and linked to group TIN/locations effective 9/12/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","PE - Premier Family Care, Inc","Humana","Participating","Enrollment Complete","2022-09-12","","","2022-11-15","11/15/2022 Per email rcvd from Vernita Young at Humana delegated roster provider load for August is complete.  Provider is PAR and linked to group TIN/locations effective 9/12/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","PE - Premier Family Care, Inc","Humana","Participating","Enrollment Complete","2022-09-12","","","2022-11-15","11/15/2022 Per email rcvd from Vernita Young at Humana delegated roster provider load for August is complete.  Provider is PAR and linked to group TIN/locations effective 9/12/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","PE - Premier Family Care, Inc","Humana","Participating","Enrollment Complete","2022-09-12","","","2022-11-15","11/15/2022 Per email rcvd from Vernita Young at Humana delegated roster provider load for August is complete.  Provider is PAR and linked to group TIN/locations effective 9/12/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","PE - Premier Family Care, Inc","Humana","Participating","Enrollment Complete","2022-09-12","","","2022-11-15","11/15/2022 Per email rcvd from Vernita Young at Humana delegated roster provider load for August is complete.  Provider is PAR and linked to group TIN/locations effective 9/12/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","PE - Premier Family Care, Inc","Humana","Participating","Enrollment Complete","2022-09-12","","","2022-11-15","11/15/2022 Per email rcvd from Vernita Young at Humana delegated roster provider load for August is complete.  Provider is PAR and linked to group TIN/locations effective 9/12/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","PE - Premier Family Care, Inc","Humana","Participating","Enrollment Complete","2022-09-12","","","2022-11-15","11/15/2022 Per email rcvd from Vernita Young at Humana delegated roster provider load for August is complete.  Provider is PAR and linked to group TIN/locations effective 9/12/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","PE - Premier Family Care, Inc","Humana","Participating","Enrollment Complete","2022-09-12","","","2022-11-15","11/15/2022 Per email rcvd from Vernita Young at Humana delegated roster provider load for August is complete.  Provider is PAR and linked to group TIN/locations effective 9/12/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","PE - Premier Family Care, Inc","United Health Care","Participating","Enrollment Complete","2022-09-12","","","2022-10-13","10/13/2022 Per email received from  from UHC monthly delegated roster submission has been completed and provider is PAR and in linked to group TIN effective 9/12/2022.   MPIN# 008193055.   DCannon"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","PE - Premier Family Care, Inc","United Health Care","Participating","Enrollment Complete","2022-09-12","","","2022-10-13","10/13/2022 Per email received from  from UHC monthly delegated roster submission has been completed and provider is PAR and in linked to group TIN effective 9/12/2022.   MPIN# 008193055.   DCannon"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","PE - Premier Family Care, Inc","United Health Care","Participating","Enrollment Complete","2022-09-12","","","2022-10-13","10/13/2022 Per email received from  from UHC monthly delegated roster submission has been completed and provider is PAR and in linked to group TIN effective 9/12/2022.   MPIN# 008193055.   DCannon"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","PE - Premier Family Care, Inc","United Health Care","Participating","Enrollment Complete","2022-09-12","","","2022-10-13","10/13/2022 Per email received from  from UHC monthly delegated roster submission has been completed and provider is PAR and in linked to group TIN effective 9/12/2022.   MPIN# 008193055.   DCannon"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","PE - Premier Family Care, Inc","United Health Care","Participating","Enrollment Complete","2022-09-12","","","2022-10-13","10/13/2022 Per email received from  from UHC monthly delegated roster submission has been completed and provider is PAR and in linked to group TIN effective 9/12/2022.   MPIN# 008193055.   DCannon"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","PE - Premier Family Care, Inc","United Health Care","Participating","Enrollment Complete","2022-09-12","","","2022-10-13","10/13/2022 Per email received from  from UHC monthly delegated roster submission has been completed and provider is PAR and in linked to group TIN effective 9/12/2022.   MPIN# 008193055.   DCannon"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","PE - Premier Family Care, Inc","United Health Care","Participating","Enrollment Complete","2022-09-12","","","2022-10-13","10/13/2022 Per email received from  from UHC monthly delegated roster submission has been completed and provider is PAR and in linked to group TIN effective 9/12/2022.   MPIN# 008193055.   DCannon"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","PE - Premier Family Care, Inc","United Health Care","Participating","Enrollment Complete","2022-09-12","","","2022-10-13","10/13/2022 Per email received from  from UHC monthly delegated roster submission has been completed and provider is PAR and in linked to group TIN effective 9/12/2022.   MPIN# 008193055.   DCannon"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","PE - Premier Family Care, Inc","United Health Care","Participating","Enrollment Complete","2022-09-12","","","2022-10-13","10/13/2022 Per email received from  from UHC monthly delegated roster submission has been completed and provider is PAR and in linked to group TIN effective 9/12/2022.   MPIN# 008193055.   DCannon"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","PE - Premier Family Care, Inc","United Health Care","Participating","Enrollment Complete","2022-09-12","","","2022-10-13","10/13/2022 Per email received from  from UHC monthly delegated roster submission has been completed and provider is PAR and in linked to group TIN effective 9/12/2022.   MPIN# 008193055.   DCannon"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","PE - Premier Family Care, Inc","United Health Care","Participating","Enrollment Complete","2022-09-12","","","2022-10-13","10/13/2022 Per email received from  from UHC monthly delegated roster submission has been completed and provider is PAR and in linked to group TIN effective 9/12/2022.   MPIN# 008193055.   DCannon"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","PE - Premier Family Care, Inc","United Health Care","Participating","Enrollment Complete","2022-09-12","","","2022-10-13","10/13/2022 Per email received from  from UHC monthly delegated roster submission has been completed and provider is PAR and in linked to group TIN effective 9/12/2022.   MPIN# 008193055.   DCannon"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","PE - Premier Family Care, Inc","United Health Care","Participating","Enrollment Complete","2022-09-12","","","2022-10-13","10/13/2022 Per email received from  from UHC monthly delegated roster submission has been completed and provider is PAR and in linked to group TIN effective 9/12/2022.   MPIN# 008193055.   DCannon"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","PE - Premier Family Care, Inc","United Health Care","Participating","Enrollment Complete","2022-09-12","","","2022-10-13","10/13/2022 Per email received from  from UHC monthly delegated roster submission has been completed and provider is PAR and in linked to group TIN effective 9/12/2022.   MPIN# 008193055.   DCannon"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","PE - Premier Family Care, Inc","United Health Care","Participating","Enrollment Complete","2022-09-12","","","2022-10-13","10/13/2022 Per email received from  from UHC monthly delegated roster submission has been completed and provider is PAR and in linked to group TIN effective 9/12/2022.   MPIN# 008193055.   DCannon"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","PE - Premier Family Care, Inc","United Health Care","Participating","Enrollment Complete","2022-09-12","","","2022-10-13","10/13/2022 Per email received from  from UHC monthly delegated roster submission has been completed and provider is PAR and in linked to group TIN effective 9/12/2022.   MPIN# 008193055.   DCannon"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","PE - Premier Family Care, Inc","United Health Care","Participating","Enrollment Complete","2022-09-12","","","2022-10-13","10/13/2022 Per email received from  from UHC monthly delegated roster submission has been completed and provider is PAR and in linked to group TIN effective 9/12/2022.   MPIN# 008193055.   DCannon"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","PE - Premier Family Care, Inc","United Health Care","Participating","Enrollment Complete","2022-09-12","","","2022-10-13","10/13/2022 Per email received from  from UHC monthly delegated roster submission has been completed and provider is PAR and in linked to group TIN effective 9/12/2022.   MPIN# 008193055.   DCannon"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","PE - Premier Family Care, Inc","United Health Care","Participating","Enrollment Complete","2022-09-12","","","2022-10-13","10/13/2022 Per email received from  from UHC monthly delegated roster submission has been completed and provider is PAR and in linked to group TIN effective 9/12/2022.   MPIN# 008193055.   DCannon"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","PE - Premier Family Care, Inc","United Health Care","Participating","Enrollment Complete","2022-09-12","","","2022-10-13","10/13/2022 Per email received from  from UHC monthly delegated roster submission has been completed and provider is PAR and in linked to group TIN effective 9/12/2022.   MPIN# 008193055.   DCannon"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","PE - Premier Family Care, Inc","United Health Care","Participating","Enrollment Complete","2022-09-12","","","2022-10-13","10/13/2022 Per email received from  from UHC monthly delegated roster submission has been completed and provider is PAR and in linked to group TIN effective 9/12/2022.   MPIN# 008193055.   DCannon"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","PE - Premier Family Care, Inc","United Health Care","Participating","Enrollment Complete","2022-09-12","","","2022-10-13","10/13/2022 Per email received from  from UHC monthly delegated roster submission has been completed and provider is PAR and in linked to group TIN effective 9/12/2022.   MPIN# 008193055.   DCannon"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","PE - Premier Family Care, Inc","United Health Care","Participating","Enrollment Complete","2022-09-12","","","2022-10-13","10/13/2022 Per email received from  from UHC monthly delegated roster submission has been completed and provider is PAR and in linked to group TIN effective 9/12/2022.   MPIN# 008193055.   DCannon"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","PE - Premier Family Care, Inc","United Health Care","Participating","Enrollment Complete","2022-09-12","","","2022-10-13","10/13/2022 Per email received from  from UHC monthly delegated roster submission has been completed and provider is PAR and in linked to group TIN effective 9/12/2022.   MPIN# 008193055.   DCannon"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","PE - Premier Family Care, Inc","United Health Care","Participating","Enrollment Complete","2022-09-12","","","2022-10-13","10/13/2022 Per email received from  from UHC monthly delegated roster submission has been completed and provider is PAR and in linked to group TIN effective 9/12/2022.   MPIN# 008193055.   DCannon"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","PE - Premier Family Care, Inc","United Health Care","Participating","Enrollment Complete","2022-09-12","","","2022-10-13","10/13/2022 Per email received from  from UHC monthly delegated roster submission has been completed and provider is PAR and in linked to group TIN effective 9/12/2022.   MPIN# 008193055.   DCannon"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","PE - Premier Family Care, Inc","United Health Care","Participating","Enrollment Complete","2022-09-12","","","2022-10-13","10/13/2022 Per email received from  from UHC monthly delegated roster submission has been completed and provider is PAR and in linked to group TIN effective 9/12/2022.   MPIN# 008193055.   DCannon"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","PE - Premier Family Care, Inc","United Health Care","Participating","Enrollment Complete","2022-09-12","","","2022-10-13","10/13/2022 Per email received from  from UHC monthly delegated roster submission has been completed and provider is PAR and in linked to group TIN effective 9/12/2022.   MPIN# 008193055.   DCannon"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","2024-06-17","","","2024-07-02","Provider is Credentialed with all locations eff 6/17/2024. MS"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","2024-06-17","","","2024-07-02","Provider is Credentialed with all locations eff 6/17/2024. MS"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","2024-06-17","","","2024-07-02","Provider is Credentialed with all locations eff 6/17/2024. MS"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","2024-06-17","","","2024-07-02","Provider is Credentialed with all locations eff 6/17/2024. MS"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","2024-06-17","","","2024-07-02","Provider is Credentialed with all locations eff 6/17/2024. MS"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","2024-06-17","","","2024-07-02","Provider is Credentialed with all locations eff 6/17/2024. MS"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","2024-06-17","","","2024-07-02","Provider is Credentialed with all locations eff 6/17/2024. MS"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","2024-06-17","","","2024-07-02","Provider is Credentialed with all locations eff 6/17/2024. MS"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","PE - Premier Family Care, Inc","Omni PPO","Participating","Enrollment Complete","2022-08-12","","","2022-10-17","10/17/2022 Per email received from German Aviles at IMS/OMNI monthly delegation roster provider load for August has been completed.  Provider is PAR and linked to group TIN effective 8/12/2022.   DCannon"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","PE - Premier Family Care, Inc","Omni PPO","Participating","Enrollment Complete","2022-08-12","","","2022-10-17","10/17/2022 Per email received from German Aviles at IMS/OMNI monthly delegation roster provider load for August has been completed.  Provider is PAR and linked to group TIN effective 8/12/2022.   DCannon"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","PE - Premier Family Care, Inc","Omni PPO","Participating","Enrollment Complete",44785,"","","2022-10-17","10/17/2022 Per email received from German Aviles at IMS/OMNI monthly delegation roster provider load for August has been completed.  Provider is PAR and linked to group TIN effective 8/12/2022.   DCannon"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","PE - Premier Family Care, Inc","Omni PPO","Participating","Enrollment Complete","2022-08-12","","","2022-10-17","10/17/2022 Per email received from German Aviles at IMS/OMNI monthly delegation roster provider load for August has been completed.  Provider is PAR and linked to group TIN effective 8/12/2022.   DCannon"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","PE - Premier Family Care, Inc","Omni PPO","Participating","Enrollment Complete","2022-08-12","","","2022-10-17","10/17/2022 Per email received from German Aviles at IMS/OMNI monthly delegation roster provider load for August has been completed.  Provider is PAR and linked to group TIN effective 8/12/2022.   DCannon"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","PE - Premier Family Care, Inc","Omni PPO","Participating","Enrollment Complete","2022-08-12","","","2022-10-17","10/17/2022 Per email received from German Aviles at IMS/OMNI monthly delegation roster provider load for August has been completed.  Provider is PAR and linked to group TIN effective 8/12/2022.   DCannon"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","PE - Premier Family Care, Inc","Omni PPO","Participating","Enrollment Complete","2022-08-12","","","2022-10-17","10/17/2022 Per email received from German Aviles at IMS/OMNI monthly delegation roster provider load for August has been completed.  Provider is PAR and linked to group TIN effective 8/12/2022.   DCannon"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","PE - Premier Family Care, Inc","Omni PPO","Participating","Enrollment Complete","2022-08-12","","","2022-10-17","10/17/2022 Per email received from German Aviles at IMS/OMNI monthly delegation roster provider load for August has been completed.  Provider is PAR and linked to group TIN effective 8/12/2022.   DCannon"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","PE - Premier Family Care, Inc","Omni PPO","Participating","Enrollment Complete","2022-08-12","","","2022-10-17","10/17/2022 Per email received from German Aviles at IMS/OMNI monthly delegation roster provider load for August has been completed.  Provider is PAR and linked to group TIN effective 8/12/2022.   DCannon"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","PE - Premier Family Care, Inc","Omni PPO","Participating","Enrollment Complete","2022-08-12","","","2022-10-17","10/17/2022 Per email received from German Aviles at IMS/OMNI monthly delegation roster provider load for August has been completed.  Provider is PAR and linked to group TIN effective 8/12/2022.   DCannon"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","PE - Premier Family Care, Inc","Omni PPO","Participating","Enrollment Complete","2022-08-12","","","2022-10-17","10/17/2022 Per email received from German Aviles at IMS/OMNI monthly delegation roster provider load for August has been completed.  Provider is PAR and linked to group TIN effective 8/12/2022.   DCannon"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","PE - Premier Family Care, Inc","Omni PPO","Participating","Enrollment Complete","2022-08-12","","","2022-10-17","10/17/2022 Per email received from German Aviles at IMS/OMNI monthly delegation roster provider load for August has been completed.  Provider is PAR and linked to group TIN effective 8/12/2022.   DCannon"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","PE - Premier Family Care, Inc","Omni PPO","Participating","Enrollment Complete","2022-08-12","","","2022-10-17","10/17/2022 Per email received from German Aviles at IMS/OMNI monthly delegation roster provider load for August has been completed.  Provider is PAR and linked to group TIN effective 8/12/2022.   DCannon"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","PE - Premier Family Care, Inc","Omni PPO","Participating","Enrollment Complete","2022-08-12","","","2022-10-17","10/17/2022 Per email received from German Aviles at IMS/OMNI monthly delegation roster provider load for August has been completed.  Provider is PAR and linked to group TIN effective 8/12/2022.   DCannon"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","PE - Premier Family Care, Inc","Omni PPO","Participating","Enrollment Complete","2022-08-12","","","2022-10-17","10/17/2022 Per email received from German Aviles at IMS/OMNI monthly delegation roster provider load for August has been completed.  Provider is PAR and linked to group TIN effective 8/12/2022.   DCannon"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","PE - Premier Family Care, Inc","Omni PPO","Participating","Enrollment Complete","2022-08-12","","","2022-10-17","10/17/2022 Per email received from German Aviles at IMS/OMNI monthly delegation roster provider load for August has been completed.  Provider is PAR and linked to group TIN effective 8/12/2022.   DCannon"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","PE - Premier Family Care, Inc","Omni PPO","Participating","Enrollment Complete","2022-08-12","","","2022-10-17","10/17/2022 Per email received from German Aviles at IMS/OMNI monthly delegation roster provider load for August has been completed.  Provider is PAR and linked to group TIN effective 8/12/2022.   DCannon"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","PE - Premier Family Care, Inc","Omni PPO","Participating","Enrollment Complete","2022-08-12","","","2022-10-17","10/17/2022 Per email received from German Aviles at IMS/OMNI monthly delegation roster provider load for August has been completed.  Provider is PAR and linked to group TIN effective 8/12/2022.   DCannon"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","PE - Premier Family Care, Inc","Omni PPO","Participating","Enrollment Complete","2022-08-12","","","2022-10-17","10/17/2022 Per email received from German Aviles at IMS/OMNI monthly delegation roster provider load for August has been completed.  Provider is PAR and linked to group TIN effective 8/12/2022.   DCannon"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","PE - Premier Family Care, Inc","Omni PPO","Participating","Enrollment Complete","2022-08-12","","","2022-10-17","10/17/2022 Per email received from German Aviles at IMS/OMNI monthly delegation roster provider load for August has been completed.  Provider is PAR and linked to group TIN effective 8/12/2022.   DCannon"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","PE - Premier Family Care, Inc","Omni PPO","Participating","Enrollment Complete","2022-08-12","","","2022-10-17","10/17/2022 Per email received from German Aviles at IMS/OMNI monthly delegation roster provider load for August has been completed.  Provider is PAR and linked to group TIN effective 8/12/2022.   DCannon"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","PE - Premier Family Care, Inc","Omni PPO","Participating","Enrollment Complete","2022-08-12","","","2022-10-17","10/17/2022 Per email received from German Aviles at IMS/OMNI monthly delegation roster provider load for August has been completed.  Provider is PAR and linked to group TIN effective 8/12/2022.   DCannon"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","PE - Premier Family Care, Inc","Omni PPO","Participating","Enrollment Complete","2022-08-12","","","2022-10-17","10/17/2022 Per email received from German Aviles at IMS/OMNI monthly delegation roster provider load for August has been completed.  Provider is PAR and linked to group TIN effective 8/12/2022.   DCannon"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","PE - Premier Family Care, Inc","Omni PPO","Participating","Enrollment Complete","2022-08-12","","","2022-10-17","10/17/2022 Per email received from German Aviles at IMS/OMNI monthly delegation roster provider load for August has been completed.  Provider is PAR and linked to group TIN effective 8/12/2022.   DCannon"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","PE - Premier Family Care, Inc","Omni PPO","Participating","Enrollment Complete","2022-08-12","","","2022-10-17","10/17/2022 Per email received from German Aviles at IMS/OMNI monthly delegation roster provider load for August has been completed.  Provider is PAR and linked to group TIN effective 8/12/2022.   DCannon"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","PE - Premier Family Care, Inc","Omni PPO","Participating","Enrollment Complete","2022-08-12","","","2022-10-17","10/17/2022 Per email received from German Aviles at IMS/OMNI monthly delegation roster provider load for August has been completed.  Provider is PAR and linked to group TIN effective 8/12/2022.   DCannon"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","PE - Premier Family Care, Inc","Omni PPO","Participating","Enrollment Complete","2022-08-12","","","2022-10-17","10/17/2022 Per email received from German Aviles at IMS/OMNI monthly delegation roster provider load for August has been completed.  Provider is PAR and linked to group TIN effective 8/12/2022.   DCannon"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","PE - Premier Family Care, Inc","Omni PPO","Participating","Enrollment Complete","2022-08-12","","","2022-10-17","10/17/2022 Per email received from German Aviles at IMS/OMNI monthly delegation roster provider load for August has been completed.  Provider is PAR and linked to group TIN effective 8/12/2022.   DCannon"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","PE - Premier Family Care, Inc","HealthSmart PPO","Participating","Enrollment Complete","2022-09-12","","","2022-10-13","10/13/2022 Per Healthsmart website provider is PAR and loaded under TIN/location effective 9/12/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","PE - Premier Family Care, Inc","HealthSmart PPO","Participating","Enrollment Complete","2022-09-12","","","2022-10-13","10/13/2022 Per Healthsmart website provider is PAR and loaded under TIN/location effective 9/12/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","PE - Premier Family Care, Inc","HealthSmart PPO","Participating","Enrollment Complete","2022-09-12","","","2022-10-13","10/13/2022 Per Healthsmart website provider is PAR and loaded under TIN/location effective 9/12/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","PE - Premier Family Care, Inc","HealthSmart PPO","Participating","Enrollment Complete","2022-09-12","","","2022-10-13","10/13/2022 Per Healthsmart website provider is PAR and loaded under TIN/location effective 9/12/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","PE - Premier Family Care, Inc","HealthSmart PPO","Participating","Enrollment Complete","2022-09-12","","","2022-10-13","10/13/2022 Per Healthsmart website provider is PAR and loaded under TIN/location effective 9/12/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","PE - Premier Family Care, Inc","HealthSmart PPO","Participating","Enrollment Complete","2022-09-12","","","2022-10-13","10/13/2022 Per Healthsmart website provider is PAR and loaded under TIN/location effective 9/12/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","PE - Premier Family Care, Inc","HealthSmart PPO","Participating","Enrollment Complete","2022-09-12","","","2022-10-13","10/13/2022 Per Healthsmart website provider is PAR and loaded under TIN/location effective 9/12/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","PE - Premier Family Care, Inc","HealthSmart PPO","Participating","Enrollment Complete","2022-09-12","","","2022-10-13","10/13/2022 Per Healthsmart website provider is PAR and loaded under TIN/location effective 9/12/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","PE - Premier Family Care, Inc","HealthSmart PPO","Participating","Enrollment Complete","2022-09-12","","","2022-10-13","10/13/2022 Per Healthsmart website provider is PAR and loaded under TIN/location effective 9/12/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","PE - Premier Family Care, Inc","HealthSmart PPO","Participating","Enrollment Complete","2022-09-12","","","2022-10-13","10/13/2022 Per Healthsmart website provider is PAR and loaded under TIN/location effective 9/12/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","PE - Premier Family Care, Inc","HealthSmart PPO","Participating","Enrollment Complete","2022-09-12","","","2022-10-13","10/13/2022 Per Healthsmart website provider is PAR and loaded under TIN/location effective 9/12/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","PE - Premier Family Care, Inc","HealthSmart PPO","Participating","Enrollment Complete",44816,"","","2022-10-13","10/13/2022 Per Healthsmart website provider is PAR and loaded under TIN/location effective 9/12/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","PE - Premier Family Care, Inc","HealthSmart PPO","Participating","Enrollment Complete",44816,"","","2022-10-13","10/13/2022 Per Healthsmart website provider is PAR and loaded under TIN/location effective 9/12/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","PE - Premier Family Care, Inc","HealthSmart PPO","Participating","Enrollment Complete",44816,"","","2022-10-13","10/13/2022 Per Healthsmart website provider is PAR and loaded under TIN/location effective 9/12/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","PE - Premier Family Care, Inc","HealthSmart PPO","Participating","Enrollment Complete",44816,"","","2022-10-13","10/13/2022 Per Healthsmart website provider is PAR and loaded under TIN/location effective 9/12/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","PE - Premier Family Care, Inc","HealthSmart PPO","Participating","Enrollment Complete",44816,"","","2022-10-13","10/13/2022 Per Healthsmart website provider is PAR and loaded under TIN/location effective 9/12/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","PE - Premier Family Care, Inc","HealthSmart PPO","Participating","Enrollment Complete",44816,"","","2022-10-13","10/13/2022 Per Healthsmart website provider is PAR and loaded under TIN/location effective 9/12/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","PE - Premier Family Care, Inc","HealthSmart PPO","Participating","Enrollment Complete",44816,"","","2022-10-13","10/13/2022 Per Healthsmart website provider is PAR and loaded under TIN/location effective 9/12/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","PE - Premier Family Care, Inc","HealthSmart PPO","Participating","Enrollment Complete",44816,"","","2022-10-13","10/13/2022 Per Healthsmart website provider is PAR and loaded under TIN/location effective 9/12/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","PE - Premier Family Care, Inc","HealthSmart PPO","Participating","Enrollment Complete",44816,"","","2022-10-13","10/13/2022 Per Healthsmart website provider is PAR and loaded under TIN/location effective 9/12/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","","","","2024-01-25","3415 N Loop 250 W #4:provider is credentialed and is in network with Tricare at this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","","","","2024-01-25","3415 N Loop 250 W #4:provider is credentialed and is in network with Tricare at this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","","","","2024-01-25","1805 S County Rd 1105: provider is credentialed and is in network with Tricare at this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","","","","2024-01-25","1805 S County Rd 1105: provider is credentialed and is in network with Tricare at this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","","","","2024-01-25","3411 Caldera Blvd: provider is credentialed and is in network with Tricare at this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","","","","2024-01-25","3411 Caldera Blvd: provider is credentialed and is in network with Tricare at this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","","","","2024-01-25","5615 Deauville Ste 240: provider is credentialed and is in network with Tricare at this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","","","","2024-01-25","5615 Deauville Ste 240: provider is credentialed and is in network with Tricare at this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","","","","2024-01-25","3620 N Big Spring St:  provider is credentialed and is in network with Tricare at this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","","","","2024-01-25","3620 N Big Spring St:  provider is credentialed and is in network with Tricare at this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","","","","2024-01-25","4214 Andrews Hwy Ste. 107: Provider is credentialed  and in network with this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","","","","2024-01-25","4214 Andrews Hwy Ste. 107: Provider is credentialed  and in network with this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","","","","2024-01-26","400 Rosalind Redfern Grover: Provider is credentialed  and in network with this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","","","","2024-01-26","400 Rosalind Redfern Grover: Provider is credentialed  and in network with this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","","","","2024-01-26","400 Rosalind Redfern Ste. 120: provider is credentialed and is in network with Tricare at this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","","","","2024-01-26","400 Rosalind Redfern Ste. 120: provider is credentialed and is in network with Tricare at this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","","","","2024-01-26","709 W Louisiana: provider is credentialed and is in network with Tricare at this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","","","","2024-01-26","709 W Louisiana: provider is credentialed and is in network with Tricare at this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","","","","2024-01-26","2402 W Wall St: provider is credentialed and is in network with Tricare at this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","","","","2024-01-26","2402 W Wall St: provider is credentialed and is in network with Tricare at this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","","","","2024-01-26","400 Rosalind Redfern Grover Ste. 120: provider is credentialed and is in network with Tricare at this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","","","","2024-01-26","400 Rosalind Redfern Grover Ste. 120: provider is credentialed and is in network with Tricare at this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","","","","2024-01-25","3415 N Loop 250 W #4:provider is credentialed and is in network with Tricare at this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","","","","2024-01-25","3415 N Loop 250 W #4:provider is credentialed and is in network with Tricare at this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","","","","2024-01-25","1805 S County Rd 1105: provider is credentialed and is in network with Tricare at this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","","","","2024-01-25","1805 S County Rd 1105: provider is credentialed and is in network with Tricare at this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","","","","2024-01-25","3411 Caldera Blvd: provider is credentialed and is in network with Tricare at this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","","","","2024-01-25","3411 Caldera Blvd: provider is credentialed and is in network with Tricare at this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","","","","2024-01-25","5615 Deauville Ste 240: provider is credentialed and is in network with Tricare at this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","","","","2024-01-25","5615 Deauville Ste 240: provider is credentialed and is in network with Tricare at this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","","","","2024-01-25","3620 N Big Spring St:  provider is credentialed and is in network with Tricare at this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","","","","2024-01-25","3620 N Big Spring St:  provider is credentialed and is in network with Tricare at this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","","","","2024-01-25","4214 Andrews Hwy Ste. 107: Provider is credentialed  and in network with this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","","","","2024-01-25","4214 Andrews Hwy Ste. 107: Provider is credentialed  and in network with this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","","","","2024-01-26","400 Rosalind Redfern Grover: Provider is credentialed  and in network with this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","","","","2024-01-26","400 Rosalind Redfern Grover: Provider is credentialed  and in network with this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","","","","2024-01-26","400 Rosalind Redfern Ste. 120: provider is credentialed and is in network with Tricare at this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","","","","2024-01-26","400 Rosalind Redfern Ste. 120: provider is credentialed and is in network with Tricare at this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","","","","2024-01-26","709 W Louisiana: provider is credentialed and is in network with Tricare at this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","","","","2024-01-26","709 W Louisiana: provider is credentialed and is in network with Tricare at this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","","","","2024-01-26","2402 W Wall St: provider is credentialed and is in network with Tricare at this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","","","","2024-01-26","2402 W Wall St: provider is credentialed and is in network with Tricare at this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","","","","2024-01-26","400 Rosalind Redfern Grover Ste. 120: provider is credentialed and is in network with Tricare at this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","","","","2024-01-26","400 Rosalind Redfern Grover Ste. 120: provider is credentialed and is in network with Tricare at this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","","","","2024-01-25","3415 N Loop 250 W #4:provider is credentialed and is in network with Tricare at this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","","","","2024-01-25","3415 N Loop 250 W #4:provider is credentialed and is in network with Tricare at this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","","","","2024-01-25","1805 S County Rd 1105: provider is credentialed and is in network with Tricare at this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","","","","2024-01-25","1805 S County Rd 1105: provider is credentialed and is in network with Tricare at this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","","","","2024-01-25","3411 Caldera Blvd: provider is credentialed and is in network with Tricare at this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","","","","2024-01-25","3411 Caldera Blvd: provider is credentialed and is in network with Tricare at this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","","","","2024-01-25","5615 Deauville Ste 240: provider is credentialed and is in network with Tricare at this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","","","","2024-01-25","5615 Deauville Ste 240: provider is credentialed and is in network with Tricare at this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","","","","2024-01-25","3620 N Big Spring St:  provider is credentialed and is in network with Tricare at this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","","","","2024-01-25","3620 N Big Spring St:  provider is credentialed and is in network with Tricare at this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","","","","2024-01-25","4214 Andrews Hwy Ste. 107: Provider is credentialed  and in network with this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","","","","2024-01-25","4214 Andrews Hwy Ste. 107: Provider is credentialed  and in network with this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","","","","2024-01-26","400 Rosalind Redfern Grover: Provider is credentialed  and in network with this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","","","","2024-01-26","400 Rosalind Redfern Grover: Provider is credentialed  and in network with this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","","","","2024-01-26","400 Rosalind Redfern Ste. 120: provider is credentialed and is in network with Tricare at this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","","","","2024-01-26","400 Rosalind Redfern Ste. 120: provider is credentialed and is in network with Tricare at this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","","","","2024-01-26","709 W Louisiana: provider is credentialed and is in network with Tricare at this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","","","","2024-01-26","709 W Louisiana: provider is credentialed and is in network with Tricare at this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","","","","2024-01-26","2402 W Wall St: provider is credentialed and is in network with Tricare at this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","","","","2024-01-26","2402 W Wall St: provider is credentialed and is in network with Tricare at this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","","","","2024-01-26","400 Rosalind Redfern Grover Ste. 120: provider is credentialed and is in network with Tricare at this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","","","","2024-01-26","400 Rosalind Redfern Grover Ste. 120: provider is credentialed and is in network with Tricare at this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","","","","2024-01-25","3415 N Loop 250 W #4:provider is credentialed and is in network with Tricare at this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","","","","2024-01-25","3415 N Loop 250 W #4:provider is credentialed and is in network with Tricare at this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","","","","2024-01-25","1805 S County Rd 1105: provider is credentialed and is in network with Tricare at this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","","","","2024-01-25","1805 S County Rd 1105: provider is credentialed and is in network with Tricare at this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","","","","2024-01-25","3411 Caldera Blvd: provider is credentialed and is in network with Tricare at this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","","","","2024-01-25","3411 Caldera Blvd: provider is credentialed and is in network with Tricare at this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","","","","2024-01-25","5615 Deauville Ste 240: provider is credentialed and is in network with Tricare at this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","","","","2024-01-25","5615 Deauville Ste 240: provider is credentialed and is in network with Tricare at this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","","","","2024-01-25","3620 N Big Spring St:  provider is credentialed and is in network with Tricare at this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","","","","2024-01-25","3620 N Big Spring St:  provider is credentialed and is in network with Tricare at this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","","","","2024-01-25","4214 Andrews Hwy Ste. 107: Provider is credentialed  and in network with this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","","","","2024-01-25","4214 Andrews Hwy Ste. 107: Provider is credentialed  and in network with this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","","","","2024-01-26","400 Rosalind Redfern Grover: Provider is credentialed  and in network with this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","","","","2024-01-26","400 Rosalind Redfern Grover: Provider is credentialed  and in network with this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","","","","2024-01-26","400 Rosalind Redfern Ste. 120: provider is credentialed and is in network with Tricare at this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","","","","2024-01-26","400 Rosalind Redfern Ste. 120: provider is credentialed and is in network with Tricare at this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","","","","2024-01-26","709 W Louisiana: provider is credentialed and is in network with Tricare at this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","","","","2024-01-26","709 W Louisiana: provider is credentialed and is in network with Tricare at this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","","","","2024-01-26","2402 W Wall St: provider is credentialed and is in network with Tricare at this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","","","","2024-01-26","2402 W Wall St: provider is credentialed and is in network with Tricare at this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","","","","2024-01-26","400 Rosalind Redfern Grover Ste. 120: provider is credentialed and is in network with Tricare at this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","","","","2024-01-26","400 Rosalind Redfern Grover Ste. 120: provider is credentialed and is in network with Tricare at this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","","","","2024-01-25","3415 N Loop 250 W #4:provider is credentialed and is in network with Tricare at this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","","","","2024-01-25","3415 N Loop 250 W #4:provider is credentialed and is in network with Tricare at this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","","","","2024-01-25","1805 S County Rd 1105: provider is credentialed and is in network with Tricare at this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","","","","2024-01-25","1805 S County Rd 1105: provider is credentialed and is in network with Tricare at this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","","","","2024-01-25","3411 Caldera Blvd: provider is credentialed and is in network with Tricare at this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","","","","2024-01-25","3411 Caldera Blvd: provider is credentialed and is in network with Tricare at this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","","","","2024-01-25","5615 Deauville Ste 240: provider is credentialed and is in network with Tricare at this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","","","","2024-01-25","5615 Deauville Ste 240: provider is credentialed and is in network with Tricare at this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","","","","2024-01-25","3620 N Big Spring St:  provider is credentialed and is in network with Tricare at this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","","","","2024-01-25","3620 N Big Spring St:  provider is credentialed and is in network with Tricare at this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","","","","2024-01-25","4214 Andrews Hwy Ste. 107: Provider is credentialed  and in network with this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","","","","2024-01-25","4214 Andrews Hwy Ste. 107: Provider is credentialed  and in network with this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","","","","2024-01-26","400 Rosalind Redfern Grover: Provider is credentialed  and in network with this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","","","","2024-01-26","400 Rosalind Redfern Grover: Provider is credentialed  and in network with this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","","","","2024-01-26","400 Rosalind Redfern Ste. 120: provider is credentialed and is in network with Tricare at this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","","","","2024-01-26","400 Rosalind Redfern Ste. 120: provider is credentialed and is in network with Tricare at this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","","","","2024-01-26","709 W Louisiana: provider is credentialed and is in network with Tricare at this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","","","","2024-01-26","709 W Louisiana: provider is credentialed and is in network with Tricare at this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","","","","2024-01-26","2402 W Wall St: provider is credentialed and is in network with Tricare at this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","","","","2024-01-26","2402 W Wall St: provider is credentialed and is in network with Tricare at this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","","","","2024-01-26","400 Rosalind Redfern Grover Ste. 120: provider is credentialed and is in network with Tricare at this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","","","","2024-01-26","400 Rosalind Redfern Grover Ste. 120: provider is credentialed and is in network with Tricare at this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","","","","2024-01-25","3415 N Loop 250 W #4:provider is credentialed and is in network with Tricare at this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","","","","2024-01-25","3415 N Loop 250 W #4:provider is credentialed and is in network with Tricare at this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","","","","2024-01-25","1805 S County Rd 1105: provider is credentialed and is in network with Tricare at this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","","","","2024-01-25","1805 S County Rd 1105: provider is credentialed and is in network with Tricare at this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","","","","2024-01-25","3411 Caldera Blvd: provider is credentialed and is in network with Tricare at this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","","","","2024-01-25","3411 Caldera Blvd: provider is credentialed and is in network with Tricare at this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","","","","2024-01-25","5615 Deauville Ste 240: provider is credentialed and is in network with Tricare at this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","","","","2024-01-25","5615 Deauville Ste 240: provider is credentialed and is in network with Tricare at this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","","","","2024-01-25","3620 N Big Spring St:  provider is credentialed and is in network with Tricare at this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","","","","2024-01-25","3620 N Big Spring St:  provider is credentialed and is in network with Tricare at this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","","","","2024-01-25","4214 Andrews Hwy Ste. 107: Provider is credentialed  and in network with this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","","","","2024-01-25","4214 Andrews Hwy Ste. 107: Provider is credentialed  and in network with this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","","","","2024-01-26","400 Rosalind Redfern Grover: Provider is credentialed  and in network with this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","","","","2024-01-26","400 Rosalind Redfern Grover: Provider is credentialed  and in network with this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","","","","2024-01-26","400 Rosalind Redfern Ste. 120: provider is credentialed and is in network with Tricare at this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","","","","2024-01-26","400 Rosalind Redfern Ste. 120: provider is credentialed and is in network with Tricare at this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","","","","2024-01-26","709 W Louisiana: provider is credentialed and is in network with Tricare at this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","","","","2024-01-26","709 W Louisiana: provider is credentialed and is in network with Tricare at this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","","","","2024-01-26","2402 W Wall St: provider is credentialed and is in network with Tricare at this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","","","","2024-01-26","2402 W Wall St: provider is credentialed and is in network with Tricare at this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","","","","2024-01-26","400 Rosalind Redfern Grover Ste. 120: provider is credentialed and is in network with Tricare at this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","","","","2024-01-26","400 Rosalind Redfern Grover Ste. 120: provider is credentialed and is in network with Tricare at this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","","","","2024-01-25","3415 N Loop 250 W #4:provider is credentialed and is in network with Tricare at this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","","","","2024-01-25","3415 N Loop 250 W #4:provider is credentialed and is in network with Tricare at this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","","","","2024-01-25","1805 S County Rd 1105: provider is credentialed and is in network with Tricare at this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","","","","2024-01-25","1805 S County Rd 1105: provider is credentialed and is in network with Tricare at this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","","","","2024-01-25","3411 Caldera Blvd: provider is credentialed and is in network with Tricare at this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","","","","2024-01-25","3411 Caldera Blvd: provider is credentialed and is in network with Tricare at this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","","","","2024-01-25","5615 Deauville Ste 240: provider is credentialed and is in network with Tricare at this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","","","","2024-01-25","5615 Deauville Ste 240: provider is credentialed and is in network with Tricare at this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","","","","2024-01-25","3620 N Big Spring St:  provider is credentialed and is in network with Tricare at this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","","","","2024-01-25","3620 N Big Spring St:  provider is credentialed and is in network with Tricare at this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","","","","2024-01-25","4214 Andrews Hwy Ste. 107: Provider is credentialed  and in network with this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","","","","2024-01-25","4214 Andrews Hwy Ste. 107: Provider is credentialed  and in network with this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","","","","2024-01-26","400 Rosalind Redfern Grover: Provider is credentialed  and in network with this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","","","","2024-01-26","400 Rosalind Redfern Grover: Provider is credentialed  and in network with this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","","","","2024-01-26","400 Rosalind Redfern Ste. 120: provider is credentialed and is in network with Tricare at this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","","","","2024-01-26","400 Rosalind Redfern Ste. 120: provider is credentialed and is in network with Tricare at this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","","","","2024-01-26","709 W Louisiana: provider is credentialed and is in network with Tricare at this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","","","","2024-01-26","709 W Louisiana: provider is credentialed and is in network with Tricare at this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","","","","2024-01-26","2402 W Wall St: provider is credentialed and is in network with Tricare at this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","","","","2024-01-26","2402 W Wall St: provider is credentialed and is in network with Tricare at this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","","","","2024-01-26","400 Rosalind Redfern Grover Ste. 120: provider is credentialed and is in network with Tricare at this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","","","","2024-01-26","400 Rosalind Redfern Grover Ste. 120: provider is credentialed and is in network with Tricare at this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","","","","2024-01-25","3415 N Loop 250 W #4:provider is credentialed and is in network with Tricare at this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","","","","2024-01-25","3415 N Loop 250 W #4:provider is credentialed and is in network with Tricare at this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","","","","2024-01-25","1805 S County Rd 1105: provider is credentialed and is in network with Tricare at this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","","","","2024-01-25","1805 S County Rd 1105: provider is credentialed and is in network with Tricare at this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","","","","2024-01-25","3411 Caldera Blvd: provider is credentialed and is in network with Tricare at this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","","","","2024-01-25","3411 Caldera Blvd: provider is credentialed and is in network with Tricare at this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","","","","2024-01-25","5615 Deauville Ste 240: provider is credentialed and is in network with Tricare at this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","","","","2024-01-25","5615 Deauville Ste 240: provider is credentialed and is in network with Tricare at this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","","","","2024-01-25","3620 N Big Spring St:  provider is credentialed and is in network with Tricare at this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","","","","2024-01-25","3620 N Big Spring St:  provider is credentialed and is in network with Tricare at this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","","","","2024-01-25","4214 Andrews Hwy Ste. 107: Provider is credentialed  and in network with this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","","","","2024-01-25","4214 Andrews Hwy Ste. 107: Provider is credentialed  and in network with this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","","","","2024-01-26","400 Rosalind Redfern Grover: Provider is credentialed  and in network with this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","","","","2024-01-26","400 Rosalind Redfern Grover: Provider is credentialed  and in network with this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","","","","2024-01-26","400 Rosalind Redfern Ste. 120: provider is credentialed and is in network with Tricare at this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","","","","2024-01-26","400 Rosalind Redfern Ste. 120: provider is credentialed and is in network with Tricare at this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","","","","2024-01-26","709 W Louisiana: provider is credentialed and is in network with Tricare at this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","","","","2024-01-26","709 W Louisiana: provider is credentialed and is in network with Tricare at this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","","","","2024-01-26","2402 W Wall St: provider is credentialed and is in network with Tricare at this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","","","","2024-01-26","2402 W Wall St: provider is credentialed and is in network with Tricare at this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","","","","2024-01-26","400 Rosalind Redfern Grover Ste. 120: provider is credentialed and is in network with Tricare at this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","","","","2024-01-26","400 Rosalind Redfern Grover Ste. 120: provider is credentialed and is in network with Tricare at this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","","","","2024-01-25","3415 N Loop 250 W #4:provider is credentialed and is in network with Tricare at this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","","","","2024-01-25","3415 N Loop 250 W #4:provider is credentialed and is in network with Tricare at this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","","","","2024-01-25","1805 S County Rd 1105: provider is credentialed and is in network with Tricare at this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","","","","2024-01-25","1805 S County Rd 1105: provider is credentialed and is in network with Tricare at this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","","","","2024-01-25","3411 Caldera Blvd: provider is credentialed and is in network with Tricare at this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","","","","2024-01-25","3411 Caldera Blvd: provider is credentialed and is in network with Tricare at this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","","","","2024-01-25","5615 Deauville Ste 240: provider is credentialed and is in network with Tricare at this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","","","","2024-01-25","5615 Deauville Ste 240: provider is credentialed and is in network with Tricare at this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","","","","2024-01-25","3620 N Big Spring St:  provider is credentialed and is in network with Tricare at this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","","","","2024-01-25","3620 N Big Spring St:  provider is credentialed and is in network with Tricare at this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","","","","2024-01-25","4214 Andrews Hwy Ste. 107: Provider is credentialed  and in network with this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","","","","2024-01-25","4214 Andrews Hwy Ste. 107: Provider is credentialed  and in network with this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","","","","2024-01-26","400 Rosalind Redfern Grover: Provider is credentialed  and in network with this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","","","","2024-01-26","400 Rosalind Redfern Grover: Provider is credentialed  and in network with this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","","","","2024-01-26","400 Rosalind Redfern Ste. 120: provider is credentialed and is in network with Tricare at this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","","","","2024-01-26","400 Rosalind Redfern Ste. 120: provider is credentialed and is in network with Tricare at this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","","","","2024-01-26","709 W Louisiana: provider is credentialed and is in network with Tricare at this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","","","","2024-01-26","709 W Louisiana: provider is credentialed and is in network with Tricare at this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","","","","2024-01-26","2402 W Wall St: provider is credentialed and is in network with Tricare at this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","","","","2024-01-26","2402 W Wall St: provider is credentialed and is in network with Tricare at this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","","","","2024-01-26","400 Rosalind Redfern Grover Ste. 120: provider is credentialed and is in network with Tricare at this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","","","","2024-01-26","400 Rosalind Redfern Grover Ste. 120: provider is credentialed and is in network with Tricare at this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","","","","2024-01-25","3415 N Loop 250 W #4:provider is credentialed and is in network with Tricare at this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","","","","2024-01-25","3415 N Loop 250 W #4:provider is credentialed and is in network with Tricare at this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","","","","2024-01-25","1805 S County Rd 1105: provider is credentialed and is in network with Tricare at this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","","","","2024-01-25","1805 S County Rd 1105: provider is credentialed and is in network with Tricare at this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","","","","2024-01-25","3411 Caldera Blvd: provider is credentialed and is in network with Tricare at this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","","","","2024-01-25","3411 Caldera Blvd: provider is credentialed and is in network with Tricare at this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","","","","2024-01-25","5615 Deauville Ste 240: provider is credentialed and is in network with Tricare at this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","","","","2024-01-25","5615 Deauville Ste 240: provider is credentialed and is in network with Tricare at this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","","","","2024-01-25","3620 N Big Spring St:  provider is credentialed and is in network with Tricare at this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","","","","2024-01-25","3620 N Big Spring St:  provider is credentialed and is in network with Tricare at this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","","","","2024-01-25","4214 Andrews Hwy Ste. 107: Provider is credentialed  and in network with this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","","","","2024-01-25","4214 Andrews Hwy Ste. 107: Provider is credentialed  and in network with this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","","","","2024-01-26","400 Rosalind Redfern Grover: Provider is credentialed  and in network with this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","","","","2024-01-26","400 Rosalind Redfern Grover: Provider is credentialed  and in network with this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","","","","2024-01-26","400 Rosalind Redfern Ste. 120: provider is credentialed and is in network with Tricare at this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","","","","2024-01-26","400 Rosalind Redfern Ste. 120: provider is credentialed and is in network with Tricare at this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","","","","2024-01-26","709 W Louisiana: provider is credentialed and is in network with Tricare at this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","","","","2024-01-26","709 W Louisiana: provider is credentialed and is in network with Tricare at this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","","","","2024-01-26","2402 W Wall St: provider is credentialed and is in network with Tricare at this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","","","","2024-01-26","2402 W Wall St: provider is credentialed and is in network with Tricare at this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","","","","2024-01-26","400 Rosalind Redfern Grover Ste. 120: provider is credentialed and is in network with Tricare at this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","","","","2024-01-26","400 Rosalind Redfern Grover Ste. 120: provider is credentialed and is in network with Tricare at this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","","","","2024-01-25","3415 N Loop 250 W #4:provider is credentialed and is in network with Tricare at this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","","","","2024-01-25","3415 N Loop 250 W #4:provider is credentialed and is in network with Tricare at this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","","","","2024-01-25","1805 S County Rd 1105: provider is credentialed and is in network with Tricare at this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","","","","2024-01-25","1805 S County Rd 1105: provider is credentialed and is in network with Tricare at this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","","","","2024-01-25","3411 Caldera Blvd: provider is credentialed and is in network with Tricare at this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","","","","2024-01-25","3411 Caldera Blvd: provider is credentialed and is in network with Tricare at this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","","","","2024-01-25","5615 Deauville Ste 240: provider is credentialed and is in network with Tricare at this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","","","","2024-01-25","5615 Deauville Ste 240: provider is credentialed and is in network with Tricare at this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","","","","2024-01-25","3620 N Big Spring St:  provider is credentialed and is in network with Tricare at this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","","","","2024-01-25","3620 N Big Spring St:  provider is credentialed and is in network with Tricare at this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","","","","2024-01-25","4214 Andrews Hwy Ste. 107: Provider is credentialed  and in network with this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","","","","2024-01-25","4214 Andrews Hwy Ste. 107: Provider is credentialed  and in network with this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","","","","2024-01-26","400 Rosalind Redfern Grover: Provider is credentialed  and in network with this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","","","","2024-01-26","400 Rosalind Redfern Grover: Provider is credentialed  and in network with this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","","","","2024-01-26","400 Rosalind Redfern Ste. 120: provider is credentialed and is in network with Tricare at this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","","","","2024-01-26","400 Rosalind Redfern Ste. 120: provider is credentialed and is in network with Tricare at this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","","","","2024-01-26","709 W Louisiana: provider is credentialed and is in network with Tricare at this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","","","","2024-01-26","709 W Louisiana: provider is credentialed and is in network with Tricare at this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","","","","2024-01-26","2402 W Wall St: provider is credentialed and is in network with Tricare at this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","","","","2024-01-26","2402 W Wall St: provider is credentialed and is in network with Tricare at this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","","","","2024-01-26","400 Rosalind Redfern Grover Ste. 120: provider is credentialed and is in network with Tricare at this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","","","","2024-01-26","400 Rosalind Redfern Grover Ste. 120: provider is credentialed and is in network with Tricare at this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","","","","2024-01-25","3415 N Loop 250 W #4:provider is credentialed and is in network with Tricare at this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","","","","2024-01-25","3415 N Loop 250 W #4:provider is credentialed and is in network with Tricare at this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","","","","2024-01-25","1805 S County Rd 1105: provider is credentialed and is in network with Tricare at this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","","","","2024-01-25","1805 S County Rd 1105: provider is credentialed and is in network with Tricare at this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","","","","2024-01-25","3411 Caldera Blvd: provider is credentialed and is in network with Tricare at this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","","","","2024-01-25","3411 Caldera Blvd: provider is credentialed and is in network with Tricare at this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","","","","2024-01-25","5615 Deauville Ste 240: provider is credentialed and is in network with Tricare at this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","","","","2024-01-25","5615 Deauville Ste 240: provider is credentialed and is in network with Tricare at this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","","","","2024-01-25","3620 N Big Spring St:  provider is credentialed and is in network with Tricare at this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","","","","2024-01-25","3620 N Big Spring St:  provider is credentialed and is in network with Tricare at this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","","","","2024-01-25","4214 Andrews Hwy Ste. 107: Provider is credentialed  and in network with this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","","","","2024-01-25","4214 Andrews Hwy Ste. 107: Provider is credentialed  and in network with this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","","","","2024-01-26","400 Rosalind Redfern Grover: Provider is credentialed  and in network with this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","","","","2024-01-26","400 Rosalind Redfern Grover: Provider is credentialed  and in network with this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","","","","2024-01-26","400 Rosalind Redfern Ste. 120: provider is credentialed and is in network with Tricare at this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","","","","2024-01-26","400 Rosalind Redfern Ste. 120: provider is credentialed and is in network with Tricare at this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","","","","2024-01-26","709 W Louisiana: provider is credentialed and is in network with Tricare at this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","","","","2024-01-26","709 W Louisiana: provider is credentialed and is in network with Tricare at this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","","","","2024-01-26","2402 W Wall St: provider is credentialed and is in network with Tricare at this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","","","","2024-01-26","2402 W Wall St: provider is credentialed and is in network with Tricare at this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","","","","2024-01-26","400 Rosalind Redfern Grover Ste. 120: provider is credentialed and is in network with Tricare at this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","","","","2024-01-26","400 Rosalind Redfern Grover Ste. 120: provider is credentialed and is in network with Tricare at this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","","","","2024-01-25","3415 N Loop 250 W #4:provider is credentialed and is in network with Tricare at this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","","","","2024-01-25","3415 N Loop 250 W #4:provider is credentialed and is in network with Tricare at this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","","","","2024-01-25","1805 S County Rd 1105: provider is credentialed and is in network with Tricare at this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","","","","2024-01-25","1805 S County Rd 1105: provider is credentialed and is in network with Tricare at this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","","","","2024-01-25","3411 Caldera Blvd: provider is credentialed and is in network with Tricare at this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","","","","2024-01-25","3411 Caldera Blvd: provider is credentialed and is in network with Tricare at this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","","","","2024-01-25","5615 Deauville Ste 240: provider is credentialed and is in network with Tricare at this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","","","","2024-01-25","5615 Deauville Ste 240: provider is credentialed and is in network with Tricare at this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","","","","2024-01-25","3620 N Big Spring St:  provider is credentialed and is in network with Tricare at this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","","","","2024-01-25","3620 N Big Spring St:  provider is credentialed and is in network with Tricare at this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","","","","2024-01-25","4214 Andrews Hwy Ste. 107: Provider is credentialed  and in network with this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","","","","2024-01-25","4214 Andrews Hwy Ste. 107: Provider is credentialed  and in network with this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","","","","2024-01-26","400 Rosalind Redfern Grover: Provider is credentialed  and in network with this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","","","","2024-01-26","400 Rosalind Redfern Grover: Provider is credentialed  and in network with this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","","","","2024-01-26","400 Rosalind Redfern Ste. 120: provider is credentialed and is in network with Tricare at this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","","","","2024-01-26","400 Rosalind Redfern Ste. 120: provider is credentialed and is in network with Tricare at this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","","","","2024-01-26","709 W Louisiana: provider is credentialed and is in network with Tricare at this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","","","","2024-01-26","709 W Louisiana: provider is credentialed and is in network with Tricare at this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","","","","2024-01-26","2402 W Wall St: provider is credentialed and is in network with Tricare at this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","","","","2024-01-26","2402 W Wall St: provider is credentialed and is in network with Tricare at this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","","","","2024-01-26","400 Rosalind Redfern Grover Ste. 120: provider is credentialed and is in network with Tricare at this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","","","","2024-01-26","400 Rosalind Redfern Grover Ste. 120: provider is credentialed and is in network with Tricare at this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","","","","2024-01-25","3415 N Loop 250 W #4:provider is credentialed and is in network with Tricare at this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","","","","2024-01-25","3415 N Loop 250 W #4:provider is credentialed and is in network with Tricare at this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","","","","2024-01-25","1805 S County Rd 1105: provider is credentialed and is in network with Tricare at this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","","","","2024-01-25","1805 S County Rd 1105: provider is credentialed and is in network with Tricare at this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","","","","2024-01-25","3411 Caldera Blvd: provider is credentialed and is in network with Tricare at this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","","","","2024-01-25","3411 Caldera Blvd: provider is credentialed and is in network with Tricare at this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","","","","2024-01-25","5615 Deauville Ste 240: provider is credentialed and is in network with Tricare at this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","","","","2024-01-25","5615 Deauville Ste 240: provider is credentialed and is in network with Tricare at this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","","","","2024-01-25","3620 N Big Spring St:  provider is credentialed and is in network with Tricare at this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","","","","2024-01-25","3620 N Big Spring St:  provider is credentialed and is in network with Tricare at this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","","","","2024-01-25","4214 Andrews Hwy Ste. 107: Provider is credentialed  and in network with this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","","","","2024-01-25","4214 Andrews Hwy Ste. 107: Provider is credentialed  and in network with this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","","","","2024-01-26","400 Rosalind Redfern Grover: Provider is credentialed  and in network with this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","","","","2024-01-26","400 Rosalind Redfern Grover: Provider is credentialed  and in network with this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","","","","2024-01-26","400 Rosalind Redfern Ste. 120: provider is credentialed and is in network with Tricare at this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","","","","2024-01-26","400 Rosalind Redfern Ste. 120: provider is credentialed and is in network with Tricare at this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","","","","2024-01-26","709 W Louisiana: provider is credentialed and is in network with Tricare at this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","","","","2024-01-26","709 W Louisiana: provider is credentialed and is in network with Tricare at this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","","","","2024-01-26","2402 W Wall St: provider is credentialed and is in network with Tricare at this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","","","","2024-01-26","2402 W Wall St: provider is credentialed and is in network with Tricare at this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","","","","2024-01-26","400 Rosalind Redfern Grover Ste. 120: provider is credentialed and is in network with Tricare at this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","","","","2024-01-26","400 Rosalind Redfern Grover Ste. 120: provider is credentialed and is in network with Tricare at this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","","","","2024-01-25","3415 N Loop 250 W #4:provider is credentialed and is in network with Tricare at this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","","","","2024-01-25","3415 N Loop 250 W #4:provider is credentialed and is in network with Tricare at this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","","","","2024-01-25","1805 S County Rd 1105: provider is credentialed and is in network with Tricare at this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","","","","2024-01-25","1805 S County Rd 1105: provider is credentialed and is in network with Tricare at this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","","","","2024-01-25","3411 Caldera Blvd: provider is credentialed and is in network with Tricare at this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","","","","2024-01-25","3411 Caldera Blvd: provider is credentialed and is in network with Tricare at this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","","","","2024-01-25","5615 Deauville Ste 240: provider is credentialed and is in network with Tricare at this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","","","","2024-01-25","5615 Deauville Ste 240: provider is credentialed and is in network with Tricare at this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","","","","2024-01-25","3620 N Big Spring St:  provider is credentialed and is in network with Tricare at this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","","","","2024-01-25","3620 N Big Spring St:  provider is credentialed and is in network with Tricare at this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","","","","2024-01-25","4214 Andrews Hwy Ste. 107: Provider is credentialed  and in network with this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","","","","2024-01-25","4214 Andrews Hwy Ste. 107: Provider is credentialed  and in network with this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","","","","2024-01-26","400 Rosalind Redfern Grover: Provider is credentialed  and in network with this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","","","","2024-01-26","400 Rosalind Redfern Grover: Provider is credentialed  and in network with this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","","","","2024-01-26","400 Rosalind Redfern Ste. 120: provider is credentialed and is in network with Tricare at this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","","","","2024-01-26","400 Rosalind Redfern Ste. 120: provider is credentialed and is in network with Tricare at this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","","","","2024-01-26","709 W Louisiana: provider is credentialed and is in network with Tricare at this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","","","","2024-01-26","709 W Louisiana: provider is credentialed and is in network with Tricare at this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","","","","2024-01-26","2402 W Wall St: provider is credentialed and is in network with Tricare at this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","","","","2024-01-26","2402 W Wall St: provider is credentialed and is in network with Tricare at this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","","","","2024-01-26","400 Rosalind Redfern Grover Ste. 120: provider is credentialed and is in network with Tricare at this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","","","","2024-01-26","400 Rosalind Redfern Grover Ste. 120: provider is credentialed and is in network with Tricare at this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","PE - Premier Family Care, Inc","Boon Chapman","Participating","Enrollment Complete","2022-08-12","","","2023-09-01","9/1/2023 Per email received from Multiplan provider is PAR and linked to group TIN/locations effective 8/12/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","PE - Premier Family Care, Inc","Boon Chapman","Participating","Enrollment Complete","2022-08-12","","","2023-09-01","9/1/2023 Per email received from Multiplan provider is PAR and linked to group TIN/locations effective 8/12/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","PE - Premier Family Care, Inc","Boon Chapman","Participating","Enrollment Complete","2022-08-12","","","2023-09-01","9/1/2023 Per email received from Multiplan provider is PAR and linked to group TIN/locations effective 8/12/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","PE - Premier Family Care, Inc","Boon Chapman","Participating","Enrollment Complete","2022-08-12","","","2023-09-01","9/1/2023 Per email received from Multiplan provider is PAR and linked to group TIN/locations effective 8/12/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","PE - Premier Family Care, Inc","Boon Chapman","Participating","Enrollment Complete","2022-08-12","","","2023-09-01","9/1/2023 Per email received from Multiplan provider is PAR and linked to group TIN/locations effective 8/12/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","PE - Premier Family Care, Inc","Boon Chapman","Participating","Enrollment Complete","2022-08-12","","","2023-09-01","9/1/2023 Per email received from Multiplan provider is PAR and linked to group TIN/locations effective 8/12/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","PE - Premier Family Care, Inc","Boon Chapman","Participating","Enrollment Complete","2022-08-12","","","2023-09-01","9/1/2023 Per email received from Multiplan provider is PAR and linked to group TIN/locations effective 8/12/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","PE - Premier Family Care, Inc","Boon Chapman","Participating","Enrollment Complete","2022-08-12","","","2023-09-01","9/1/2023 Per email received from Multiplan provider is PAR and linked to group TIN/locations effective 8/12/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","PE - Premier Family Care, Inc","Boon Chapman","Participating","Enrollment Complete","2022-08-12","","","2023-09-01","9/1/2023 Per email received from Multiplan provider is PAR and linked to group TIN/locations effective 8/12/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","PE - Premier Family Care, Inc","Boon Chapman","Participating","Enrollment Complete","2022-08-12","","","2023-09-01","9/1/2023 Per email received from Multiplan provider is PAR and linked to group TIN/locations effective 8/12/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","PE - Premier Family Care, Inc","Boon Chapman","Participating","Enrollment Complete","2022-08-12","","","2023-09-01","9/1/2023 Per email received from Multiplan provider is PAR and linked to group TIN/locations effective 8/12/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","PE - Premier Family Care, Inc","Boon Chapman","Participating","Enrollment Complete","2022-08-12","","","2023-09-01","9/1/2023 Per email received from Multiplan provider is PAR and linked to group TIN/locations effective 8/12/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","PE - Premier Family Care, Inc","Boon Chapman","Participating","Enrollment Complete","2022-08-12","","","2023-09-01","9/1/2023 Per email received from Multiplan provider is PAR and linked to group TIN/locations effective 8/12/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","PE - Premier Family Care, Inc","Boon Chapman","Participating","Enrollment Complete","2022-08-12","","","2023-09-01","9/1/2023 Per email received from Multiplan provider is PAR and linked to group TIN/locations effective 8/12/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","PE - Premier Family Care, Inc","Boon Chapman","Participating","Enrollment Complete","2022-08-12","","","2023-09-01","9/1/2023 Per email received from Multiplan provider is PAR and linked to group TIN/locations effective 8/12/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","PE - Premier Family Care, Inc","Boon Chapman","Participating","Enrollment Complete","2022-08-12","","","2023-09-01","9/1/2023 Per email received from Multiplan provider is PAR and linked to group TIN/locations effective 8/12/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","PE - Premier Family Care, Inc","Boon Chapman","Participating","Enrollment Complete","2022-08-12","","","2023-09-01","9/1/2023 Per email received from Multiplan provider is PAR and linked to group TIN/locations effective 8/12/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","PE - Premier Family Care, Inc","Boon Chapman","Participating","Enrollment Complete","2022-08-12","","","2023-09-01","9/1/2023 Per email received from Multiplan provider is PAR and linked to group TIN/locations effective 8/12/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","PE - Premier Family Care, Inc","Boon Chapman","Participating","Enrollment Complete","2022-08-12","","","2023-09-01","9/1/2023 Per email received from Multiplan provider is PAR and linked to group TIN/locations effective 8/12/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","PE - Premier Family Care, Inc","Boon Chapman","Participating","Enrollment Complete","2022-08-12","","","2023-09-01","9/1/2023 Per email received from Multiplan provider is PAR and linked to group TIN/locations effective 8/12/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","PE - Premier Family Care, Inc","Boon Chapman","Participating","Enrollment Complete","2022-08-12","","","2023-09-01","9/1/2023 Per email received from Multiplan provider is PAR and linked to group TIN/locations effective 8/12/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","PE - Premier Family Care, Inc","Boon Chapman","Participating","Enrollment Complete","2022-08-12","","","2023-09-01","9/1/2023 Per email received from Multiplan provider is PAR and linked to group TIN/locations effective 8/12/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","PE - Premier Family Care, Inc","Boon Chapman","Participating","Enrollment Complete","2022-08-12","","","2023-09-01","9/1/2023 Per email received from Multiplan provider is PAR and linked to group TIN/locations effective 8/12/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","PE - Premier Family Care, Inc","Boon Chapman","Participating","Enrollment Complete","2022-08-12","","","2023-09-01","9/1/2023 Per email received from Multiplan provider is PAR and linked to group TIN/locations effective 8/12/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","PE - Premier Family Care, Inc","Boon Chapman","Participating","Enrollment Complete","2022-08-12","","","2023-09-01","9/1/2023 Per email received from Multiplan provider is PAR and linked to group TIN/locations effective 8/12/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","PE - Premier Family Care, Inc","Boon Chapman","Participating","Enrollment Complete","2022-08-12","","","2023-09-01","9/1/2023 Per email received from Multiplan provider is PAR and linked to group TIN/locations effective 8/12/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","PE - Premier Family Care, Inc","Boon Chapman","Participating","Enrollment Complete","2022-08-12","","","2023-09-01","9/1/2023 Per email received from Multiplan provider is PAR and linked to group TIN/locations effective 8/12/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","PE - Premier Family Care, Inc","Boon Chapman","Participating","Enrollment Complete","2022-08-12","","","2023-09-01","9/1/2023 Per email received from Multiplan provider is PAR and linked to group TIN/locations effective 8/12/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","PE - Premier Family Care, Inc","Aetna","In Process","Application Submitted","","","","2024-06-28","Fax submitted to 859-455-8650 to add the above listed service locations. MS"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","PE - Premier Family Care, Inc","Aetna","In Process","Application Submitted","","","","2024-06-28","Fax submitted to 859-455-8650 to add the above listed service locations. MS"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","PE - Premier Family Care, Inc","Aetna","In Process","Application Submitted","","","","2024-06-28","Fax submitted to 859-455-8650 to add the above listed service locations. MS"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","PE - Premier Family Care, Inc","Aetna","In Process","Application Submitted","","","","2024-06-28","Fax submitted to 859-455-8650 to add the above listed service locations. MS"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","PE - Premier Family Care, Inc","Aetna","In Process","Application Submitted","","","","2024-06-28","Fax submitted to 859-455-8650 to add the above listed service locations. MS"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","PE - Premier Family Care, Inc","Aetna","In Process","Application Submitted","","","","2024-06-28","Fax submitted to 859-455-8650 to add the above listed service locations. MS"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","PE - Premier Family Care, Inc","Aetna","In Process","Application Submitted","","","","2024-06-28","Fax submitted to 859-455-8650 to add the above listed service locations. MS"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","PE - Premier Family Care, Inc","Aetna","In Process","Application Submitted","","","","2024-06-28","Fax submitted to 859-455-8650 to add the above listed service locations. MS"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","PE - Premier Family Care, Inc","Cigna","Participating","Enrollment Complete","2023-03-10","8909854","","2023-03-13","3/13/2023 Rcvd email from Cigna that provider is PAR and linked to group TIN/locations effective 3/10/2023.  PID# 8909854 DCannon"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","PE - Premier Family Care, Inc","Cigna","Participating","Enrollment Complete","2023-03-10","8909854","","2023-03-13","3/13/2023 Rcvd email from Cigna that provider is PAR and linked to group TIN/locations effective 3/10/2023.  PID# 8909854 DCannon"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","PE - Premier Family Care, Inc","Cigna","Participating","Enrollment Complete","2023-03-10","8909854","","2023-03-13","3/13/2023 Rcvd email from Cigna that provider is PAR and linked to group TIN/locations effective 3/10/2023.  PID# 8909854 DCannon"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","PE - Premier Family Care, Inc","Cigna","Participating","Enrollment Complete","2023-03-10","8909854","","2023-03-13","3/13/2023 Rcvd email from Cigna that provider is PAR and linked to group TIN/locations effective 3/10/2023.  PID# 8909854 DCannon"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","PE - Premier Family Care, Inc","Cigna","Participating","Enrollment Complete","2023-03-10","8909854","","2023-03-13","3/13/2023 Rcvd email from Cigna that provider is PAR and linked to group TIN/locations effective 3/10/2023.  PID# 8909854 DCannon"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","PE - Premier Family Care, Inc","Cigna","Participating","Enrollment Complete","2023-03-10","8909854","","2023-03-13","3/13/2023 Rcvd email from Cigna that provider is PAR and linked to group TIN/locations effective 3/10/2023.  PID# 8909854 DCannon"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","PE - Premier Family Care, Inc","Cigna","Participating","Enrollment Complete","2023-03-10","8909854","","2023-03-13","3/13/2023 Rcvd email from Cigna that provider is PAR and linked to group TIN/locations effective 3/10/2023.  PID# 8909854 DCannon"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","PE - Premier Family Care, Inc","Cigna","Participating","Enrollment Complete","2023-03-10","8909854","","2023-03-13","3/13/2023 Rcvd email from Cigna that provider is PAR and linked to group TIN/locations effective 3/10/2023.  PID# 8909854 DCannon"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","PE - Premier Family Care, Inc","Cigna","Participating","Enrollment Complete","2023-03-10","8909854","","2023-03-13","3/13/2023 Rcvd email from Cigna that provider is PAR and linked to group TIN/locations effective 3/10/2023.  PID# 8909854 DCannon"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","PE - Premier Family Care, Inc","Cigna","Participating","Enrollment Complete","2023-03-10","8909854","","2023-03-13","3/13/2023 Rcvd email from Cigna that provider is PAR and linked to group TIN/locations effective 3/10/2023.  PID# 8909854 DCannon"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","PE - Premier Family Care, Inc","Cigna","Participating","Enrollment Complete","2023-03-10","8909854","","2023-03-13","3/13/2023 Rcvd email from Cigna that provider is PAR and linked to group TIN/locations effective 3/10/2023.  PID# 8909854 DCannon"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","PE - Premier Family Care, Inc","Cigna","Participating","Enrollment Complete","2023-03-10","8909854","","2023-03-13","3/13/2023 Rcvd email from Cigna that provider is PAR and linked to group TIN/locations effective 3/10/2023.  PID# 8909854 DCannon"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","PE - Premier Family Care, Inc","Cigna","Participating","Enrollment Complete","2023-03-10","8909854","","2023-03-13","3/13/2023 Rcvd email from Cigna that provider is PAR and linked to group TIN/locations effective 3/10/2023.  PID# 8909854 DCannon"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","PE - Premier Family Care, Inc","Cigna","Participating","Enrollment Complete","2023-03-10","8909854","","2023-03-13","3/13/2023 Rcvd email from Cigna that provider is PAR and linked to group TIN/locations effective 3/10/2023.  PID# 8909854 DCannon"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","PE - Premier Family Care, Inc","Cigna","Participating","Enrollment Complete","2023-03-10","8909854","","2023-03-13","3/13/2023 Rcvd email from Cigna that provider is PAR and linked to group TIN/locations effective 3/10/2023.  PID# 8909854 DCannon"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","PE - Premier Family Care, Inc","Cigna","Participating","Enrollment Complete","2023-03-10","8909854","","2023-03-13","3/13/2023 Rcvd email from Cigna that provider is PAR and linked to group TIN/locations effective 3/10/2023.  PID# 8909854 DCannon"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","PE - Premier Family Care, Inc","Cigna","Participating","Enrollment Complete",44995,"8909854","","2023-03-13","3/13/2023 Rcvd email from Cigna that provider is PAR and linked to group TIN/locations effective 3/10/2023.  PID# 8909854 DCannon"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","PE - Premier Family Care, Inc","Cigna","Participating","Enrollment Complete","2023-03-10","8909854","","2023-03-13","3/13/2023 Rcvd email from Cigna that provider is PAR and linked to group TIN/locations effective 3/10/2023.  PID# 8909854 DCannon"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","PE - Premier Family Care, Inc","Cigna","Participating","Enrollment Complete","2023-03-10","8909854","","2023-03-13","3/13/2023 Rcvd email from Cigna that provider is PAR and linked to group TIN/locations effective 3/10/2023.  PID# 8909854 DCannon"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","PE - Premier Family Care, Inc","Cigna","Participating","Enrollment Complete","2023-03-10","8909854","","2023-03-13","3/13/2023 Rcvd email from Cigna that provider is PAR and linked to group TIN/locations effective 3/10/2023.  PID# 8909854 DCannon"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","PE - Premier Family Care, Inc","Cigna","Participating","Enrollment Complete","2023-03-10","8909854","","2023-03-13","3/13/2023 Rcvd email from Cigna that provider is PAR and linked to group TIN/locations effective 3/10/2023.  PID# 8909854 DCannon"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","PE - Premier Family Care, Inc","Cigna","Participating","Enrollment Complete","2023-03-10","8909854","","2023-03-13","3/13/2023 Rcvd email from Cigna that provider is PAR and linked to group TIN/locations effective 3/10/2023.  PID# 8909854 DCannon"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","PE - Premier Family Care, Inc","Cigna","Participating","Enrollment Complete","2023-03-10","8909854","","2023-03-13","3/13/2023 Rcvd email from Cigna that provider is PAR and linked to group TIN/locations effective 3/10/2023.  PID# 8909854 DCannon"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","PE - Premier Family Care, Inc","Cigna","Participating","Enrollment Complete","2023-03-10","8909854","","2023-03-13","3/13/2023 Rcvd email from Cigna that provider is PAR and linked to group TIN/locations effective 3/10/2023.  PID# 8909854 DCannon"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","PE - Premier Family Care, Inc","Cigna","Participating","Enrollment Complete","2023-03-10","8909854","","2023-03-13","3/13/2023 Rcvd email from Cigna that provider is PAR and linked to group TIN/locations effective 3/10/2023.  PID# 8909854 DCannon"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","PE - Premier Family Care, Inc","Cigna","Participating","Enrollment Complete","2023-03-10","8909854","","2023-03-13","3/13/2023 Rcvd email from Cigna that provider is PAR and linked to group TIN/locations effective 3/10/2023.  PID# 8909854 DCannon"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","PE - Premier Family Care, Inc","Cigna","Participating","Enrollment Complete","2023-03-10","8909854","","2023-03-13","3/13/2023 Rcvd email from Cigna that provider is PAR and linked to group TIN/locations effective 3/10/2023.  PID# 8909854 DCannon"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","PE - Premier Family Care, Inc","Cigna","Participating","Enrollment Complete","2023-03-10","8909854","","2023-03-13","3/13/2023 Rcvd email from Cigna that provider is PAR and linked to group TIN/locations effective 3/10/2023.  PID# 8909854 DCannon"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","PE - Premier Family Care, Inc","Medicaid","Participating","Enrollment Complete","2022-08-28","1922658319","","2022-10-24","10/24/2022 Rcvd TMHP approval letter.  Provider is PAR and linked to group effective 8/28/2022.  TPI # 1922658319.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","PE - Premier Family Care, Inc","Medicaid","Participating","Enrollment Complete","2022-08-28","1922658319","","2022-10-24","10/24/2022 Rcvd TMHP approval letter.  Provider is PAR and linked to group effective 8/28/2022.  TPI # 1922658319.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","PE - Premier Family Care, Inc","Medicaid","Participating","Enrollment Complete","2022-08-28","1922658319","","2022-10-24","10/24/2022 Rcvd TMHP approval letter.  Provider is PAR and linked to group effective 8/28/2022.  TPI # 1922658319.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","PE - Premier Family Care, Inc","Medicaid","Participating","Enrollment Complete","2022-08-28","1922658319","","2022-10-24","10/24/2022 Rcvd TMHP approval letter.  Provider is PAR and linked to group effective 8/28/2022.  TPI # 1922658319.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","PE - Premier Family Care, Inc","Medicaid","Participating","Enrollment Complete","2022-08-28","1922658319","","2022-10-24","10/24/2022 Rcvd TMHP approval letter.  Provider is PAR and linked to group effective 8/28/2022.  TPI # 1922658319.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","PE - Premier Family Care, Inc","Medicaid","Participating","Enrollment Complete","2022-08-28","1922658319","","2022-10-24","10/24/2022 Rcvd TMHP approval letter.  Provider is PAR and linked to group effective 8/28/2022.  TPI # 1922658319.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","PE - Premier Family Care, Inc","Medicaid","Participating","Enrollment Complete","2022-08-28","1922658319","","2022-10-24","10/24/2022 Rcvd TMHP approval letter.  Provider is PAR and linked to group effective 8/28/2022.  TPI # 1922658319.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","PE - Premier Family Care, Inc","Medicaid","Participating","Enrollment Complete","2022-08-28","1922658319","","2022-10-24","10/24/2022 Rcvd TMHP approval letter.  Provider is PAR and linked to group effective 8/28/2022.  TPI # 1922658319.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","PE - Premier Family Care, Inc","Medicaid","Participating","Enrollment Complete","2022-08-28","1922658319","","2022-10-24","10/24/2022 Rcvd TMHP approval letter.  Provider is PAR and linked to group effective 8/28/2022.  TPI # 1922658319.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","PE - Premier Family Care, Inc","Medicaid","Participating","Enrollment Complete","2022-08-28","1922658319","","2022-10-24","10/24/2022 Rcvd TMHP approval letter.  Provider is PAR and linked to group effective 8/28/2022.  TPI # 1922658319.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","PE - Premier Family Care, Inc","Medicaid","Participating","Enrollment Complete","2022-08-28","1922658319","","2022-10-24","10/24/2022 Rcvd TMHP approval letter.  Provider is PAR and linked to group effective 8/28/2022.  TPI # 1922658319.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","PE - Premier Family Care, Inc","Medicaid","Participating","Enrollment Complete","2022-08-28","1922658319","","2022-10-24","10/24/2022 Rcvd TMHP approval letter.  Provider is PAR and linked to group effective 8/28/2022.  TPI # 1922658319.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","PE - Premier Family Care, Inc","Medicaid","Participating","Enrollment Complete","2022-08-28","1922658319","","2022-10-24","10/24/2022 Rcvd TMHP approval letter.  Provider is PAR and linked to group effective 8/28/2022.  TPI # 1922658319.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","PE - Premier Family Care, Inc","Medicaid","Participating","Enrollment Complete","2022-08-28","1922658319","","2022-10-24","10/24/2022 Rcvd TMHP approval letter.  Provider is PAR and linked to group effective 8/28/2022.  TPI # 1922658319.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","PE - Premier Family Care, Inc","Medicaid","Participating","Enrollment Complete","2022-08-28","1922658319","","2022-10-24","10/24/2022 Rcvd TMHP approval letter.  Provider is PAR and linked to group effective 8/28/2022.  TPI # 1922658319.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","PE - Premier Family Care, Inc","Medicaid","Participating","Enrollment Complete","2022-08-28","1922658319","","2022-10-24","10/24/2022 Rcvd TMHP approval letter.  Provider is PAR and linked to group effective 8/28/2022.  TPI # 1922658319.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","PE - Premier Family Care, Inc","Medicaid","Participating","Enrollment Complete","2022-08-28","1922658319","","2022-10-24","10/24/2022 Rcvd TMHP approval letter.  Provider is PAR and linked to group effective 8/28/2022.  TPI # 1922658319.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","PE - Premier Family Care, Inc","Medicaid","Participating","Enrollment Complete","2022-08-28","1922658319","","2022-10-24","10/24/2022 Rcvd TMHP approval letter.  Provider is PAR and linked to group effective 8/28/2022.  TPI # 1922658319.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","PE - Premier Family Care, Inc","Medicaid","Participating","Enrollment Complete",44801,"1922658319","","2022-10-24","10/24/2022 Rcvd TMHP approval letter.  Provider is PAR and linked to group effective 8/28/2022.  TPI # 1922658319.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","PE - Premier Family Care, Inc","Medicaid","Participating","Enrollment Complete",44801,"1922658319","","2022-10-24","10/24/2022 Rcvd TMHP approval letter.  Provider is PAR and linked to group effective 8/28/2022.  TPI # 1922658319.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","PE - Premier Family Care, Inc","Medicaid","Participating","Enrollment Complete",44801,"1922658319","","2022-10-24","10/24/2022 Rcvd TMHP approval letter.  Provider is PAR and linked to group effective 8/28/2022.  TPI # 1922658319.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","PE - Premier Family Care, Inc","Medicaid","Participating","Enrollment Complete",44801,"1922658319","","2022-10-24","10/24/2022 Rcvd TMHP approval letter.  Provider is PAR and linked to group effective 8/28/2022.  TPI # 1922658319.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","PE - Premier Family Care, Inc","Medicaid","Participating","Enrollment Complete",44801,"1922658319","","2022-10-24","10/24/2022 Rcvd TMHP approval letter.  Provider is PAR and linked to group effective 8/28/2022.  TPI # 1922658319.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","PE - Premier Family Care, Inc","Medicaid","Participating","Enrollment Complete",44801,"1922658319","","2022-10-24","10/24/2022 Rcvd TMHP approval letter.  Provider is PAR and linked to group effective 8/28/2022.  TPI # 1922658319.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","PE - Premier Family Care, Inc","Medicaid","Participating","Enrollment Complete",44801,"1922658319","","2022-10-24","10/24/2022 Rcvd TMHP approval letter.  Provider is PAR and linked to group effective 8/28/2022.  TPI # 1922658319.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","PE - Premier Family Care, Inc","Medicaid","Participating","Enrollment Complete",44801,"1922658319","","2022-10-24","10/24/2022 Rcvd TMHP approval letter.  Provider is PAR and linked to group effective 8/28/2022.  TPI # 1922658319.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","PE - Premier Family Care, Inc","Medicaid","Participating","Enrollment Complete",44801,"1922658319","","2022-10-24","10/24/2022 Rcvd TMHP approval letter.  Provider is PAR and linked to group effective 8/28/2022.  TPI # 1922658319.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","PE - Premier Family Care, Inc","Medicaid","Participating","Enrollment Complete",44801,"1922658319","","2022-10-24","10/24/2022 Rcvd TMHP approval letter.  Provider is PAR and linked to group effective 8/28/2022.  TPI # 1922658319.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","PE - Premier Family Care, Inc","Amerigroup","Participating","Enrollment Complete",44785,"","","2024-08-29","Received confirmation from Cassandra Dunagon the remaining address are effective 8/12/2022.  FC"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","PE - Premier Family Care, Inc","Amerigroup","Participating","Enrollment Complete",44785,"","","2024-08-29","Received confirmation from Cassandra Dunagon the remaining address are effective 8/12/2022.  FC"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","PE - Premier Family Care, Inc","Amerigroup","Participating","Enrollment Complete",44785,"","","2024-08-29","Received confirmation from Cassandra Dunagon the remaining address are effective 8/12/2022.  FC"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","PE - Premier Family Care, Inc","Amerigroup","Participating","Enrollment Complete",44785,"","","2024-08-29","Received confirmation from Cassandra Dunagon the remaining address are effective 8/12/2022.  FC"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","PE - Premier Family Care, Inc","Amerigroup","Participating","Enrollment Complete",44785,"","","2024-08-29","Received confirmation from Cassandra Dunagon the remaining address are effective 8/12/2022.  FC"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","PE - Premier Family Care, Inc","Amerigroup","Participating","Enrollment Complete",44785,"","","2024-08-29","Received confirmation from Cassandra Dunagon the remaining address are effective 8/12/2022.  FC"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","PE - Premier Family Care, Inc","Amerigroup","Participating","Enrollment Complete",44785,"","","2024-08-29","Received confirmation from Cassandra Dunagon the remaining address are effective 8/12/2022.  FC"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","PE - Premier Family Care, Inc","Amerigroup","Participating","Enrollment Complete",44785,"","","2024-08-29","Received confirmation from Cassandra Dunagon the remaining address are effective 8/12/2022.  FC"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","PE - Premier Family Care, Inc","Medicaid","In Process","Payor Follow Up","","","","2024-08-21","Application in PE Review status. Jen Videan"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","PE - Premier Family Care, Inc","Medicaid","In Process","Payor Follow Up","","","","2024-08-21","Application in PE Review status. Jen Videan"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","PE - Premier Family Care, Inc","Medicaid","In Process","Payor Follow Up","","","","2024-08-21","Application in PE Review status. Jen Videan"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","PE - Premier Family Care, Inc","Medicaid","In Process","Payor Follow Up","","","","2024-08-21","Application in PE Review status. Jen Videan"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","PE - Premier Family Care, Inc","Scott&White (First Care)","Participating","Enrollment Complete",44816,"","","2022-09-15","9/15/2022 Received approval notification from Scott & White that provider is PAR and linked to group TIN/location effective 9/12/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","PE - Premier Family Care, Inc","Scott&White (First Care)","Participating","Enrollment Complete",44816,"","","2022-09-15","9/15/2022 Received approval notification from Scott & White that provider is PAR and linked to group TIN/location effective 9/12/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","PE - Premier Family Care, Inc","Scott&White (First Care)","Participating","Enrollment Complete",44816,"","","2022-09-15","9/15/2022 Received approval notification from Scott & White that provider is PAR and linked to group TIN/location effective 9/12/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","PE - Premier Family Care, Inc","Scott&White (First Care)","Participating","Enrollment Complete",44816,"","","2022-09-15","9/15/2022 Received approval notification from Scott & White that provider is PAR and linked to group TIN/location effective 9/12/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","PE - Premier Family Care, Inc","Scott&White (First Care)","Participating","Enrollment Complete",44816,"","","2022-09-15","9/15/2022 Received approval notification from Scott & White that provider is PAR and linked to group TIN/location effective 9/12/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","PE - Premier Family Care, Inc","Scott&White (First Care)","Participating","Enrollment Complete",44816,"","","2022-09-15","9/15/2022 Received approval notification from Scott & White that provider is PAR and linked to group TIN/location effective 9/12/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","PE - Premier Family Care, Inc","Scott&White (First Care)","Participating","Enrollment Complete",44816,"","","2022-09-15","9/15/2022 Received approval notification from Scott & White that provider is PAR and linked to group TIN/location effective 9/12/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","PE - Premier Family Care, Inc","Scott&White (First Care)","Participating","Enrollment Complete",44816,"","","2022-09-15","9/15/2022 Received approval notification from Scott & White that provider is PAR and linked to group TIN/location effective 9/12/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","PE - Premier Family Care, Inc","Scott&White (First Care)","Participating","Enrollment Complete",44816,"","","2022-09-15","9/15/2022 Received approval notification from Scott & White that provider is PAR and linked to group TIN/location effective 9/12/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","PE - Premier Family Care, Inc","Scott&White (First Care)","Participating","Enrollment Complete",44816,"","","2022-09-15","9/15/2022 Received approval notification from Scott & White that provider is PAR and linked to group TIN/location effective 9/12/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","PE - Premier Family Care, Inc","Scott&White (First Care)","Participating","Enrollment Complete",44816,"","","2022-09-15","9/15/2022 Received approval notification from Scott & White that provider is PAR and linked to group TIN/location effective 9/12/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","PE - Premier Family Care, Inc","Scott&White (First Care)","Participating","Enrollment Complete",44816,"","","2022-09-15","9/15/2022 Received approval notification from Scott & White that provider is PAR and linked to group TIN/location effective 9/12/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","PE - Premier Family Care, Inc","Scott&White (First Care)","Participating","Enrollment Complete",44816,"","","2022-09-15","9/15/2022 Received approval notification from Scott & White that provider is PAR and linked to group TIN/location effective 9/12/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","PE - Premier Family Care, Inc","Scott&White (First Care)","Participating","Enrollment Complete",44816,"","","2022-09-15","9/15/2022 Received approval notification from Scott & White that provider is PAR and linked to group TIN/location effective 9/12/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","PE - Premier Family Care, Inc","Scott&White (First Care)","Participating","Enrollment Complete",44816,"","","2022-09-15","9/15/2022 Received approval notification from Scott & White that provider is PAR and linked to group TIN/location effective 9/12/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","PE - Premier Family Care, Inc","Scott&White (First Care)","Participating","Enrollment Complete",44816,"","","2022-09-15","9/15/2022 Received approval notification from Scott & White that provider is PAR and linked to group TIN/location effective 9/12/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","PE - Premier Family Care, Inc","Scott&White (First Care)","Participating","Enrollment Complete",44816,"","","2022-09-15","9/15/2022 Received approval notification from Scott & White that provider is PAR and linked to group TIN/location effective 9/12/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","PE - Premier Family Care, Inc","Scott&White (First Care)","Participating","Enrollment Complete",44816,"","","2022-09-15","9/15/2022 Received approval notification from Scott & White that provider is PAR and linked to group TIN/location effective 9/12/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","PE - Premier Family Care, Inc","Scott&White (First Care)","Participating","Enrollment Complete",44816,"","","2022-09-15","9/15/2022 Received approval notification from Scott & White that provider is PAR and linked to group TIN/location effective 9/12/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","PE - Premier Family Care, Inc","Scott&White (First Care)","Participating","Enrollment Complete",44816,"","","2022-09-15","9/15/2022 Received approval notification from Scott & White that provider is PAR and linked to group TIN/location effective 9/12/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","PE - Premier Family Care, Inc","Scott&White (First Care)","Participating","Enrollment Complete",44816,"","","2022-09-15","9/15/2022 Received approval notification from Scott & White that provider is PAR and linked to group TIN/location effective 9/12/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","PE - Premier Family Care, Inc","Scott&White (First Care)","Participating","Enrollment Complete",44816,"","","2022-09-15","9/15/2022 Received approval notification from Scott & White that provider is PAR and linked to group TIN/location effective 9/12/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","PE - Premier Family Care, Inc","Scott&White (First Care)","Participating","Enrollment Complete",44816,"","","2022-09-15","9/15/2022 Received approval notification from Scott & White that provider is PAR and linked to group TIN/location effective 9/12/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","PE - Premier Family Care, Inc","Scott&White (First Care)","Participating","Enrollment Complete",44816,"","","2022-09-15","9/15/2022 Received approval notification from Scott & White that provider is PAR and linked to group TIN/location effective 9/12/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","PE - Premier Family Care, Inc","Scott&White (First Care)","Participating","Enrollment Complete",44816,"","","2022-09-15","9/15/2022 Received approval notification from Scott & White that provider is PAR and linked to group TIN/location effective 9/12/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","PE - Premier Family Care, Inc","Scott&White (First Care)","Participating","Enrollment Complete",44816,"","","2022-09-15","9/15/2022 Received approval notification from Scott & White that provider is PAR and linked to group TIN/location effective 9/12/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","PE - Premier Family Care, Inc","Scott&White (First Care)","Participating","Enrollment Complete",44816,"","","2022-09-15","9/15/2022 Received approval notification from Scott & White that provider is PAR and linked to group TIN/location effective 9/12/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","PE - Premier Family Care, Inc","Scott&White (First Care)","Participating","Enrollment Complete",44816,"","","2022-09-15","9/15/2022 Received approval notification from Scott & White that provider is PAR and linked to group TIN/location effective 9/12/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","PE - Premier Family Care, Inc","Caprock (CapStar)","In Process","Payor Follow Up","","","","2024-08-22",""]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","PE - Premier Family Care, Inc","Caprock (CapStar)","In Process","Payor Follow Up","","","","2024-08-22",""]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","PE - Premier Family Care, Inc","Caprock (CapStar)","In Process","Payor Follow Up","","","","2024-08-22",""]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","PE - Premier Family Care, Inc","Caprock (CapStar)","In Process","Payor Follow Up","","","","2024-08-22",""]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","PE - Premier Family Care, Inc","Caprock (CapStar)","In Process","Payor Follow Up","","","","2024-08-22",""]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","PE - Premier Family Care, Inc","Caprock (CapStar)","In Process","Payor Follow Up","","","","2024-08-22",""]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","PE - Premier Family Care, Inc","Caprock (CapStar)","In Process","Payor Follow Up","","","","2024-08-22",""]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","PE - Premier Family Care, Inc","Caprock (CapStar)","In Process","Payor Follow Up","","","","2024-08-22",""]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","PE - Premier Family Care, Inc","Cigna","Participating","Enrollment Complete",45444,"8909854","","2024-07-03","Received confirmation the provider has been linked to these new locations. MS"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","PE - Premier Family Care, Inc","Cigna","Participating","Enrollment Complete",45444,"8909854","","2024-07-03","Received confirmation the provider has been linked to these new locations. MS"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","PE - Premier Family Care, Inc","Cigna","Participating","Enrollment Complete",45444,"8909854","","2024-07-03","Received confirmation the provider has been linked to these new locations. MS"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","PE - Premier Family Care, Inc","Cigna","Participating","Enrollment Complete",45444,"8909854","","2024-07-03","Received confirmation the provider has been linked to these new locations. MS"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","PE - Premier Family Care, Inc","Cigna","Participating","Enrollment Complete",45444,"8909854","","2024-07-03","Received confirmation the provider has been linked to these new locations. MS"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","PE - Premier Family Care, Inc","Cigna","Participating","Enrollment Complete",45444,"8909854","","2024-07-03","Received confirmation the provider has been linked to these new locations. MS"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","PE - Premier Family Care, Inc","Cigna","Participating","Enrollment Complete",45444,"8909854","","2024-07-03","Received confirmation the provider has been linked to these new locations. MS"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","PE - Premier Family Care, Inc","Cigna","Participating","Enrollment Complete",45444,"8909854","","2024-07-03","Received confirmation the provider has been linked to these new locations. MS"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","PE - Premier Family Care, Inc","IMS","Participating","Enrollment Complete",44785,"","","2022-10-17","10/17/2022 Per email received from German Aviles at IMS/OMNI monthly delegation roster provider load for August has been completed.  Provider is PAR and linked to group TIN effective 8/12/2022.   DCannon"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","PE - Premier Family Care, Inc","IMS","Participating","Enrollment Complete",44785,"","","2022-10-17","10/17/2022 Per email received from German Aviles at IMS/OMNI monthly delegation roster provider load for August has been completed.  Provider is PAR and linked to group TIN effective 8/12/2022.   DCannon"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","PE - Premier Family Care, Inc","IMS","Participating","Enrollment Complete",44785,"","","2022-10-17","10/17/2022 Per email received from German Aviles at IMS/OMNI monthly delegation roster provider load for August has been completed.  Provider is PAR and linked to group TIN effective 8/12/2022.   DCannon"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","PE - Premier Family Care, Inc","IMS","Participating","Enrollment Complete",44785,"","","2022-10-17","10/17/2022 Per email received from German Aviles at IMS/OMNI monthly delegation roster provider load for August has been completed.  Provider is PAR and linked to group TIN effective 8/12/2022.   DCannon"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","PE - Premier Family Care, Inc","IMS","Participating","Enrollment Complete",44785,"","","2022-10-17","10/17/2022 Per email received from German Aviles at IMS/OMNI monthly delegation roster provider load for August has been completed.  Provider is PAR and linked to group TIN effective 8/12/2022.   DCannon"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","PE - Premier Family Care, Inc","IMS","Participating","Enrollment Complete",44785,"","","2022-10-17","10/17/2022 Per email received from German Aviles at IMS/OMNI monthly delegation roster provider load for August has been completed.  Provider is PAR and linked to group TIN effective 8/12/2022.   DCannon"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","PE - Premier Family Care, Inc","IMS","Participating","Enrollment Complete",44785,"","","2022-10-17","10/17/2022 Per email received from German Aviles at IMS/OMNI monthly delegation roster provider load for August has been completed.  Provider is PAR and linked to group TIN effective 8/12/2022.   DCannon"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","PE - Premier Family Care, Inc","IMS","Participating","Enrollment Complete",44785,"","","2022-10-17","10/17/2022 Per email received from German Aviles at IMS/OMNI monthly delegation roster provider load for August has been completed.  Provider is PAR and linked to group TIN effective 8/12/2022.   DCannon"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","PE - Premier Family Care, Inc","IMS","Participating","Enrollment Complete",44785,"","","2022-10-17","10/17/2022 Per email received from German Aviles at IMS/OMNI monthly delegation roster provider load for August has been completed.  Provider is PAR and linked to group TIN effective 8/12/2022.   DCannon"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","PE - Premier Family Care, Inc","IMS","Participating","Enrollment Complete",44785,"","","2022-10-17","10/17/2022 Per email received from German Aviles at IMS/OMNI monthly delegation roster provider load for August has been completed.  Provider is PAR and linked to group TIN effective 8/12/2022.   DCannon"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","PE - Premier Family Care, Inc","IMS","Participating","Enrollment Complete",44785,"","","2022-10-17","10/17/2022 Per email received from German Aviles at IMS/OMNI monthly delegation roster provider load for August has been completed.  Provider is PAR and linked to group TIN effective 8/12/2022.   DCannon"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","PE - Premier Family Care, Inc","IMS","Participating","Enrollment Complete",44785,"","","2022-10-17","10/17/2022 Per email received from German Aviles at IMS/OMNI monthly delegation roster provider load for August has been completed.  Provider is PAR and linked to group TIN effective 8/12/2022.   DCannon"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","PE - Premier Family Care, Inc","IMS","Participating","Enrollment Complete",44785,"","","2022-10-17","10/17/2022 Per email received from German Aviles at IMS/OMNI monthly delegation roster provider load for August has been completed.  Provider is PAR and linked to group TIN effective 8/12/2022.   DCannon"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","PE - Premier Family Care, Inc","IMS","Participating","Enrollment Complete",44785,"","","2022-10-17","10/17/2022 Per email received from German Aviles at IMS/OMNI monthly delegation roster provider load for August has been completed.  Provider is PAR and linked to group TIN effective 8/12/2022.   DCannon"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","PE - Premier Family Care, Inc","IMS","Participating","Enrollment Complete",44785,"","","2022-10-17","10/17/2022 Per email received from German Aviles at IMS/OMNI monthly delegation roster provider load for August has been completed.  Provider is PAR and linked to group TIN effective 8/12/2022.   DCannon"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","PE - Premier Family Care, Inc","IMS","Participating","Enrollment Complete",44785,"","","2022-10-17","10/17/2022 Per email received from German Aviles at IMS/OMNI monthly delegation roster provider load for August has been completed.  Provider is PAR and linked to group TIN effective 8/12/2022.   DCannon"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","PE - Premier Family Care, Inc","IMS","Participating","Enrollment Complete",44785,"","","2022-10-17","10/17/2022 Per email received from German Aviles at IMS/OMNI monthly delegation roster provider load for August has been completed.  Provider is PAR and linked to group TIN effective 8/12/2022.   DCannon"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","PE - Premier Family Care, Inc","IMS","Participating","Enrollment Complete",44785,"","","2022-10-17","10/17/2022 Per email received from German Aviles at IMS/OMNI monthly delegation roster provider load for August has been completed.  Provider is PAR and linked to group TIN effective 8/12/2022.   DCannon"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","PE - Premier Family Care, Inc","IMS","Participating","Enrollment Complete",44785,"","","2022-10-17","10/17/2022 Per email received from German Aviles at IMS/OMNI monthly delegation roster provider load for August has been completed.  Provider is PAR and linked to group TIN effective 8/12/2022.   DCannon"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","PE - Premier Family Care, Inc","IMS","Participating","Enrollment Complete",44785,"","","2022-10-17","10/17/2022 Per email received from German Aviles at IMS/OMNI monthly delegation roster provider load for August has been completed.  Provider is PAR and linked to group TIN effective 8/12/2022.   DCannon"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","PE - Premier Family Care, Inc","IMS","Participating","Enrollment Complete",44785,"","","2022-10-17","10/17/2022 Per email received from German Aviles at IMS/OMNI monthly delegation roster provider load for August has been completed.  Provider is PAR and linked to group TIN effective 8/12/2022.   DCannon"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","PE - Premier Family Care, Inc","IMS","Participating","Enrollment Complete",44785,"","","2022-10-17","10/17/2022 Per email received from German Aviles at IMS/OMNI monthly delegation roster provider load for August has been completed.  Provider is PAR and linked to group TIN effective 8/12/2022.   DCannon"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","PE - Premier Family Care, Inc","IMS","Participating","Enrollment Complete",44785,"","","2022-10-17","10/17/2022 Per email received from German Aviles at IMS/OMNI monthly delegation roster provider load for August has been completed.  Provider is PAR and linked to group TIN effective 8/12/2022.   DCannon"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","PE - Premier Family Care, Inc","IMS","Participating","Enrollment Complete",44785,"","","2022-10-17","10/17/2022 Per email received from German Aviles at IMS/OMNI monthly delegation roster provider load for August has been completed.  Provider is PAR and linked to group TIN effective 8/12/2022.   DCannon"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","PE - Premier Family Care, Inc","IMS","Participating","Enrollment Complete",44785,"","","2022-10-17","10/17/2022 Per email received from German Aviles at IMS/OMNI monthly delegation roster provider load for August has been completed.  Provider is PAR and linked to group TIN effective 8/12/2022.   DCannon"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","PE - Premier Family Care, Inc","IMS","Participating","Enrollment Complete",44785,"","","2022-10-17","10/17/2022 Per email received from German Aviles at IMS/OMNI monthly delegation roster provider load for August has been completed.  Provider is PAR and linked to group TIN effective 8/12/2022.   DCannon"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","PE - Premier Family Care, Inc","IMS","Participating","Enrollment Complete",44785,"","","2022-10-17","10/17/2022 Per email received from German Aviles at IMS/OMNI monthly delegation roster provider load for August has been completed.  Provider is PAR and linked to group TIN effective 8/12/2022.   DCannon"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","PE - Premier Family Care, Inc","IMS","Participating","Enrollment Complete",44785,"","","2022-10-17","10/17/2022 Per email received from German Aviles at IMS/OMNI monthly delegation roster provider load for August has been completed.  Provider is PAR and linked to group TIN effective 8/12/2022.   DCannon"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","PE - Premier Family Care, Inc","Omni PPO","Participating","Enrollment Complete",45453,"","","2024-08-16","Received confirmation from German Aviles via email provider participating for the 3 locations as of 6/10/2024. FC"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","PE - Premier Family Care, Inc","Omni PPO","Participating","Enrollment Complete",45453,"","","2024-08-16","Received confirmation from German Aviles via email provider participating for the 3 locations as of 6/10/2024. FC"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","PE - Premier Family Care, Inc","Omni PPO","Participating","Enrollment Complete",45453,"","","2024-08-16","Received confirmation from German Aviles via email provider participating for the 3 locations as of 6/10/2024. FC"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","PE - Premier Family Care, Inc","Omni PPO","Participating","Enrollment Complete",45453,"","","2024-08-16","Received confirmation from German Aviles via email provider participating for the 3 locations as of 6/10/2024. FC"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","PE - Premier Family Care, Inc","Omni PPO","Participating","Enrollment Complete",45453,"","","2024-08-16","Received confirmation from German Aviles via email provider participating for the 3 locations as of 6/10/2024. FC"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","PE - Premier Family Care, Inc","Omni PPO","Participating","Enrollment Complete",45453,"","","2024-08-16","Received confirmation from German Aviles via email provider participating for the 3 locations as of 6/10/2024. FC"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","PE - Premier Family Care, Inc","Omni PPO","Participating","Enrollment Complete",45453,"","","2024-08-16","Received confirmation from German Aviles via email provider participating for the 3 locations as of 6/10/2024. FC"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","PE - Premier Family Care, Inc","Omni PPO","Participating","Enrollment Complete",45453,"","","2024-08-16","Received confirmation from German Aviles via email provider participating for the 3 locations as of 6/10/2024. FC"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","PE - Premier Family Care, Inc","IMS","Participating","Enrollment Complete",45453,"","","2024-08-16","Received confirmation from German Aviles via email provider participating for the 3 locations as of 6/10/2024. FC"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","PE - Premier Family Care, Inc","IMS","Participating","Enrollment Complete",45453,"","","2024-08-16","Received confirmation from German Aviles via email provider participating for the 3 locations as of 6/10/2024. FC"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","PE - Premier Family Care, Inc","IMS","Participating","Enrollment Complete",45453,"","","2024-08-16","Received confirmation from German Aviles via email provider participating for the 3 locations as of 6/10/2024. FC"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","PE - Premier Family Care, Inc","IMS","Participating","Enrollment Complete",45453,"","","2024-08-16","Received confirmation from German Aviles via email provider participating for the 3 locations as of 6/10/2024. FC"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","PE - Premier Family Care, Inc","IMS","Participating","Enrollment Complete",45453,"","","2024-08-16","Received confirmation from German Aviles via email provider participating for the 3 locations as of 6/10/2024. FC"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","PE - Premier Family Care, Inc","IMS","Participating","Enrollment Complete",45453,"","","2024-08-16","Received confirmation from German Aviles via email provider participating for the 3 locations as of 6/10/2024. FC"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","PE - Premier Family Care, Inc","IMS","Participating","Enrollment Complete",45453,"","","2024-08-16","Received confirmation from German Aviles via email provider participating for the 3 locations as of 6/10/2024. FC"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","PE - Premier Family Care, Inc","IMS","Participating","Enrollment Complete",45453,"","","2024-08-16","Received confirmation from German Aviles via email provider participating for the 3 locations as of 6/10/2024. FC"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","PE - Premier Family Care, Inc","HealthSmart PPO","No Value Specified","Add Info Submitted","","","","2024-06-17","Submitted 4507 Santa Rosa, 4214 Andrews Hwy suite 102-103, and 400 Rosalind Redfern Grover Pkwy via delegated roster on 6/14/2024. FC"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","PE - Premier Family Care, Inc","HealthSmart PPO","No Value Specified","Add Info Submitted","","","","2024-06-17","Submitted 4507 Santa Rosa, 4214 Andrews Hwy suite 102-103, and 400 Rosalind Redfern Grover Pkwy via delegated roster on 6/14/2024. FC"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","PE - Premier Family Care, Inc","HealthSmart PPO","No Value Specified","Add Info Submitted","","","","2024-06-17","Submitted 4507 Santa Rosa, 4214 Andrews Hwy suite 102-103, and 400 Rosalind Redfern Grover Pkwy via delegated roster on 6/14/2024. FC"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","PE - Premier Family Care, Inc","HealthSmart PPO","No Value Specified","Add Info Submitted","","","","2024-06-17","Submitted 4507 Santa Rosa, 4214 Andrews Hwy suite 102-103, and 400 Rosalind Redfern Grover Pkwy via delegated roster on 6/14/2024. FC"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","PE - Premier Family Care, Inc","HealthSmart PPO","No Value Specified","Add Info Submitted","","","","2024-06-17","Submitted 4507 Santa Rosa, 4214 Andrews Hwy suite 102-103, and 400 Rosalind Redfern Grover Pkwy via delegated roster on 6/14/2024. FC"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","PE - Premier Family Care, Inc","HealthSmart PPO","No Value Specified","Add Info Submitted","","","","2024-06-17","Submitted 4507 Santa Rosa, 4214 Andrews Hwy suite 102-103, and 400 Rosalind Redfern Grover Pkwy via delegated roster on 6/14/2024. FC"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","PE - Premier Family Care, Inc","HealthSmart PPO","No Value Specified","Add Info Submitted","","","","2024-06-17","Submitted 4507 Santa Rosa, 4214 Andrews Hwy suite 102-103, and 400 Rosalind Redfern Grover Pkwy via delegated roster on 6/14/2024. FC"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","PE - Premier Family Care, Inc","HealthSmart PPO","No Value Specified","Add Info Submitted","","","","2024-06-17","Submitted 4507 Santa Rosa, 4214 Andrews Hwy suite 102-103, and 400 Rosalind Redfern Grover Pkwy via delegated roster on 6/14/2024. FC"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","PE - Premier Family Care, Inc","Medicare","Participating","Enrollment Complete",44801,"2G9994","0008AH","2022-08-11","8/11/2022 Rcvd Medicare approval letter.  Provider is PAR and linked to group/locations -   PTAN # 2G9994 - effective 8/28/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","PE - Premier Family Care, Inc","Medicare","Participating","Enrollment Complete",44801,"2G9994","0008AH","2022-08-11","8/11/2022 Rcvd Medicare approval letter.  Provider is PAR and linked to group/locations -   PTAN # 2G9994 - effective 8/28/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","PE - Premier Family Care, Inc","Medicare","Participating","Enrollment Complete",44801,"2G9994","0008AH","2022-08-11","8/11/2022 Rcvd Medicare approval letter.  Provider is PAR and linked to group/locations -   PTAN # 2G9994 - effective 8/28/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","PE - Premier Family Care, Inc","Medicare","Participating","Enrollment Complete",44801,"2G9994","0008AH","2022-08-11","8/11/2022 Rcvd Medicare approval letter.  Provider is PAR and linked to group/locations -   PTAN # 2G9994 - effective 8/28/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","PE - Premier Family Care, Inc","Medicare","Participating","Enrollment Complete",44801,"2G9994","0008AH","2022-08-11","8/11/2022 Rcvd Medicare approval letter.  Provider is PAR and linked to group/locations -   PTAN # 2G9994 - effective 8/28/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","PE - Premier Family Care, Inc","Medicare","Participating","Enrollment Complete",44801,"2G9994","0008AH","2022-08-11","8/11/2022 Rcvd Medicare approval letter.  Provider is PAR and linked to group/locations -   PTAN # 2G9994 - effective 8/28/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","PE - Premier Family Care, Inc","Medicare","Participating","Enrollment Complete",44801,"2G9994","0008AH","2022-08-11","8/11/2022 Rcvd Medicare approval letter.  Provider is PAR and linked to group/locations -   PTAN # 2G9994 - effective 8/28/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","PE - Premier Family Care, Inc","Medicare","Participating","Enrollment Complete",44801,"2G9994","0008AH","2022-08-11","8/11/2022 Rcvd Medicare approval letter.  Provider is PAR and linked to group/locations -   PTAN # 2G9994 - effective 8/28/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","PE - Premier Family Care, Inc","Medicare","Participating","Enrollment Complete",44801,"2G9994","0008AH","2022-08-11","8/11/2022 Rcvd Medicare approval letter.  Provider is PAR and linked to group/locations -   PTAN # 2G9994 - effective 8/28/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","PE - Premier Family Care, Inc","Medicare","Participating","Enrollment Complete",44801,"2G9994","0008AH","2022-08-11","8/11/2022 Rcvd Medicare approval letter.  Provider is PAR and linked to group/locations -   PTAN # 2G9994 - effective 8/28/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","PE - Premier Family Care, Inc","Medicare","Participating","Enrollment Complete",44801,"2G9994","0008AH","2022-08-11","8/11/2022 Rcvd Medicare approval letter.  Provider is PAR and linked to group/locations -   PTAN # 2G9994 - effective 8/28/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","PE - Premier Family Care, Inc","Medicare","Participating","Enrollment Complete",44801,"2G9994","0008AH","2022-08-11","8/11/2022 Rcvd Medicare approval letter.  Provider is PAR and linked to group/locations -   PTAN # 2G9994 - effective 8/28/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","PE - Premier Family Care, Inc","Medicare","Participating","Enrollment Complete",44801,"2G9994","0008AH","2022-08-11","8/11/2022 Rcvd Medicare approval letter.  Provider is PAR and linked to group/locations -   PTAN # 2G9994 - effective 8/28/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","PE - Premier Family Care, Inc","Medicare","Participating","Enrollment Complete",44801,"2G9994","0008AH","2022-08-11","8/11/2022 Rcvd Medicare approval letter.  Provider is PAR and linked to group/locations -   PTAN # 2G9994 - effective 8/28/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","PE - Premier Family Care, Inc","Medicare","Participating","Enrollment Complete",44801,"2G9994","0008AH","2022-08-11","8/11/2022 Rcvd Medicare approval letter.  Provider is PAR and linked to group/locations -   PTAN # 2G9994 - effective 8/28/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","PE - Premier Family Care, Inc","Medicare","Participating","Enrollment Complete",44801,"2G9994","0008AH","2022-08-11","8/11/2022 Rcvd Medicare approval letter.  Provider is PAR and linked to group/locations -   PTAN # 2G9994 - effective 8/28/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","PE - Premier Family Care, Inc","Medicare","Participating","Enrollment Complete",44801,"2G9994","0008AH","2022-08-11","8/11/2022 Rcvd Medicare approval letter.  Provider is PAR and linked to group/locations -   PTAN # 2G9994 - effective 8/28/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","PE - Premier Family Care, Inc","Medicare","Participating","Enrollment Complete",44801,"2G9994","0008AH","2022-08-11","8/11/2022 Rcvd Medicare approval letter.  Provider is PAR and linked to group/locations -   PTAN # 2G9994 - effective 8/28/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","PE - Premier Family Care, Inc","Medicare","Participating","Enrollment Complete",44801,"2G9994","0008AH","2022-08-11","8/11/2022 Rcvd Medicare approval letter.  Provider is PAR and linked to group/locations -   PTAN # 2G9994 - effective 8/28/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","PE - Premier Family Care, Inc","Medicare","Participating","Enrollment Complete",44801,"2G9994","0008AH","2022-08-11","8/11/2022 Rcvd Medicare approval letter.  Provider is PAR and linked to group/locations -   PTAN # 2G9994 - effective 8/28/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","PE - Premier Family Care, Inc","Medicare","Participating","Enrollment Complete",44801,"2G9994","0008AH","2022-08-11","8/11/2022 Rcvd Medicare approval letter.  Provider is PAR and linked to group/locations -   PTAN # 2G9994 - effective 8/28/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","PE - Premier Family Care, Inc","Medicare","Participating","Enrollment Complete",44801,"2G9994","0008AH","2022-08-11","8/11/2022 Rcvd Medicare approval letter.  Provider is PAR and linked to group/locations -   PTAN # 2G9994 - effective 8/28/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","PE - Premier Family Care, Inc","Medicare","Participating","Enrollment Complete",44801,"2G9994","0008AH","2022-08-11","8/11/2022 Rcvd Medicare approval letter.  Provider is PAR and linked to group/locations -   PTAN # 2G9994 - effective 8/28/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","PE - Premier Family Care, Inc","Medicare","Participating","Enrollment Complete",44801,"2G9994","0008AH","2022-08-11","8/11/2022 Rcvd Medicare approval letter.  Provider is PAR and linked to group/locations -   PTAN # 2G9994 - effective 8/28/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","PE - Premier Family Care, Inc","Medicare","Participating","Enrollment Complete",44801,"2G9994","0008AH","2022-08-11","8/11/2022 Rcvd Medicare approval letter.  Provider is PAR and linked to group/locations -   PTAN # 2G9994 - effective 8/28/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","PE - Premier Family Care, Inc","Medicare","Participating","Enrollment Complete",44801,"2G9994","0008AH","2022-08-11","8/11/2022 Rcvd Medicare approval letter.  Provider is PAR and linked to group/locations -   PTAN # 2G9994 - effective 8/28/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","PE - Premier Family Care, Inc","Medicare","Participating","Enrollment Complete",44801,"2G9994","0008AH","2022-08-11","8/11/2022 Rcvd Medicare approval letter.  Provider is PAR and linked to group/locations -   PTAN # 2G9994 - effective 8/28/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","PE - Premier Family Care, Inc","Medicare","Participating","Enrollment Complete",44801,"2G9994","0008AH","2022-08-11","8/11/2022 Rcvd Medicare approval letter.  Provider is PAR and linked to group/locations -   PTAN # 2G9994 - effective 8/28/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","PE - Premier Family Care, Inc","Caprock (CapStar)","Participating","Enrollment Complete",43831,"","","2022-10-12","10/12/2022 Per email from Priscilla Albertine she rcvd confirmation from Mary Rodriguez at Caprock that provider is PAR and linked to group TIN/locations effective 1/1/2020.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","PE - Premier Family Care, Inc","Caprock (CapStar)","Participating","Enrollment Complete",43831,"","","2022-10-12","10/12/2022 Per email from Priscilla Albertine she rcvd confirmation from Mary Rodriguez at Caprock that provider is PAR and linked to group TIN/locations effective 1/1/2020.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","PE - Premier Family Care, Inc","Caprock (CapStar)","Participating","Enrollment Complete",43831,"","","2022-10-12","10/12/2022 Per email from Priscilla Albertine she rcvd confirmation from Mary Rodriguez at Caprock that provider is PAR and linked to group TIN/locations effective 1/1/2020.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","PE - Premier Family Care, Inc","Caprock (CapStar)","Participating","Enrollment Complete",43831,"","","2022-10-12","10/12/2022 Per email from Priscilla Albertine she rcvd confirmation from Mary Rodriguez at Caprock that provider is PAR and linked to group TIN/locations effective 1/1/2020.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","PE - Premier Family Care, Inc","Caprock (CapStar)","Participating","Enrollment Complete",43831,"","","2022-10-12","10/12/2022 Per email from Priscilla Albertine she rcvd confirmation from Mary Rodriguez at Caprock that provider is PAR and linked to group TIN/locations effective 1/1/2020.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","PE - Premier Family Care, Inc","Caprock (CapStar)","Participating","Enrollment Complete",43831,"","","2022-10-12","10/12/2022 Per email from Priscilla Albertine she rcvd confirmation from Mary Rodriguez at Caprock that provider is PAR and linked to group TIN/locations effective 1/1/2020.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","PE - Premier Family Care, Inc","Caprock (CapStar)","Participating","Enrollment Complete",43831,"","","2022-10-12","10/12/2022 Per email from Priscilla Albertine she rcvd confirmation from Mary Rodriguez at Caprock that provider is PAR and linked to group TIN/locations effective 1/1/2020.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","PE - Premier Family Care, Inc","Caprock (CapStar)","Participating","Enrollment Complete",43831,"","","2022-10-12","10/12/2022 Per email from Priscilla Albertine she rcvd confirmation from Mary Rodriguez at Caprock that provider is PAR and linked to group TIN/locations effective 1/1/2020.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","PE - Premier Family Care, Inc","Caprock (CapStar)","Participating","Enrollment Complete",43831,"","","2022-10-12","10/12/2022 Per email from Priscilla Albertine she rcvd confirmation from Mary Rodriguez at Caprock that provider is PAR and linked to group TIN/locations effective 1/1/2020.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","PE - Premier Family Care, Inc","Caprock (CapStar)","Participating","Enrollment Complete",43831,"","","2022-10-12","10/12/2022 Per email from Priscilla Albertine she rcvd confirmation from Mary Rodriguez at Caprock that provider is PAR and linked to group TIN/locations effective 1/1/2020.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","PE - Premier Family Care, Inc","Caprock (CapStar)","Participating","Enrollment Complete",43831,"","","2022-10-12","10/12/2022 Per email from Priscilla Albertine she rcvd confirmation from Mary Rodriguez at Caprock that provider is PAR and linked to group TIN/locations effective 1/1/2020.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","PE - Premier Family Care, Inc","Caprock (CapStar)","Participating","Enrollment Complete",43831,"","","2022-10-12","10/12/2022 Per email from Priscilla Albertine she rcvd confirmation from Mary Rodriguez at Caprock that provider is PAR and linked to group TIN/locations effective 1/1/2020.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","PE - Premier Family Care, Inc","Caprock (CapStar)","Participating","Enrollment Complete",43831,"","","2022-10-12","10/12/2022 Per email from Priscilla Albertine she rcvd confirmation from Mary Rodriguez at Caprock that provider is PAR and linked to group TIN/locations effective 1/1/2020.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","PE - Premier Family Care, Inc","Caprock (CapStar)","Participating","Enrollment Complete",43831,"","","2022-10-12","10/12/2022 Per email from Priscilla Albertine she rcvd confirmation from Mary Rodriguez at Caprock that provider is PAR and linked to group TIN/locations effective 1/1/2020.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","PE - Premier Family Care, Inc","Caprock (CapStar)","Participating","Enrollment Complete",43831,"","","2022-10-12","10/12/2022 Per email from Priscilla Albertine she rcvd confirmation from Mary Rodriguez at Caprock that provider is PAR and linked to group TIN/locations effective 1/1/2020.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","PE - Premier Family Care, Inc","Caprock (CapStar)","Participating","Enrollment Complete",43831,"","","2022-10-12","10/12/2022 Per email from Priscilla Albertine she rcvd confirmation from Mary Rodriguez at Caprock that provider is PAR and linked to group TIN/locations effective 1/1/2020.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","PE - Premier Family Care, Inc","Caprock (CapStar)","Participating","Enrollment Complete",43831,"","","2022-10-12","10/12/2022 Per email from Priscilla Albertine she rcvd confirmation from Mary Rodriguez at Caprock that provider is PAR and linked to group TIN/locations effective 1/1/2020.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","PE - Premier Family Care, Inc","Caprock (CapStar)","Participating","Enrollment Complete",43831,"","","2022-10-12","10/12/2022 Per email from Priscilla Albertine she rcvd confirmation from Mary Rodriguez at Caprock that provider is PAR and linked to group TIN/locations effective 1/1/2020.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","PE - Premier Family Care, Inc","Caprock (CapStar)","Participating","Enrollment Complete",43831,"","","2022-10-12","10/12/2022 Per email from Priscilla Albertine she rcvd confirmation from Mary Rodriguez at Caprock that provider is PAR and linked to group TIN/locations effective 1/1/2020.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","PE - Premier Family Care, Inc","Caprock (CapStar)","Participating","Enrollment Complete",43831,"","","2022-10-12","10/12/2022 Per email from Priscilla Albertine she rcvd confirmation from Mary Rodriguez at Caprock that provider is PAR and linked to group TIN/locations effective 1/1/2020.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","PE - Premier Family Care, Inc","Caprock (CapStar)","Participating","Enrollment Complete",43831,"","","2022-10-12","10/12/2022 Per email from Priscilla Albertine she rcvd confirmation from Mary Rodriguez at Caprock that provider is PAR and linked to group TIN/locations effective 1/1/2020.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","PE - Premier Family Care, Inc","Caprock (CapStar)","Participating","Enrollment Complete",43831,"","","2022-10-12","10/12/2022 Per email from Priscilla Albertine she rcvd confirmation from Mary Rodriguez at Caprock that provider is PAR and linked to group TIN/locations effective 1/1/2020.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","PE - Premier Family Care, Inc","Caprock (CapStar)","Participating","Enrollment Complete",43831,"","","2022-10-12","10/12/2022 Per email from Priscilla Albertine she rcvd confirmation from Mary Rodriguez at Caprock that provider is PAR and linked to group TIN/locations effective 1/1/2020.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","PE - Premier Family Care, Inc","Caprock (CapStar)","Participating","Enrollment Complete",43831,"","","2022-10-12","10/12/2022 Per email from Priscilla Albertine she rcvd confirmation from Mary Rodriguez at Caprock that provider is PAR and linked to group TIN/locations effective 1/1/2020.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","PE - Premier Family Care, Inc","Caprock (CapStar)","Participating","Enrollment Complete",43831,"","","2022-10-12","10/12/2022 Per email from Priscilla Albertine she rcvd confirmation from Mary Rodriguez at Caprock that provider is PAR and linked to group TIN/locations effective 1/1/2020.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","PE - Premier Family Care, Inc","Caprock (CapStar)","Participating","Enrollment Complete",43831,"","","2022-10-12","10/12/2022 Per email from Priscilla Albertine she rcvd confirmation from Mary Rodriguez at Caprock that provider is PAR and linked to group TIN/locations effective 1/1/2020.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","PE - Premier Family Care, Inc","Caprock (CapStar)","Participating","Enrollment Complete",43831,"","","2022-10-12","10/12/2022 Per email from Priscilla Albertine she rcvd confirmation from Mary Rodriguez at Caprock that provider is PAR and linked to group TIN/locations effective 1/1/2020.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","PE - Premier Family Care, Inc","Caprock (CapStar)","Participating","Enrollment Complete",43831,"","","2022-10-12","10/12/2022 Per email from Priscilla Albertine she rcvd confirmation from Mary Rodriguez at Caprock that provider is PAR and linked to group TIN/locations effective 1/1/2020.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","PE - Premier Family Care, Inc","USA PPO","Participating","Enrollment Complete",44816,"","","2023-03-24","3/24/2023 In following up with USAMCO (800-872-3860) I was told that you can confirm participating via the USA MCO website  https://providersearch.usamco.com/hwprovsearch.  Provider is PAR and linked to location/TIN effective 9/12/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","PE - Premier Family Care, Inc","USA PPO","Participating","Enrollment Complete",44816,"","","2023-03-24","3/24/2023 In following up with USAMCO (800-872-3860) I was told that you can confirm participating via the USA MCO website  https://providersearch.usamco.com/hwprovsearch.  Provider is PAR and linked to location/TIN effective 9/12/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","PE - Premier Family Care, Inc","USA PPO","Participating","Enrollment Complete",44816,"","","2023-03-24","3/24/2023 In following up with USAMCO (800-872-3860) I was told that you can confirm participating via the USA MCO website  https://providersearch.usamco.com/hwprovsearch.  Provider is PAR and linked to location/TIN effective 9/12/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","PE - Premier Family Care, Inc","USA PPO","Participating","Enrollment Complete",44816,"","","2023-03-24","3/24/2023 In following up with USAMCO (800-872-3860) I was told that you can confirm participating via the USA MCO website  https://providersearch.usamco.com/hwprovsearch.  Provider is PAR and linked to location/TIN effective 9/12/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","PE - Premier Family Care, Inc","USA PPO","Participating","Enrollment Complete",44816,"","","2023-03-24","3/24/2023 In following up with USAMCO (800-872-3860) I was told that you can confirm participating via the USA MCO website  https://providersearch.usamco.com/hwprovsearch.  Provider is PAR and linked to location/TIN effective 9/12/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","PE - Premier Family Care, Inc","USA PPO","Participating","Enrollment Complete",44816,"","","2023-03-24","3/24/2023 In following up with USAMCO (800-872-3860) I was told that you can confirm participating via the USA MCO website  https://providersearch.usamco.com/hwprovsearch.  Provider is PAR and linked to location/TIN effective 9/12/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","PE - Premier Family Care, Inc","USA PPO","Participating","Enrollment Complete",44816,"","","2023-03-24","3/24/2023 In following up with USAMCO (800-872-3860) I was told that you can confirm participating via the USA MCO website  https://providersearch.usamco.com/hwprovsearch.  Provider is PAR and linked to location/TIN effective 9/12/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","PE - Premier Family Care, Inc","USA PPO","Participating","Enrollment Complete",44816,"","","2023-03-24","3/24/2023 In following up with USAMCO (800-872-3860) I was told that you can confirm participating via the USA MCO website  https://providersearch.usamco.com/hwprovsearch.  Provider is PAR and linked to location/TIN effective 9/12/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","PE - Premier Family Care, Inc","USA PPO","Participating","Enrollment Complete",44816,"","","2023-03-24","3/24/2023 In following up with USAMCO (800-872-3860) I was told that you can confirm participating via the USA MCO website  https://providersearch.usamco.com/hwprovsearch.  Provider is PAR and linked to location/TIN effective 9/12/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","PE - Premier Family Care, Inc","USA PPO","Participating","Enrollment Complete",44816,"","","2023-03-24","3/24/2023 In following up with USAMCO (800-872-3860) I was told that you can confirm participating via the USA MCO website  https://providersearch.usamco.com/hwprovsearch.  Provider is PAR and linked to location/TIN effective 9/12/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","PE - Premier Family Care, Inc","USA PPO","Participating","Enrollment Complete",44816,"","","2023-03-24","3/24/2023 In following up with USAMCO (800-872-3860) I was told that you can confirm participating via the USA MCO website  https://providersearch.usamco.com/hwprovsearch.  Provider is PAR and linked to location/TIN effective 9/12/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","PE - Premier Family Care, Inc","USA PPO","Participating","Enrollment Complete",44816,"","","2023-03-24","3/24/2023 In following up with USAMCO (800-872-3860) I was told that you can confirm participating via the USA MCO website  https://providersearch.usamco.com/hwprovsearch.  Provider is PAR and linked to location/TIN effective 9/12/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","PE - Premier Family Care, Inc","USA PPO","Participating","Enrollment Complete",44816,"","","2023-03-24","3/24/2023 In following up with USAMCO (800-872-3860) I was told that you can confirm participating via the USA MCO website  https://providersearch.usamco.com/hwprovsearch.  Provider is PAR and linked to location/TIN effective 9/12/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","PE - Premier Family Care, Inc","USA PPO","Participating","Enrollment Complete",44816,"","","2023-03-24","3/24/2023 In following up with USAMCO (800-872-3860) I was told that you can confirm participating via the USA MCO website  https://providersearch.usamco.com/hwprovsearch.  Provider is PAR and linked to location/TIN effective 9/12/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","PE - Premier Family Care, Inc","USA PPO","Participating","Enrollment Complete",44816,"","","2023-03-24","3/24/2023 In following up with USAMCO (800-872-3860) I was told that you can confirm participating via the USA MCO website  https://providersearch.usamco.com/hwprovsearch.  Provider is PAR and linked to location/TIN effective 9/12/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","PE - Premier Family Care, Inc","USA PPO","Participating","Enrollment Complete",44816,"","","2023-03-24","3/24/2023 In following up with USAMCO (800-872-3860) I was told that you can confirm participating via the USA MCO website  https://providersearch.usamco.com/hwprovsearch.  Provider is PAR and linked to location/TIN effective 9/12/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","PE - Premier Family Care, Inc","USA PPO","Participating","Enrollment Complete",44816,"","","2023-03-24","3/24/2023 In following up with USAMCO (800-872-3860) I was told that you can confirm participating via the USA MCO website  https://providersearch.usamco.com/hwprovsearch.  Provider is PAR and linked to location/TIN effective 9/12/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","PE - Premier Family Care, Inc","USA PPO","Participating","Enrollment Complete",44816,"","","2023-03-24","3/24/2023 In following up with USAMCO (800-872-3860) I was told that you can confirm participating via the USA MCO website  https://providersearch.usamco.com/hwprovsearch.  Provider is PAR and linked to location/TIN effective 9/12/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","PE - Premier Family Care, Inc","USA PPO","Participating","Enrollment Complete",44816,"","","2023-03-24","3/24/2023 In following up with USAMCO (800-872-3860) I was told that you can confirm participating via the USA MCO website  https://providersearch.usamco.com/hwprovsearch.  Provider is PAR and linked to location/TIN effective 9/12/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","PE - Premier Family Care, Inc","USA PPO","Participating","Enrollment Complete",44816,"","","2023-03-24","3/24/2023 In following up with USAMCO (800-872-3860) I was told that you can confirm participating via the USA MCO website  https://providersearch.usamco.com/hwprovsearch.  Provider is PAR and linked to location/TIN effective 9/12/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","PE - Premier Family Care, Inc","Aetna","Participating","Enrollment Complete",44880,"","","2023-01-23","1.23.23 Rcvd confirmation from Aetna that provider is PAR at the following locations only (709 W Louisiana Ave, 3411 Caldera, 3415 N Loop 250) effective 11/15/2022 Provider ID is 6669419. Link Letter and W9 will need to be submitted by fax @859-455-8650 to Aetna (attn to network management) to link provider to other locations.  TAT is 10-15 business days. ABoles"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","PE - Premier Family Care, Inc","Aetna","Participating","Enrollment Complete",44880,"","","2023-01-23","1.23.23 Rcvd confirmation from Aetna that provider is PAR at the following locations only (709 W Louisiana Ave, 3411 Caldera, 3415 N Loop 250) effective 11/15/2022 Provider ID is 6669419. Link Letter and W9 will need to be submitted by fax @859-455-8650 to Aetna (attn to network management) to link provider to other locations.  TAT is 10-15 business days. ABoles"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","PE - Premier Family Care, Inc","Aetna","Participating","Enrollment Complete",44880,"","","2023-01-23","1.23.23 Rcvd confirmation from Aetna that provider is PAR at the following locations only (709 W Louisiana Ave, 3411 Caldera, 3415 N Loop 250) effective 11/15/2022 Provider ID is 6669419. Link Letter and W9 will need to be submitted by fax @859-455-8650 to Aetna (attn to network management) to link provider to other locations.  TAT is 10-15 business days. ABoles"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","PE - Premier Family Care, Inc","Aetna","Participating","Enrollment Complete",44880,"","","2023-01-23","1.23.23 Rcvd confirmation from Aetna that provider is PAR at the following locations only (709 W Louisiana Ave, 3411 Caldera, 3415 N Loop 250) effective 11/15/2022 Provider ID is 6669419. Link Letter and W9 will need to be submitted by fax @859-455-8650 to Aetna (attn to network management) to link provider to other locations.  TAT is 10-15 business days. ABoles"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","PE - Premier Family Care, Inc","Aetna","Participating","Enrollment Complete",44880,"","","2023-01-23","1.23.23 Rcvd confirmation from Aetna that provider is PAR at the following locations only (709 W Louisiana Ave, 3411 Caldera, 3415 N Loop 250) effective 11/15/2022 Provider ID is 6669419. Link Letter and W9 will need to be submitted by fax @859-455-8650 to Aetna (attn to network management) to link provider to other locations.  TAT is 10-15 business days. ABoles"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","PE - Premier Family Care, Inc","Aetna","Participating","Enrollment Complete",44880,"","","2023-01-23","1.23.23 Rcvd confirmation from Aetna that provider is PAR at the following locations only (709 W Louisiana Ave, 3411 Caldera, 3415 N Loop 250) effective 11/15/2022 Provider ID is 6669419. Link Letter and W9 will need to be submitted by fax @859-455-8650 to Aetna (attn to network management) to link provider to other locations.  TAT is 10-15 business days. ABoles"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","PE - Premier Family Care, Inc","Aetna","Participating","Enrollment Complete",44880,"","","2023-01-23","1.23.23 Rcvd confirmation from Aetna that provider is PAR at the following locations only (709 W Louisiana Ave, 3411 Caldera, 3415 N Loop 250) effective 11/15/2022 Provider ID is 6669419. Link Letter and W9 will need to be submitted by fax @859-455-8650 to Aetna (attn to network management) to link provider to other locations.  TAT is 10-15 business days. ABoles"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","PE - Premier Family Care, Inc","Aetna","Participating","Enrollment Complete",44880,"","","2023-01-23","1.23.23 Rcvd confirmation from Aetna that provider is PAR at the following locations only (709 W Louisiana Ave, 3411 Caldera, 3415 N Loop 250) effective 11/15/2022 Provider ID is 6669419. Link Letter and W9 will need to be submitted by fax @859-455-8650 to Aetna (attn to network management) to link provider to other locations.  TAT is 10-15 business days. ABoles"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","PE - Premier Family Care, Inc","Aetna","Participating","Enrollment Complete",44880,"","","2023-01-23","1.23.23 Rcvd confirmation from Aetna that provider is PAR at the following locations only (709 W Louisiana Ave, 3411 Caldera, 3415 N Loop 250) effective 11/15/2022 Provider ID is 6669419. Link Letter and W9 will need to be submitted by fax @859-455-8650 to Aetna (attn to network management) to link provider to other locations.  TAT is 10-15 business days. ABoles"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","PE - Premier Family Care, Inc","Aetna","Participating","Enrollment Complete",44880,"","","2023-01-23","1.23.23 Rcvd confirmation from Aetna that provider is PAR at the following locations only (709 W Louisiana Ave, 3411 Caldera, 3415 N Loop 250) effective 11/15/2022 Provider ID is 6669419. Link Letter and W9 will need to be submitted by fax @859-455-8650 to Aetna (attn to network management) to link provider to other locations.  TAT is 10-15 business days. ABoles"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","PE - Premier Family Care, Inc","Aetna","Participating","Enrollment Complete",44880,"","","2023-01-23","1.23.23 Rcvd confirmation from Aetna that provider is PAR at the following locations only (709 W Louisiana Ave, 3411 Caldera, 3415 N Loop 250) effective 11/15/2022 Provider ID is 6669419. Link Letter and W9 will need to be submitted by fax @859-455-8650 to Aetna (attn to network management) to link provider to other locations.  TAT is 10-15 business days. ABoles"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","PE - Premier Family Care, Inc","Aetna","Participating","Enrollment Complete",44880,"","","2023-01-23","1.23.23 Rcvd confirmation from Aetna that provider is PAR at the following locations only (709 W Louisiana Ave, 3411 Caldera, 3415 N Loop 250) effective 11/15/2022 Provider ID is 6669419. Link Letter and W9 will need to be submitted by fax @859-455-8650 to Aetna (attn to network management) to link provider to other locations.  TAT is 10-15 business days. ABoles"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","PE - Premier Family Care, Inc","Aetna","Participating","Enrollment Complete",44880,"","","2023-01-23","1.23.23 Rcvd confirmation from Aetna that provider is PAR at the following locations only (709 W Louisiana Ave, 3411 Caldera, 3415 N Loop 250) effective 11/15/2022 Provider ID is 6669419. Link Letter and W9 will need to be submitted by fax @859-455-8650 to Aetna (attn to network management) to link provider to other locations.  TAT is 10-15 business days. ABoles"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","PE - Premier Family Care, Inc","Aetna","Participating","Enrollment Complete",44880,"","","2023-01-23","1.23.23 Rcvd confirmation from Aetna that provider is PAR at the following locations only (709 W Louisiana Ave, 3411 Caldera, 3415 N Loop 250) effective 11/15/2022 Provider ID is 6669419. Link Letter and W9 will need to be submitted by fax @859-455-8650 to Aetna (attn to network management) to link provider to other locations.  TAT is 10-15 business days. ABoles"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","PE - Premier Family Care, Inc","Aetna","Participating","Enrollment Complete",44880,"","","2023-01-23","1.23.23 Rcvd confirmation from Aetna that provider is PAR at the following locations only (709 W Louisiana Ave, 3411 Caldera, 3415 N Loop 250) effective 11/15/2022 Provider ID is 6669419. Link Letter and W9 will need to be submitted by fax @859-455-8650 to Aetna (attn to network management) to link provider to other locations.  TAT is 10-15 business days. ABoles"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","PE - Premier Family Care, Inc","Aetna","Participating","Enrollment Complete",44880,"","","2023-01-23","1.23.23 Rcvd confirmation from Aetna that provider is PAR at the following locations only (709 W Louisiana Ave, 3411 Caldera, 3415 N Loop 250) effective 11/15/2022 Provider ID is 6669419. Link Letter and W9 will need to be submitted by fax @859-455-8650 to Aetna (attn to network management) to link provider to other locations.  TAT is 10-15 business days. ABoles"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","PE - Premier Family Care, Inc","Aetna","Participating","Enrollment Complete",44880,"","","2023-01-23","1.23.23 Rcvd confirmation from Aetna that provider is PAR at the following locations only (709 W Louisiana Ave, 3411 Caldera, 3415 N Loop 250) effective 11/15/2022 Provider ID is 6669419. Link Letter and W9 will need to be submitted by fax @859-455-8650 to Aetna (attn to network management) to link provider to other locations.  TAT is 10-15 business days. ABoles"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","PE - Premier Family Care, Inc","Aetna","Participating","Enrollment Complete",44880,"","","2023-01-23","1.23.23 Rcvd confirmation from Aetna that provider is PAR at the following locations only (709 W Louisiana Ave, 3411 Caldera, 3415 N Loop 250) effective 11/15/2022 Provider ID is 6669419. Link Letter and W9 will need to be submitted by fax @859-455-8650 to Aetna (attn to network management) to link provider to other locations.  TAT is 10-15 business days. ABoles"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","PE - Premier Family Care, Inc","Aetna","Participating","Enrollment Complete",44880,"","","2023-01-23","1.23.23 Rcvd confirmation from Aetna that provider is PAR at the following locations only (709 W Louisiana Ave, 3411 Caldera, 3415 N Loop 250) effective 11/15/2022 Provider ID is 6669419. Link Letter and W9 will need to be submitted by fax @859-455-8650 to Aetna (attn to network management) to link provider to other locations.  TAT is 10-15 business days. ABoles"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","PE - Premier Family Care, Inc","Aetna","Participating","Enrollment Complete",44880,"","","2023-01-23","1.23.23 Rcvd confirmation from Aetna that provider is PAR at the following locations only (709 W Louisiana Ave, 3411 Caldera, 3415 N Loop 250) effective 11/15/2022 Provider ID is 6669419. Link Letter and W9 will need to be submitted by fax @859-455-8650 to Aetna (attn to network management) to link provider to other locations.  TAT is 10-15 business days. ABoles"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","PE - Premier Family Care, Inc","Aetna","Participating","Enrollment Complete",44880,"","","2023-01-23","1.23.23 Rcvd confirmation from Aetna that provider is PAR at the following locations only (709 W Louisiana Ave, 3411 Caldera, 3415 N Loop 250) effective 11/15/2022 Provider ID is 6669419. Link Letter and W9 will need to be submitted by fax @859-455-8650 to Aetna (attn to network management) to link provider to other locations.  TAT is 10-15 business days. ABoles"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","PE - Premier Family Care, Inc","Aetna","Participating","Enrollment Complete",44880,"","","2023-01-23","1.23.23 Rcvd confirmation from Aetna that provider is PAR at the following locations only (709 W Louisiana Ave, 3411 Caldera, 3415 N Loop 250) effective 11/15/2022 Provider ID is 6669419. Link Letter and W9 will need to be submitted by fax @859-455-8650 to Aetna (attn to network management) to link provider to other locations.  TAT is 10-15 business days. ABoles"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","PE - Premier Family Care, Inc","Aetna","Participating","Enrollment Complete",44880,"","","2023-01-23","1.23.23 Rcvd confirmation from Aetna that provider is PAR at the following locations only (709 W Louisiana Ave, 3411 Caldera, 3415 N Loop 250) effective 11/15/2022 Provider ID is 6669419. Link Letter and W9 will need to be submitted by fax @859-455-8650 to Aetna (attn to network management) to link provider to other locations.  TAT is 10-15 business days. ABoles"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","PE - Premier Family Care, Inc","Aetna","Participating","Enrollment Complete",44880,"","","2023-01-23","1.23.23 Rcvd confirmation from Aetna that provider is PAR at the following locations only (709 W Louisiana Ave, 3411 Caldera, 3415 N Loop 250) effective 11/15/2022 Provider ID is 6669419. Link Letter and W9 will need to be submitted by fax @859-455-8650 to Aetna (attn to network management) to link provider to other locations.  TAT is 10-15 business days. ABoles"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","PE - Premier Family Care, Inc","Aetna","Participating","Enrollment Complete",44880,"","","2023-01-23","1.23.23 Rcvd confirmation from Aetna that provider is PAR at the following locations only (709 W Louisiana Ave, 3411 Caldera, 3415 N Loop 250) effective 11/15/2022 Provider ID is 6669419. Link Letter and W9 will need to be submitted by fax @859-455-8650 to Aetna (attn to network management) to link provider to other locations.  TAT is 10-15 business days. ABoles"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","PE - Premier Family Care, Inc","Aetna","Participating","Enrollment Complete",44880,"","","2023-01-23","1.23.23 Rcvd confirmation from Aetna that provider is PAR at the following locations only (709 W Louisiana Ave, 3411 Caldera, 3415 N Loop 250) effective 11/15/2022 Provider ID is 6669419. Link Letter and W9 will need to be submitted by fax @859-455-8650 to Aetna (attn to network management) to link provider to other locations.  TAT is 10-15 business days. ABoles"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","PE - Premier Family Care, Inc","Aetna","Participating","Enrollment Complete",44880,"","","2023-01-23","1.23.23 Rcvd confirmation from Aetna that provider is PAR at the following locations only (709 W Louisiana Ave, 3411 Caldera, 3415 N Loop 250) effective 11/15/2022 Provider ID is 6669419. Link Letter and W9 will need to be submitted by fax @859-455-8650 to Aetna (attn to network management) to link provider to other locations.  TAT is 10-15 business days. ABoles"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","PE - Premier Family Care, Inc","Aetna","Participating","Enrollment Complete",44880,"","","2023-01-23","1.23.23 Rcvd confirmation from Aetna that provider is PAR at the following locations only (709 W Louisiana Ave, 3411 Caldera, 3415 N Loop 250) effective 11/15/2022 Provider ID is 6669419. Link Letter and W9 will need to be submitted by fax @859-455-8650 to Aetna (attn to network management) to link provider to other locations.  TAT is 10-15 business days. ABoles"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","PE - Premier Family Care, Inc","Wellmed","Participating","Enrollment Complete",44785,"","","2023-03-23","3/23/2023 Rcvd roster from UHC w/ all Wellmed participating providers.  Provider is PAR effective 8/12/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","PE - Premier Family Care, Inc","Wellmed","Participating","Enrollment Complete",44785,"","","2023-03-23","3/23/2023 Rcvd roster from UHC w/ all Wellmed participating providers.  Provider is PAR effective 8/12/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","PE - Premier Family Care, Inc","Wellmed","Participating","Enrollment Complete",44785,"","","2023-03-23","3/23/2023 Rcvd roster from UHC w/ all Wellmed participating providers.  Provider is PAR effective 8/12/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","PE - Premier Family Care, Inc","Wellmed","Participating","Enrollment Complete",44785,"","","2023-03-23","3/23/2023 Rcvd roster from UHC w/ all Wellmed participating providers.  Provider is PAR effective 8/12/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","PE - Premier Family Care, Inc","Wellmed","Participating","Enrollment Complete",44785,"","","2023-03-23","3/23/2023 Rcvd roster from UHC w/ all Wellmed participating providers.  Provider is PAR effective 8/12/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","PE - Premier Family Care, Inc","Wellmed","Participating","Enrollment Complete",44785,"","","2023-03-23","3/23/2023 Rcvd roster from UHC w/ all Wellmed participating providers.  Provider is PAR effective 8/12/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","PE - Premier Family Care, Inc","Wellmed","Participating","Enrollment Complete",44785,"","","2023-03-23","3/23/2023 Rcvd roster from UHC w/ all Wellmed participating providers.  Provider is PAR effective 8/12/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","PE - Premier Family Care, Inc","Wellmed","Participating","Enrollment Complete",44785,"","","2023-03-23","3/23/2023 Rcvd roster from UHC w/ all Wellmed participating providers.  Provider is PAR effective 8/12/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","PE - Premier Family Care, Inc","Wellmed","Participating","Enrollment Complete",44785,"","","2023-03-23","3/23/2023 Rcvd roster from UHC w/ all Wellmed participating providers.  Provider is PAR effective 8/12/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","PE - Premier Family Care, Inc","Wellmed","Participating","Enrollment Complete",44785,"","","2023-03-23","3/23/2023 Rcvd roster from UHC w/ all Wellmed participating providers.  Provider is PAR effective 8/12/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","PE - Premier Family Care, Inc","Wellmed","Participating","Enrollment Complete",44785,"","","2023-03-23","3/23/2023 Rcvd roster from UHC w/ all Wellmed participating providers.  Provider is PAR effective 8/12/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","PE - Premier Family Care, Inc","Wellmed","Participating","Enrollment Complete",44785,"","","2023-03-23","3/23/2023 Rcvd roster from UHC w/ all Wellmed participating providers.  Provider is PAR effective 8/12/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","PE - Premier Family Care, Inc","Wellmed","Participating","Enrollment Complete",44785,"","","2023-03-23","3/23/2023 Rcvd roster from UHC w/ all Wellmed participating providers.  Provider is PAR effective 8/12/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","PE - Premier Family Care, Inc","Wellmed","Participating","Enrollment Complete",44785,"","","2023-03-23","3/23/2023 Rcvd roster from UHC w/ all Wellmed participating providers.  Provider is PAR effective 8/12/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","PE - Premier Family Care, Inc","Wellmed","Participating","Enrollment Complete",44785,"","","2023-03-23","3/23/2023 Rcvd roster from UHC w/ all Wellmed participating providers.  Provider is PAR effective 8/12/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","PE - Premier Family Care, Inc","Wellmed","Participating","Enrollment Complete",44785,"","","2023-03-23","3/23/2023 Rcvd roster from UHC w/ all Wellmed participating providers.  Provider is PAR effective 8/12/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","PE - Premier Family Care, Inc","Wellmed","Participating","Enrollment Complete",44785,"","","2023-03-23","3/23/2023 Rcvd roster from UHC w/ all Wellmed participating providers.  Provider is PAR effective 8/12/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","PE - Premier Family Care, Inc","Wellmed","Participating","Enrollment Complete",44785,"","","2023-03-23","3/23/2023 Rcvd roster from UHC w/ all Wellmed participating providers.  Provider is PAR effective 8/12/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","PE - Premier Family Care, Inc","Wellmed","Participating","Enrollment Complete",44785,"","","2023-03-23","3/23/2023 Rcvd roster from UHC w/ all Wellmed participating providers.  Provider is PAR effective 8/12/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","PE - Premier Family Care, Inc","Wellmed","Participating","Enrollment Complete",44785,"","","2023-03-23","3/23/2023 Rcvd roster from UHC w/ all Wellmed participating providers.  Provider is PAR effective 8/12/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","PE - Premier Family Care, Inc","Wellmed","Participating","Enrollment Complete",44785,"","","2023-03-23","3/23/2023 Rcvd roster from UHC w/ all Wellmed participating providers.  Provider is PAR effective 8/12/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","PE - Premier Family Care, Inc","Wellmed","Participating","Enrollment Complete",44785,"","","2023-03-23","3/23/2023 Rcvd roster from UHC w/ all Wellmed participating providers.  Provider is PAR effective 8/12/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","PE - Premier Family Care, Inc","Wellmed","Participating","Enrollment Complete",44785,"","","2023-03-23","3/23/2023 Rcvd roster from UHC w/ all Wellmed participating providers.  Provider is PAR effective 8/12/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","PE - Premier Family Care, Inc","Wellmed","Participating","Enrollment Complete",44785,"","","2023-03-23","3/23/2023 Rcvd roster from UHC w/ all Wellmed participating providers.  Provider is PAR effective 8/12/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","PE - Premier Family Care, Inc","Wellmed","Participating","Enrollment Complete",44785,"","","2023-03-23","3/23/2023 Rcvd roster from UHC w/ all Wellmed participating providers.  Provider is PAR effective 8/12/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","PE - Premier Family Care, Inc","Wellmed","Participating","Enrollment Complete",44785,"","","2023-03-23","3/23/2023 Rcvd roster from UHC w/ all Wellmed participating providers.  Provider is PAR effective 8/12/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","PE - Premier Family Care, Inc","Wellmed","Participating","Enrollment Complete",44785,"","","2023-03-23","3/23/2023 Rcvd roster from UHC w/ all Wellmed participating providers.  Provider is PAR effective 8/12/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","PE - Premier Family Care, Inc","Wellmed","Participating","Enrollment Complete",44785,"","","2023-03-23","3/23/2023 Rcvd roster from UHC w/ all Wellmed participating providers.  Provider is PAR effective 8/12/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","PE - Premier Family Care, Inc","Multiplan","Participating","Enrollment Complete",44785,"","","2023-09-01","9/1/2023 Per email received from Multiplan provider is PAR and linked to group TIN/locations effective 8/12/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","PE - Premier Family Care, Inc","Multiplan","Participating","Enrollment Complete",44785,"","","2023-09-01","9/1/2023 Per email received from Multiplan provider is PAR and linked to group TIN/locations effective 8/12/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","PE - Premier Family Care, Inc","Multiplan","Participating","Enrollment Complete",44785,"","","2023-09-01","9/1/2023 Per email received from Multiplan provider is PAR and linked to group TIN/locations effective 8/12/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","PE - Premier Family Care, Inc","Multiplan","Participating","Enrollment Complete",44785,"","","2023-09-01","9/1/2023 Per email received from Multiplan provider is PAR and linked to group TIN/locations effective 8/12/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","PE - Premier Family Care, Inc","Multiplan","Participating","Enrollment Complete",44785,"","","2023-09-01","9/1/2023 Per email received from Multiplan provider is PAR and linked to group TIN/locations effective 8/12/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","PE - Premier Family Care, Inc","Multiplan","Participating","Enrollment Complete",44785,"","","2023-09-01","9/1/2023 Per email received from Multiplan provider is PAR and linked to group TIN/locations effective 8/12/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","PE - Premier Family Care, Inc","Multiplan","Participating","Enrollment Complete",44785,"","","2023-09-01","9/1/2023 Per email received from Multiplan provider is PAR and linked to group TIN/locations effective 8/12/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","PE - Premier Family Care, Inc","Multiplan","Participating","Enrollment Complete",44785,"","","2023-09-01","9/1/2023 Per email received from Multiplan provider is PAR and linked to group TIN/locations effective 8/12/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","PE - Premier Family Care, Inc","Multiplan","Participating","Enrollment Complete",44785,"","","2023-09-01","9/1/2023 Per email received from Multiplan provider is PAR and linked to group TIN/locations effective 8/12/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","PE - Premier Family Care, Inc","Multiplan","Participating","Enrollment Complete",44785,"","","2023-09-01","9/1/2023 Per email received from Multiplan provider is PAR and linked to group TIN/locations effective 8/12/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","PE - Premier Family Care, Inc","Multiplan","Participating","Enrollment Complete",44785,"","","2023-09-01","9/1/2023 Per email received from Multiplan provider is PAR and linked to group TIN/locations effective 8/12/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","PE - Premier Family Care, Inc","Multiplan","Participating","Enrollment Complete",44785,"","","2023-09-01","9/1/2023 Per email received from Multiplan provider is PAR and linked to group TIN/locations effective 8/12/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","PE - Premier Family Care, Inc","Multiplan","Participating","Enrollment Complete",44785,"","","2023-09-01","9/1/2023 Per email received from Multiplan provider is PAR and linked to group TIN/locations effective 8/12/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","PE - Premier Family Care, Inc","Multiplan","Participating","Enrollment Complete",44785,"","","2023-09-01","9/1/2023 Per email received from Multiplan provider is PAR and linked to group TIN/locations effective 8/12/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","PE - Premier Family Care, Inc","Multiplan","Participating","Enrollment Complete",44785,"","","2023-09-01","9/1/2023 Per email received from Multiplan provider is PAR and linked to group TIN/locations effective 8/12/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","PE - Premier Family Care, Inc","Multiplan","Participating","Enrollment Complete",44785,"","","2023-09-01","9/1/2023 Per email received from Multiplan provider is PAR and linked to group TIN/locations effective 8/12/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","PE - Premier Family Care, Inc","Multiplan","Participating","Enrollment Complete",44785,"","","2023-09-01","9/1/2023 Per email received from Multiplan provider is PAR and linked to group TIN/locations effective 8/12/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","PE - Premier Family Care, Inc","Multiplan","Participating","Enrollment Complete",44785,"","","2023-09-01","9/1/2023 Per email received from Multiplan provider is PAR and linked to group TIN/locations effective 8/12/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","PE - Premier Family Care, Inc","Multiplan","Participating","Enrollment Complete",44785,"","","2023-09-01","9/1/2023 Per email received from Multiplan provider is PAR and linked to group TIN/locations effective 8/12/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","PE - Premier Family Care, Inc","Multiplan","Participating","Enrollment Complete",44785,"","","2023-09-01","9/1/2023 Per email received from Multiplan provider is PAR and linked to group TIN/locations effective 8/12/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","PE - Premier Family Care, Inc","Multiplan","Participating","Enrollment Complete",44785,"","","2023-09-01","9/1/2023 Per email received from Multiplan provider is PAR and linked to group TIN/locations effective 8/12/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","PE - Premier Family Care, Inc","Multiplan","Participating","Enrollment Complete",44785,"","","2023-09-01","9/1/2023 Per email received from Multiplan provider is PAR and linked to group TIN/locations effective 8/12/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","PE - Premier Family Care, Inc","Multiplan","Participating","Enrollment Complete",44785,"","","2023-09-01","9/1/2023 Per email received from Multiplan provider is PAR and linked to group TIN/locations effective 8/12/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","PE - Premier Family Care, Inc","Multiplan","Participating","Enrollment Complete",44785,"","","2023-09-01","9/1/2023 Per email received from Multiplan provider is PAR and linked to group TIN/locations effective 8/12/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","PE - Premier Family Care, Inc","Multiplan","Participating","Enrollment Complete",44785,"","","2023-09-01","9/1/2023 Per email received from Multiplan provider is PAR and linked to group TIN/locations effective 8/12/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","PE - Premier Family Care, Inc","Multiplan","Participating","Enrollment Complete",44785,"","","2023-09-01","9/1/2023 Per email received from Multiplan provider is PAR and linked to group TIN/locations effective 8/12/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","PE - Premier Family Care, Inc","Multiplan","Participating","Enrollment Complete",44785,"","","2023-09-01","9/1/2023 Per email received from Multiplan provider is PAR and linked to group TIN/locations effective 8/12/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","PE - Premier Family Care, Inc","Multiplan","Participating","Enrollment Complete",44785,"","","2023-09-01","9/1/2023 Per email received from Multiplan provider is PAR and linked to group TIN/locations effective 8/12/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","PE - Premier Family Care, Inc","TriCare Standard","Participating","Enrollment Complete",44931,"","","2023-01-18","1/18/2023 Rcvd letter from Tricare that provider is now Tricare certified effective 1//5/2023.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","PE - Premier Family Care, Inc","TriCare Standard","Participating","Enrollment Complete",44931,"","","2023-01-18","1/18/2023 Rcvd letter from Tricare that provider is now Tricare certified effective 1//5/2023.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","PE - Premier Family Care, Inc","TriCare Standard","Participating","Enrollment Complete",44931,"","","2024-01-25","4214 Andrews Hwy Ste. 107: Confirmed provider is credentialed and in network with this location. MS"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","PE - Premier Family Care, Inc","TriCare Standard","Participating","Enrollment Complete",44931,"","","2024-01-25","4214 Andrews Hwy Ste. 107: Confirmed provider is credentialed and in network with this location. MS"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","PE - Premier Family Care, Inc","TriCare Standard","Participating","Enrollment Complete",44931,"","","2023-01-18","1/18/2023 Rcvd letter from Tricare that provider is now Tricare certified effective 1//5/2023.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","PE - Premier Family Care, Inc","TriCare Standard","Participating","Enrollment Complete",44931,"","","2023-01-18","1/18/2023 Rcvd letter from Tricare that provider is now Tricare certified effective 1//5/2023.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","PE - Premier Family Care, Inc","TriCare Standard","Participating","Enrollment Complete",44931,"","","2024-01-25","4214 Andrews Hwy Ste. 107: Confirmed provider is credentialed and in network with this location. MS"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","PE - Premier Family Care, Inc","TriCare Standard","Participating","Enrollment Complete",44931,"","","2024-01-25","4214 Andrews Hwy Ste. 107: Confirmed provider is credentialed and in network with this location. MS"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","PE - Premier Family Care, Inc","TriCare Standard","Participating","Enrollment Complete",44931,"","","2023-01-18","1/18/2023 Rcvd letter from Tricare that provider is now Tricare certified effective 1//5/2023.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","PE - Premier Family Care, Inc","TriCare Standard","Participating","Enrollment Complete",44931,"","","2023-01-18","1/18/2023 Rcvd letter from Tricare that provider is now Tricare certified effective 1//5/2023.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","PE - Premier Family Care, Inc","TriCare Standard","Participating","Enrollment Complete",44931,"","","2024-01-25","4214 Andrews Hwy Ste. 107: Confirmed provider is credentialed and in network with this location. MS"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","PE - Premier Family Care, Inc","TriCare Standard","Participating","Enrollment Complete",44931,"","","2024-01-25","4214 Andrews Hwy Ste. 107: Confirmed provider is credentialed and in network with this location. MS"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","PE - Premier Family Care, Inc","TriCare Standard","Participating","Enrollment Complete",44931,"","","2023-01-18","1/18/2023 Rcvd letter from Tricare that provider is now Tricare certified effective 1//5/2023.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","PE - Premier Family Care, Inc","TriCare Standard","Participating","Enrollment Complete",44931,"","","2023-01-18","1/18/2023 Rcvd letter from Tricare that provider is now Tricare certified effective 1//5/2023.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","PE - Premier Family Care, Inc","TriCare Standard","Participating","Enrollment Complete",44931,"","","2024-01-25","4214 Andrews Hwy Ste. 107: Confirmed provider is credentialed and in network with this location. MS"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","PE - Premier Family Care, Inc","TriCare Standard","Participating","Enrollment Complete",44931,"","","2024-01-25","4214 Andrews Hwy Ste. 107: Confirmed provider is credentialed and in network with this location. MS"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","PE - Premier Family Care, Inc","TriCare Standard","Participating","Enrollment Complete",44931,"","","2023-01-18","1/18/2023 Rcvd letter from Tricare that provider is now Tricare certified effective 1//5/2023.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","PE - Premier Family Care, Inc","TriCare Standard","Participating","Enrollment Complete",44931,"","","2023-01-18","1/18/2023 Rcvd letter from Tricare that provider is now Tricare certified effective 1//5/2023.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","PE - Premier Family Care, Inc","TriCare Standard","Participating","Enrollment Complete",44931,"","","2024-01-25","4214 Andrews Hwy Ste. 107: Confirmed provider is credentialed and in network with this location. MS"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","PE - Premier Family Care, Inc","TriCare Standard","Participating","Enrollment Complete",44931,"","","2024-01-25","4214 Andrews Hwy Ste. 107: Confirmed provider is credentialed and in network with this location. MS"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","PE - Premier Family Care, Inc","TriCare Standard","Participating","Enrollment Complete",44931,"","","2023-01-18","1/18/2023 Rcvd letter from Tricare that provider is now Tricare certified effective 1//5/2023.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","PE - Premier Family Care, Inc","TriCare Standard","Participating","Enrollment Complete",44931,"","","2023-01-18","1/18/2023 Rcvd letter from Tricare that provider is now Tricare certified effective 1//5/2023.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","PE - Premier Family Care, Inc","TriCare Standard","Participating","Enrollment Complete",44931,"","","2024-01-25","4214 Andrews Hwy Ste. 107: Confirmed provider is credentialed and in network with this location. MS"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","PE - Premier Family Care, Inc","TriCare Standard","Participating","Enrollment Complete",44931,"","","2024-01-25","4214 Andrews Hwy Ste. 107: Confirmed provider is credentialed and in network with this location. MS"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","PE - Premier Family Care, Inc","TriCare Standard","Participating","Enrollment Complete",44931,"","","2023-01-18","1/18/2023 Rcvd letter from Tricare that provider is now Tricare certified effective 1//5/2023.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","PE - Premier Family Care, Inc","TriCare Standard","Participating","Enrollment Complete",44931,"","","2023-01-18","1/18/2023 Rcvd letter from Tricare that provider is now Tricare certified effective 1//5/2023.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","PE - Premier Family Care, Inc","TriCare Standard","Participating","Enrollment Complete",44931,"","","2024-01-25","4214 Andrews Hwy Ste. 107: Confirmed provider is credentialed and in network with this location. MS"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","PE - Premier Family Care, Inc","TriCare Standard","Participating","Enrollment Complete",44931,"","","2024-01-25","4214 Andrews Hwy Ste. 107: Confirmed provider is credentialed and in network with this location. MS"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","PE - Premier Family Care, Inc","TriCare Standard","Participating","Enrollment Complete",44931,"","","2023-01-18","1/18/2023 Rcvd letter from Tricare that provider is now Tricare certified effective 1//5/2023.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","PE - Premier Family Care, Inc","TriCare Standard","Participating","Enrollment Complete",44931,"","","2023-01-18","1/18/2023 Rcvd letter from Tricare that provider is now Tricare certified effective 1//5/2023.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","PE - Premier Family Care, Inc","TriCare Standard","Participating","Enrollment Complete",44931,"","","2024-01-25","4214 Andrews Hwy Ste. 107: Confirmed provider is credentialed and in network with this location. MS"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","PE - Premier Family Care, Inc","TriCare Standard","Participating","Enrollment Complete",44931,"","","2024-01-25","4214 Andrews Hwy Ste. 107: Confirmed provider is credentialed and in network with this location. MS"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","PE - Premier Family Care, Inc","TriCare Standard","Participating","Enrollment Complete",44931,"","","2023-01-18","1/18/2023 Rcvd letter from Tricare that provider is now Tricare certified effective 1//5/2023.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","PE - Premier Family Care, Inc","TriCare Standard","Participating","Enrollment Complete",44931,"","","2023-01-18","1/18/2023 Rcvd letter from Tricare that provider is now Tricare certified effective 1//5/2023.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","PE - Premier Family Care, Inc","TriCare Standard","Participating","Enrollment Complete",44931,"","","2024-01-25","4214 Andrews Hwy Ste. 107: Confirmed provider is credentialed and in network with this location. MS"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","PE - Premier Family Care, Inc","TriCare Standard","Participating","Enrollment Complete",44931,"","","2024-01-25","4214 Andrews Hwy Ste. 107: Confirmed provider is credentialed and in network with this location. MS"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","PE - Premier Family Care, Inc","TriCare Standard","Participating","Enrollment Complete",44931,"","","2023-01-18","1/18/2023 Rcvd letter from Tricare that provider is now Tricare certified effective 1//5/2023.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","PE - Premier Family Care, Inc","TriCare Standard","Participating","Enrollment Complete",44931,"","","2023-01-18","1/18/2023 Rcvd letter from Tricare that provider is now Tricare certified effective 1//5/2023.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","PE - Premier Family Care, Inc","TriCare Standard","Participating","Enrollment Complete",44931,"","","2024-01-25","4214 Andrews Hwy Ste. 107: Confirmed provider is credentialed and in network with this location. MS"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","PE - Premier Family Care, Inc","TriCare Standard","Participating","Enrollment Complete",44931,"","","2024-01-25","4214 Andrews Hwy Ste. 107: Confirmed provider is credentialed and in network with this location. MS"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","PE - Premier Family Care, Inc","TriCare Standard","Participating","Enrollment Complete",44931,"","","2023-01-18","1/18/2023 Rcvd letter from Tricare that provider is now Tricare certified effective 1//5/2023.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","PE - Premier Family Care, Inc","TriCare Standard","Participating","Enrollment Complete",44931,"","","2023-01-18","1/18/2023 Rcvd letter from Tricare that provider is now Tricare certified effective 1//5/2023.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","PE - Premier Family Care, Inc","TriCare Standard","Participating","Enrollment Complete",44931,"","","2024-01-25","4214 Andrews Hwy Ste. 107: Confirmed provider is credentialed and in network with this location. MS"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","PE - Premier Family Care, Inc","TriCare Standard","Participating","Enrollment Complete",44931,"","","2024-01-25","4214 Andrews Hwy Ste. 107: Confirmed provider is credentialed and in network with this location. MS"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","PE - Premier Family Care, Inc","TriCare Standard","Participating","Enrollment Complete",44931,"","","2023-01-18","1/18/2023 Rcvd letter from Tricare that provider is now Tricare certified effective 1//5/2023.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","PE - Premier Family Care, Inc","TriCare Standard","Participating","Enrollment Complete",44931,"","","2023-01-18","1/18/2023 Rcvd letter from Tricare that provider is now Tricare certified effective 1//5/2023.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","PE - Premier Family Care, Inc","TriCare Standard","Participating","Enrollment Complete",44931,"","","2024-01-25","4214 Andrews Hwy Ste. 107: Confirmed provider is credentialed and in network with this location. MS"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","PE - Premier Family Care, Inc","TriCare Standard","Participating","Enrollment Complete",44931,"","","2024-01-25","4214 Andrews Hwy Ste. 107: Confirmed provider is credentialed and in network with this location. MS"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","PE - Premier Family Care, Inc","TriCare Standard","Participating","Enrollment Complete",44931,"","","2023-01-18","1/18/2023 Rcvd letter from Tricare that provider is now Tricare certified effective 1//5/2023.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","PE - Premier Family Care, Inc","TriCare Standard","Participating","Enrollment Complete",44931,"","","2023-01-18","1/18/2023 Rcvd letter from Tricare that provider is now Tricare certified effective 1//5/2023.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","PE - Premier Family Care, Inc","TriCare Standard","Participating","Enrollment Complete",44931,"","","2024-01-25","4214 Andrews Hwy Ste. 107: Confirmed provider is credentialed and in network with this location. MS"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","PE - Premier Family Care, Inc","TriCare Standard","Participating","Enrollment Complete",44931,"","","2024-01-25","4214 Andrews Hwy Ste. 107: Confirmed provider is credentialed and in network with this location. MS"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","PE - Premier Family Care, Inc","TriCare Standard","Participating","Enrollment Complete",44931,"","","2023-01-18","1/18/2023 Rcvd letter from Tricare that provider is now Tricare certified effective 1//5/2023.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","PE - Premier Family Care, Inc","TriCare Standard","Participating","Enrollment Complete",44931,"","","2023-01-18","1/18/2023 Rcvd letter from Tricare that provider is now Tricare certified effective 1//5/2023.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","PE - Premier Family Care, Inc","TriCare Standard","Participating","Enrollment Complete",44931,"","","2024-01-25","4214 Andrews Hwy Ste. 107: Confirmed provider is credentialed and in network with this location. MS"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","PE - Premier Family Care, Inc","TriCare Standard","Participating","Enrollment Complete",44931,"","","2024-01-25","4214 Andrews Hwy Ste. 107: Confirmed provider is credentialed and in network with this location. MS"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","PE - Premier Family Care, Inc","Multiplan","Participating","Enrollment Complete",45449,"","","2024-07-31","7/31/2024 As Per Jessica Bess, 400 Rosalind Redfern Ste 230 eff date 6/6/2024, 4214 Andrews Hwy Ste 102 & 103 eff 6/6/2024, 4507 Santa Rosa eff 6/6/2024. FC"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","PE - Premier Family Care, Inc","Multiplan","Participating","Enrollment Complete",45449,"","","2024-07-31","7/31/2024 As Per Jessica Bess, 400 Rosalind Redfern Ste 230 eff date 6/6/2024, 4214 Andrews Hwy Ste 102 & 103 eff 6/6/2024, 4507 Santa Rosa eff 6/6/2024. FC"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","PE - Premier Family Care, Inc","Multiplan","Participating","Enrollment Complete",45449,"","","2024-07-31","7/31/2024 As Per Jessica Bess, 400 Rosalind Redfern Ste 230 eff date 6/6/2024, 4214 Andrews Hwy Ste 102 & 103 eff 6/6/2024, 4507 Santa Rosa eff 6/6/2024. FC"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","PE - Premier Family Care, Inc","Multiplan","Participating","Enrollment Complete",45449,"","","2024-07-31","7/31/2024 As Per Jessica Bess, 400 Rosalind Redfern Ste 230 eff date 6/6/2024, 4214 Andrews Hwy Ste 102 & 103 eff 6/6/2024, 4507 Santa Rosa eff 6/6/2024. FC"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","PE - Premier Family Care, Inc","Multiplan","Participating","Enrollment Complete",45449,"","","2024-07-31","7/31/2024 As Per Jessica Bess, 400 Rosalind Redfern Ste 230 eff date 6/6/2024, 4214 Andrews Hwy Ste 102 & 103 eff 6/6/2024, 4507 Santa Rosa eff 6/6/2024. FC"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","PE - Premier Family Care, Inc","Multiplan","Participating","Enrollment Complete","2024-06-06","","","2024-07-31","7/31/2024 As Per Jessica Bess, 400 Rosalind Redfern Ste 230 eff date 6/6/2024, 4214 Andrews Hwy Ste 102 & 103 eff 6/6/2024, 4507 Santa Rosa eff 6/6/2024. FC"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","PE - Premier Family Care, Inc","Multiplan","Participating","Enrollment Complete","2024-06-06","","","2024-07-31","7/31/2024 As Per Jessica Bess, 400 Rosalind Redfern Ste 230 eff date 6/6/2024, 4214 Andrews Hwy Ste 102 & 103 eff 6/6/2024, 4507 Santa Rosa eff 6/6/2024. FC"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","PE - Premier Family Care, Inc","Multiplan","Participating","Enrollment Complete","2024-06-06","","","2024-07-31","7/31/2024 As Per Jessica Bess, 400 Rosalind Redfern Ste 230 eff date 6/6/2024, 4214 Andrews Hwy Ste 102 & 103 eff 6/6/2024, 4507 Santa Rosa eff 6/6/2024. FC"]
["Ana M Rodriguez, APRN-FNP-BC","1437790284","75-2656723","TX","PE - Premier Family Care, 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-BC","1437790284","75-2656723","TX","PE - Premier Family Care, 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-BC","1437790284","75-2656723","TX","PE - Premier Family Care, 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-BC","1437790284","75-2656723","TX","PE - Premier Family Care, 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-BC","1437790284","75-2656723","TX","PE - Premier Family Care, Inc","Medicaid","Participating","Enrollment Complete","2020-10-01","403920802","","2024-06-13","Per TMHP license has been updated. Jen Videan"]
["Ana M Rodriguez, APRN-FNP-BC","1437790284","75-2656723","TX","PE - Premier Family Care, Inc","United Health Care","Participating","Enrollment Complete",44119,"","","2020-11-20","11/20/20 - Rcvd confirmation email from UHC confirming enrollment at this location.  DCannon"]
["Ana M Rodriguez, APRN-FNP-BC","1437790284","75-2656723","TX","PE - Premier Family Care, 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-BC","1437790284","75-2656723","TX","PE - Premier Family Care, 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-BC","1437790284","75-2656723","TX","PE - Premier Family Care, Inc","Humana","Participating","Enrollment Complete","2021-09-01","","","2021-11-18","11/18/2021 Rcvd full roster from Humana listing provider as PAR and linked to group TIN/location effective 9/1/2021.  DCannon"]
["Ana M Rodriguez, APRN-FNP-BC","1437790284","75-2656723","TX","PE - Premier Family Care, Inc","Wellmed","Participating","Enrollment Complete","2022-01-01","","","2023-03-23","3/23/2023 Rcvd roster from UHC w/ all Wellmed participating providers.  Provider is PAR effective 1/1/2022.  DCannon"]
["Ana M Rodriguez, APRN-FNP-BC","1437790284","75-2656723","TX","PE - Premier Family Care, Inc","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-BC","1437790284","75-2656723","TX","PE - Premier Family Care, Inc","Ambetter","Participating","Enrollment Complete","2022-06-01","","","2022-06-13","6/13/2022 Per roster received from Superior provider is PAR and linked to group delegation roster effective 6/1/2022."]
["Ana M Rodriguez, APRN-FNP-BC","1437790284","75-2656723","TX","PE - Premier Family Care, 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-BC","1437790284","75-2656723","TX","PE - Premier Family Care, 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-BC","1437790284","75-2656723","TX","PE - Premier Family Care, 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-BC","1437790284","75-2656723","TX","PE - Premier Family Care, 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-BC","1437790284","75-2656723","TX","PE - Premier Family Care, 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-BC","1437790284","75-2656723","TX","PE - Premier Family Care, Inc","CAQH","Participating","CAQH Reattested","2024-08-27","14485629","","2024-08-27","08/27/2024 CAQH Reattested updated and uploaded COI wthompson"]
["Ana M Rodriguez, APRN-FNP-BC","1437790284","75-2656723","TX","PE - Premier Family Care, 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-BC","1437790284","75-2656723","TX","PE - Premier Family Care, 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-BC","1437790284","75-2656723","TX","PE - Premier Family Care, 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-BC","1437790284","75-2656723","TX","PE - Premier Family Care, 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",44440,"","","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","2024-07-05","","","2024-07-05","07/05/2024 CAQH Reattested all locations current and all expirables up to date wthompson"]
["Olufemi Aduroja, MD","1366762874","47-5554737","TX","","CAQH","Participating","CAQH Reattested","2024-07-05","","","2024-07-05","07/05/2024 CAQH Reattested all locations current and all expirables up to date wthompson"]
["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","Wellmed","Participating","Enrollment Complete","2022-01-01","","","2023-03-23","3/23/2023 Rcvd roster from UHC w/ all Wellmed participating providers.  Provider is PAR effective 1/1/2022.  DCannon"]
["Olufemi Aduroja, MD","1366762874","47-5554737","TX","","Wellmed","Participating","Enrollment Complete","2022-01-01","","","2023-03-23","3/23/2023 Rcvd roster from UHC w/ all Wellmed participating providers.  Provider is PAR effective 1/1/2022.  DCannon"]
["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",43891,"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",43861,"1366762874","","2020-06-25",""]
["Olufemi Aduroja, MD","1366762874","47-5554737","TX","","Omni PPO","Participating","Enrollment Complete",43861,"1366762874","","2020-06-25",""]
["Olufemi Aduroja, MD","1366762874","47-5554737","TX","PE - Midland Inpatient Medical Association","Medicaid","Participating","Enrollment Complete",45732,"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, Inc","Scott&White (First Care)","Participating","Enrollment Complete","2020-05-08","","","2024-01-29","1/29/2024 Rcvd confirmation from S&W that provider is PAR and linked to group TIN/location effective 5/8/2020.  DCannon"]
["James D Richardson, MD","1306827266","75-2656723","TX","PE - Premier Family Care, Inc","Omni PPO","Participating","Enrollment Complete","2023-11-06","","","2024-01-02","1/2/2024 Rcvd email from German Avilies at IMS/OMNI that December delegation roster is complete.  Provider is PAR and linked to group TIN/location effective 11/6/2023.  DCannon"]
["James D Richardson, MD","1306827266","75-2656723","TX","PE - Premier Family Care, Inc","Ambetter","Participating","Enrollment Complete","2024-01-01","","","2024-01-12","1/12/2024 Per email rcvd from Superior, December roster is complete provider is PAR and linked to group TIN/locations effective 1/1/2024.  DCannon"]
["James D Richardson, MD","1306827266","75-2656723","TX","PE - Premier Family Care, Inc","Boon Chapman","Participating","Enrollment Complete","2023-11-06","","","2024-05-24","Par through Multiplan enrollment, eff. 11/06/2023. PA"]
["James D Richardson, MD","1306827266","75-2656723","TX","PE - Premier Family Care, Inc","CAQH","Participating","CAQH Reattested","2024-08-27","","","2024-08-27","08/27/2024 CAQH Reattested updated and uploaded COI wthompson"]
["James D Richardson, MD","1306827266","75-2656723","TX","PE - Premier Family Care, Inc","USA PPO","In Process","Payor Follow Up","","","","2024-07-30","Sent email to payor requesting enrollment status update. PA."]
["James D Richardson, MD","1306827266","75-2656723","TX","PE - Premier Family Care, Inc","Caprock (CapStar)","Participating","Enrollment Complete","2023-11-06","","","2023-12-28","12/28/2023 Per email received from Caprock December delegated roster is complete.  Provider is PAR and linked to group TIN/locations effective 11/6/2023.  DCannon"]
["James D Richardson, MD","1306827266","75-2656723","TX","PE - Premier Family Care, Inc","Humana","Participating","Enrollment Complete","2020-01-28","","","2024-06-21","Received email confirmation from Marcus Wester, provider is par and linked to TIN/location, eff. 01/28/2020. PA"]
["James D Richardson, MD","1306827266","75-2656723","TX","PE - Premier Family Care, Inc","Medicare","Participating","Enrollment Complete","2020-01-24","937962","","2023-12-12","After receiving surrogacy, the provider already linked under this TIN effective 1/24/2020. MS"]
["James D Richardson, MD","1306827266","75-2656723","TX","PE - Premier Family Care, Inc","Cigna","Participating","Enrollment Complete","2023-11-06","6886462","","2023-12-19","S/W JasonG of Cigna @ 1-800-882-4462. Per rep, Provider is in network with Cigna for the state of TX and linked to the group and TIN# effective 11/06/2023. Next recredentialing date is on 11/01/2026. PIN: 6886462. Servicing location is on file. Payer# 62308. Call ref# JasonG12192023. - Willie Ravas"]
["James D Richardson, MD","1306827266","75-2656723","TX","PE - Premier Family Care, Inc","TriCare Standard","Participating","Enrollment Complete","2024-01-02","","","2024-01-09","Received confirmation via self service portal. MS"]
["James D Richardson, MD","1306827266","75-2656723","TX","PE - Premier Family Care, Inc","First Health Coventry","Participating","Enrollment Complete","","","","2024-05-22","Confirmed the provider is active and location linked. MS"]
["James D Richardson, MD","1306827266","75-2656723","TX","PE - Premier Family Care, Inc","Medicaid","Participating","Enrollment Complete","2023-02-17","","","2023-11-29","Per TMHP location has been approved. Effective 02/26/2023. Jen Videan"]
["James D Richardson, MD","1306827266","75-2656723","TX","PE - Premier Family Care, Inc","Multiplan","Participating","Enrollment Complete","2023-11-06","","","2024-05-24","Received email confirmation from Multiplan rep Jessica Bess (jessica.bess@multiplan.com), provider is PAR, eff. 11/06/2023. PA."]
["James D Richardson, MD","1306827266","75-2656723","TX","PE - Premier Family Care, Inc","Aetna","Participating","Enrollment Complete","2023-11-06","5693040","","2024-01-03",""]
["James D Richardson, MD","1306827266","75-2656723","TX","PE - Premier Family Care, Inc","Wellmed","Participating","Enrollment Complete","2023-11-06","","","2024-01-11","1/11/2024 Per UHC web portal provider is PAR and linked to group TIN/location effective 11/1/2023.    DCannon"]
["James D Richardson, MD","1306827266","75-2656723","TX","PE - Premier Family Care, Inc","United Health Care","Participating","Enrollment Complete","2023-11-06","001320566","","2024-01-11","1/11/2024 Per UHC web portal provider is PAR and linked to group TIN/location effective 11/1/2023.  MPIN# 001320566003.  DCannon"]
["James D Richardson, MD","1306827266","75-2656723","TX","PE - Premier Family Care, Inc","Galaxy Health","Participating","Enrollment Complete","2023-11-06","","","2024-01-11","1/11/2024 Per email rcvd from Karen Avalos at Galaxy December roster is complete.  Provider is PAR and linked to group TIN/locations effective 11/6/2023.  DCannon"]
["James D Richardson, MD","1306827266","75-2656723","TX","PE - Premier Family Care, Inc","Superior","Participating","Enrollment Complete","2024-01-01","","","2024-01-12","1/12/2024 Per email rcvd from Superior, December roster is complete provider is PAR and linked to group TIN/locations effective 1/1/2024.  DCannon"]
["James D Richardson, MD","1306827266","75-2656723","TX","PE - Premier Family Care, Inc","HealthSmart PPO","Participating","Enrollment Complete","","","","2024-02-29","Per roster received from Aleece Moerbe (Aleece.Moerbe@healthsmart.com) on 02/23/2024, provider is PAR, eff. 11/6/2023. and linked to location  400 Rosalind Redfern Grover PKWY, suite 230. PA."]
["James D Richardson, MD","1306827266","75-2656723","TX","PE - Premier Family Care, Inc","Wellcare","Participating","Enrollment Complete","2024-01-01","","","2024-01-12","1/12/2024 Per email rcvd from Superior, December roster is complete provider is PAR and linked to group TIN/locations effective 1/1/2024.  DCannon"]
["James D Richardson, MD","1306827266","75-2656723","TX","PE - Premier Family Care, Inc","IMS","Participating","Enrollment Complete","2023-11-06","","","2024-01-02","1/2/2024 Rcvd email from German Avilies at IMS/OMNI that December delegation roster is complete.  Provider is PAR and linked to group TIN/location effective 11/6/2023.  DCannon"]
["James D Richardson, MD","1306827266","75-2656723","TX","PE - Premier Family Care, Inc","Amerigroup","Participating","Enrollment Complete","","","","2024-03-21","3/21/2024 Provider effective as of 5/4/2020 via Wellpoint roster. FC"]
["Stephanie D Crawford, FNP","1265081616","27-4061759","TX","PE - Permian Cardiology Inc.","Amerigroup","Participating","Enrollment Complete","2022-12-19","","","2023-02-16","2.16.2023 Per follow-up note - S/W Qjuana of Amerigroup @ 800-454-3730. Provider is on file and participating. Link under the group and TIN effective 12/19/2022. Location is on file. Provider ID is 15465202.   DCannon"]
["Stephanie D Crawford, FNP","1265081616","27-4061759","TX","PE - Permian Cardiology Inc.","Triwest VA","In House Enrollment","In House Enrollment","","","","2022-11-21",""]
["Stephanie D Crawford, FNP","1265081616","27-4061759","TX","PE - Permian Cardiology Inc.","Medicaid","Participating","Enrollment Complete","2022-08-07","","","2023-08-21","Stephanie Crawford  Medicaid par effective 08/07/22. Jen Videan"]
["Stephanie D Crawford, FNP","1265081616","27-4061759","TX","PE - Permian Cardiology Inc.","First Health Coventry","Participating","Enrollment Complete","2022-12-19","3641811","","2023-07-24","Confirmed enrollment via online directory. MS"]
["Stephanie D Crawford, FNP","1265081616","27-4061759","TX","PE - Permian Cardiology Inc.","USA PPO","Participating","Enrollment Complete","2022-12-19","","","2023-03-24","3/24/2023 In following up with USAMCO (800-872-3860) I was told that you can confirm participating via the USA MCO website  https://providersearch.usamco.com/hwprovsearch.  Provider is PAR and linked to location/TIN effective 12/19/2022.  DCannon"]
["Stephanie D Crawford, FNP","1265081616","27-4061759","TX","PE - Permian Cardiology Inc.","Tricare Prime","Panel Closed","Panel Closed","","","","2022-11-28","11/28/2022 Tricare Prime panel is closed and currently not accepting requests to join the network.  DCannon"]
["Stephanie D Crawford, FNP","1265081616","27-4061759","TX","PE - Permian Cardiology Inc.","Boon Chapman","Participating","Enrollment Complete","2022-12-19","","","2023-07-26","7/26/2023 Rcvd email from Jessica Bess at Multiplan with a full roster and provider is PAR w/ group and location effective 12/19/2022.  DCannon"]
["Stephanie D Crawford, FNP","1265081616","27-4061759","TX","PE - Permian Cardiology Inc.","Ambetter","Participating","Enrollment Complete","2023-02-01","","","2023-03-23","3/23/2023 Rcvd email Superior w/ confirmation from that provider is PAR and linked to group effective 2/1/2023.  DCannon"]
["Stephanie D Crawford, FNP","1265081616","27-4061759","TX","PE - Permian Cardiology Inc.","TriCare Standard","Participating","Enrollment Complete","2022-11-28","","","2022-12-28","12/28/2022  Per Humana Military/Tricare portal, provider is provider is PAR and linked to group effective 11/28/2022. DCannon"]
["Stephanie D Crawford, FNP","1265081616","27-4061759","TX","PE - Permian Cardiology Inc.","Medicare","Participating","Enrollment Complete","2019-12-01","902816","TXB115966","2022-11-28","11/28/2022 Per PECOS provider is PAR and linked to group effective 12/1/2019.  PTAN # 902816.  DCannon"]
["Stephanie D Crawford, FNP","1265081616","27-4061759","TX","PE - Permian Cardiology Inc.","Cigna","Participating","Enrollment Complete","2023-01-01","0970113","","2023-12-19","Received confirmation effective 1/1/2023. MS"]
["Stephanie D Crawford, FNP","1265081616","27-4061759","TX","PE - Permian Cardiology Inc.","United Health Care","Participating","Enrollment Complete","2022-12-19","","","2023-02-08","2/8/2023 Rcvd email from UHC that January delegated roster provider load has been completed and provider is PAR and linked to group TIN effective 12/19/2022.  MPIN# 007288273.  DCannon"]
["Stephanie D Crawford, FNP","1265081616","27-4061759","TX","PE - Permian Cardiology Inc.","Scott&White (First Care)","Participating","Enrollment Complete","2023-02-14","","","2023-08-24","8/24/2023 Per email rcvd from Scott & White provider is PAR and linked to group TIN/location effective 2/14/2023.  DCannon"]
["Stephanie D Crawford, FNP","1265081616","27-4061759","TX","PE - Permian Cardiology Inc.","Wellmed","Participating","Enrollment Complete","2022-12-19","","","2023-03-23","3/23/2023 Rcvd roster from UHC w/ all Wellmed participating providers.  Provider is PAR effective 12/19/2022.  DCannon"]
["Stephanie D Crawford, FNP","1265081616","27-4061759","TX","PE - Permian Cardiology Inc.","Wellcare","Participating","Enrollment Complete","2023-02-01","","","2023-03-23","3/23/2023 Rcvd email Superior w/ confirmation from that provider is PAR and linked to group effective 2/1/2023.  DCannon"]
["Stephanie D Crawford, FNP","1265081616","27-4061759","TX","PE - Permian Cardiology Inc.","Humana","Participating","Enrollment Complete","2022-12-19","","","2023-08-31","8/31/2023 Per email from Marcus Wester at Humana January delegated roster has been completed and provider is PAR effective 12/19/2022.  DCannon"]
["Stephanie D Crawford, FNP","1265081616","27-4061759","TX","PE - Permian Cardiology Inc.","Aetna","Participating","Enrollment Complete","2023-01-09","6492054","","2023-04-03","04.03.2023 S/W Julie of Aetna @ 800-353-1232. Per rep, provider is showing participating with an Effective date 01/09/2023 and link under Group and TIN. Provider ID 6492054, Payer ID 60054 and Recredentialing date 12/16/2025. Service location is on file. Call ref#:6140925184. -Danico Gabriel Melendres"]
["Stephanie D Crawford, FNP","1265081616","27-4061759","TX","PE - Permian Cardiology Inc.","Rail Road Medicare","Participating","Enrollment Complete","2019-12-01","Q00373156","DS1746","2022-11-28","11/28/2022 Rcvd RR Medicare approval letter.  PTAN # Q00373156 - effective 12/1/2019.  DCannon"]
["Stephanie D Crawford, FNP","1265081616","27-4061759","TX","PE - Permian Cardiology Inc.","Superior","Participating","Enrollment Complete","2023-02-01","","","2023-02-09","2/9/2023 Rcvd confirmation email from Superior that January delegation roster has been processed and provider has been loaded to delegation roster and PAR w/ group effective 2/1/2023.  DCannon"]
["Stephanie D Crawford, FNP","1265081616","27-4061759","TX","PE - Permian Cardiology Inc.","Caprock (CapStar)","Participating","Enrollment Complete","2022-12-19","","","2023-01-20","1/20/2023 Rcvd email  confirmation from Caprock that provider is PAR and linked to group TIN/locations effective 12/19/2022.  DCannon"]
["Stephanie D Crawford, FNP","1265081616","27-4061759","TX","PE - Permian Cardiology Inc.","Multiplan","Participating","Enrollment Complete","2022-12-19","","","2023-06-21","Rcvd effective date of 12/19/2022 from jessica.bess@MultiPlan.com.\nJen Videan"]
["Stephanie D Crawford, FNP","1265081616","27-4061759","TX","PE - Permian Cardiology Inc.","HealthSmart PPO","Participating","Enrollment Complete","2022-12-19","","","2023-02-28","2/28/2023 Per Healthsmart website provider is PAR and loaded under TIN/location effective 12/19/2022.  DCannon"]
["Stephanie D Crawford, FNP","1265081616","27-4061759","TX","PE - Permian Cardiology Inc.","Omni PPO","Participating","Enrollment Complete","2022-12-19","","","2023-01-31","1/31/2023 Per email received from German Aviles at IMS/OMNI monthly delegation roster provider load for December has been completed.  Provider is PAR and linked to group TIN effective 11/28/2022.   DCannon"]
["Stephanie D Crawford, FNP","1265081616","27-4061759","TX","PE - Permian Cardiology Inc.","Galaxy Health","Participating","Enrollment Complete","2022-12-19","","","2023-03-09","3/9/2023 Per email rcvd from Karen Avalos at Galaxy, January monthly roster has been completed.  Provider is PAR and linked to group effective 12/19/2022.  DCannon"]
["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","Medicaid","Participating","Enrollment Complete","","","","2024-06-25","Medicaid revalidation approval rcvd. Jen Videan"]
["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","Molina","Pending Other Enrollment","Pending Contracting","","","","2024-08-07","Contract request form for the group and provider was submitted to mhtcontractrequest@molinahealthcare.com MS"]
["Rachelle M Campos, APRN-FNP-BC","1447882915","46-3131679","TX","PE - Midland Texas Orthopedic Group Inc","Cigna Healthspring","Pending Other Enrollment","Pending Other Enrollment","","","","2024-07-23","Group letter of interest was submitted. They payer has received it and after reviewing if they want to contract, they will be reaching out to me for additional info and the roster. Nothing is needed until then. MS"]
["Rachelle M Campos, APRN-FNP-BC","1447882915","46-3131679","TX","PE - Midland Texas Orthopedic Group Inc","Sedgwick","Participating","Enrollment Complete","2024-06-19","1447882915","","2024-06-28","Approval ltr rcvd. Provider eff 06/19/2024. Jen Videan"]
["Rachelle M Campos, APRN-FNP-BC","1447882915","46-3131679","TX","PE - Midland Texas Orthopedic Group Inc","Aetna","Participating","Enrollment Complete","2020-10-01","","","2024-08-27","Provider participating as of 10/1/2020 received via email from Brandy Smith. FC"]
["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","Coventry Workers Comp","In Process","Add Info Submitted","","","","2024-08-19","8/19/2024 Submitted via roster to Coventry. FC"]
["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","Alliance WC","In Process","Payor Follow Up","","","","2024-08-13","Per michelle.killough@pswca.org, provider has been approved to join network. Submit Provider Data Form with license, DEA, Cert, COI and W9. \nEmailed above to michelle.killough@pswca.org. Jen Videan"]
["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","Tricare Prime","Participating","Enrollment Complete","2020-07-24","","","2024-01-26","Confirmed provider is credentialed and in network with Tricare. MS"]
["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","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","Corvel Healthcare Corp.","In Process","Payor Follow Up","","","","2024-08-13","Allow up to 180 days for processing. Roster just submitted 07/29/2024. Allow more time. Jen Videan"]
["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",43957,"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",44652,"","","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",43957,"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",43957,"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",43872,"P02476693","DU5783","2020-07-20","07/20/2020 - downloaded and attached welcome letter - Stacey Hudak"]
["Rachelle M Campos, APRN-FNP-BC","1447882915","46-3131679","TX","PE - Midland Texas Orthopedic Group Inc","Triwest VA","In House Enrollment","In House Enrollment","","","","2021-01-13","01/13/2021 - MQA Team is working with Representatives at BCBS-TX to ensure all providers are enrolled and loaded to participate with the VACCN network in a timely manner. However, we are currently awaiting a full roster of providers currently participating and will update all records accordingly upon receipt. Kfrazier"]
["Rachelle M Campos, APRN-FNP-BC","1447882915","46-3131679","TX","PE - Midland Texas Orthopedic Group Inc","Zurich","Participating","Enrollment Complete",44470,"","","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",44239,"10337649","","2023-09-20","9/20/2023 Per email received from Amerigroup provider is PAR and linked to group TIN effective 2/12/2021.  DCannon"]
["Rachelle M Campos, APRN-FNP-BC","1447882915","46-3131679","TX","PE - Midland Texas Orthopedic Group Inc","Texas Mutual","Participating","Enrollment Complete",43983,"","","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","Texas Municipal League","Thru Other Payor","Thru Other Payor","","","","2024-08-13","Please see status updates under Alliance WC payor line. Jen Videan"]
["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","Broadspire Services Inc.","Participating","Enrollment Complete",45302,"","","2024-07-08","Contract complete. Effective 01/11/2024. Provider was listed on par provider roster submitted with contract. Jen Videan"]
["Rachelle M Campos, APRN-FNP-BC","1447882915","46-3131679","TX","PE - Midland Texas Orthopedic Group Inc","Scott&White (First Care)","Participating","Enrollment Complete",44102,"","","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",44044,"1447882915","","2020-08-06","8/6/2020 - Rec'd an email from the payer stating this provider was added to their database EFF: 8-1-2020 after receiving/processing the July roster - Stacey Hudak"]
["Rachelle M Campos, APRN-FNP-BC","1447882915","46-3131679","TX","PE - Midland Texas Orthopedic Group Inc","Wellmed","Participating","Enrollment Complete",44562,"","","2023-03-23","3/23/2023 Rcvd roster from UHC w/ all Wellmed participating providers.  Provider is PAR effective 1/1/2022.  DCannon"]
["Rachelle M Campos, APRN-FNP-BC","1447882915","46-3131679","TX","PE - Midland Texas Orthopedic Group Inc","Humana","Participating","Enrollment Complete",43957,"","","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",44055,"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",43709,"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",45478,"","","2024-07-05","07/05/2024 CAQH Reattested all locations current and all expirables up to date wthompson"]
["Cindy Marriner, FNP","1922008234","75-2656723","TX","PE - Premier Family Care, Inc","Rail Road Medicare","Participating","Enrollment Complete",41944,"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","TX","PE - Premier Family Care, Inc","Scott&White (First Care)","Participating","Enrollment Complete",43231,"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","TX","PE - Premier Family Care, Inc","CAQH","Participating","CAQH Reattested",45478,"12080988","","2024-07-05","07/05/2024 CAQH Reattested updated and uploaded COI wthompson"]
["Cindy Marriner, FNP","1922008234","75-2656723","TX","PE - Premier Family Care, Inc","Scott&White (First Care)","Participating","Enrollment Complete",43266,"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","TX","PE - Premier Family Care, Inc","United Health Care","Participating","Enrollment Complete",44041,"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","TX","PE - Premier Family Care, Inc","Cigna","Participating","Enrollment Complete",41883,"","","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","TX","PE - Premier Family Care, Inc","IMS","Participating","Enrollment Complete",43709,"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","TX","PE - Premier Family Care, Inc","USA PPO","Participating","Enrollment Complete",41675,"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","TX","PE - Premier Family Care, Inc","First Health Coventry","Participating","Enrollment Complete",44075,"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","TX","PE - Premier Family Care, Inc","Medicare","Participating","Enrollment Complete",41944,"372052YPVD","0008AH","2020-01-29","01/29/2020 - confirmed EFF through PECOS group enrollment - Stacey Hudak"]
["Cindy Marriner, FNP","1922008234","75-2656723","TX","PE - Premier Family Care, Inc","Omni PPO","Participating","Enrollment Complete",43709,"1922008234","","2020-07-27","IMS complete"]
["Cindy Marriner, FNP","1922008234","75-2656723","TX","PE - Premier Family Care, Inc","Medicaid","Participating","Enrollment Complete",44832,"154421503","079837301","2023-10-19","Welcome letter rcvd, revalidation complete. Jen Videan"]
["Cindy Marriner, FNP","1922008234","75-2656723","TX","PE - Premier Family Care, 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","TX","PE - Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete",44126,"","","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","TX","PE - Premier Family Care, Inc","Caprock (CapStar)","Participating","Enrollment Complete",41974,"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","TX","PE - Premier Family Care, 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","TX","PE - Premier Family Care, 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","TX","PE - Premier Family Care, Inc","Humana","Participating","Enrollment Complete","2020-01-01","1922008234","","2020-07-16","7/16/2020 - Received email spreadsheet from the payor confirming that this provider is EFF at this service location and PAR with the PRIMED DELEGATED agreement - Pam Porter"]
["Cindy Marriner, FNP","1922008234","75-2656723","TX","PE - Premier Family Care, Inc","Wellcare","Participating","Enrollment Complete","2021-11-01","","","2022-12-01","12/1/2022 Per roster received from Wellcare provider is PAR and linked to group TIN/location effective 11/1/2021.  DCannon"]
["Cindy Marriner, FNP","1922008234","75-2656723","TX","PE - Premier Family Care, Inc","Wellcare","Participating","Enrollment Complete","2021-11-01","","","2022-12-01","12/1/2022 Per roster received from Wellcare provider is PAR and linked to group TIN/location effective 11/1/2021.  DCannon"]
["Cindy Marriner, FNP","1922008234","75-2656723","TX","PE - Premier Family Care, Inc","Wellcare","Participating","Enrollment Complete","2021-11-01","","","2022-12-01","12/1/2022 Per roster received from Wellcare provider is PAR and linked to group TIN/location effective 11/1/2021.  DCannon"]
["Cindy Marriner, FNP","1922008234","75-2656723","TX","PE - Premier Family Care, Inc","Wellcare","Participating","Enrollment Complete","2021-11-01","","","2022-12-01","12/1/2022 Per roster received from Wellcare provider is PAR and linked to group TIN/location effective 11/1/2021.  DCannon"]
["Cindy Marriner, FNP","1922008234","75-2656723","TX","PE - Premier Family Care, 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","TX","PE - Premier Family Care, 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","TX","PE - Premier Family Care, Inc","Triwest VA","Facility Enrollment","Facility Enrollment","","","","2022-10-17","10/17/2022 - Received roster from Scarlett of TriWest VA; provider status: \"No Action.  TIN is CCN participating under own DCN.\""]
["Cindy Marriner, FNP","1922008234","75-2656723","TX","PE - Premier Family Care, Inc","Cigna","Participating","Enrollment Complete","2019-09-01","8335090","","2020-06-17","06/17/2020 - rec'd email from the payer stating \"request completed\" - Stacey Hudak"]
["Cindy Marriner, FNP","1922008234","75-2656723","TX","PE - Premier Family Care, 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","TX","PE - Premier Family Care, Inc","Ambetter","Participating","Enrollment Complete","2022-06-01","","","2022-06-13","6/13/2022 Per roster received from Superior provider is PAR and linked to group delegation roster effective 6/1/2022."]
["Cindy Marriner, FNP","1922008234","75-2656723","TX","PE - Premier Family Care, Inc","Ambetter","Participating","Enrollment Complete","2022-06-01","","","2022-06-13","6/13/2022 Per roster received from Superior provider is PAR and linked to group delegation roster effective 6/1/2022."]
["Cindy Marriner, FNP","1922008234","75-2656723","TX","PE - Premier Family Care, Inc","Ambetter","Participating","Enrollment Complete","2022-06-01","","","2022-06-13","6/13/2022 Per roster received from Superior provider is PAR and linked to group delegation roster effective 6/1/2022."]
["Cindy Marriner, FNP","1922008234","75-2656723","TX","PE - Premier Family Care, Inc","Ambetter","Participating","Enrollment Complete","2022-06-01","","","2022-06-13","6/13/2022 Per roster received from Superior provider is PAR and linked to group delegation roster effective 6/1/2022."]
["Cindy Marriner, FNP","1922008234","75-2656723","TX","PE - Premier Family Care, 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","TX","PE - Premier Family Care, 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","TX","PE - Premier Family Care, 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","TX","PE - Premier Family Care, 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","TX","PE - Premier Family Care, Inc","Wellmed","Participating","Enrollment Complete","2022-01-01","","","2023-03-23","3/23/2023 Rcvd roster from UHC w/ all Wellmed participating providers.  Provider is PAR effective 1/1/2022.  DCannon"]
["Cindy Marriner, FNP","1922008234","75-2656723","TX","PE - Premier Family Care, Inc","Wellmed","Participating","Enrollment Complete","2022-01-01","","","2023-03-23","3/23/2023 Rcvd roster from UHC w/ all Wellmed participating providers.  Provider is PAR effective 1/1/2022.  DCannon"]
["Cindy Marriner, FNP","1922008234","75-2656723","TX","PE - Premier Family Care, Inc","Wellmed","Participating","Enrollment Complete","2022-01-01","","","2023-03-23","3/23/2023 Rcvd roster from UHC w/ all Wellmed participating providers.  Provider is PAR effective 1/1/2022.  DCannon"]
["Cindy Marriner, FNP","1922008234","75-2656723","TX","PE - Premier Family Care, Inc","Wellmed","Participating","Enrollment Complete","2022-01-01","","","2023-03-23","3/23/2023 Rcvd roster from UHC w/ all Wellmed participating providers.  Provider is PAR effective 1/1/2022.  DCannon"]
["Cindy Marriner, FNP","1922008234","75-2656723","TX","PE - Premier Family Care, Inc","Boon Chapman","Participating","Enrollment Complete","2014-12-04","1922008234","","2020-10-05","Enrollment thru PHCS"]
["Cindy Marriner, FNP","1922008234","75-2656723","TX","PE - Premier Family Care, 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","TX","PE - Premier Family Care, 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","TX","PE - Premier Family Care, Inc","Omni PPO","Participating","Enrollment Complete","2019-09-01","1922008234","","2020-07-27","IMS complete"]
["Cindy Marriner, FNP","1922008234","75-2656723","TX","PE - Premier Family Care, 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","TX","PE - Premier Family Care, Inc","Humana","Participating","Enrollment Complete","2020-01-01","1922008234","","2020-07-16","7/16/2020 - Received email spreadsheet from the payor confirming that this provider is EFF at this service location and PAR with the PRIMED DELEGATED agreement - Pam Porter"]
["Cindy Marriner, FNP","1922008234","75-2656723","TX","PE - Premier Family Care, 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","TX","PE - Premier Family Care, 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","TX","PE - Premier Family Care, 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","TX","PE - Premier Family Care, 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","TX","PE - Premier Family Care, 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","TX","PE - Premier Family Care, 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","TX","PE - Premier Family Care, Inc","Multiplan","Participating","Enrollment Complete",41974,"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","TX","PE - Premier Family Care, Inc","Superior","Participating","Enrollment Complete",44044,"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","TX","PE - Premier Family Care, Inc","Galaxy Health","Participating","Enrollment Complete","2014-12-01","1922008234","","2020-07-10","07/10/2020 - updated payer line to enrollment complete status instead of \"Delegated status\" for report running purposes - Stacey Hudak"]
["Cindy Marriner, FNP","1922008234","75-2656723","TX","PE - Premier Family Care, 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","TX","PE - Premier Family Care, Inc","Triwest VA","Facility Enrollment","Facility Enrollment","","","","2022-10-17","10/17/2022 - Received roster from Scarlett; provider status: \"No Action.  TIN is CCN participating under own DCN.\""]
["Cindy Marriner, FNP","1922008234","75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","2018-11-26","","","2024-01-25","During the Tricare audit, it was found this provider is credentialed and is in network with Tricare at this location. MS"]
["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",43800,"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",44501,"","","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",44501,"","","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",44501,"","","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",44501,"","","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",44501,"","","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",44501,"","","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",44501,"","","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",44501,"","","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","Wellmed","Participating","Enrollment Complete","2022-01-01","","","2023-03-23","3/23/2023 Rcvd roster from UHC w/ all Wellmed participating providers.  Provider is PAR effective 1/1/2022.  DCannon"]
["Swetha Reddy Jangangari, MD","1750796009","83-0358685","TX","PE - Midland Community Healthcare Services","Wellmed","Participating","Enrollment Complete","2022-01-01","","","2023-03-23","3/23/2023 Rcvd roster from UHC w/ all Wellmed participating providers.  Provider is PAR effective 1/1/2022.  DCannon"]
["Swetha Reddy Jangangari, MD","1750796009","83-0358685","TX","PE - Midland Community Healthcare Services","Wellmed","Participating","Enrollment Complete","2022-01-01","","","2023-03-23","3/23/2023 Rcvd roster from UHC w/ all Wellmed participating providers.  Provider is PAR effective 1/1/2022.  DCannon"]
["Swetha Reddy Jangangari, MD","1750796009","83-0358685","TX","PE - Midland Community Healthcare Services","Wellmed","Participating","Enrollment Complete","2022-01-01","","","2023-03-23","3/23/2023 Rcvd roster from UHC w/ all Wellmed participating providers.  Provider is PAR effective 1/1/2022.  DCannon"]
["Swetha Reddy Jangangari, MD","1750796009","83-0358685","TX","PE - Midland Community Healthcare Services","Wellmed","Participating","Enrollment Complete","2022-01-01","","","2023-03-23","3/23/2023 Rcvd roster from UHC w/ all Wellmed participating providers.  Provider is PAR effective 1/1/2022.  DCannon"]
["Swetha Reddy Jangangari, MD","1750796009","83-0358685","TX","PE - Midland Community Healthcare Services","Wellmed","Participating","Enrollment Complete","2022-01-01","","","2023-03-23","3/23/2023 Rcvd roster from UHC w/ all Wellmed participating providers.  Provider is PAR effective 1/1/2022.  DCannon"]
["Swetha Reddy Jangangari, MD","1750796009","83-0358685","TX","PE - Midland Community Healthcare Services","Wellmed","Participating","Enrollment Complete","2022-01-01","","","2023-03-23","3/23/2023 Rcvd roster from UHC w/ all Wellmed participating providers.  Provider is PAR effective 1/1/2022.  DCannon"]
["Swetha Reddy Jangangari, MD","1750796009","83-0358685","TX","PE - Midland Community Healthcare Services","Wellmed","Participating","Enrollment Complete","2022-01-01","","","2023-03-23","3/23/2023 Rcvd roster from UHC w/ all Wellmed participating providers.  Provider is PAR effective 1/1/2022.  DCannon"]
["Swetha Reddy Jangangari, MD","1750796009","83-0358685","TX","PE - Midland Community Healthcare Services","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",44348,"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",43159,"","","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","Superior","Participating","Enrollment Complete","2021-08-01","","","2021-08-05","8/5/2021 Rcvd email from Superior that monthly delegation roster for May is complete and providers are loaded under TIN/locations effective 8/1/2021.  DCannon"]
["Trinidad Marquez, FNP","1447701602","83-0358685","TX","PE - Midland Community Healthcare Services","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","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","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","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","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","Cigna","Participating","Enrollment Complete",44348,"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","HealthSmart PPO","Participating","Enrollment Complete",42766,"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","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","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","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","Wellmed","Participating","Enrollment Complete","2022-01-01","","","2023-03-23","3/23/2023 Rcvd roster from UHC w/ all Wellmed participating providers.  Provider is PAR effective 1/1/2022.  DCannon"]
["Trinidad Marquez, FNP","1447701602","83-0358685","TX","PE - Midland Community Healthcare Services","Wellmed","Participating","Enrollment Complete","2022-01-01","","","2023-03-23","3/23/2023 Rcvd roster from UHC w/ all Wellmed participating providers.  Provider is PAR effective 1/1/2022.  DCannon"]
["Trinidad Marquez, FNP","1447701602","83-0358685","TX","PE - Midland Community Healthcare Services","Wellmed","Participating","Enrollment Complete","2022-01-01","","","2023-03-23","3/23/2023 Rcvd roster from UHC w/ all Wellmed participating providers.  Provider is PAR effective 1/1/2022.  DCannon"]
["Trinidad Marquez, FNP","1447701602","83-0358685","TX","PE - Midland Community Healthcare Services","Ambetter","Participating","Enrollment Complete","2022-06-01","","","2022-06-20","6/20/2022 Per roster received from Superior provider is PAR and linked to group delegation roster effective 6/1/2022."]
["Trinidad Marquez, FNP","1447701602","83-0358685","TX","PE - Midland Community Healthcare Services","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","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",""]
["Chabacana Maxwell, FNP","1154767234","83-0358685","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","HealthSmart PPO","Participating","Enrollment Complete",44348,"","","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","TX","PE - Midland Community Healthcare Services","Omni PPO","Participating","Enrollment Complete",42245,"","","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","TX","PE - Midland Community Healthcare Services","First Health Coventry","Participating","Enrollment Complete",42248,"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","TX","PE - Midland Community Healthcare Services","HealthSmart PPO","Participating","Enrollment Complete",42236,"","","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","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","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","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","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","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","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","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","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","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","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","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","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","Wellmed","Participating","Enrollment Complete","2022-01-01","","","2023-03-23","3/23/2023 Rcvd roster from UHC w/ all Wellmed participating providers.  Provider is PAR effective 1/1/2022.  DCannon"]
["Chabacana Maxwell, FNP","1154767234","83-0358685","TX","PE - Midland Community Healthcare Services","Wellmed","Participating","Enrollment Complete","2022-01-01","","","2023-03-23","3/23/2023 Rcvd roster from UHC w/ all Wellmed participating providers.  Provider is PAR effective 1/1/2022.  DCannon"]
["Tonya Murphy, FNP","1891931341","83-0358685","TX","PE - Midland Community Healthcare Services","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","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","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","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","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","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","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","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","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","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","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","Wellmed","Participating","Enrollment Complete","2022-01-01","","","2023-03-23","3/23/2023 Rcvd roster from UHC w/ all Wellmed participating providers.  Provider is PAR effective 1/1/2022.  DCannon"]
["Tonya Murphy, FNP","1891931341","83-0358685","TX","PE - Midland Community Healthcare Services","Wellmed","Participating","Enrollment Complete","2022-01-01","","","2023-03-23","3/23/2023 Rcvd roster from UHC w/ all Wellmed participating providers.  Provider is PAR effective 1/1/2022.  DCannon"]
["Tonya Murphy, FNP","1891931341","83-0358685","TX","PE - Midland Community Healthcare Services","United Health Care","Participating","Enrollment Complete",43800,"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","Humana","Participating","Enrollment Complete",43516,"","","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","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",44501,"","","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","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",43952,"","","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","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",44501,"","","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","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","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","Caprock (CapStar)","Participating","Enrollment Complete","2019-10-21","1205299922","","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 Okoye, DO","1205299922","83-0358685","TX","PE - Midland Community Healthcare Services","Galaxy Health","Participating","Enrollment Complete",44348,"","","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"]
["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","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","Molina","Participating","Enrollment Complete","2020-01-15","","","2022-10-20","10/20/2022 Rcvd email from Priscilla Albertine at MQA with roster from Marcie Eckhart-Havens at Multiplan with confirmation that provider is PAR w/ Molina under group TIN/location effective 1/15/2020.  DCannon"]
["Michael Okoye, DO","1205299922","83-0358685","TX","PE - Midland Community Healthcare Services","Medicaid","Participating","In House Enrollment","2019-09-09","405063501","165581301","2020-10-02","10/2/2020 - Rec'd an email from the clinic with the medicaid approval letter. This enrollment is maintained in house. Symplr is storing this information in Cactus for use with other enrollments/payers - Stacey Hudak"]
["Michael Okoye, DO","1205299922","83-0358685","TX","PE - Midland Community Healthcare Services","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","Wellmed","Participating","Enrollment Complete","2022-01-01","","","2023-03-23","3/23/2023 Rcvd roster from UHC w/ all Wellmed participating providers.  Provider is PAR effective 1/1/2022.  DCannon"]
["Michael Okoye, DO","1205299922","83-0358685","TX","PE - Midland Community Healthcare Services","Wellmed","Participating","Enrollment Complete","2022-01-01","","","2023-03-23","3/23/2023 Rcvd roster from UHC w/ all Wellmed participating providers.  Provider is PAR effective 1/1/2022.  DCannon"]
["Michael Okoye, DO","1205299922","83-0358685","TX","PE - Midland Community Healthcare Services","Aetna","Participating","Enrollment Complete","2020-08-01","6609675","","2020-07-20","07/20/2020 - Rec'd an email from the payer stating \"Welcome to the provider network effective 8/1/2020. Your Provider Identification Number (PIN) is: 6609675\" - Stacey HUdak"]
["Michael Okoye, DO","1205299922","83-0358685","TX","PE - Midland Community Healthcare Services","Cigna","Participating","Enrollment Complete","2021-06-01","522362","","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 522362. KFrazier"]
["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","Caprock (CapStar)","Participating","Enrollment Complete","2019-10-21","","","2020-09-14",""]
["Michael Okoye, DO","1205299922","83-0358685","TX","PE - Midland Community Healthcare Services","Scott&White (First Care)","Participating","Enrollment Complete","2019-10-29","","","2021-01-29","1/29/2021 - Rcvd roster from Scott&White (First Care) confirming participation of provider with TIN and location effective dates.  DCannon"]
["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","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","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"]
["Jose Saucedo, FNP","1184265050","83-0358685","TX","PE - Midland Community Healthcare Services","Aetna","Participating","Enrollment Complete","2021-06-01","6838699","","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 # 6838699 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","Galaxy Health","Participating","Enrollment Complete","2021-06-01","","","2021-08-05","8/5/2021 Per Karen Avalos at Galaxy Health monthly delegated submission is complete and provider is PAR and linked to group TIN/locations effective  6/1/2021.  DCannon"]
["Jose Saucedo, FNP","1184265050","83-0358685","TX","PE - Midland Community Healthcare Services","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","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","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","Galaxy Health","Participating","Enrollment Complete","2021-06-01","","","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  6/1/2021.  DCannon"]
["Jose Saucedo, FNP","1184265050","83-0358685","TX","PE - Midland Community Healthcare Services","Scott&White (First Care)","Participating","Enrollment Complete",44348,"","","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"]
["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","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"]
["Jose Saucedo, FNP","1184265050","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"]
["Jose Saucedo, FNP","1184265050","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"]
["Jose Saucedo, FNP","1184265050","83-0358685","TX","PE - Midland Community Healthcare Services","Galaxy Health","Participating","Enrollment Complete","2021-06-01","","","2021-08-05","8/5/2021 Per Karen Avalos at Galaxy Health monthly delegated submission is complete and provider is PAR and linked to group TIN/locations effective  6/1/2021.  DCannon"]
["Jose Saucedo, FNP","1184265050","83-0358685","TX","PE - Midland Community Healthcare Services","Triwest VA","DO NOT ENROLL","In House Enrollment","","","","2021-08-04","7/31/2021 This will be processed by group. KFrazier"]
["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","Aetna","Participating","Enrollment Complete",44044,"","","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"]
["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","TriCare Standard","Participating","Enrollment Complete","2021-06-03","","","2021-09-14","9/14/2021 Confirmed via self-service portal, provider is certified under group Tax ID effective 06/03/2021. Cbankston"]
["Jose Saucedo, FNP","1184265050","83-0358685","TX","PE - Midland Community Healthcare Services","HealthSmart PPO","Participating","Enrollment Complete",44348,"","","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","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"]
["Jose Saucedo, FNP","1184265050","83-0358685","TX","PE - Midland Community Healthcare Services","Wellmed","Participating","Enrollment Complete","2022-01-01","","","2023-03-23","3/23/2023 Rcvd roster from UHC w/ all Wellmed participating providers.  Provider is PAR effective 1/1/2022.  DCannon"]
["Jose Saucedo, FNP","1184265050","83-0358685","TX","PE - Midland Community Healthcare Services","Wellmed","Participating","Enrollment Complete","2022-01-01","","","2023-03-23","3/23/2023 Rcvd roster from UHC w/ all Wellmed participating providers.  Provider is PAR effective 1/1/2022.  DCannon"]
["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"]
["Justin D Shanks, APRN-FNP-BC","1205477874","84-2617748","TX","PE - Midland Medicine PA","Scott&White (First Care)","Participating","Enrollment Complete","2022-06-01","","","2022-08-11","8/11/2022 Rcvd email from Scott & White that monthly delegated roster for June has been completed and providers are loaded to group delegation roster effective 6/1/2022.  DCannon"]
["Justin D Shanks, APRN-FNP-BC","1205477874","84-2617748","ME","PE - Midland Medicine PA","Aetna","Participating","Enrollment Complete","2021-09-01","6124960","","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 # 6124960 DCannon"]
["Justin D Shanks, APRN-FNP-BC","1205477874","84-2617748","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","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","TX","PE - Midland Medicine PA","Omni PPO","Participating","Enrollment Complete","2022-06-01","","","2022-07-05","7/5/2022 Rcvd email from G.Aviles at IMS/OMNI that delegation roster provider load for June has been completed.  Provider is PAR and linked to group effective 6/1/2022.  DCannon"]
["Justin D Shanks, APRN-FNP-BC","1205477874","84-2617748","ME","PE - Midland Medicine PA","HealthSmart PPO","Participating","Enrollment Complete",44417,"","","2021-10-06","10/6/2021 Per Healthsmart website provider is PAR and loaded under TIN/location effective 8/9/2021.  DCannon"]
["Justin D Shanks, APRN-FNP-BC","1205477874","84-2617748","ME","PE - Midland Medicine PA","USA PPO","Participating","Enrollment Complete","2021-08-09","","","2021-12-03","12/32021  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 8/9/2021.  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","84-2617748","ME","PE - Midland Medicine 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"]
["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","Multiplan","Participating","Enrollment Complete","2019-09-01","","","2021-06-29","6/29/2021 Rcvd roster from Multiplan confirming provider is PAR under TIN effective 9/1/2019.  DCannon"]
["Hagos Z Aymut, MD","1922548890","47-5554737","TX","PE - Midland Inpatient Medical Association","Superior","Participating","Enrollment Complete","2020-08-01","1922548890","","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"]
["Suresh K Ravuri, MD","1750539268","47-5554737","TX","PE - Midland Inpatient Medical Association","TriCare Standard","Participating","Enrollment Complete","2020-07-29","","","2020-09-24","Confirmed via self-service portal, provider is a certified non-network provider under group Tax ID and appropriate location. Group is not contracted as 'participating' only non-network.  Kimberly Frazier"]
["Suresh K Ravuri, MD","1750539268","47-5554737","TX","PE - Midland Inpatient Medical Association","Multiplan","Participating","Enrollment Complete","2020-06-23","","","2021-06-29","6/29/2021 Rcvd roster from Multiplan confirming provider is PAR under TIN effective 6/23/2020.  DCannon"]
["Suresh K Ravuri, MD","1750539268","47-5554737","TX","PE - Midland Inpatient Medical Association","Cigna","Participating","Enrollment Complete","2019-09-01","3176267","","2020-05-19","05/19/2020 - Rec'd email from the payer stating \"This is to confirm that your request has been completed\" _ Stacey Hudak"]
["Suresh K Ravuri, MD","1750539268","47-5554737","TX","PE - Midland Inpatient Medical Association","Scott&White (First Care)","Participating","Enrollment Complete","2020-09-28","","","2021-01-14","1/14/2021 - Rcvd email from payer that provider is participating and loaded under tax ID effective 9/28/2020.  DCannon"]
["Suresh K Ravuri, MD","1750539268","47-5554737","TX","PE - Midland Inpatient Medical Association","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","IMS","Participating","Enrollment Complete","2019-09-01","1750539268","","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"]
["Suresh K Ravuri, MD","1750539268","47-5554737","TX","PE - Midland Inpatient Medical Association","Galaxy Health","Participating","Enrollment Complete","2020-09-01","1750539268","","2020-08-24","08/21/2020 - Rec'd email confirmation that this roster was processed and this provider was made effective with the requested eff date of 9-1-2019 - Stacey Hudak"]
["Jordan Elizabeth Friday, NP","1215575576","46-0950925","TX","PE - Urgent Orthopedic Specialists, PLLC","USA PPO","Participating","Enrollment Complete","2021-01-26","1312302","","2021-03-12","3/12/2021 Per verification on payor website USAMCO.com provider is loaded as participating.  Rcvd Roster LeNetrice Myart with provider numbers and effective dates for providers.  DCannon"]
["Jordan Elizabeth Friday, NP","1215575576","46-0950925","TX","PE - Urgent Orthopedic Specialists, PLLC","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","PPHP","Participating","Enrollment Complete","2022-07-08","","","2022-09-15","9/15/2022 Provider PAR and linked to group effective 7/8/2022."]
["Jordan Elizabeth Friday, NP","1215575576","46-0950925","TX","PE - Urgent Orthopedic Specialists, PLLC","HealthSmart PPO","Participating","Enrollment Complete","2020-05-06","13727511","","2020-07-21","07/21/2020 - Rec'd emailed spreadsheet from the payer stating this provider/service location/TIN are EFF under WEST TEXAS PHYSICIANS ALLIANCE Delegated agreement - Stacey Hudak"]
["Satish Nayak, MD","1518053149","57-1157825","TX","PE - Satish Nayak","HealthSmart PPO","Participating","Enrollment Complete","2021-07-06","","","2021-09-15","9/15/2021 Per Healthsmart website provider is PAR and loaded under TIN/location effective 7/6/2021.  DCannon"]
["Satish Nayak, MD","1518053149","57-1157825","TX","PE - Satish Nayak","Superior","Participating","Enrollment Complete","2017-01-01","1518053149","","2020-07-14","07/14/2020 - Rec'd email from the payer stating this provider is EFF under PRIMED DELEGATED agreement - Stacey Hudak"]
["Satish Nayak, MD","1518053149","57-1157825","TX","PE - Satish Nayak","Omni PPO","Participating","Enrollment Complete","2004-02-16","1518053149","","2020-06-26",""]
["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","Amerigroup","Participating","Payor Follow Up","2023-07-15","","","2024-05-16","5/16/2024 Submitted new address via delegated roster on 5/15/2024- new address is not in their system. FC"]
["Abiodun A Okin-Ayileka, MD","1922328079","84-4724927","ME","PE - ADA Adult and Children Family Clinic LLC","Ambetter","Participating","Enrollment Complete",44652,"","","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","Wellmed","Participating","Enrollment Complete","2023-07-15","","","2023-10-02","10/2/2023 Per email response from UHC June delegated roster is provider load is complete.  Provider is PAR and linked to group TIN/location effective 7/15/2023.  DCannon"]
["Abiodun A Okin-Ayileka, MD","1922328079","84-4724927","ME","PE - ADA Adult and Children Family Clinic LLC","Cigna","Participating","Enrollment Complete","2019-09-01","9763901","","2020-06-22","06/22/2020 - Rec'd effective email from the payer - Stacey Hudak"]
["Abiodun A Okin-Ayileka, MD","1922328079","84-4724927","TX","ADA Adult and Children Family Clinic LLC","Aetna","Participating","Enrollment Complete","2020-08-01","1922328079","","2020-09-22","9/22/2020 Provider is PAR and linked to group effective 8/1/2020."]
["Abiodun A Okin-Ayileka, MD","1922328079","84-4724927","TX","PE - ADA Adult and Children Family Clinic LLC","HealthSmart PPO","Participating","Enrollment Complete","2023-05-01","","","2023-11-13","11/13/2023 Per phone conversation with Lee Kinard at Healthsmart provider is PAR and linked to group TIN/location effective 5/1/2023.  DCannon"]
["Abiodun A Okin-Ayileka, MD","1922328079","84-4724927","ME","","First Health Coventry","Participating","Enrollment Complete","2020-06-12","","","2023-07-21","7/21/2023 Per email received from Priscilla Albertine provider is PAR and linked to group/TIN effective 7/15/2023.  DCannon"]
["Abiodun A Okin-Ayileka, MD","1922328079","84-4724927","TX","ADA Adult and Children Family Clinic LLC","Triwest VA","Participating","Enrollment Complete","2022-02-01","","","2024-02-23","Received email confirmation provider is par, with the location linked: 2407 W. Lousiana Ave, eff.  02/1/2022. PA."]
["Abiodun A Okin-Ayileka, MD","1922328079","84-4724927","ME","PE - ADA Adult and Children Family Clinic LLC","IMS","Participating","Enrollment Complete","2019-09-01","1922328079","","2020-07-27","07/27/2020 - Rec'd roster response back from the payer regarding 7/15/2020 submission stating that all requested providers/service locations have been added to PriMed agreement - Stacey Hudak"]
["Abiodun A Okin-Ayileka, MD","1922328079","84-4724927","TX","PE - ADA Adult and Children Family Clinic LLC","Scott&White (First Care)","Participating","Enrollment Complete","2023-07-15","","","2023-08-17","8/17/2023 Received email from Scott & White HPDELEGATION@BSWHealth.org that provider load from June has been completed and provider is PAR effective 7/15/2023.  DCannon"]
["Abiodun A Okin-Ayileka, MD","1922328079","84-4724927","TX","PE - ADA Adult and Children Family Clinic LLC","Caprock (CapStar)","Participating","Enrollment Complete","2023-07-15","","","2023-07-26","7/26/2023 Rcvd email  confirmation from Caprock that provider is PAR and linked to group TIN/locations effective 7/15/2023.  DCannon"]
["Abiodun A Okin-Ayileka, MD","1922328079","84-4724927","TX","ADA Adult and Children Family Clinic LLC","Amerigroup","Participating","Enrollment Complete",43726,"","","2021-08-26","8/26/2021 Rcvd full roster from Joe Rodriguez at Amerigroup listing provider as PAR w/ group TIN and location effective 9/18/2019.  DCannon"]
["Abiodun A Okin-Ayileka, MD","1922328079","84-4724927","ME","PE - ADA Adult and Children Family Clinic LLC","Sedgwick","Participating","Enrollment Complete","2021-01-26","","","2021-05-06","5/6/2021  In following up with USAMCO (800-872-3860) I was told that you can confirm participating via the USA MCO website  https://providersearch.usamco.com/hwprovsearch.  Provider is PAR and linked to location/TIN effective 1/26/2021.  DCannon"]
["Abiodun A Okin-Ayileka, MD","1922328079","84-4724927","TX","PE - ADA Adult and Children Family Clinic LLC","Medicaid","Participating","Enrollment Complete","2021-09-27","","","2023-12-01","NPI is a performing provider of the group for any location of the group. Dr. Okin-Ayileka does not need to be added as a performing provider for this location. Per Priscilla at TMHP the way the file is set up for ADA, Dr. Okin is considered a performing provider at any location of the group without having to add her to the individual locations. Jen Videan"]
["Jonathan C Burkes, MD","1538571609","46-3131679","TX","PE - Midland Texas Orthopedic Group Inc","USA PPO","Participating","Enrollment Complete","2020-10-13","","","2021-03-12","3/12/2021 Per verification on payor website USAMCO.com provider is loaded as participating.  Sent email to LeNetrice Myart for a roster for the PriMed delegation agreement.  DCannon"]
["Jonathan C Burkes, MD","1538571609","46-3131679","TX","PE - Midland Texas Orthopedic Group Inc","First Health Coventry","Participating","Enrollment Complete","2020-11-01","","","2021-01-26","1/26/2021 - Per follow-up notes provider is par with TIN and location effective 11/1/2020.  DCannon"]
["Jonathan C Burkes, MD","1538571609","46-3131679","TX","PE - Midland Texas Orthopedic Group Inc","Triwest VA","In House Enrollment","In House Enrollment","","","","2021-01-13","1/6/2021 MQA Team is working with Representatives at BCBS-TX to ensure all providers are enrolled and loaded to participate with the VACCN network in a timely manner. However, we are currently awaiting a full roster of providers currently participating and will update all records accordingly upon receipt. Kfrazier"]
["Jonathan C Burkes, MD","1538571609","46-3131679","TX","PE - Midland Texas Orthopedic Group Inc","Superior","Participating","Enrollment Complete","2020-10-01","1538571609","","2020-10-02","10/02/2020 - Rec'd email from the payer stating this provider has been added to the PriMed delegation - Stacey Hudak"]
["Jonathan C Burkes, MD","1538571609","46-3131679","TX","PE - Midland Texas Orthopedic Group Inc","Broadspire Services Inc.","Participating","Enrollment Complete","2024-01-11","","","2024-07-08","Contract complete. Effective 01/11/2024. Provider was listed on par provider roster submitted with contract. Jen Videan"]
["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","Cigna Healthspring","Pending Other Enrollment","Pending Other Enrollment","","","","2024-07-23","Group letter of interest was submitted. They payer has received it and after reviewing if they want to contract, they will be reaching out to me for additional info and the roster. Nothing is needed until then. MS"]
["Jonathan C Burkes, MD","1538571609","46-3131679","TX","PE - Midland Texas Orthopedic Group Inc","Rail Road Medicare","Participating","Enrollment Complete","2020-08-24","Q00083402","DU5783","2021-06-09","6/9/2021 Submitted on-line application and immediately received assigned RR PTAN, which is Q00083402 under group RR PTAN DU5783, effective 8/24/2020. KFrazier"]
["Carlos Molina, DO","1225277833","75-1997880","TX","PE - Andrews County Hospital District","Aetna","Participating","Enrollment Complete","2019-12-13"," 9959784","","2020-06-26","06/26/2020 - moved to completed status after reviewing Follow Up Complete note - Stacey Hudak"]
["Carlos Molina, DO","1225277833","75-1997880","TX","PE - Andrews County Hospital District","Zurich","Delegated - Third Party","Thru Other Payor","","","","2024-01-29","Check Coventry portal for enrollment status. Provider currently not showing as active.  Jen Videan"]
["Carlos Molina, DO","1225277833","26-3789190","TX","PE - Permian Physician Services","Scott&White (First Care)","Participating","Enrollment Complete","2017-03-13","","","2021-01-29","1/29/2021 - Rcvd roster from Scott&White (First Care) confirming participation of provider with TIN and location effective dates.  DCannon"]
["Carlos Molina, DO","1225277833","75-1997880","TX","PE - Andrews County Hospital District","Corvel Healthcare Corp.","Enrollment Stopped","Enrollment Stopped","","","","2024-01-16","Per Melody Starcher mstarcher@permianregional.com, Permian Physician Services and Andrews Family Medicine have  decided not to sign a contract  with Corvel. Jen Videan"]
["Carlos Molina, DO","1225277833","26-3789190","TX","PE - Permian Physician Services","Aetna","Participating","Enrollment Complete",43812,"1225277833","","2020-09-24","09/24/2020 - moved to completed status after reviewing follow up complete - Stacey Hudak"]
["Carlos Molina, DO","1225277833","75-1997880","TX","PE - Andrews County Hospital District","United Health Care","Participating","Enrollment Complete","2020-01-01","1225277833","","2020-08-31","08/31/2020 - moved to completed status after reviewing follow up complete note - Stacey Hudak"]
["Carlos Molina, DO","1225277833","75-1997880","TX","PE - Andrews County Hospital District","HealthSmart PPO","Participating","Enrollment Complete","2017-03-22","1225277833","","2020-07-01","07/01/2020 - Rec'd confirmation email from the payer stating this provider is EFF - Stacey Hudak"]
["Carlos Molina, DO","1225277833","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"]
["Carlos Molina, DO","1225277833","26-3789190","TX","PE - Permian Physician Services","Cigna","Participating","Enrollment Complete",42671,"","","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","Cigna","Participating","Enrollment Complete",42671,"7968637","",44007,"6-25-2020 - Moved to completed status based on info rec'd during follow up complete call - Stacey Hudak"]
["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","Alliance WC","Participating","Enrollment Complete","2023-07-21","","","2023-09-01","Per Michelle Killough @ pswca provider effective 07/21/2023. Jen Videan"]
["Carlos Molina, DO","1225277833","26-3789190","TX","PE - Permian Physician Services","USA PPO","Participating","Enrollment Complete","2017-04-03","1225277833","263789190","2020-08-19","Confirmed provider is participating with PPO and H&W networks (list of networks attached). Kimberly Frazier"]
["Carlos Molina, DO","1225277833","26-3789190","TX","PE - Permian Physician Services","Zurich","Delegated - Third Party","Thru Other Payor","","","","2024-02-01","Check Coventry portal for enrollment status. Provider currently not showing as active.  Jen Videan"]
["Carlos Molina, DO","1225277833","26-3789190","TX","PE - Permian Physician Services","HealthSmart PPO","Participating","Enrollment Complete","2017-03-22","1225277833","","2020-09-23","09/23/2020 - moved to completed status after reviewing follow up complete note - Stacey Hudak"]
["Carlos Molina, DO","1225277833","26-3789190","TX","PE - Permian Physician Services","Amerigroup","Participating","Enrollment Complete","2020-07-17","04579868","","2021-02-13","2/13/2021 - Verification on payer website Amerigroup.healthsparq.com provider is participating and linked to TIN and location for the following plans CHIP, CHIP-PERINATAL, STAR, STAR-KIDS, STAR-PLUS.  DCannon"]
["Alyssa Tochterman, MD","1972942209","26-3789190","TX","PE - Permian Physician Services","Ambetter","Participating","Enrollment Complete","2022-04-01","","","2022-06-13","6/13/2022 Per roster received from Superior provider is PAR and linked to group delegation roster effective 4/1/2022."]
["Alyssa Tochterman, MD","1972942209","75-1997880","TX","PE - Andrews County Hospital District","Liberty Mutual","Participating","Enrollment Complete","","","","2024-01-27","Confirmed via the Coventry portal, the provider is enrolled. MS"]
["Alyssa Tochterman, MD","1972942209","75-1997880","TX","PE - Andrews County Hospital District","Triwest VA","Participating","Enrollment Complete",44774,"","","2022-11-14","11/14/22- Per Scarlett Abigail, TIN has active 400TX DCN.  TIN has association of RHC."]
["Alyssa Tochterman, MD","1972942209","75-1997880","TX","PE - Andrews County Hospital District","Broadspire Services Inc.","Enrollment Stopped","Enrollment Stopped","","","","2023-10-04","Per Melody Starcher, they would like to hold off on Broadspire WC enrollment at this time. If they start to see a large amount of patients coming in with it, then they will reassess. 10/04/2023 Jen Videan"]
["Alyssa Tochterman, MD","1972942209","75-1997880","TX","PE - Andrews County Hospital District","Hartford","Delegated - Third Party","Thru Other Payor","","","","2024-01-27","Check Coventry portal for enrollment status. MS"]
["Alyssa Tochterman, MD","1972942209","26-3789190","TX","PE - Permian Physician Services","Texas Mutual","Participating","Enrollment Complete","2024-04-01","","","2024-04-05","Approval ltr rcvd. Effective 04/01/2024. Jen Videan"]
["Alyssa Tochterman, MD","1972942209","26-3789190","TX","PE - Permian Physician Services","Broadspire Services Inc.","Enrollment Stopped","Enrollment Stopped","","","","2023-11-21","Permian Physician Services would like to hold off contracting with Broadspire at this time. Jen Videan"]
["Alyssa Tochterman, MD","1972942209","26-3789190","TX","PE - Permian Physician Services","Sedgwick","Participating","Enrollment Complete","2024-05-21","1972942209","","2024-05-22","Approval ltr rcvd. Effective date 05/21/2024. Jen Videan"]
["Alyssa Tochterman, MD","1972942209","26-3789190","TX","PE - Permian Physician Services","Galaxy Health","Participating","Enrollment Complete","2019-09-01","1972942209","","2020-08-21","08/21/2020 - Rec'd email confirmation that this roster was processed and this provider was made effective with the requested eff date of 9-1-2019 - Stacey Hudak"]
["Alyssa Tochterman, MD","1972942209","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"]
["Alyssa Tochterman, MD","1972942209","75-1997880","TX","PE - Andrews County Hospital District","Sedgwick","Participating","Enrollment Complete","2024-05-21","1972942209","","2024-05-22","Approval ltr rcvd. Effective date 05/21/2024. Jen Videan"]
["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","Scott&White (First Care)","Participating","Enrollment Complete","2016-10-19","1972942209","","2020-08-04","8/4/2020 - Rec'd email from the payer stating this provider is EFF/loaded under AFM group NPI - Stacey Hudak\n\n**confirmed the provider is PAR with the following networks: \nFirstCare MyChoice PPO\nCHIP\nFirstCare Select Benefit Network\nHMO Enhanced Benefit Network\nMedicaid (FC)\nMedicare (FC)\nPPO Limited Benefit Network"]
["Alyssa Tochterman, MD","1972942209","26-3789190","TX","PE - Permian Physician Services","Zurich","Participating","Enrollment Complete","","","","2024-02-01","Per Coventry portal provider is enrolled. Jen Videan"]
["Alyssa Tochterman, MD","1972942209","75-1997880","TX","PE - Andrews County Hospital District","Medicare","Facility Enrollment","Facility Enrollment","","RHC 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"]
["Alyssa Tochterman, MD","1972942209","26-3789190","TX","PE - Permian Physician Services","Travelers WC","Participating","Enrollment Complete","","","","2024-02-01","Per Coventry portal provider is enrolled. Jen Videan"]
["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","First Health Coventry","Participating","Enrollment Complete","2021-12-01","","","2023-05-02","5/2.2023 Per confirm par status -  Per rep, provider is showing participating with an effective date 12/1/2021 and link under the Group and TIN. Provider ID 2680644.  Service location is on file. Call ref#:610334. DCannon"]
["Margaret Merriam, DO","1083867147","75-1997880","TX","PE - Andrews County Hospital District","HealthSmart PPO","Participating","Enrollment Complete","2017-05-31","","","2021-04-11","4/11/2021 Rcvd email from HealthSmart <mdipsupport@healthsmart.com> confirming participation of provider under TIN and location effective 5/31/2017.  DCannon"]
["Margaret Merriam, DO","1083867147","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","Scott&White (First Care)","Participating","Enrollment Complete","2017-10-23","1083867147","","2020-08-19","8/19/2020 - Rec'd email from the payer stating this provider is already affiliated with the PRIMED DELEGATED AGREEMENT and enrolled with this group TIN/Service Location and group NPI# 1124054069 - Stacey Hudak\n\n**Verified this provider is networked with:\nFirstCare MyChoice PPO\nCHIP\nFirstCare Select Benefit Network\nHMO Enhanced Benefit Network\nMedicaid (FC)\nMedicare (FC)\nPPO Limited Benefit Network"]
["Margaret Merriam, DO","1083867147","75-1997880","TX","PE - Andrews County Hospital District","Hartford","Delegated - Third Party","Thru Other Payor","","","","2024-01-29","Check Coventry portal for enrollment status. Provider currently not showing as active. Jen Videan"]
["Margaret Merriam, DO","1083867147","26-3789190","TX","PE - Permian Physician Services","Zurich","Delegated - Third Party","Thru Other Payor","","","","2024-02-01","Check Coventry portal for enrollment status. Provider currently not showing as active.  Jen Videan"]
["Margaret Merriam, DO","1083867147","26-3789190","TX","PE - Permian Physician Services","Triwest VA","Participating","Enrollment Complete","2018-01-01","","","2022-10-06","09/28/2022 -  Received Permian Physician Services roster from TriWest VA (Scarlett Abigail, Scarlett_Abigail@bcbstx.com); provider listed as participating, eff. 01/01/2018  |  Priscilla A"]
["Margaret Merriam, DO","1083867147","26-3789190","TX","PE - Permian Physician Services","United Health Care","Participating","Enrollment Complete","2019-11-01","1083867147","","2020-10-02","10/02/2020 - moved to completed status after reviewing follow up complete note - Stacey Hudak"]
["Margaret Merriam, DO","1083867147","26-3789190","TX","PE - Permian Physician Services","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","75-1997880","TX","PE - Andrews County Hospital District","Wellmed","Participating","Enrollment Complete","2022-01-01","","","2023-03-23","3/23/2023 Rcvd roster from UHC w/ all Wellmed participating providers.  Provider is PAR effective 1/1/2022.  DCannon"]
["Margaret Merriam, DO","1083867147","75-1997880","TX","PE - Andrews County Hospital District","Amerigroup","Participating","Enrollment Complete","2020-08-05","04727806","","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"]
["Margaret Merriam, DO","1083867147","75-1997880","TX","PE - Andrews County Hospital District","Humana","Participating","Enrollment Complete","2017-06-05","","","2021-11-18","11/18/2021 Rcvd full roster from Humana listing provider as PAR and linked to group TIN/location effective 6/5/2017.  DCannon"]
["Jennifer B Hada-Ondriezek, DPM","1669617981","26-3789190","TX","PE - Permian Physician Services","Triwest VA","Participating","Enrollment Complete","2015-01-01","","","2022-10-06","09/28/2022 -  Received Permian Physician Services roster from TriWest VA (Scarlett Abigail, Scarlett_Abigail@bcbstx.com); provider listed as participating, eff. 01/01/2015 | Priscilla A"]
["Jennifer B Hada-Ondriezek, DPM","1669617981","26-3789190","TX","PE - Permian Physician Services","Aetna","Participating","Enrollment Complete","2020-09-16","9363366","","2021-07-01","7/1/2021 Per Aetna roster received from Jamie Roberts provider is PAR and linked to TIN/locations effective 9/16/2020.  DCannon"]
["Jennifer B Hada-Ondriezek, DPM","1669617981","26-3789190","TX","PE - Permian Physician Services","Texas Mutual","Participating","Enrollment Complete","2024-04-01","","","2024-04-05","Approval ltr rcvd. Effective 04/01/2024. Jen Videan"]
["Jennifer B Hada-Ondriezek, DPM","1669617981","75-1997880","TX","PE - Andrews County Hospital District","First Health Coventry","Participating","Enrollment Complete","2010-01-15","","","2023-05-02","5/2.2023 Per confirm par status -  Per rep, provider is showing participating with an effective date 1/15/2010 and link under the Group and TIN. Provider ID 2099013.  Service location is on file. Call ref#:610334. DCannon"]
["Jennifer B Hada-Ondriezek, DPM","1669617981","75-1997880","TX","PE - Andrews County Hospital District","Sedgwick","Participating","Enrollment Complete","2024-05-21","1669617981","","2024-05-24","Approval ltr rcvd. Effective date 05/21/2024. Jen Videan"]
["Jennifer B Hada-Ondriezek, DPM","1669617981","26-3789190","TX","PE - Permian Physician Services","United Health Care","Participating","Enrollment Complete","2019-11-01","","","2021-01-18","1/18/2021 - Per follow-up notes provider NPI# is on file for the provider and is participating effective 11/01/2019 for Commercial Choice, 08/02/2017 for Community and State and 06/01/2020 for Medicare under the group and TIN#.  DCannon"]
["Jennifer B Hada-Ondriezek, DPM","1669617981","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"]
["Jennifer B Hada-Ondriezek, DPM","1669617981","75-1997880","TX","PE - Andrews County Hospital District","Wellmed","Participating","Enrollment Complete","2022-01-01","","","2023-03-23","3/23/2023 Rcvd roster from UHC w/ all Wellmed participating providers.  Provider is PAR effective 1/1/2022.  DCannon"]
["Jennifer B Hada-Ondriezek, 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","26-3789190","TX","PE - Permian Physician Services","TriCare Standard","Participating","Enrollment Complete","","","","2021-09-15","7/2/2021- S/W Tierra OF TRICARE Standard @ 8004445445, call was transferred to WPS for further assistance, Spoke to Sandra, as per Rep, NPI#is on file for the provider, shows certified Non particpiating under the group and TIN# effective 6/1/2021-11/1/2022 under the physical location. Provider ID is 26-3789190-79714-C006. to become a Par provider need to contact PR liason for assistance, Rep do not have the contact info and TAT for the process. Call ref# Herminia Gilongos"]
["Jennifer B Hada-Ondriezek, DPM","1669617981","75-1997880","TX","PE - Andrews County Hospital District","CAQH","Participating","CAQH Reattested",45481,"","",45481,"07/08/2024 CAQH Reattested all locations current and all expirables up to date wthompson"]
["Jennifer B Hada-Ondriezek, DPM","1669617981","26-3789190","TX","PE - Permian Physician Services","First Health Coventry","Participating","Enrollment Complete","2020-09-16","","","2023-05-02","5/2.2023 Per confirm par status.  Per rep, provider is showing participating with an effective date 9/16/2020 and link under the Group and TIN. Provider ID 2099013.  Service location is on file. Call ref#:610334. DCannon"]
["Jennifer B Hada-Ondriezek, 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","Galaxy Health","Participating","Enrollment Complete","2019-09-01","1972073906","","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"]
["Shannan Clawson, NP","1972073906","75-1997880","TX","","Tricare Prime","Participating","Enrollment Complete","2022-03-02","","","2024-03-06",""]
["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","Medicare","Facility Enrollment","Facility Enrollment","","RHC GROUP NPI - Part A Only","","2020-07-28","07/28/2020 - This is an RHC only Group NPI - Part A only. You cannot link providers to this group as it is a Facility enrollment only. \n\nI've marked it effective just to move it out off the work list - Stacey Hudak"]
["Shannan Clawson, NP","1972073906","75-1997880","TX","PE - Andrews County Hospital District","Sedgwick","Participating","Enrollment Complete","2024-06-19","","","2024-07-22","Approval ltr rcvd. Effective 06/19/2024. Jen Videan"]
["Kristie M Chu, MD","1780078089","75-2656723","TX","PE - Premier Family Care, Inc","First Health Coventry","Participating","Re-Credentialing","2021-05-15","","","2024-04-19","4/19/2024- Submitted recred status via delegated monthly roster on 4/15/2024. FC"]
["Kristie M Chu, MD","1780078089","75-2656723","TX","PE - Premier Family Care, Inc","Wellcare","Participating","Enrollment Complete","2021-11-01","","","2022-11-15","11/15/2022 Per roster received from Wellcare provider is PAR and linked to group TIN/location effective 11/1/2021.  DCannon"]
["Kristie M Chu, MD","1780078089","75-2656723","TX","PE - Premier Family Care, Inc","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"]
["Kristie M Chu, MD","1780078089","75-2656723","TX","PE - Premier Family Care, Inc","Triwest VA","Facility Enrollment","Facility Enrollment","","","","2022-10-17","10/17/2022 - Received roster from Scarlett of TriWest VA; provider status: \"No Action.  TIN is CCN participating under own DCN.\""]
["Kristie M Chu, MD","1780078089","75-2656723","TX","PE - Premier Family Care, Inc","Wellmed","Participating","Enrollment Complete","2021-06-21","","","2023-03-23","3/23/2023 Rcvd roster from UHC w/ all Wellmed participating providers.  Provider is PAR effective 6/21/2021.  DCannon"]
["Kristie M Chu, MD","1780078089","75-2656723","TX","PE - Premier Family Care, 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"]
["Kristie M Chu, MD","1780078089","75-2656723","TX","PE - Premier Family Care, 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"]
["Barbara Norris, NP-C","1720353592","75-1997880","TX","PE - Andrews County Hospital District","Medicaid","Participating","In House Enrollment","2020-05-01","331529303","324676101","2020-10-26","10/26/2020 - Rec'd requested proof of medicaid enrollment from the clinic. This enrollment is maintained in house. Storing here for use with other payers - Stacey Hudak"]
["Barbara Norris, NP-C","1720353592","75-1997880","TX","PE - Andrews County Hospital District","HealthSmart PPO","Participating","Enrollment Complete","2014-04-29","1720353592","","2020-09-23","09/23/2020 - moved to completed status after reviewing follow up complete - Stacey Hudak"]
["Barbara Norris, NP-C","1720353592","75-1997880","TX","PE - Andrews County Hospital District","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-C","1720353592","75-1997880","TX","PE - Andrews County Hospital District","Triwest VA","Facility Enrollment","Facility Enrollment","","","","2022-10-17","10/17/2022 - Received roster from Scarlett of TriWest VA; provider status: \"No Action.  TIN has active 400TX DCN.  TIN has association of RHC.\""]
["Barbara Norris, NP-C","1720353592","75-1997880","TX","PE - Andrews County Hospital District","First Health Coventry","Participating","Enrollment Complete","2014-04-01","","","2023-05-02","5/2.2023 Per confirm par status note.   Per rep, provider is showing participating with an effective date 4/1/2014 and link under the Group and TIN. Provider ID 2609103.  Service location is on file. Call ref#:610334. DCannon"]
["Stephanie Jean Fitzgerald, MD","1184035313","75-1997880","TX","PE - Andrews County Hospital District","TriCare Standard","Participating","Enrollment Complete","2020-06-22","","","2020-10-27","10/27/2020 Confirmed provider is certified as a non-network provider under group and Tax ID. Kimberly Frazier"]
["Stephanie Jean Fitzgerald, MD","1184035313","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."]
["Stephanie Jean Fitzgerald, MD","1184035313","75-1997880","TX","PE - Andrews County Hospital District","Alliance WC","Participating","Enrollment Complete","2020-12-04","","","2020-12-23","12/23/2020 Received welcome letter of approval from Rep Alejandro Castellanos which indicates an effective date of 12/4/2020, which was forwarded to Stacy Salazar for their files. KFrazier"]
["Stephanie Jean Fitzgerald, MD","1184035313","75-1997880","TX","PE - Andrews County Hospital District","USA PPO","Participating","Enrollment Complete","2021-01-26","1312291","","2021-03-12","3/12/2021 Per verification on payor website USAMCO.com provider is loaded as participating.  Rcvd Roster LeNetrice Myart with provider numbers and effective dates for providers.  DCannon"]
["Stephanie Jean Fitzgerald, MD","1184035313","26-3789190","TX","PE - Permian Physician Services","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","First Health Coventry","Participating","Enrollment Complete","2023-05-28","637492","","2023-07-25","7/25/2023 Per follow-up note - Per rep, provider is showing participating with First Health and link under the Group and TIN with an Effective date 05/28/2023. Provider ID 637492, Payer ID 60025 and Recredentialing date 05/28/2026. Service location is on file. Call ref#:6149441125. 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","75-1997880","TX","PE - Andrews County Hospital District","HealthSmart PPO","Participating","Enrollment Complete","2020-08-05","","","2021-12-03","12/3/2021 Per Healthsmart website provider is PAR and loaded under TIN/location effective 8/5/2020.  DCannon"]
["Stephanie Jean Fitzgerald, MD","1184035313","75-1997880","TX","PE - Andrews County Hospital District","Multiplan","Participating","Enrollment Complete","2020-08-05","","","2022-07-23","7/23/2022 Per email from Marcie Eckhart-Haven at Multiplan provider is PAR and linked to group TIN effective 8/5/2020.  DCannon"]
["Stephanie Jean Fitzgerald, MD","1184035313","26-3789190","TX","PE - Permian Physician Services","Wellmed","Participating","Enrollment Complete","2022-01-01","","","2023-03-23","3/23/2023 Rcvd roster from UHC w/ all Wellmed participating providers.  Provider is PAR effective 1/1/2022.  DCannon"]
["Stephanie Jean Fitzgerald, MD","1184035313","75-1997880","TX","PE - Andrews County Hospital District","Triwest VA","Participating","Enrollment Complete","2022-10-01","","","2022-11-11","11/11/22 Confirmed participating effective date 10/1/22 per Scarlett Abigail"]
["Stephanie Jean Fitzgerald, MD","1184035313","26-3789190","TX","PE - Permian Physician Services","Alliance WC","Participating","Enrollment Complete",44169,"","","2023-05-22","Michelle Killough confirmed provider is effective 12/4/2020. MS"]
["Cynthia A Hill, CNS","1225271224","75-1997880","TX","PE - Andrews County Hospital District","Ambetter","Participating","Enrollment Complete",44652,"","","2022-06-13","6/13/2022 Received April Monthly Validation roster from Superior and provider is PAR and linked effective 4/1/2022.  DCannon"]
["Cynthia A Hill, CNS","1225271224","75-1997880","TX","PE - Andrews County Hospital District","Multiplan","Participating","Enrollment Complete","2020-07-17","","","2022-07-23","7/23/2022 Per email from Marcie Eckhart-Haven at Multiplan provider is PAR and linked to group TIN effective  7/17/2020. DCannon"]
["Cynthia A Hill, CNS","1225271224","75-1997880","TX","PE - Andrews County Hospital District","CAQH","Participating","CAQH Reattested","2024-07-08","","","2024-07-08","07/08/2024 all locations current and all expirables up to date wthompson"]
["Cynthia A Hill, CNS","1225271224","75-1997880","TX","PE - Andrews County Hospital District","Tricare Prime","Participating","Enrollment Complete","2022-10-04","","","2024-03-06","Re-Cred completed effective 10/4/2022. MS"]
["Cynthia A Hill, CNS","1225271224","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"]
["Cynthia A Hill, CNS","1225271224","75-1997880","TX","PE - Andrews County Hospital District","Galaxy Health","Participating","Enrollment Complete","2020-01-01","1225271224","","2020-10-05","10/5/2020 - Rec'd email back from the payer stating this enrollment has been completed - Stacey"]
["Cynthia A Hill, CNS","1225271224","75-1997880","TX","PE - Andrews County Hospital District","Aetna","Participating","Enrollment Complete","2021-12-31","9885355","","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 12/31/21 under the group and TIN# as out of network, per rep the TAX ID has a Facility Contract, even the Provider is out of network she can still build the claim under the TAX ID and it will be process as in network. PIN 9885355.Physical location is on file. Ref# 6075333572. - DCannon"]
["Rahul Dinesh Puri, MD","1306928098","75-1997880","TX","PE - Andrews County Hospital District","Galaxy Health","Participating","Enrollment Complete","2019-09-01","1306928098","","2020-08-21",""]
["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","26-3789190","TX","","Texas Mutual","Participating","Enrollment Complete","2020-07-02","","","2021-01-23","11/25/2020-Confirmed provider is participating under group Tax ID and practice location. -Elonah Grace B. Gelig"]
["Rahul Dinesh Puri, MD","1306928098","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","26-3789190","TX","PE - Permian Physician Services","Multiplan","Participating","Enrollment Complete","2020-07-13","","","2022-07-23","7/23/2022 Per email from Marcie Eckhart-Haven at Multiplan provider is PAR and linked to group TIN effective 7/13/2022.  DCannon"]
["Rahul Dinesh Puri, MD","1306928098","26-3789190","TX","","Amerigroup","Participating","Enrollment Complete","2020-07-14","05227920","","2021-02-13","2/13/2021 - Verification on payer website Amerigroup.healthsparq.com provider is participating and linked to TIN and location for the following plans CHIP, CHIP-PERINATAL, STAR, STAR-KIDS, STAR-PLUS.  DCannon"]
["Rahul Dinesh Puri, MD","1306928098","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","75-1997880","TX","","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",43938,"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","HealthSmart PPO","Participating","Enrollment Complete",40848,"","","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","","HealthSmart PPO","Participating","Enrollment Complete","2011-11-01","","","2021-04-11","4/11/2021 Rcvd email from HealthSmart <mdipsupport@healthsmart.com> confirming participation of provider under TIN and location effective 11/01/2011.  DCannon"]
["Rahul Dinesh Puri, MD","1306928098","26-3789190","TX","PE - Permian Physician Services","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","PE - Permian Physician Services","Galaxy Health","Participating","Enrollment Complete","2019-09-01","1306928098","","2020-08-21","08/21/2020 - Rec'd email confirmation that this roster was processed and this provider was made effective with the requested eff date of 9-1-2019 - Stacey Hudak"]
["Rahul Dinesh Puri, MD","1306928098","26-3789190","TX","PE - Permian Physician Services","Boon Chapman","Participating","Enrollment Complete","2016-07-07","1306928098","","2020-10-05","Enrolled thru PHCS"]
["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","75-1997880","TX","PE - Andrews County Hospital District","First Health Coventry","Participating","Enrollment Complete","","","","2023-07-24","Confirmed enrollment via online directory. MS"]
["Rahul Dinesh Puri, MD","1306928098","26-3789190","TX","","Wellmed","Participating","Enrollment Complete","2022-01-01","","","2023-03-23","3/23/2023 Rcvd roster from UHC w/ all Wellmed participating providers.  Provider is PAR effective 1/1/2022.  DCannon"]
["Rahul Dinesh Puri, MD","1306928098","26-3789190","TX","PE - Permian Physician Services","First Health Coventry","Participating","Enrollment Complete","","","","2023-07-24","Confirmed enrollment via online directory. MS"]
["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","75-1997880","TX","PE - Andrews County Hospital District","Sedgwick","Participating","Enrollment Complete","2024-05-21","1306928098","","2024-05-22","Approval ltr rcvd. Effective date 05/21/2024. Jen Videan"]
["Paul Slaughter, DO","1184626749","75-1997880","TX","PE - Andrews County Hospital District","Medicare","Participating","Enrollment Complete","2013-08-26","315563YSCJ","290001","2020-07-24","07/24/2020 - moved to completed status after confirming through group PECOS that this provider is linked to Part B Quick Care Clinic Group PTAN 290001. - Stacey Hudak"]
["Paul Slaughter, DO","1184626749","75-1997880","TX","PE - Andrews County Hospital District","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","2024-07-08","","","2024-07-08","07/08/2024 CAQH Reattested all locations current and all expirables up to date wthompson"]
["Paul Slaughter, DO","1184626749","75-1997880","TX","PE - Andrews County Hospital District","First Health Coventry","Participating","Enrollment Complete",41760,"1098076","","2023-05-02","5/2/2023 Per confirm par status note - Per rep, provider is showing participating with an effective date 05/01/2014 and link under the Group and TIN. Provider ID 1098076. As per Donna from Credentialing Dept they don't have the provider's next recredentialing date then advised that their Network Team will inform the provider if the recredentialing date is available. Service location is on file. Call ref#:610344. DCannon"]
["Paul Slaughter, DO","1184626749","75-1997880","TX","PE - Andrews County Hospital District","Aetna","Participating","Enrollment Complete",39904,"1184626749","","2020-07-20","07/20/2020 - moved to completed status after reviewing follow up complete note. Provider has a DELEGATED agreement - Stacey Hudak"]
["Paul Slaughter, DO","1184626749","75-1997880","TX","PE - Andrews County Hospital District","Multiplan","Participating","Enrollment Complete",44025,"","","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"]
["Maria Montero, MD","1508218843","75-2656723","TX","PE - North Big Spring Family Care","Medicare","Participating","Enrollment Complete","2020-09-09","1G8516","0008AH","2020-09-15","09/25/2020 - Rec 'd email from this payer to be EFF and linked to this group - Stacey Hudak"]
["Maria Montero, MD","1508218843","75-2656723","TX","PE - North Big Spring Family Care","Wellmed","Participating","Enrollment Complete","2022-02-01","","","2023-03-23","3/23/2023 Rcvd roster from UHC w/ all Wellmed participating providers.  Provider is PAR effective 2/1/2022.  DCannon"]
["Maria Montero, MD","1508218843","75-2656723","TX","PE - North Big Spring Family Care","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","75-2656723","TX","PE - North Big Spring Family Care","Galaxy Health","Participating","Enrollment Complete","2020-01-01","1508218843","","2020-10-05","10/5/2020 - Rec'd email back from the payer stating this enrollment has been completed - Stacey"]
["Maria Montero, MD","1508218843","75-2656723","TX","","Tricare Prime","Participating","Enrollment Complete",44140,"","","2021-05-09","5/9/2021 Upon review of the self-service portal, provider is participating under group Tax ID and location effective 11/5/2020. Also states action needed, which is typically the payor notification to process a new back-ground check. KFrazier"]
["Christopher Stansell, FNP","1285065946","75-1997880","TX","PE - Andrews County Hospital District","USA PPO","Participating","Enrollment Complete","2014-06-30","1205392","","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"]
["Christopher Stansell, FNP","1285065946","75-1997880","TX","PE - Andrews County Hospital District","Cigna","Participating","Enrollment Complete",43195,"1285065946","","2020-08-26","08/26/2020 - moved to completed status after reviewing previous follow up complete note - Stacey Hudak"]
["Christopher Stansell, FNP","1285065946","75-1997880","TX","PE - Andrews County Hospital District","Tricare Prime","Participating","Enrollment Complete",41579,"","","2020-12-24","12/24/2020 Per email response from Carolyn Anguiano, provider requires background check on their end, and she's forwarded for processing to their credentialing team. KFrazier"]
["Christopher Stansell, FNP","1285065946","75-1997880","TX","PE - Andrews County Hospital District","Galaxy Health","Participating","Enrollment Complete",43831,"1285065946","","2020-10-05","10/5/2020 - Rec'd email back from the payer stating this enrollment has been completed - Stacey"]
["Christopher Stansell, FNP","1285065946","75-1997880","TX","PE - Andrews County Hospital District","Wellmed","Participating","Enrollment Complete","2022-01-01","","","2023-03-23","3/23/2023 Rcvd roster from UHC w/ all Wellmed participating providers.  Provider is PAR effective 1/1/2022.  DCannon"]
["Leslie Michelle Rowland, FNP","1720111883","75-2656723","TX","PE - Premier Family Care, 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, 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, Inc","Tricare Prime","Participating","Enrollment Complete","2021-10-08","","","2024-01-25","Confirmed provider is credentialed and in network with Tricare. MS"]
["Leslie Michelle Rowland, FNP","1720111883","75-2656723","TX","PE - Premier Family Care, Inc","Triwest VA","Facility Enrollment","In House Enrollment","","","","2021-01-13","1/6/2021 MQA Team is working with Representatives at BCBS-TX to ensure all providers are enrolled and loaded to participate with the VACCN network in a timely manner. However, we are currently awaiting a full roster of providers currently participating and will update all records accordingly upon receipt. Kfrazier"]
["Leslie Michelle Rowland, FNP","1720111883","75-2656723","TX","PE - Premier Family Care, Inc","Omni PPO","Participating","Enrollment Complete","2020-09-17","","","2021-01-06","1/6/2020 - Rcvd confirmation from payor that provider load is complete.  DCannon"]
["Leslie Michelle Rowland, FNP","1720111883","75-2656723","TX","PE - Premier Family Care, Inc","Ambetter","Participating","Enrollment Complete",44713,"","","2022-06-13","6/13/2022 Per roster received from Superior provider is PAR and linked to group delegation roster effective 6/1/2022."]
["Leslie Michelle Rowland, FNP","1720111883","75-2656723","TX","PE - Premier Family Care, Inc","USA PPO","Participating","Enrollment Complete",44222,"1312371","","2021-03-12","3/12/2021 Per verification on payor website USAMCO.com provider is loaded as participating.  Rcvd Roster LeNetrice Myart with provider numbers and effective dates for providers.  DCannon"]
["Leslie Michelle Rowland, FNP","1720111883","75-2656723","TX","PE - Premier Family Care, Inc","Medicare","Participating","Enrollment Complete",44116,"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","1720111883","75-2656723","TX","PE - Premier Family Care, Inc","Amerigroup","Participating","Enrollment Complete","2011-05-12","","","2021-12-03","12/3/2021 Per Amerigroup roster received Joe Rodriguez provider is PAR under group TIN/location effective 5/12/2011.   DCannon"]
["Leslie Michelle Rowland, FNP","1720111883","75-2656723","TX","PE - Premier Family Care, Inc","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, Inc","Wellmed","Participating","Enrollment Complete","2022-04-01","","","2023-03-23","3/23/2023 Rcvd roster from UHC w/ all Wellmed participating providers.  Provider is PAR effective 4/1/2022.  DCannon"]
["Leslie Michelle Rowland, FNP","1720111883","75-2656723","TX","PE - Premier Family Care, Inc","Cigna","Participating","Enrollment Complete","2024-05-09","4138818","","2024-06-07","Specialty update has been processed. MS"]
["Leslie Michelle Rowland, FNP","1720111883","75-2656723","TX","PE - Premier Family Care, Inc","Omni PPO","Participating","Enrollment Complete","2020-09-17","","","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","1720111883","75-2656723","TX","PE - Premier Family Care, Inc","TriCare Standard","Participating","Enrollment Complete","2021-05-19","","","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, Inc","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"]
["Ni Adams, APRN-NP","1194355339","75-2656723","TX","PE - Premier Family Care, Inc","Triwest VA","Facility Enrollment","Facility Enrollment","","","","2022-10-17","10/17/2022 - Received roster from Scarlett of TriWest VA; provider status: \"No Action.  TIN is CCN participating under own DCN.\""]
["Ni Adams, APRN-NP","1194355339","75-2656723","TX","PE - Premier Family Care, Inc","Medicare","Participating","Enrollment Complete","2020-10-01","1K2965","","2020-12-17","12/17/2020 Received email of Medicare approval with assigned PTAN 1K2965 effective 10/1/2020. KFrazier"]
["Ni Adams, APRN-NP","1194355339","75-2656723","TX","PE - Premier Family Care, Inc","First Health Coventry","Participating","Enrollment Complete","","","","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, APRN-NP","1194355339","75-2656723","TX","PE - Premier Family Care, Inc","Galaxy Health","Participating","Enrollment Complete",44117,"","","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, APRN-NP","1194355339","75-2656723","TX","PE - Premier Family Care, Inc","Medicaid","Participating","Enrollment Complete",44105,"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, APRN-NP","1194355339","75-2656723","TX","PE - Premier Family Care, Inc","TriCare Standard","Participating","Enrollment Complete",44622,"","","2022-03-09","3/9/2022 Per Tricare portal provider is certified and in network with location as of 3/2/2022. Cbankston"]
["Rachel Ann Murphy, RD","1124637160","75-2656723","TX","PE - Premier Family Care, Inc","First Health Coventry","Participating","Enrollment Complete",44896,"3632548","","2023-10-04","10/4/2023 Per email received from Priscilla Albertina at MQA she confirmed First Health enrollment status for provider.  Provider is PAR and linked to group effective 12/1/2022.  DCannon"]
["Rachel Ann Murphy, RD","1124637160","75-2656723","TX","PE - Premier Family Care, Inc","Amerigroup","Participating","Enrollment Complete",44172,"","","2021-08-26","8/26/2021 Rcvd full roster from Joe Rodriguez at Amerigroup listing provider as PAR w/ group TIN and location effective 12/7/2020.  DCannon"]
["Rachel Ann Murphy, RD","1124637160","75-2656723","TX","PE - Premier Family Care, Inc","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 Ann Murphy, RD","1124637160","75-2656723","TX","PE - Premier Family Care, Inc","CAQH","Participating","CAQH Reattested","2024-08-02","","","2024-08-02","08/02/2024 CAQH Reattested all locations current and all expirables up to date wthompson"]
["Eliana Kelley, APRN-FNP-BC","1184278251","75-1997880","TX","PE - Andrews County Hospital District","Caprock (CapStar)","Participating","Enrollment Complete","2021-01-07","","","2021-04-09","4/9/2020 Rcvd roster from Mary Rodriguez <mary.rodriguez@90degreebenefits.com> at Caprock listing provider as participating under TIN.  DCannon"]
["Eliana Kelley, APRN-FNP-BC","1184278251","75-1997880","TX","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, APRN-FNP-BC","1184278251","75-1997880","TX","PE - Andrews County Hospital District","Medicare","Participating","No Enrollment Required",43739,"","","2020-12-09","12/9/2020 Enrollment not required for adding provider under RHC. KFrazier"]
["Eliana Kelley, APRN-FNP-BC","1184278251","75-1997880","TX","PE - Andrews County Hospital District","Boon Chapman","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"]
["Eliana Kelley, APRN-FNP-BC","1184278251","75-1997880","TX","PE - Andrews County Hospital District","Scott&White (First Care)","Participating","Enrollment Complete","2021-02-12","","","2021-01-29","1/29/2021 - Rcvd roster from Scott&White (First Care) confirming participation of provider with TIN and location effective dates.  DCannon"]
["Eliana Kelley, APRN-FNP-BC","1184278251","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"]
["Julie Parker, APRN-NP","1720538606","75-1997880","TX","PE - Andrews County Hospital District","TriCare Standard","Participating","Enrollment Complete","2022-08-18","","","2022-09-15","9/15/2022 Per Tricare portal provider is PAR and linked to group TIN/location effective 8/18/2022.  DCannon"]
["Julie Parker, APRN-NP","1720538606","75-1997880","TX","PE - Andrews County Hospital District","Superior","Participating","Enrollment Complete","2021-02-01","","","2021-02-02","2/2/2021 - Rcvd confirmation from payer that provider is participating and linked to TIN effective 12/1/2020.  DCannon"]
["Julie Parker, APRN-NP","1720538606","75-1997880","TX","PE - Andrews County Hospital District","Tricare Prime","Participating","Enrollment Complete","2022-08-18","","","2024-01-26","Confirmed provider is credentialed and in network with Tricare. MS"]
["Julie Parker, APRN-NP","1720538606","75-1997880","TX","PE - Andrews County Hospital District","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"]
["Julie Parker, APRN-NP","1720538606","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."]
["Julie Parker, APRN-NP","1720538606","75-1997880","TX","PE - Andrews County Hospital District","Sedgwick","Participating","Enrollment Complete","2024-08-21","","","2024-08-22","Approval ltr rcvd. Effective 08/21/2024. Jen Videan"]
["Julie Parker, APRN-NP","1720538606","75-1997880","TX","PE - Andrews County Hospital District","CAQH","Participating","CAQH Reattested","2024-08-02","","","2024-08-02","08/02/2024 CAQH Reattested all locations current and all expirables up to date wthompson"]
["Julie Parker, APRN-NP","1720538606","75-1997880","TX","","Triwest VA","Enrollment on Hold","Enrollment on Hold","","","","","RHC."]
["Daniel J Dominguez, APRN-FNP-BC","1720610447","74-2348334","TX","PE - Permian Gastroenterology PA","Tricare Prime","Panel Closed","Panel Closed","","","","2023-09-25","Payer panel is currently closed. MS"]
["Daniel J Dominguez, APRN-FNP-BC","1720610447","74-2348334","TX","PE - Permian Gastroenterology PA","TriCare Standard","Participating","Enrollment Complete","2023-11-06","","","2023-12-07","Provider is linked to this location. MS"]
["Daniel J Dominguez, APRN-FNP-BC","1720610447","74-2348334","TX","PE - Permian Gastroenterology PA","Boon Chapman","Participating","Enrollment Complete","2023-07-17","","","2023-11-09","11/9/2023 Rcvd email confirmation from Jessica Bess at Multiplan that October roster has been processed and provider is PAR w/ group effective 7/17/2023.  DCannon"]
["Daniel J Dominguez, APRN-FNP-BC","1720610447","74-2348334","TX","","Aetna","Participating","Re-Credentialing","2023-06-15","6761851","","2024-04-15","4/17/2024- Submitted recred status via delegated monthly roster on 4/15/2024. FC."]
["Daniel J Dominguez, APRN-FNP-BC","1720610447","74-2348334","TX","PE - Permian Gastroenterology PA","Rail Road Medicare","Participating","Enrollment Complete","2023-12-12","Q00658568","CI6074","2024-02-07","Received welcome letter. MS"]
["Paula Kaye Brookings, APRN-FNP-BC","1295136034","75-2656723","TX","PE - Premier Family Care, Inc","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"]
["Paula Kaye Brookings, APRN-FNP-BC","1295136034","75-2656723","TX","PE - Premier Family Care, Inc","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"]
["Paula Kaye Brookings, APRN-FNP-BC","1295136034","75-2656723","TX","","Triwest VA","In House Enrollment","Facility Enrollment","","","","","10/17/2022 - Received roster from Scarlett; provider status: \"No Action.  TIN is CCN participating under own DCN.\""]
["Paula Kaye Brookings, APRN-FNP-BC","1295136034","75-2656723","TX","PE - Premier Family Care, Inc","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"]
["Paula Kaye Brookings, APRN-FNP-BC","1295136034","75-2656723","TX","PE - Premier Family Care, Inc","Aetna","Participating","Enrollment Complete",44203,"6518709","","2021-03-24","3/19/21 (kstrickland) Called Atena SW Allen Call ref # 6008145974. Provider is in network address was confirmed. Provider ID: 6518709 effective 1/7/2021.  DCannon"]
["Paula Kaye Brookings, APRN-FNP-BC","1295136034","75-2656723","TX","PE - Premier Family Care, Inc","First Health Coventry","Participating","Enrollment Complete","2020-11-01","","","2022-02-01","2/1/2022 Received email from FirstHealthCustomerServiceMailbox@AETNA.com, provider has been added to location.  CBankston"]
["Paula Kaye Brookings, APRN-FNP-BC","1295136034","75-2656723","TX","PE - Premier Family Care, Inc","CAQH","Participating","CAQH Reattested","2024-08-02","","","2024-08-02","08/02/2024 CAQH Reattested all locations current and all expirables up to date wthompson"]
["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",44440,"","","2021-11-18","11/18/2021 Rcvd full roster from Humana listing provider as PAR and linked to group TIN/location effective 9/1/2021.  DCannon"]
["Jennifer Lynn Delk-Fikes, APRN-FNP-BC","1386288876","20-4063608","TX","PE - C Vallie CFNP Limited Partnership","Wellmed","Participating","Enrollment Complete","2022-01-01","","","2023-03-23","3/23/2023 Rcvd roster from UHC w/ all Wellmed participating providers.  Provider is PAR effective 1/1/2022.  DCannon"]
["Jennifer Lynn Delk-Fikes, APRN-FNP-BC","1386288876","20-4063608","TX","PE - C Vallie CFNP Limited Partnership","Multiplan","Participating","Enrollment Complete",44203,"","","2022-07-24","7/24/2022 Per email from Marcie Eckhart-Havens Multiplan July delegated roster has been completed  and provider is PAR and linked to group TIN effective 1/7/2021.  DCannon"]
["Jennifer Lynn Delk-Fikes, APRN-FNP-BC","1386288876","20-4063608","TX","PE - C Vallie CFNP Limited Partnership","United Health Care","Participating","Enrollment Complete","2021-02-12","7369251","","2021-05-04","5/4/2021 Received a Roster of enrollment status from networkhelp@uhc.com which confirms provider is participating under group Tax ID with Commercial Choice, Community & State, and Medicare effective 2/12/2021 under unique ID 7369251. KFrazier"]
["Meagan Leighann Cunningham, APRN-FNP-BC","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, APRN-FNP-BC","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, APRN-FNP-BC","1891302931","75-1997880","TX","PE - Andrews County Hospital District","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"]
["Meagan Leighann Cunningham, APRN-FNP-BC","1891302931","75-1997880","TX","PE - Andrews County Hospital District","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"]
["Meagan Leighann Cunningham, APRN-FNP-BC","1891302931","75-1997880","TX","PE - Andrews County Hospital District","First Health Coventry","Participating","Enrollment Complete",44476,"","","2023-06-02","06.02.2023 S/W Trina of First Health @ 800-226-5116. Rep advised to call aetna first to see if provider is credentialed with aetna. S/W Chris of Aetna @ 1-800-353-1232. Per rep, provider is showing participating with First Health and link under the Group and TIN with an Effective date 10/07/2021. Provider ID 6806263, Payer ID 60025 and Recredentialing date 10/07/2024. Service location is on file. Call ref#:6149441125. - Danico Gabriel Melendres"]
["Bola O Jaiyeola, NP","1235605064","47-5554737","TX","PE - Midland Inpatient Medical Association","First Health Coventry","Participating","Enrollment Complete",45108,"","","2023-08-11","08.11.2023 S/W April of First Health @ 800-226-5116. Per rep, provider is showing par and link under the Group and TIN with an Effective date 07/01/2023. Provider ID 3336831. Service location is on file. Call ref#:725024.-Danico Gabriel Melendres"]
["Bola O Jaiyeola, NP","1235605064","47-5554737","TX","PE - Midland Inpatient Medical Association","Omni PPO","Participating","Enrollment Complete","2021-02-08","","","2021-04-01","4/1/2021  Rcvd confirmation email from German Aviles that providers have been loaded according to the monthly delegation roster.  DCannon"]
["Bola O Jaiyeola, NP","1235605064","47-5554737","TX","PE - Midland Inpatient Medical Association","HealthSmart PPO","Participating","Enrollment Complete",44235,"","","2021-05-04","5/4/2021 Rcvd confirmation from Healthsmart <cgc.data@healthsmart.com> that provider is PAR and loaded under TIN and location effective 2/8/2021.  DCannon"]
["Bola O Jaiyeola, NP","1235605064","47-5554737","TX","PE - Midland Inpatient Medical Association","Boon Chapman","Participating","Enrollment Complete",44235,"","","2022-07-24","7/24/2022 Per email from Marcie Eckhart-Havens Multiplan July delegated roster has been completed  and provider is PAR and linked to group TIN effective 2/8/2021.  DCannon"]
["Bola O Jaiyeola, NP","1235605064","47-5554737","TX","PE - Midland Inpatient Medical Association","Cigna","Participating","Enrollment Complete",44136,"2955877","","2021-04-06","4/6/2021 Received an email from PDMCOGZ@cigna.com confirming provider is now approved and participating under group Tax ID effective 11/1/2020 with assigned provider ID number 2955877. KFrazier"]
["Bola O Jaiyeola, NP","1235605064","47-5554737","TX","PE - Midland Inpatient Medical Association","United Health Care","Participating","Enrollment Complete","2021-02-18","","","2021-05-10","5/10/2021 Received an email response from Rep jean.lambert@optum.com with confirmation provider has been approved under group Tax ID effective 2/18/2021. KFrazier"]
["Rebecca McClay, DNP","1629613070","47-5554737","TX","PE - Midland Inpatient Medical Association","HealthSmart PPO","Participating","Re-Credentialing","2021-02-08","","","2024-02-20","2/20/2024- Submitted recred status via delegated monthly roster on 2/15/2024. FC."]
["Rebecca McClay, DNP","1629613070","47-5554737","TX","PE - Midland Inpatient Medical Association","United Health Care","Participating","Enrollment Complete",44257,"","","2021-05-10","5/10/2021 Received an email from Rep jean.lambert@optum.com confirming provider is participating under group Tax ID effective 3/2/2021. KFrazier"]
["Rebecca McClay, DNP","1629613070","47-5554737","TX","PE - Midland Inpatient Medical Association","Superior","Participating","Enrollment Complete","2021-05-01","","","2021-05-04","5/4/2021 Rcvd email from Superior confirming that the providers are PAR and loaded under TIN/locations effective 5/1/2021.  DCannon"]
["Rebecca McClay, DNP","1629613070","47-5554737","TX","PE - Midland Inpatient Medical Association","Wellmed","Participating","Enrollment Complete",44562,"","","2023-03-23","3/23/2023 Rcvd roster from UHC w/ all Wellmed participating providers.  Provider is PAR effective 1/1/2022.  DCannon"]
["Rebecca McClay, DNP","1629613070","47-5554737","TX","PE - Midland Inpatient Medical Association","First Health Coventry","Participating","Re-Credentialing","2022-03-01","3546235","","2024-02-20","2/20/2024- Submitted recred status via delegated monthly roster on 2/15/2024. FC."]
["Amanda Compton, MD","1679953517","26-3789190","TX","PE - Permian Physician Services","USA PPO","Participating","Enrollment Complete","2021-04-06","","","2023-05-19","Checked enrollment status via https://providersearch.usamco.com/wintprovsearch . Provider is enrolled with Group Health and Wellness PPO. MS"]
["Amanda Compton, MD","1679953517","26-3789190","TX","PE - Permian Physician Services","Texas Mutual","Participating","Enrollment Complete",45047,"","","2023-05-10","5/10/2023 Rcvd TX Mutual - WorkWell approval letter.  Provider is PAR and linked to group effective 5/1/2023.  DCannon"]
["Amanda Compton, MD","1679953517","75-1997880","TX","PE - Andrews County Hospital District","HealthSmart PPO","Participating","Re-Credentialing","2021-04-06","","","2024-03-18","3/18/2024- Submitted recred status via delegated monthly roster on 3/15/2024. FC."]
["Amanda Compton, MD","1679953517","26-3789190","TX","PE - Permian Physician Services","Scott&White (First Care)","Participating","Enrollment Complete","2023-01-15","","","2023-08-08","Per response from hpdelegation@bswhealth.org, Amanda Compton is effective 01/15/2023. Jen Videan"]
["Amanda Compton, MD","1679953517","26-3789190","TX","PE - Permian Physician Services","HealthSmart PPO","Participating","Re-Credentialing","2022-12-01","","","2024-03-18","3/18/2024- Submitted recred status via delegated monthly roster on 3/15/2024. FC."]
["Amanda Compton, MD","1679953517","26-3789190","TX","PE - Permian Physician Services","Caprock (CapStar)","Participating","Re-Credentialing",44896,"","","2024-03-18","3/18/2024- Submitted recred status via delegated monthly roster on 3/15/2024. FC."]
["Amanda Compton, MD","1679953517","75-1997880","TX","PE - Andrews County Hospital District","Amerigroup","Participating","Re-Credentialing","2019-08-01","","","2024-03-18","3/18/2024- Submitted recred status via delegated monthly roster on 3/15/2024. FC."]
["Amanda Compton, MD","1679953517","26-3789190","TX","PE - Permian Physician Services","Tricare Prime","Panel Closed","Panel Closed","","","","2022-12-15","12/15/2022 Per Tricare/Humana Military is currently not accepting requests to join the medical surgical network. Will check back soon to see if we are accepting network providers.  DCannon"]
["Amanda Compton, MD","1679953517","26-3789190","TX","PE - Permian Physician Services","Boon Chapman","Participating","Enrollment Complete","2022-12-01","","","2023-07-25","7/25/2023 Rcvd email from Jessica Bess at Multiplan with a full roster and provider is PAR w/ group effective 12/1/2022.  DCannon"]
["Amanda Compton, MD","1679953517","75-1997880","TX","PE - Andrews County Hospital District","First Health Coventry","Participating","Enrollment Complete","2022-12-01","3629097","","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","26-3789190","TX","PE - Permian Physician Services","IMS","Participating","Re-Credentialing",44896,"","","2024-03-18","3/18/2024- Submitted recred status via delegated monthly roster on 3/15/2024. FC."]
["Amanda Compton, MD","1679953517","26-3789190","TX","PE - Permian Physician Services","Humana","Participating","Enrollment Complete",44896,"","","2023-02-25","2/25/2023 Per email received from Vernita Young November delegated roster has been processed and provider is PAR effective 12/1/2022.  DCannon"]
["Amanda Compton, MD","1679953517","75-1997880","TX","PE - Andrews County Hospital District","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"]
["Amanda Compton, MD","1679953517","26-3789190","TX","PE - Permian Physician Services","First Health Coventry","Participating","Enrollment Complete","2022-12-01","","","2023-04-06","4/6/2023 Per confirm par status note -  provider is showing participating with an Effective date 12/01/2022 and link under the Group and TIN. Provider ID 3629097, Recredentialing date 12/01/2025. Service location is on file. DCannon"]
["Amanda Compton, MD","1679953517","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"]
["Karthik Chakrala, DO","1043633233","47-5554737","TX","PE - Midland Inpatient Medical Association","Cigna","Participating","Enrollment Complete","2021-06-08","1147058","","2021-07-06","7/2/2021 Received email from PDMCOGZ@Cigna.com confirming provider is now participating under group Tax ID effective 6/8/2021 with provider ID 1147058. KFrazier"]
["Karthik Chakrala, DO","1043633233","47-5554737","TX","PE - Midland Inpatient Medical Association","Aetna","Participating","Re-Credentialing",44326,"","","2024-04-19","4/19/2024- Submitted recred status via delegated monthly roster on 4/15/2024. FC"]
["Karthik Chakrala, DO","1043633233","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"]
["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","CAQH","Participating","CAQH Reattested",45533,"","","2024-08-29","08/29/2024 CAQH Reattested updated and uploaded COI wthompson"]
["Karthik Chakrala, DO","1043633233","47-5554737","TX","PE - Midland Inpatient Medical Association","Caprock (CapStar)","Participating","Re-Credentialing","2021-05-10","","","2024-04-19","4/19/2024- Submitted recred status via delegated monthly roster on 4/15/2024. FC"]
["Karthik Chakrala, DO","1043633233","47-5554737","TX","PE - Midland Inpatient Medical Association","Galaxy Health","Participating","Enrollment Complete","2021-05-10","","","2021-06-03","6/3/2021 Rcvd email from Galaxy Health, Karen Avalos <kavalos@ghn.mci.com> that monthly delegation roster for May is complete and providers are loaded under TIN/locations effective 5/10/2021.  DCannon"]
["Orlando Enrique Garner Cruz, MD","1417309105","75-2656723","TX","PE - Premier Family Care, Inc","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"]
["Orlando Enrique Garner Cruz, MD","1417309105","75-2656723","TX","","USA PPO","Participating","Enrollment Complete","2021-05-10","","","2022-06-29","6/29/2022 Per email received from Priscilla Albertine at MQA from a follow-up email she received from USA PPO provider is PAR and in linked to group TIN effective 5/10/2021.  DCannon"]
["Orlando Enrique Garner Cruz, MD","1417309105","75-2656723","TX","PE - Premier Family Care, Inc","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, Inc","Wellmed","Participating","Enrollment Complete","2021-05-10","","","2023-03-23","3/23/2023 Rcvd roster from UHC w/ all Wellmed participating providers.  Provider is PAR effective 5/10/2021.  DCannon"]
["Orlando Enrique Garner Cruz, MD","1417309105","75-2656723","TX","","United Health Care","Participating","Enrollment Complete","2021-05-10","","","2022-06-11","6/11/2022 Per email from Janice Edwards @ UHC delegated roster provider load has been completed and providers PAR and linked to group TIN effective 5/10/2021.  DCannon"]
["Orlando Enrique Garner Cruz, MD","1417309105","75-2656723","TX","PE - Premier Family Care, Inc","Wellcare","Participating","Enrollment Complete",44501,"","","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","","Amerigroup","Participating","Re-Credentialing","2021-05-10","","","2024-04-19","4/19/2024- Submitted recred status via delegated monthly roster on 4/15/2024. FC"]
["Orlando Enrique Garner Cruz, MD","1417309105","75-2656723","TX","PE - Premier Family Care, Inc","Humana","Participating","Enrollment Complete",44440,"","","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","1417309105","75-2656723","TX","","Multiplan","Participating","Re-Credentialing","2021-05-10","","","2024-04-19","4/19/2024- Submitted recred status via delegated monthly roster on 4/15/2024. FC"]
["Orlando Enrique Garner Cruz, MD","1417309105","75-2656723","TX","PE - Premier Family Care, Inc","Triwest VA","Facility Enrollment","Facility Enrollment","","","","2022-10-17","10/17/2022 - Received roster from Scarlett of TriWest VA; provider status: \"No Action.  TIN is CCN participating under own DCN.\""]
["Orlando Enrique Garner Cruz, MD","1417309105","75-2656723","TX","PE - Premier Family Care, Inc","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"]
["Orlando Enrique Garner Cruz, MD","1417309105","75-2656723","TX","","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"]
["Kristin M Moose, APRN-FNP-BC","1215213970","75-2182177","TX","PE - Debbie P. Reese, MD PA","Cigna","Participating","Enrollment Complete","2023-12-11","1427540","","2024-01-02","Received confirmation of approval effective 12/11/2023. MS"]
["Kristin M Moose, APRN-FNP-BC","1215213970","75-2182177","TX","PE - Debbie P. Reese, MD PA","Triwest VA","In House Enrollment","In House Enrollment","","","","2023-12-15",""]
["Kristin M Moose, APRN-FNP-BC","1215213970","75-2182177","TX","PE - Debbie P. Reese, MD PA","IMS","Participating","Enrollment Complete","2023-12-11","","","2024-01-02","1/2/2024 Rcvd email from German Avilies at IMS/OMNI that December delegation roster is complete.  Provider is PAR and linked to group TIN/location effective 12/11/2023.  DCannon"]
["Kristin M Moose, APRN-FNP-BC","1215213970","75-2182177","TX","PE - Debbie P. Reese, MD PA","Medicaid","Participating","Enrollment Complete","2024-04-24","1215213970","","2024-06-11","Approval ltr rcvd. Provider effective 04/24/2024. Jen Videan"]
["Kristin M Moose, APRN-FNP-BC","1215213970","75-2182177","TX","PE - Debbie P. Reese, MD PA","Superior","Participating","Enrollment Complete","2024-01-01","","","2024-01-12","1/12/2024 Per email rcvd from Superior, December roster is complete provider is PAR and linked to group TIN/locations effective 1/1/2024.  DCannon"]
["Emily N Baker Butler","1053817940","75-2656723","TX","PE - Premier Family Care, Inc","Galaxy Health","Participating","Enrollment Complete","2021-08-09","","","2021-10-06","10/6/2021 Rcvd email from Karen Avalos at Galaxy confirming that the August delegated roser provider load has been completed and providers are loaded under TIN/locations effective 8/9/2021.  DCannon"]
["Emily N Baker Butler","1053817940","75-2656723","TX","","IMS","Participating","Application Resubmitted","2021-08-09","","","2024-07-18","Submitted reapplication via delegated roster on 7/15/2024. FC"]
["Emily N Baker Butler","1053817940","75-2656723","TX","PE - Premier Family Care, Inc","Scott&White (First Care)","Participating","Enrollment Complete","2021-08-27","","","2021-10-13","10/13/21 Received email from BSWHPEXPEDITES@BSWHealth.org, provder is effective as of 08/27/2021. However, please allow 3-4 weeks before submitting claims to ensure he/she is completely configured in our system; otherwise, claims may deny. Cbankston"]
["Emily N Baker Butler","1053817940","75-2656723","TX","PE - Premier Family Care, Inc","USA PPO","Participating","Enrollment Complete","2021-08-09","","","2021-12-03","12/3/2021  In following up with USAMCO (800-872-3860) I was told that you can confirm participating via the USA MCO website  https://providersearch.usamco.com/hwprovsearch.  Provider is PAR and linked to location/TIN effective 8/9/2021.  DCannon"]
["Emily N Baker Butler","1053817940","75-2656723","TX","","Multiplan","Participating","Application Resubmitted",44470,"13951752","","2024-07-18","Submitted reapplication via delegated roster on 7/15/2024. FC"]
["Emily N Baker Butler","1053817940","75-2656723","TX","","Caprock (CapStar)","Participating","Application Resubmitted",44417,"","","2024-07-18","Submitted reapplication via delegated roster on 7/15/2024. FC"]
["Emily N Baker Butler","1053817940","75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","","","","2024-04-25","Tricare Standard completed, and Prime is automatically updated. MS"]
["Emily N Baker Butler","1053817940","75-2656723","TX","","Medicare","Participating","Application Resubmitted","2021-08-01","1R7343","0008AH","2024-08-14","It was confirmed the client corrected the providers NPPES and the application to update the last name has been submitted via PECOS. MS"]
["Emily N Baker Butler","1053817940","75-2656723","TX","PE - Premier Family Care, Inc","TriCare Standard","Participating","Enrollment Complete","2021-07-21","","","2021-07-22","7/22/2021 Received an email from Rep Katlyn.Cooper@wpsic.com confirming provider is now certified under the group Tax ID. KFrazier"]
["Emily N Baker Butler","1053817940","75-2656723","TX","","Amerigroup","Participating","Application Resubmitted","2021-08-09","","","2024-07-18","Submitted reapplication via delegated roster on 7/15/2024. FC"]
["Emily N Baker Butler","1053817940","75-2656723","TX","PE - Premier Family Care, Inc","Omni PPO","Participating","Add Info Submitted","2021-08-09","","","2024-04-19","4/19/2024- Submitted new last name via delegated roster on 4/15/2024. FC"]
["Emily N Baker Butler","1053817940","75-2656723","TX","PE - Premier Family Care, Inc","Medicaid","Participating","Enrollment Complete","2021-08-01","426462401","","2021-08-30","8/30/2021 Received an email from Candace Wynne the provider's Medicaid has been approved with assigned TPI 426462401 under group effective 8/1/2021. KFrazier"]
["Emily N Baker Butler","1053817940","75-2656723","TX","PE - Premier Family Care, Inc","HealthSmart PPO","Participating","Application Resubmitted","2021-08-09","","","2024-07-18","Submitted reapplication via delegated roster on 7/15/2024. FC"]
["Sandra Maerzacker, MD","1396190823","92-1786827","TX","Sandra Maerzacker, MD, PLLC","Omni PPO","Participating","Application Resubmitted","2023-01-03","","","2024-07-18","Submitted reapplication via delegated roster on 7/15/2024. FC"]
["Sandra Maerzacker, MD","1396190823","92-1786827","TX","","Omni PPO","Participating","Application Resubmitted","2023-01-03","","","2024-07-18","Submitted reapplication via delegated roster on 7/15/2024. FC"]
["Sandra Maerzacker, MD","1396190823","92-1786827","TX","Sandra Maerzacker, MD, PLLC","Multiplan","Participating","Enrollment Complete","2021-08-13","","","2023-06-21","Rcvd effective date of 08/13/2021 from jessica.bess@MultiPlan.com.\nJen Videan"]
["Sandra Maerzacker, MD","1396190823","92-1786827","TX","Sandra Maerzacker, MD, PLLC","USA PPO","Participating","Enrollment Complete","2023-03-15","","","2023-10-18","10/18/2023 Per USA MCO roster received correct effective date is 3/15/2023.  DCannon"]
["Sandra Maerzacker, MD","1396190823","92-1786827","TX","Sandra Maerzacker, MD, PLLC","IMS","Participating","Enrollment Complete","2023-01-03","","","2023-05-17","5/17//2023 Rcvd email from German Aviles at IMS/OMNI that delegation roster for July & August have been completed and updated in their system effective 1/3/2023.  DCannon"]
["Sandra Maerzacker, MD","1396190823","92-1786827","TX","","IMS","Participating","Enrollment Complete","2023-01-03","","","2023-05-17","5/17//2023 Rcvd email from German Aviles at IMS/OMNI that delegation roster for July & August have been completed and updated in their system effective 1/3/2023.  DCannon"]
["Sandra Maerzacker, MD","1396190823","92-1786827","TX","Sandra Maerzacker, MD, PLLC","First Health Coventry","Participating","Enrollment Complete","2023-11-01","","","2023-10-31","10/31/2023 Rcvd copy of signed and executed contract from First Health.  Provider and group are PAR effective 11/1/2023.  DCannon"]
["Sandra Maerzacker, MD","1396190823","92-1786827","TX","Sandra Maerzacker, MD, PLLC","Aetna","Participating","Enrollment Complete","2023-01-03","","","2023-08-21","8/21/2023 Rcvd email from Priscilla Albertine at MQA with correct effective date for provider should be 1/3/2023.  DCannon"]
["Sandra Maerzacker, MD","1396190823","92-1786827","TX","","HealthSmart PPO","Participating","Enrollment Complete","2023-01-03","","","2023-11-13","11/13/2023 Per phone conversation w/ Lee Kinard at Healthsmart provider is PAR and linked to group TIN effective 1/3/2023.  DCannon"]
["Sandra Maerzacker, MD","1396190823","92-1786827","TX","Sandra Maerzacker, MD, PLLC","HealthSmart PPO","Participating","Application Resubmitted","2023-01-03","","","2024-07-18","Submitted reapplication via delegated roster on 7/15/2024. FC"]
["Sandra Maerzacker, MD","1396190823","92-1786827","TX","","Amerigroup","Participating","Application Resubmitted","2021-08-13","","","2024-07-18","Submitted reapplication via delegated roster on 7/15/2024. FC"]
["Brenda Campos-Ilesanmi, APRN-NP","1740807304","75-2656723","TX","PE - Premier Family Care, 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","75-2656723","TX","PE - Premier Family Care, Inc","CAQH","Participating","CAQH Reattested","2024-08-28","","","2024-08-28","08/28/2024 CAQH Reattested updated and uploaded COI wthompson"]
["Brenda Campos-Ilesanmi, APRN-NP","1740807304","75-2656723","TX","PE - Premier Family Care, Inc","Galaxy Health","Participating","Enrollment Complete","2023-04-27","","","2023-07-20","7/20/2023 Per email received from Galaxy May delegated roster has been processed and provider is PAR and linked to group effective 4/27/2023.  DCannon"]
["Brenda Campos-Ilesanmi, APRN-NP","1740807304","75-2656723","TX","PE - Premier Family Care, Inc","Medicaid","Participating","Enrollment Complete","2022-07-26","","","2023-08-21","Per TMHP website provider effective 07/26/2022 at 400 Rosalind Redfern Grover Pkwy Ste 120. Jen Videan"]
["Brenda Campos-Ilesanmi, APRN-NP","1740807304","75-2656723","TX","PE - Premier Family Care, 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"]
["Brenda Campos-Ilesanmi, APRN-NP","1740807304","75-2656723","TX","PE - Premier Family Care, Inc","Medicare","Participating","Enrollment Complete","2022-07-12","2G2470","0008AH","2023-07-19","7/19/2023 Per PECOS provider is PAR and linked to group and location 4214 Andrews Hwy, Ste. 102.  DCannon"]
["Brenda Campos-Ilesanmi, APRN-NP","1740807304","75-2656723","TX","PE - Premier Family Care, 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","75-2656723","TX","PE - Premier Family Care, Inc","Superior","Participating","Enrollment Complete","2022-08-01","","","2023-07-17","7/17/2023 Rcvd email from Superior that provider is PAR and linked to new location via group delegated roster effective 6/1/2023.  DCannon"]
["Brenda Campos-Ilesanmi, APRN-NP","1740807304","75-2656723","TX","PE - Premier Family Care, Inc","Galaxy Health","Participating","Enrollment Complete","2022-08-01","","","2022-08-17","8/17/2022 Per email from Karen Avalos at Galaxy delegated roster for July is complete and provider is loaded effective 8/1/2022.  DCannon"]
["Brenda Campos-Ilesanmi, APRN-NP","1740807304","75-2656723","TX","PE - Premier Family Care, Inc","First Health Coventry","Participating","Enrollment Complete","2022-08-01","3546219","","2023-11-20","11/20/2023 S/W Sam of First Health @ 800-226-5116, per rep provider is showing participating and link under the Group and TIN with an Effective date 8/1/2022. Provider ID 3546219. Physical locations are on file. Call ref#:773026. - DCannon"]
["Brenda Campos-Ilesanmi, APRN-NP","1740807304","75-2656723","TX","PE - Premier Family Care, Inc","TriCare Standard","Participating","Enrollment Complete","","","","2023-10-19","Confirmed enrollment. MS"]
["Brenda Campos-Ilesanmi, APRN-NP","1740807304","75-2656723","TX","PE - Premier Family Care, Inc","USA PPO","Participating","Enrollment Complete","2022-08-01","","","2023-08-23","8/23/2023 In following up with USAMCO (800-872-3860) I was told that you can confirm participating via the USA MCO website  https://providersearch.usamco.com/hwprovsearch.  Provider is PAR and linked to location/TIN effective 8/1/2022.  DCannon"]
["Addis Getahun, MD","1548765183","47-5554737","TX","PE - Midland Inpatient Medical Association","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"]
["Addis Getahun, MD","1548765183","47-5554737","TX","PE - Midland Inpatient Medical Association","Superior","Participating","Enrollment Complete","2021-12-01","","","2022-04-18","4/18/2022 Per Superior Validation roster provider is PAR and linked to group/location effective 12/1/2021.  DCannon"]
["Addis Getahun, MD","1548765183","47-5554737","TX","PE - Midland Inpatient Medical Association","Omni PPO","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"]
["Addis Getahun, MD","1548765183","47-5554737","TX","PE - Midland Inpatient Medical Association","First Health Coventry","Participating","Enrollment Complete","2022-12-01","","","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 3630197, Payer ID 73159 and Recredentialing date 12/01/2025. Service location is on file. Call ref#:517681. -Danico Gabriel Melendres"]
["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","First Health Coventry","Participating","Enrollment Complete","2023-09-01","3733859","","2023-10-19","10.17.2023 S/W Shanon of First Health @ 800-226-5116 but it was transferred to Trina. Per rep, provider is showing participating and link under the Group and TIN with an Effective date 09/01/2023. Provider ID 3733859. Service location is on file. Call ref#:788591.-Danico Gabriel Melendres"]
["Martha Denise Mourning, NP","1922552959","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"]
["Martha Denise Mourning, NP","1922552959","47-5554737","TX","PE - Midland Inpatient Medical Association","CAQH","Participating","CAQH Reattested","2024-08-29","","","2024-08-29","08/29/2024 CAQH Reattested updated and uploaded COI wthompson"]
["Martha Denise Mourning, NP","1922552959","47-5554737","TX","PE - Midland Inpatient Medical Association","Rail Road Medicare","Participating","Enrollment Complete",44507,"Q00152414","DW7662","2021-10-25","10/25/2021 Rcvd RR Medicare PTAN Approval letter.   PTAN - Q00152414 - effective 11/7/2021.  DCannon"]
["Martha Denise Mourning, NP","1922552959","47-5554737","TX","PE - Midland Inpatient Medical Association","Galaxy Health","Participating","Enrollment Complete",44498,"","","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 10/29/2021.  DCannon"]
["Daniel Gellan, MD","1811315880","47-5554737","TX","PE - Midland Inpatient Medical Association","Superior","Participating","Enrollment Complete","2022-01-01","","","2022-02-07","2/7/2022 Rcvd email from Superior that provider is PAR and linked to group TIN/location effective 1/1/2022.  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","Cigna","Participating","Enrollment Complete","2021-10-12","0056401","","2021-10-28","10/28/2021 Per follow-up notes.  Provider NPI# is on file for the provider and is participating effective 10/12/2021 under the group and TIN#. PIN 0056401. Physical location is on file. Call ref# Roberts10272021. DCannon"]
["Daniel Gellan, MD","1811315880","47-5554737","TX","PE - Midland Inpatient Medical Association","CAQH","Participating","CAQH Reattested","2024-08-12","","","2024-08-12","08/12/2024 CAQH Reattested all locations current and all expirables up to date wthompson"]
["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"]
["Venkatasubbaraya Achanta, MD","1780693648","47-5554737","TX","PE - Midland Inpatient Medical Association","Medicaid","Participating","Enrollment Complete","","1780693648","1851764963","2023-01-24","1/24/2023 Per TMHP web portal provider is PAR and linked to group effective 11/7/2007.  TPI # 1780693648.  DCannon"]
["Venkatasubbaraya Achanta, MD","1780693648","47-5554737","TX","PE - Midland Inpatient Medical Association","CAQH","Participating","CAQH Reattested","2024-07-08","","","2024-07-08","07/08/2024 CAQH Reattested updated and uploaded DEA wthompson"]
["Venkatasubbaraya Achanta, MD","1780693648","47-5554737","TX","PE - Midland Inpatient Medical Association","Multiplan","Participating","Enrollment Complete","2022-01-15","","","2022-01-24","1/24/2022 Rcvd approval letter, provider is PAR and linked to group/location effective 1/15/2022.  DCannon"]
["Venkatasubbaraya Achanta, MD","1780693648","47-5554737","TX","PE - Midland Inpatient Medical Association","TriCare Standard","Participating","No Enrollment Required","2021-12-01","","","2021-11-09","11/9/2021 Provider is currently certified as non-network so no application is needed. KFrazier"]
["Venkatasubbaraya Achanta, MD","1780693648","47-5554737","TX","PE - Midland Inpatient Medical Association","Superior","Participating","Enrollment Complete",44593,"","","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"]
["Venkatasubbaraya Achanta, MD","1780693648","47-5554737","TX","PE - Midland Inpatient Medical Association","United Health Care","Participating","Enrollment Complete",44571,"002937778","","2022-05-11","5/11/2022 Received email confirmation that provider is PAR and linked to group TIN/location effective 1/10/2022.  MPIN# 002937778.  DCannon"]
["Brandon H Rayne, PA","1912482209","46-0950925","TX","PE - Urgent Orthopedic Specialists, PLLC","United Health Care","Participating","Enrollment Complete","2023-09-08","008166599","","2023-10-27","10/27/2023 Received email confirmation from Priscilla Albertine and UHC that effective date has been corrected to 9/8/2023.  DCannon"]
["Brandon H Rayne, PA","1912482209","46-0950925","TX","PE - Urgent Orthopedic Specialists, PLLC","Medicare","Participating","Enrollment Complete","2021-11-04","1Z9417","","2023-10-12","Confirmed via PECOS the provider is enrolled and active under this TIN. MS"]
["Brandon H Rayne, PA","1912482209","46-0950925","TX","PE - Urgent Orthopedic Specialists, PLLC","Amerigroup","Participating","Enrollment Complete",45047,"","",45523,"As per Cassandra Dunagon received confirmation provider participating as of 5/1/2023 via email. FC"]
["Brandon H Rayne, PA","1912482209","46-0950925","TX","","Amerigroup","Participating","Enrollment Complete","2023-05-01","","","2024-08-19","As per Cassandra Dunagon received confirmation provider participating as of 5/1/2023 via email. FC"]
["Brandon H Rayne, PA","1912482209","46-0950925","TX","PE - Urgent Orthopedic Specialists, PLLC","Sedgwick","Participating","Enrollment Complete","2024-02-21","","","2024-02-21","Rcvd approval ltr. Provider is effective 02/21/2024. Jen Videan"]
["Brandon H Rayne, PA","1912482209","46-0950925","TX","PE - Urgent Orthopedic Specialists, PLLC","Zurich","Participating","Enrollment Complete","","","","2024-02-02","Per Coventry portal provider is enrolled. Jen Videan"]
["Brandon H Rayne, PA","1912482209","46-0950925","TX","PE - Urgent Orthopedic Specialists, PLLC","Coventry Workers Comp","Participating","Enrollment Complete","2023-09-01","","","2024-02-02","Per Coventry portal provider is enrolled. Jen Videan"]
["Brandon H Rayne, PA","1912482209","46-0950925","TX","PE - Urgent Orthopedic Specialists, PLLC","First Health Coventry","Participating","Enrollment Complete",45177,"3746084","","2023-11-20","11/20/2023 S/W Sam of First Health @ 800-226-5116, per rep provider is showing participating and link under the Group and TIN with an Effective date 9/8/2023. Provider ID 3746084. Physical locations are on file. Call ref#:773026. - DCannon"]
["Ragini Sastry, DO","1942568431","26-3789190","TX","PE - Permian Physician Services","Corvel Healthcare Corp.","Enrollment Stopped","Enrollment Stopped","","","","2024-01-16","Per Melody Starcher mstarcher@permianregional.com, Permian Physician Services and Andrews Family Medicine have  decided not to sign a contract  with Corvel. Jen Videan"]
["Ragini Sastry, DO","1942568431","26-3789190","TX","PE - Permian Physician Services","Aetna","Participating","Enrollment Complete","2022-05-09","6410096","","2022-06-08","6/8/2022 Per Aetna provider directory provider is PAR and linked to group TIN/location effective 5/9/2022.   DCannon"]
["Ragini Sastry, DO","1942568431","26-3789190","TX","PE - Permian Physician Services","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","75-1997880","TX","PE - Andrews County Hospital District","Tricare Prime","Participating","Enrollment Complete","2022-12-14","","","2024-01-26","Confirmed provider is credentialed and in network with Tricare. MS"]
["Ragini Sastry, DO","1942568431","26-3789190","TX","PE - Permian Physician Services","CAQH","Participating","CAQH Reattested","2024-08-13","","","2024-08-13","08/13/2024 CAQH Reattested all locations current and all expirables up to date wthompson"]
["Ragini Sastry, DO","1942568431","26-3789190","TX","PE - Permian Physician Services","HealthSmart PPO","Participating","Enrollment Complete","2022-05-09","","","2022-07-14","7/14/2022 Per Healthsmart website provider is PAR and loaded under TIN/location effective 5/9/2022.  DCannon"]
["Ragini Sastry, DO","1942568431","75-1997880","TX","PE - Andrews County Hospital District","HealthSmart PPO","Participating","Enrollment Complete","2022-05-09","","","2022-07-14","7/14/2022 Per Healthsmart website provider is PAR and loaded under TIN/location effective 5/9/2022.  DCannon"]
["Ragini Sastry, DO","1942568431","75-1997880","TX","PE - Andrews County Hospital District","First Health Coventry","Participating","Enrollment Complete","2022-05-01","3218967","","2023-05-02","5/2/2023 Per confirm par status note -  Per rep, provider is showing participating with an effective date 05/01/2022 and link under the Group and TIN. Provider ID 3218967, No Payer ID and No recredentialing date. Service location is on file. Call ref#:610385.-DCannon"]
["Ragini Sastry, DO","1942568431","26-3789190","TX","PE - Permian Physician Services","Medicare","Participating","In House Enrollment",44531,"1X1116","0A3812","2021-12-31","12/31/2021 Per PECOS provider is PAR and linked to group/locations.  PTAN# 1X1116 - effective 12/1/2021.  DCannon"]
["Ragini Sastry, DO","1942568431","75-1997880","TX","PE - Andrews County Hospital District","Rail Road Medicare","No Enrollment Required","No Enrollment Required","","","","2022-03-10","3/10/2022 No RR Medicare enrollment since provider is not enrolled in Medicare at this location since it is an RHC.  DCannon"]
["Ragini Sastry, DO","1942568431","26-3789190","TX","PE - Permian Physician Services","Cigna","Participating","Enrollment Complete","2021-12-01","0570215","","2022-04-06","4/6/2022 Received email from pdmcogz@cigna.com, provider is eff and linked to group as of 12/1/2021. PID 0570215. Cbankston"]
["Ragini Sastry, DO","1942568431","26-3789190","TX","PE - Permian Physician Services","Broadspire Services Inc.","Enrollment Stopped","Enrollment Stopped","","","","2023-12-11","Permian Physician Services would like to hold off contracting with Broadspire at this time. Jen Videan"]
["Ragini Sastry, DO","1942568431","75-1997880","TX","PE - Andrews County Hospital District","Caprock (CapStar)","Participating","Enrollment Complete",43831,"","","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","75-1997880","TX","PE - Andrews County Hospital District","Travelers WC","Delegated - Third Party","Thru Other Payor","","","","2024-01-30","Check Coventry portal for enrollment status. Provider currently not showing as active.  Jen Videan"]
["Ragini Sastry, DO","1942568431","26-3789190","TX","PE - Permian Physician Services","Ambetter","Participating","Enrollment Complete","2022-06-01","","","2022-06-13","6/13/2022 Per roster received from Superior provider is PAR and linked to group delegation roster effective 6/1/2022."]
["Ragini Sastry, DO","1942568431","26-3789190","TX","PE - Permian Physician Services","Travelers WC","Delegated - Third Party","Thru Other Payor","","","","2024-02-01","Check Coventry portal for enrollment status. Provider currently not showing as active.  Jen Videan"]
["Judy J Jia, MD","1588983134","75-2656723","TX","PE - Premier Family Care, 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"]
["Judy J Jia, MD","1588983134","75-2656723","TX","PE - Premier Family Care, 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"]
["Judy J Jia, MD","1588983134","75-2656723","TX","PE - Premier Family Care, Inc","IMS","Participating","Enrollment Complete","2022-04-11","","","2022-05-26","5/26/2022 Rcvd email from G. Aviles at IMS/OMNI stating that the monthly delegated roster provider loads for April has been completed.  Provider is PAR and linked to location/TIN effective 4/11/2022. DCannon"]
["Judy J Jia, MD","1588983134","75-2656723","TX","PE - Premier Family Care, Inc","First Health Coventry","Participating","Enrollment Complete","2022-07-01","2763424","","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","1588983134","75-2656723","TX","PE - Premier Family Care, Inc","Multiplan","Participating","Enrollment Complete","2022-04-11","","","2022-07-24","7/24/2022 Per email from Marcie Eckhart-Havens Multiplan July delegated roster has been completed  and provider is PAR and linked to group TIN effective 4/11/2022.  DCannon"]
["Claude B Nguyen, MD","1619130929","75-2656723","TX","PE - Premier Family Care, Inc","Medicaid","Participating","Enrollment Complete","2012-06-15","1619130929","","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","1619130929","75-2656723","TX","PE - Premier Family Care, Inc","Ambetter","Participating","Enrollment Complete",44682,"","","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","1619130929","75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","2022-03-10","","","2024-01-25","Confirmed provider is credentialed and in network with Tricare. MS"]
["Claude B Nguyen, MD","1619130929","75-2656723","TX","PE - Premier Family Care, Inc","Galaxy Health","Participating","Enrollment Complete",44622,"","","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","1619130929","75-2656723","TX","PE - Premier Family Care, Inc","Humana","Participating","Enrollment Complete","2022-04-11","","","2022-07-14","7/14/2022 Per email received from Humana provider is PAR and linked to group TIN/location effective 4/11/2022.  DCannon"]
["Claude B Nguyen, MD","1619130929","75-2656723","TX","PE - Premier Family Care, 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"]
["Claude B Nguyen, MD","1619130929","75-2656723","TX","PE - Premier Family Care, Inc","HealthSmart PPO","Participating","Enrollment Complete","2022-03-02","","","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","1558343988","75-2656723","TX","PE - Premier Family Care, Inc","Wellmed","Participating","Enrollment Complete","2022-08-23","","","2023-03-23","3/23/2023 Rcvd roster from UHC w/ all Wellmed participating providers.  Provider is PAR effective 8/23/2022.  DCannon"]
["John H Ownby, MD","1558343988","75-2656723","TX","PE - Premier Family Care, Inc","Galaxy Health","Participating","Enrollment Complete",44662,"","","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, Inc","USA PPO","Participating","Enrollment Complete",44662,"","","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","1558343988","75-2656723","TX","PE - Premier Family Care, Inc","Cigna","Participating","Enrollment Complete",44613,"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, Inc","Wellcare","Participating","Enrollment Complete",44682,"","","2022-07-01","7/1/2022 Received May Monthly Validation roster from Superior and provider is PAR and linked effective 5/1/2022.  DCannon"]
["Elena Krendelshchikova, APRN-NP","1356714406","27-4061759","TX","PE - Permian Cardiology Inc.","Rail Road Medicare","Participating","Enrollment Complete","2021-12-16","P02651504","DS1746","2022-05-26","5/26/2022 Rcvd RR Medicare approval letter. RR Medicare PTAN #  P02651504 - effective 12/16/2021.  DCannon"]
["Elena Krendelshchikova, APRN-NP","1356714406","27-4061759","TX","PE - Permian Cardiology Inc.","Wellmed","In Process","Application Resubmitted","2022-05-13","","","2024-08-15","Application resubmitted to payor with new cred status. PA."]
["Elena Krendelshchikova, APRN-NP","1356714406","27-4061759","TX","PE - Permian Cardiology Inc.","Caprock (CapStar)","In Process","Application Submitted","","","","2024-08-19","Submitted via delegated roster on 8/15/2024. FC"]
["Elena Krendelshchikova, APRN-NP","1356714406","27-4061759","TX","PE - Permian Cardiology Inc.","Superior","In Process","Application Resubmitted",44621,"","","2024-08-15","Application resubmitted to payor with new cred status. PA."]
["Elena Krendelshchikova, APRN-NP","1356714406","27-4061759","TX","PE - Permian Cardiology Inc.","Amerigroup","In Process","Application Submitted","","","","2024-08-19","Submitted via delegated roster on 8/15/2024. FC"]
["Elena Krendelshchikova, APRN-NP","1356714406","27-4061759","TX","PE - Permian Cardiology Inc.","Multiplan","In Process","Application Submitted","","","","2024-08-19","Submitted via delegated roster on 8/15/2024. FC"]
["Megan E Rosa, PA","1720698640","75-2656723","TX","PE - Premier Family Care, Inc","CAQH","Provider Load","CAQH Reattested","2024-09-03","","","2024-09-03","09/03/2024 CAQH Sweep Updated practice locations and cred contact wthompson"]
["Megan E Rosa, PA","1720698640","75-2656723","TX","PE - Premier Family Care, Inc","Cigna","Provider Load","Provider Load","2024-09-03","","","2024-09-03",""]
["Amanda J Wilson, FNP-BC","1609484419","84-2617748","TX","PE - Midland Medicine PA","Superior","Participating","Enrollment Complete","2022-06-01","","","2022-06-01","6/1/2022 Rcvd roster from Superior Health Plan confirming provider is PAR and linked to group TIN/location effective 6/1/2022.  DCannon"]
["Amanda J Wilson, FNP-BC","1609484419","84-2617748","TX","PE - Midland Medicine PA","Omni PPO","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"]
["Amanda J Wilson, FNP-BC","1609484419","84-2617748","TX","PE - Midland Medicine PA","BCBSTX","Participating","Enrollment Complete","2022-02-18","","","2024-08-29","Received email confirmation provider is par and linked to TIN/location, eff. 02/18/2022. PA."]
["Kendra Cooper, APRN-FNP-BC","1780334193","75-2656723","TX","PE - Premier Family Care, Inc","United Health Care","Participating","Enrollment Complete","2022-07-01","008051513","","2022-08-10","8/10/2022 Rcvd email from UHC that July monthly delegation roster has been completed and provider is PAR and linked to group TIN effective 7/1/2022.  MPIN # 008051513  DCannon"]
["Kendra Cooper, APRN-FNP-BC","1780334193","75-2656723","TX","PE - Premier Family Care, Inc","Medicaid","Participating","Enrollment Complete","2022-07-01","","","2023-08-21","Rcvd TMHP welcome letter, provider effective 07/01/2022. Jen Videan"]
["Kendra Cooper, APRN-FNP-BC","1780334193","75-2656723","TX","PE - Premier Family Care, Inc","USA PPO","Participating","Enrollment Complete","2023-07-19","","","2023-08-23","8/23/2023 In following up with USAMCO (800-872-3860) I was told that you can confirm participating via the USA MCO website  https://providersearch.usamco.com/hwprovsearch.  Provider is PAR and linked to location/TIN effective 7/19/2023.  DCannon"]
["Kendra Cooper, APRN-FNP-BC","1780334193","75-2656723","TX","PE - Premier Family Care, Inc","Aetna","Participating","Enrollment Complete","2022-08-22","","","2022-09-29","9/29/2022 Per follow-up note -   provider is showing participating with an effective date 08/22/2022 and link under the Group and TIN. Provider ID 6312366 and Recredentialing date 08/22/2025. Service location is on file.  DCannon"]
["Kendra Cooper, APRN-FNP-BC","1780334193","75-2656723","TX","PE - Premier Family Care, Inc","Humana","Participating","Enrollment Complete",44743,"","","2024-06-21","Received email confirmation from Marcus Wester, provider is par and linked to TIN/location, eff. 07/01/2022. PA."]
["Kendra Cooper, APRN-FNP-BC","1780334193","75-2656723","TX","PE - Premier Family Care, Inc","Triwest VA","In House Enrollment","In House Enrollment","","","",45129,""]
["Kendra Cooper, APRN-FNP-BC","1780334193","75-2656723","TX","PE - Premier Family Care, Inc","Medicaid","Participating","Enrollment Complete","2022-07-01","1780334193","","2022-10-20","10/20/2022 Rcvd TMHP approval letter provider is PAR effective 7/1/2022.  TPI # 1780334193.  DCannon"]
["Kendra Cooper, APRN-FNP-BC","1780334193","75-2656723","TX","PE - Premier Family Care, Inc","Wellmed","Participating","Enrollment Complete","2023-07-19","00160243123","","2023-11-15","11/15/2023 Per email received from UHC provider is PAR and linked to group TIN effective 7/19/2023.  MPIN# 00160243123.  DCannon"]
["Kendra Cooper, APRN-FNP-BC","1780334193","75-2656723","TX","PE - Premier Family Care, 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 July has been completed.  Provider is PAR and linked to group TIN effective 7/1/2022.   DCannon"]
["Kendra Cooper, APRN-FNP-BC","1780334193","75-2656723","TX","PE - Premier Family Care, Inc","CAQH","Participating","CAQH Reattested","2024-08-13","","","2024-08-13","08/13/2024 CAQH Reattested all locations current and all expirables up to date wthompson"]
["Kendra Cooper, APRN-FNP-BC","1780334193","75-2656723","TX","PE - Premier Family Care, Inc","HealthSmart PPO","Participating","Enrollment Complete",44743,"","","2023-07-11","Received confirmation from Client. MS"]
["Kendra Cooper, APRN-FNP-BC","1780334193","75-2656723","TX","PE - Premier Family Care, Inc","Cigna","Participating","Enrollment Complete",45175,"","","2023-09-19","Received completion email. Eff 9/6/2023 MS"]
["Kendra Cooper, APRN-FNP-BC","1780334193","75-2656723","TX","PE - Premier Family Care, Inc","Triwest VA","Facility Enrollment","Facility Enrollment","","","",45134,"7/27/2023 - Received roster from Scarlett; provider status: \"No Action.  TIN is CCN participating under own DCN.\""]
["Valarie Ramirez Alcala, PA","1790251031","46-3131679","TX","PE - Midland Texas Orthopedic Group Inc","Gallagher","Participating","Enrollment Complete","","","","2024-01-26","TIN is delegated. Confirmed enrollment via Coventry Portal. MS"]
["Valarie Ramirez Alcala, PA","1790251031","46-3131679","TX","PE - Midland Texas Orthopedic Group Inc","Wellcare","Participating","Enrollment Complete","2022-06-01","","","2022-07-01","7/1/2022 Received June Monthly Validation roster from Superior and provider is PAR and linked effective 6/1/2022.  DCannon"]
["Valarie Ramirez Alcala, PA","1790251031","46-3131679","TX","PE - Midland Texas Orthopedic Group Inc","USA PPO","Participating","Enrollment Complete","2022-05-09","","","2022-10-13","10/13/2022 In following up with USAMCO (800-872-3860) I was told that you can confirm participating via the USA MCO website  https://providersearch.usamco.com/hwprovsearch.  Provider is PAR and linked to location/TIN effective 5/9/2022.  DCannon"]
["Valarie Ramirez Alcala, PA","1790251031","46-3131679","TX","PE - Midland Texas Orthopedic Group Inc","Tricare Prime","Participating","Enrollment Complete","2022-04-29","","","2022-06-02","6/1/2022 Per Tricare portal provider is PAR and linked to group TIN/location effective 4/29/2022.  DCannon"]
["Valarie Ramirez Alcala, PA","1790251031","46-3131679","TX","PE - Midland Texas Orthopedic Group Inc","Humana","Participating","Enrollment Complete","2022-05-09","","","2022-08-20","8/20/2022 Per email received from Vernita Young July monthly delegated roster is complete and provider is PAR and linked to group TIN/location effective 5/9/2022.  DCannon"]
["Valarie Ramirez Alcala, PA","1790251031","46-3131679","TX","PE - Midland Texas Orthopedic Group Inc","Caprock (CapStar)","Participating","Enrollment Complete","2022-04-14","","","2022-07-15","7/15/2022 Per roster rcvd from Caprock provider is PAR and linked to group effective 4/14/2022.  DCannon"]
["Valarie Ramirez Alcala, PA","1790251031","46-3131679","TX","PE - Midland Texas Orthopedic Group Inc","Rail Road Medicare","Participating","Enrollment Complete","2022-03-14","Q00321030","DU5783","2022-09-06","9/6/2022 Rcvd RR Medicare approval letter. RR Medicare PTAN #  Q00321030 - effective 3/14/2022.  DCannon"]
["Valarie Ramirez Alcala, PA","1790251031","46-3131679","TX","PE - Midland Texas Orthopedic Group Inc","Omni PPO","Participating","Enrollment Complete","2022-05-09","","","2022-07-05","7/5/2022 Rcvd email from G.Aviles at IMS/OMNI that delegation roster provider load for June has been completed.  Provider is PAR and linked to group effective 5/9/2022.  DCannon"]
["Valarie Ramirez Alcala, PA","1790251031","46-3131679","TX","PE - Midland Texas Orthopedic Group Inc","Broadspire Services Inc.","Participating","Enrollment Complete","2024-01-11","","","2024-07-08","Contract complete. Effective 01/11/2024. Provider was listed on par provider roster submitted with contract. Jen Videan"]
["Caroline D Hammond, PA","1720698574","46-3131679","TX","PE - Midland Texas Orthopedic Group Inc","First Health Coventry","Participating","Enrollment Complete","2022-05-01","3557984","","2022-10-11","10.11.2022: MA: S/W Lesly of First Health @800-226-5116. Provider NPI# is on file for the provider, in netwrok with First Health and link under the group and TIN effective 05/01/2022. Provider ID# 3557984. Physical location is on file. Ref# 438604. - Mary Rose Acebedo"]
["Caroline D Hammond, PA","1720698574","46-3131679","TX","PE - Midland Texas Orthopedic Group Inc","Medicare","Participating","Enrollment Complete","2022-03-14","2D2395","320497","2022-05-06","5/6/2022 Rcvd Medicare approval letter.  PTAN # 2D2395 - effective 3/14/2022.  DCannon"]
["Caroline D Hammond, PA","1720698574","46-3131679","TX","PE - Midland Texas Orthopedic Group Inc","Travelers WC","Participating","Enrollment Complete","","","","2024-01-26","Confirmed via Coventry Portal. MS"]
["Caroline D Hammond, PA","1720698574","46-3131679","TX","PE - Midland Texas Orthopedic Group Inc","Omni PPO","Participating","Enrollment Complete",44690,"","",44747,"7/5/2022 Rcvd email from G.Aviles at IMS/OMNI that delegation roster provider load for June has been completed.  Provider is PAR and linked to group effective 5/9/2022.  DCannon"]
["Caroline D Hammond, PA","1720698574","46-3131679","TX","PE - Midland Texas Orthopedic Group Inc","Texas Municipal League","Participating","Enrollment Complete","2022-09-16","","","2022-09-27","9/27/2022 Rcvd PSWCA - Alliance approval letter.  Provider is PAR and linked to group TIN effective 9/16/2022.  DCannon"]
["Caroline D Hammond, PA","1720698574","46-3131679","TX","PE - Midland Texas Orthopedic Group Inc","USA PPO","Participating","Enrollment Complete","2022-05-09","","","2022-09-06","9/6/2022 In following up with USAMCO (800-872-3860) I was told that you can confirm participating via the USA MCO website  https://providersearch.usamco.com/hwprovsearch.  Provider is PAR and linked to location/TIN effective 5/9/2022.  DCannon"]
["Caroline D Hammond, PA","1720698574","46-3131679","TX","PE - Midland Texas Orthopedic Group Inc","Aetna","Participating","Enrollment Complete","2022-05-09","6227554","","2022-06-02","6/2/2022 Per Aetna provider directory provider is PAR and linked to group TIN/location effective 5/9/2022.   DCannon"]
["Caroline D Hammond, PA","1720698574","46-3131679","TX","","Tricare Prime","Participating","Enrollment Complete","2022-10-01","","","2024-02-28","Re-Cred has been completed. eff 10/1/2022. MS"]
["Caroline D Hammond, PA","1720698574","46-3131679","TX","PE - Midland Texas Orthopedic Group Inc","Texas Mutual","Participating","Enrollment Complete","2022-08-01","","","2022-08-04","8/4/2022 Received approval letter for TX Mutual/Workwell.  Provider is PAR effective 8/1/2022.  DCannon"]
["Caroline D Hammond, PA","1720698574","46-3131679","TX","PE - Midland Texas Orthopedic Group Inc","Humana","Participating","Enrollment Complete","2022-05-09","","","2022-08-20","8/20/2022 Per email received from Vernita Young July monthly delegated roster is complete and provider is PAR and linked to group TIN/location effective 5/9/2022.  DCannon"]
["Innocentia Ifunanya Onyemetu, NP","1790457075","83-0358685","TX","PE - Midland Community Healthcare Services","USA PPO","Participating","Enrollment Complete","2022-05-09","","","2022-08-10","8/10/2022 In following up with USAMCO (800-872-3860) I was told that you can confirm participating via the USA MCO website  https://providersearch.usamco.com/hwprovsearch.  Provider is PAR and linked to location/TIN effective 5/9/2022.  DCannon"]
["Innocentia Ifunanya Onyemetu, NP","1790457075","83-0358685","TX","PE - Midland Community Healthcare Services","USA PPO","Participating","Enrollment Complete",44690,"","","2022-08-10","8/10/2022 In following up with USAMCO (800-872-3860) I was told that you can confirm participating via the USA MCO website  https://providersearch.usamco.com/hwprovsearch.  Provider is PAR and linked to location/TIN effective 5/9/2022.  DCannon"]
["Innocentia Ifunanya Onyemetu, NP","1790457075","83-0358685","TX","PE - Midland Community Healthcare Services","First Health Coventry","Participating","Enrollment Complete","2022-05-09","3558012","","2022-08-10","8/10/2022 Per First Health web portal provider is PAR and linked to group TIN/location effective 5/9/2022.  PID# 3558012  DCannon"]
["Innocentia Ifunanya Onyemetu, NP","1790457075","83-0358685","TX","PE - Midland Community Healthcare Services","First Health Coventry","Participating","Enrollment Complete","2022-05-09","3558012","","2022-08-10","8/10/2022 Per First Health web portal provider is PAR and linked to group TIN/location effective 5/9/2022.  PID# 3558012  DCannon"]
["Innocentia Ifunanya Onyemetu, NP","1790457075","83-0358685","TX","PE - Midland Community Healthcare Services","United Health Care","Participating","Enrollment Complete","2022-05-09","007929415","","2022-06-29","6/29/2022 Per email received from  from UHC monthly delegated roster submission has been completed and provider is PAR and in linked to group TIN effective 5/9/2022.   MPIN# 007929415.   DCannon"]
["Innocentia Ifunanya Onyemetu, NP","1790457075","83-0358685","TX","PE - Midland Community Healthcare Services","United Health Care","Participating","Enrollment Complete","2022-05-09","007929415","","2022-06-29","6/29/2022 Per email received from  from UHC monthly delegated roster submission has been completed and provider is PAR and in linked to group TIN effective 5/9/2022.   MPIN# 007929415.   DCannon"]
["Innocentia Ifunanya Onyemetu, NP","1790457075","83-0358685","TX","PE - Midland Community Healthcare Services","Humana","Participating","Enrollment Complete","2022-05-09","","","2022-08-20","8/20/2022 Per email received from Vernita Young July monthly delegated roster is complete and provider is PAR and linked to group TIN/location effective 5/9/2022.  DCannon"]
["Innocentia Ifunanya Onyemetu, NP","1790457075","83-0358685","TX","PE - Midland Community Healthcare Services","Humana","Participating","Enrollment Complete","2022-05-09","","","2022-08-20","8/20/2022 Per email received from Vernita Young July monthly delegated roster is complete and provider is PAR and linked to group TIN/location effective 5/9/2022.  DCannon"]
["Innocentia Ifunanya Onyemetu, NP","1790457075","83-0358685","TX","PE - Midland Community Healthcare Services","Wellcare","Participating","Enrollment Complete","2022-06-01","","","2022-07-01","7/1/2022 Received June Monthly Validation roster from Superior and provider is PAR and linked effective 6/1/2022.  DCannon"]
["Innocentia Ifunanya Onyemetu, NP","1790457075","83-0358685","TX","PE - Midland Community Healthcare Services","Tricare Prime","Panel Closed","Panel Closed","","","","2022-10-28","10/28/2022 Per Tricare/Humana Military is currently not accepting requests to join the medical surgical network. Will check back soon to see if we are accepting network providers.  DCannon"]
["Innocentia Ifunanya Onyemetu, NP","1790457075","83-0358685","TX","PE - Midland Community Healthcare Services","Tricare Prime","Panel Closed","Panel Closed","","","","2022-10-28","10/28/2022 Per Tricare/Humana Military is currently not accepting requests to join the medical surgical network. Will check back soon to see if we are accepting network providers.  DCannon"]
["Innocentia Ifunanya Onyemetu, NP","1790457075","83-0358685","TX","PE - Midland Community Healthcare Services","Tricare Prime","Panel Closed","Panel Closed","","","","2022-10-28","10/28/2022 Per Tricare/Humana Military is currently not accepting requests to join the medical surgical network. Will check back soon to see if we are accepting network providers.  DCannon"]
["Innocentia Ifunanya Onyemetu, NP","1790457075","83-0358685","TX","PE - Midland Community Healthcare Services","Boon Chapman","Participating","Enrollment Complete","2022-05-09","","","2022-07-24","7/24/2022 Per email from Marcie Eckhart-Havens Multiplan July delegated roster has been completed  and provider is PAR and linked to group TIN effective 5/9/2022.  DCannon"]
["Innocentia Ifunanya Onyemetu, NP","1790457075","83-0358685","TX","PE - Midland Community Healthcare Services","Boon Chapman","Participating","Enrollment Complete","2022-05-09","","","2022-07-24","7/24/2022 Per email from Marcie Eckhart-Havens Multiplan July delegated roster has been completed  and provider is PAR and linked to group TIN effective 5/9/2022.  DCannon"]
["Innocentia Ifunanya Onyemetu, NP","1790457075","83-0358685","TX","PE - Midland Community Healthcare Services","Wellmed","Participating","Enrollment Complete","2022-07-24","","","2023-03-23","3/23/2023 Rcvd roster from UHC w/ all Wellmed participating providers.  Provider is PAR effective 7/24/2022.  DCannon"]
["Innocentia Ifunanya Onyemetu, NP","1790457075","83-0358685","TX","PE - Midland Community Healthcare Services","Wellmed","Participating","Enrollment Complete","2022-07-24","","","2023-03-23","3/23/2023 Rcvd roster from UHC w/ all Wellmed participating providers.  Provider is PAR effective 7/24/2022.  DCannon"]
["Innocentia Ifunanya Onyemetu, NP","1790457075","83-0358685","TX","PE - Midland Community Healthcare Services","Triwest VA","In House Enrollment","In House Enrollment","","","","2022-04-26",""]
["Innocentia Ifunanya Onyemetu, NP","1790457075","83-0358685","TX","PE - Midland Community Healthcare Services","Scott&White (First Care)","Participating","Enrollment Complete","2022-05-09","","","2022-08-11","8/11/2022 Rcvd email from Scott & White that monthly delegated roster for June has been completed and providers are loaded to group delegation roster effective 5/9/2022.  DCannon"]
["Innocentia Ifunanya Onyemetu, NP","1790457075","83-0358685","TX","PE - Midland Community Healthcare Services","Scott&White (First Care)","Participating","Enrollment Complete","2022-05-09","","","2022-08-11","8/11/2022 Rcvd email from Scott & White that monthly delegated roster for June has been completed and providers are loaded to group delegation roster effective 5/9/2022.  DCannon"]
["Innocentia Ifunanya Onyemetu, NP","1790457075","83-0358685","TX","PE - Midland Community Healthcare Services","Scott&White (First Care)","Participating","Enrollment Complete","2022-05-09","","","2022-08-11","8/11/2022 Rcvd email from Scott & White that monthly delegated roster for June has been completed and providers are loaded to group delegation roster effective 5/9/2022.  DCannon"]
["Innocentia Ifunanya Onyemetu, NP","1790457075","83-0358685","TX","PE - Midland Community Healthcare Services","Amerigroup","Participating","Enrollment Complete","2022-05-09","","","2022-09-23","9/23/2022 Per roster received from Joe Rodriguez at Amerigroup provider is PAR and linked to group TIN effective 5/9/2022.  DCannon"]
["Innocentia Ifunanya Onyemetu, NP","1790457075","83-0358685","TX","PE - Midland Community Healthcare Services","Galaxy Health","Participating","Enrollment Complete","2022-05-09","","","2022-08-17","8/17/2022 Per email from Karen Avalos at Galaxy delegated roster for May is complete and provider is loaded effective 5/9/2022.  DCannon"]
["Innocentia Ifunanya Onyemetu, NP","1790457075","83-0358685","TX","PE - Midland Community Healthcare Services","Galaxy Health","Participating","Enrollment Complete","2022-05-09","","","2022-08-17","8/17/2022 Per email from Karen Avalos at Galaxy delegated roster for May is complete and provider is loaded effective 5/9/2022.  DCannon"]
["Innocentia Ifunanya Onyemetu, NP","1790457075","83-0358685","TX","PE - Midland Community Healthcare Services","Multiplan","Participating","Enrollment Complete","2022-05-09","","","2022-07-24","7/24/2022 Per email from Marcie Eckhart-Havens Multiplan July delegated roster has been completed  and provider is PAR and linked to group TIN effective 5/9/2022.  DCannon"]
["Innocentia Ifunanya Onyemetu, NP","1790457075","83-0358685","TX","PE - Midland Community Healthcare Services","Multiplan","Participating","Enrollment Complete",44690,"","","2022-07-24","7/24/2022 Per email from Marcie Eckhart-Havens Multiplan July delegated roster has been completed  and provider is PAR and linked to group TIN effective 5/9/2022.  DCannon"]
["Innocentia Ifunanya Onyemetu, NP","1790457075","83-0358685","TX","PE - Midland Community Healthcare Services","TriCare Standard","Participating","Enrollment Complete","2022-06-29","","","2022-07-14","7/14/2022 Per Humana Military provider portal provider is PAR and linked to group TIN/location effective 6/29/2022.  DCannon"]
["Innocentia Ifunanya Onyemetu, NP","1790457075","83-0358685","TX","PE - Midland Community Healthcare Services","TriCare Standard","Participating","Enrollment Complete","2022-06-29","","","2022-07-14","7/14/2022 Per Humana Military provider portal provider is PAR and linked to group TIN/location effective 6/29/2022.  DCannon"]
["Innocentia Ifunanya Onyemetu, NP","1790457075","83-0358685","TX","PE - Midland Community Healthcare Services","Omni PPO","Participating","Enrollment Complete","2022-05-09","","","2022-07-05","7/5/2022 Rcvd email from G.Aviles at IMS/OMNI that delegation roster provider load for June has been completed.  Provider is PAR and linked to group effective 5/9/2022.  DCannon"]
["Innocentia Ifunanya Onyemetu, NP","1790457075","83-0358685","TX","PE - Midland Community Healthcare Services","Omni PPO","Participating","Enrollment Complete","2022-05-09","","","2022-07-05","7/5/2022 Rcvd email from G.Aviles at IMS/OMNI that delegation roster provider load for June has been completed.  Provider is PAR and linked to group effective 5/9/2022.  DCannon"]
["Innocentia Ifunanya Onyemetu, NP","1790457075","83-0358685","TX","PE - Midland Community Healthcare Services","Superior","Participating","Enrollment Complete","2022-06-01","","","2022-06-01","6/1/2022 Per roster received from Superior May monthly delegated submission is complete and provider is PAR and linked to group TIN/locations effective  6/1/2022.  DCannon"]
["Innocentia Ifunanya Onyemetu, NP","1790457075","83-0358685","TX","PE - Midland Community Healthcare Services","IMS","Participating","Enrollment Complete","2022-05-09","","","2022-07-05","7/5/2022 Rcvd email from G.Aviles at IMS/OMNI that delegation roster provider load for June has been completed.  Provider is PAR and linked to group effective 5/9/2022.  DCannon"]
["Innocentia Ifunanya Onyemetu, NP","1790457075","83-0358685","TX","PE - Midland Community Healthcare Services","IMS","Participating","Enrollment Complete","2022-05-09","","","2022-07-05","7/5/2022 Rcvd email from G.Aviles at IMS/OMNI that delegation roster provider load for June has been completed.  Provider is PAR and linked to group effective 5/9/2022.  DCannon"]
["Innocentia Ifunanya Onyemetu, NP","1790457075","83-0358685","TX","PE - Midland Community Healthcare Services","IMS","Participating","Enrollment Complete","2022-05-09","","","2022-07-05","7/5/2022 Rcvd email from G.Aviles at IMS/OMNI that delegation roster provider load for June has been completed.  Provider is PAR and linked to group effective 5/9/2022.  DCannon"]
["Innocentia Ifunanya Onyemetu, NP","1790457075","83-0358685","TX","PE - Midland Community Healthcare Services","Ambetter","Participating","Enrollment Complete","2022-06-01","","","2022-06-20","6/20/2022 Per roster received from Superior provider is PAR and linked to group delegation roster effective 6/1/2022."]
["Innocentia Ifunanya Onyemetu, NP","1790457075","83-0358685","TX","PE - Midland Community Healthcare Services","Aetna","Participating","Enrollment Complete","2022-05-09","6689991","","2022-06-21","6/21/2022 Per follow-up note - S/w Joan of Aetna @ 800-353-1232. Provider NPI# is on file for the provider and is participating effective 05/09/2022  under the group and TIN#. PIN: 6689991. Physical location is on file. Call ref# 6094998732. - DCannon"]
["Innocentia Ifunanya Onyemetu, NP","1790457075","83-0358685","TX","PE - Midland Community Healthcare Services","Aetna","Participating","Enrollment Complete","2022-05-09","6689991","","2022-06-21","6/21/2022 Per follow-up note - S/w Joan of Aetna @ 800-353-1232. Provider NPI# is on file for the provider and is participating effective 05/09/2022  under the group and TIN#. PIN: 6689991. Physical location is on file. Call ref# 6094998732. - DCannon"]
["Innocentia Ifunanya Onyemetu, NP","1790457075","83-0358685","TX","PE - Midland Community Healthcare Services","Aetna","Participating","Enrollment Complete","2022-05-09","6689991","","2022-06-21","6/21/2022 Per follow-up note - S/w Joan of Aetna @ 800-353-1232. Provider NPI# is on file for the provider and is participating effective 05/09/2022  under the group and TIN#. PIN: 6689991. Physical location is on file. Call ref# 6094998732. - DCannon"]
["Innocentia Ifunanya Onyemetu, NP","1790457075","83-0358685","TX","PE - Midland Community Healthcare Services","HealthSmart PPO","Participating","Enrollment Complete","2022-05-09","","","2022-07-14","7/14/2022 Per Healthsmart website provider is PAR and loaded under TIN/location effective 5/9/2022.  DCannon"]
["Innocentia Ifunanya Onyemetu, NP","1790457075","83-0358685","TX","PE - Midland Community Healthcare Services","Caprock (CapStar)","Participating","Enrollment Complete","2022-05-09","","","2022-08-30","8/30/2022 Received a roster from Priscilla Albertine at MQA that she received from Michelle Rodriguez.  Provider is PAR and linked to group TIN/locations effective 5/9/2022.  DCannon"]
["Innocentia Ifunanya Onyemetu, NP","1790457075","83-0358685","TX","PE - Midland Community Healthcare Services","Caprock (CapStar)","Participating","Enrollment Complete","2022-05-09","","","2022-08-30","8/30/2022 Received a roster from Priscilla Albertine at MQA that she received from Michelle Rodriguez.  Provider is PAR and linked to group TIN/locations effective 5/9/2022.  DCannon"]
["Innocentia Ifunanya Onyemetu, NP","1790457075","83-0358685","TX","PE - Midland Community Healthcare Services","Caprock (CapStar)","Participating","Enrollment Complete","2022-05-09","","","2022-08-30","8/30/2022 Received a roster from Priscilla Albertine at MQA that she received from Michelle Rodriguez.  Provider is PAR and linked to group TIN/locations effective 5/9/2022.  DCannon"]
["Innocentia Ifunanya Onyemetu, NP","1790457075","83-0358685","TX","PE - Midland Community Healthcare Services","Cigna","Participating","Enrollment Complete","2022-04-05","6841061","","2022-06-21","6/21/2022 Per follow-up note - NPI# for the provider is on file shows link and Par under the group and TIN# effective 4/5/2022, the physical location is on file and the Provider ID is 6841061.  Call ref # Angel6142022. - DCannon"]
["Sridhar R Allam, MD","1700061819","88-1668292","TX","PE - Premier Texas Kidney Care, PLLC","Superior","Participating","Enrollment Complete",44774,"","","2022-08-10","8/10/2022 Per roster received from Superior July monthly delegated submission is complete and provider is PAR and linked to group TIN/locations effective  8/1/2022.  DCannon"]
["Sridhar R Allam, MD","1700061819","88-1668292","TX","","Superior","Participating","Enrollment Complete",44774,"","","2022-08-10","8/10/2022 Per roster received from Superior July monthly delegated submission is complete and provider is PAR and linked to group TIN/locations effective  8/1/2022.  DCannon"]
["Sridhar R Allam, MD","1700061819","88-1668292","TX","PE - Premier Texas Kidney Care, PLLC","Omni PPO","Participating","Enrollment Complete","2022-06-20","","","2022-10-17","10/17/2022 Per email received from German Aviles at IMS/OMNI monthly delegation roster provider load for July has been completed.  Provider is PAR and linked to group TIN effective 6/20/2022.   DCannon"]
["Sridhar R Allam, MD","1700061819","88-1668292","TX","","Humana","Participating","Enrollment Complete","2022-06-20","","","2022-08-20","8/20/2022 Per email received from Vernita Young July monthly delegated roster is complete and provider is PAR and linked to group TIN/location effective 6/20/2022.  DCannon"]
["Sridhar R Allam, MD","1700061819","88-1668292","TX","PE - Premier Texas Kidney Care, PLLC","USA PPO","Participating","Enrollment Complete",44732,"","","2023-10-23","10/23/2023 Per roster received from USA PPO provider is PAR and linked to group TIN effective 6/20/2022.  DCannon"]
["Sridhar R Allam, MD","1700061819","88-1668292","TX","","USA PPO","Participating","Enrollment Complete",44732,"","","2023-10-23","10/23/2023 Per roster received from USA PPO provider is PAR and linked to group TIN effective 6/20/2022.  DCannon"]
["Sridhar R Allam, MD","1700061819","88-1668292","TX","","HealthSmart PPO","Participating","Enrollment Complete","2022-06-20","","","2023-07-11","Received confirmation from Client. MS"]
["Sridhar R Allam, MD","1700061819","88-1668292","TX","PE - Premier Texas Kidney Care, PLLC","Medicaid","Participating","Enrollment Complete","2022-05-01","","","2024-01-31","Provider was added during group enrollment. Provider is active with Medicaid, effective 05/01/2022. Jen Videan"]
["Sridhar R Allam, MD","1700061819","88-1668292","TX","","Wellcare","Participating","Enrollment Complete","2022-08-01","","","2022-08-10","8/10/2022 Per roster received from Superior May monthly delegated submission is complete and provider is PAR and linked to group TIN/locations effective  8/1/2022.  DCannon"]
["Sridhar R Allam, MD","1700061819","88-1668292","TX","PE - Premier Texas Kidney Care, PLLC","Cigna","Participating","Enrollment Complete",44682,"0461877","","2022-07-15","7/15/2022 Per confirm par status note on 6/3/2022 - S/W Frank at Cigna, who confirmed provider is credentialed in TX through a delegation and is linked to tax ID as of 5/1/2022. Provider ID is 0461877. Ref # is frank 6/3/2022. HSmith"]
["Sridhar R Allam, MD","1700061819","88-1668292","TX","","Cigna Healthspring","Panel Closed","Panel Closed","","","","2024-04-09","Received panel closed letter. MS"]
["Vishnu S Brahmandam, MD","1548447899","75-2656723","TX","PE - Premier Family Care, 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","Facility Enrollment","","","","2022-10-17","10/17/2022 - Received roster from Scarlett of TriWest VA; provider status: \"No Action.  TIN is CCN participating under own DCN.\""]
["Vishnu S Brahmandam, MD","1548447899","75-2656723","TX","PE - Premier Family Care, Inc","Caprock (CapStar)","Participating","Enrollment Complete","2020-01-01","","","2022-10-12","10/12/2022 Per email from Priscilla Albertine she rcvd confirmation from Mary Rodriguez at Caprock that provider is PAR and linked to group TIN/locations effective 1/1/2020.  DCannon"]
["Vishnu S Brahmandam, MD","1548447899","75-2656723","TX","PE - Premier Family Care, 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 September has been completed.  Provider is PAR and linked to group TIN effective 9/12/2022.   DCannon"]
["Vishnu S Brahmandam, MD","1548447899","75-2656723","TX","","First Health Coventry","Participating","Enrollment Complete",44788,"","","2023-02-28","2/28/2023 Per First Health web portal provider is PAR and linked to group TIN/location effective 8/15/2022.  DCannon"]
["Vishnu S Brahmandam, MD","1548447899","75-2656723","TX","PE - Premier Family Care, Inc","Medicare","Participating","Enrollment Complete",44788,"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","","Medicare","Participating","Enrollment Complete",44788,"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","PE - Premier Family Care, Inc","United Health Care","Participating","Enrollment Complete","2022-09-12","003315195","","2022-11-01","11/1/2022 Rcvd email from UCH that provider load has been completed and provider is PAR and linked to group TIN/location effective 9/12/2022.  DCannon"]
["Vishnu S Brahmandam, MD","1548447899","75-2656723","TX","","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","","Rail Road Medicare","Participating","Enrollment Complete","2022-08-15","Q00322555","CD1588","2022-09-08","9/8/2022 Rcvd RR Medicare approval letter.  PTAN # Q00322555 - effective 8/15/2022.  DCannon"]
["Vishnu S Brahmandam, MD","1548447899","75-2656723","TX","PE - Premier Family Care, Inc","Galaxy Health","Participating","Enrollment Complete",44816,"","","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","1548447899","75-2656723","TX","","Cigna","Participating","Enrollment Complete",44788,"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","PE - Premier Family Care, 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","","HealthSmart PPO","Participating","Enrollment Complete","2022-06-20","","","2023-07-11","Received confirmation from Client. MS"]
["Christopher A Stack, MD","1568704971","75-2656723","TX","PE - Premier Family Care, Inc","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"]
["Christopher A Stack, MD","1568704971","75-2656723","TX","","USA PPO","Participating","Enrollment Complete",44732,"","","2023-03-24","3/24/2023 In following up with USAMCO (800-872-3860) I was told that you can confirm participating via the USA MCO website  https://providersearch.usamco.com/hwprovsearch.  Provider is PAR and linked to location/TIN effective 6/20/2022.  DCannon"]
["Christopher A Stack, MD","1568704971","75-2656723","TX","","Superior","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, 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"]
["Christopher A Stack, MD","1568704971","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"]
["Christopher A Stack, MD","1568704971","75-2656723","TX","PE - Premier Family Care, 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","","Galaxy Health","Participating","Enrollment Complete","2022-06-20","","","2022-08-17","8/17/2022 Per email from Karen Avalos at Galaxy delegated roster for July is complete and provider is loaded effective 6/20/2022.  DCannon"]
["Christopher A Stack, MD","1568704971","75-2656723","TX","PE - Premier Family Care, 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"]
["Christopher A Stack, MD","1568704971","75-2656723","TX","","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"]
["Christopher A Stack, MD","1568704971","75-2656723","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"]
["Christopher A Stack, MD","1568704971","75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","2022-09-22","","","2024-01-26","Confirmed provider is credentialed and in network with Tricare. MS"]
["Annabelle Rivera, APRN-NP","1871250191","75-2656723","TX","PE - Premier Family Care, Inc","Ambetter","Participating","Enrollment Complete","2022-11-01","","","2022-12-29","12/29/2022 Rcvd confirmation email from Superior that October delegation roster has been processed and provider has been loaded to delegation roster and PAR w/ group effective 11/1/2022.  DCannon"]
["Annabelle Rivera, APRN-NP","1871250191","75-2656723","TX","PE - Premier Family Care, Inc","IMS","Participating","Enrollment Complete","2022-09-26","","","2022-10-17","10/17/2022 Per email received from German Aviles at IMS/OMNI monthly delegation roster provider load for October has been completed.  Provider is PAR and linked to group TIN effective 9/26/2022.   DCannon"]
["Annabelle Rivera, APRN-NP","1871250191","75-2656723","TX","PE - Premier Family Care, Inc","Superior","Participating","Enrollment Complete","2022-11-01","","","2022-12-08","12/08/2022 Rcvd confirmation email from Superior that October delegation roster has been processed and provider has been loaded to delegation roster and PAR w/ group effective 11/1/2022.  DCannon"]
["Annabelle Rivera, APRN-NP","1871250191","75-2656723","TX","PE - Premier Family Care, Inc","Triwest VA","In House Enrollment","In House Enrollment","","","","2022-08-03",""]
["Annabelle Rivera, APRN-NP","1871250191","75-2656723","TX","PE - Premier Family Care, Inc","HealthSmart PPO","Participating","Enrollment Complete",44830,"","","2022-11-28","11/28/2022 Per Healthsmart website provider is PAR and loaded under TIN/location effective 9/26/2022.  DCannon"]
["Annabelle Rivera, APRN-NP","1871250191","75-2656723","TX","PE - Premier Family Care, Inc","Rail Road Medicare","Participating","Enrollment Complete",44801,"Q00328215","CE1588","2022-09-16","9/16/2022 Rcvd RR Medicare approval letter.  PTAN # Q00328215 - effective 8/28/2022.  DCannon"]
["Joyce O. Alase, MD","1295168318","88-2797281","TX","PE - Healing Hands Medical Clinic","First Health Coventry","Participating","Enrollment Complete","2022-11-01","3284256","","2023-07-25","7/25/2023 Per email response from First Health provider is PAR and linked to group effective 11/1/2022.   Billing and mailing address on file are correct.  PID # 3284256 DCannon"]
["Joyce O. Alase, MD","1295168318","88-2797281","TX","PE - Healing Hands Medical Clinic","USA PPO","Participating","Enrollment Complete","2022-09-01","","","2024-01-11","1/11/2024 Per email from USA MCO - LaNetricia Myart provider is PAR and linked to group TIN/location effective 9/1/2022.  Provider is also listed on the online provider directory.  DCannon"]
["Joyce O. Alase, MD","1295168318","88-2797281","TX","PE - Healing Hands Medical Clinic","Aetna","Participating","Enrollment Complete","2022-11-01","","","2023-05-19","Rep confirmed provider is participating under the TIN effective 11/1/2022. MS"]
["Joyce O. Alase, MD","1295168318","88-2797281","TX","PE - Healing Hands Medical Clinic","Medicare","Participating","Enrollment Complete","2023-01-25","2U7317","2U7269","2023-06-15","Confirmed provider is participating. MS"]
["Joyce O. Alase, MD","1295168318","88-2797281","TX","PE - Healing Hands Medical Clinic","Boon Chapman","Participating","Enrollment Complete","2022-08-29","","","2023-07-25","7/25/2023 Rcvd email from Jessica Bess at Multiplan with a full roster and provider is PAR w/ group and location effective 8/29/2022.  DCannon"]
["Joyce O. Alase, MD","1295168318","88-2797281","TX","PE - Healing Hands Medical Clinic","United Health Care","Participating","Enrollment Complete",44802,"006795726","","2022-10-27","10/27/2022 Rcvd email from UCH that provider load has been completed and provider is PAR and linked to group TIN/location effective 8/29/2022.  MPIN # 006795726.   DCannon"]
["Hannah Heflin, RD","1366172579","75-2656723","TX","PE - Premier Family Care, Inc","Aetna","Participating","Enrollment Complete",44927,"","","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","1366172579","75-2656723","TX","PE - Premier Family Care, Inc","Omni PPO","Participating","Enrollment Complete",44785,"","","2022-10-17","10/17/2022 Per email received from German Aviles at IMS/OMNI monthly delegation roster provider load for August has been completed.  Provider is PAR and linked to group TIN effective 8/12/2022.   DCannon"]
["Hannah Heflin, RD","1366172579","75-2656723","TX","PE - Premier Family Care, Inc","Triwest VA","Facility Enrollment","Facility Enrollment","","","","2022-10-17","10/17/2022 - Received roster from Scarlett of TriWest VA; provider status: \"No Action.  TIN is CCN participating under own DCN.\""]
["Hannah Heflin, RD","1366172579","75-2656723","TX","PE - Premier Family Care, Inc","Multiplan","Participating","Enrollment Complete","2022-08-12","","","2023-09-01","9/1/2023 Per email received from Multiplan provider is PAR and linked to group TIN/locations effective 8/12/2022.  DCannon"]
["Hannah Heflin, RD","1366172579","75-2656723","TX","PE - Premier Family Care, Inc","Scott&White (First Care)","Participating","Enrollment Complete",44922,"","","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","1366172579","75-2656723","TX","PE - Premier Family Care, Inc","Wellmed","Participating","Enrollment Complete",44785,"","","2023-03-23","3/23/2023 Rcvd roster from UHC w/ all Wellmed participating providers.  Provider is PAR effective 8/12/2022.  DCannon"]
["Mark Stevens Clee, MD","1972946648","83-0358685","TX","PE - Midland Community Healthcare Services","Amerigroup","Participating","Enrollment Complete",44802,"","","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",44804,"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","Medicaid","Participating","Enrollment Complete",44804,"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","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","First Health Coventry","Participating","Enrollment Complete",44866,"","","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","Multiplan","Participating","Enrollment Complete","2022-08-29","","","2023-03-10","3/10/2023 Per email from Priscilla Albertine at MQA, she received confirmation from Multiplan that provider is PAR and linked to group TIN/locations effective 8/29/2022.  DCannon"]
["Mark Stevens Clee, MD","1972946648","83-0358685","TX","PE - Midland Community Healthcare Services","Multiplan","Participating","Enrollment Complete","2022-08-29","","","2023-03-10","3/10/2023 Per email from Priscilla Albertine at MQA, she received confirmation from Multiplan that provider is PAR and linked to group TIN/locations effective 8/29/2022.  DCannon"]
["Mark Stevens Clee, MD","1972946648","83-0358685","TX","PE - Midland Community Healthcare Services","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",44802,"","","2022-10-17","10/17/2022 Per email received from German Aviles at IMS/OMNI monthly delegation roster provider load for September has been completed.  Provider is PAR and linked to group TIN effective 8/29/2022.   DCannon"]
["Mark Stevens Clee, MD","1972946648","83-0358685","TX","PE - Midland Community Healthcare Services","Omni PPO","Participating","Enrollment Complete",44802,"","","2022-10-17","10/17/2022 Per email received from German Aviles at IMS/OMNI monthly delegation roster provider load for September has been completed.  Provider is PAR and linked to group TIN effective 8/29/2022.   DCannon"]
["Mark Stevens Clee, MD","1972946648","83-0358685","TX","PE - Midland Community Healthcare Services","Omni PPO","Participating","Enrollment Complete",44802,"","","2022-10-17","10/17/2022 Per email received from German Aviles at IMS/OMNI monthly delegation roster provider load for September has been completed.  Provider is PAR and linked to group TIN effective 8/29/2022.   DCannon"]
["Mark Stevens Clee, MD","1972946648","83-0358685","TX","PE - Midland Community Healthcare Services","IMS","Participating","Enrollment Complete","2022-08-29","","","2022-10-17","10/17/2022 Per email received from German Aviles at IMS/OMNI monthly delegation roster provider load for September has been completed.  Provider is PAR and linked to group TIN effective 8/29/2022.   DCannon"]
["Mark Stevens Clee, MD","1972946648","83-0358685","TX","PE - Midland Community Healthcare Services","Superior","Participating","Enrollment Complete","2022-10-01","","","2022-12-19","12/19/2022 Rcvd email from Priscilla Albertine at MQA w/ confirmation from Superior that provider is PAR and linked to group effective 10/01/2022.  DCannon"]
["Mark Stevens Clee, MD","1972946648","83-0358685","TX","PE - Midland Community Healthcare Services","Superior","Participating","Enrollment Complete","2022-10-01","","","2022-12-19","12/19/2022 Rcvd email from Priscilla Albertine at MQA w/ confirmation from Superior that provider is PAR and linked to group effective 10/01/2022.  DCannon"]
["Mark Stevens Clee, MD","1972946648","83-0358685","TX","PE - Midland Community Healthcare Services","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","Wellcare","Participating","Enrollment Complete",44835,"","","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","Wellmed","Participating","Enrollment Complete","2022-08-29","","","2023-03-23","3/23/2023 Rcvd roster from UHC w/ all Wellmed participating providers.  Provider is PAR effective 8/29/2022.  DCannon"]
["Mark Stevens Clee, MD","1972946648","83-0358685","TX","PE - Midland Community Healthcare Services","Wellmed","Participating","Enrollment Complete","2022-08-29","","","2023-03-23","3/23/2023 Rcvd roster from UHC w/ all Wellmed participating providers.  Provider is PAR effective 8/29/2022.  DCannon"]
["Mark Stevens Clee, MD","1972946648","83-0358685","TX","PE - Midland Community Healthcare Services","Galaxy Health","Participating","Enrollment Complete","2022-08-29","","","2022-09-27","9/27/2022 Rcvd email from Karen Avalos at Galaxy that delegated roster submission for September has been completed.  Provider is PAR and linked to group TIN effective 8/29/2022.  DCannon"]
["Mark Stevens Clee, MD","1972946648","83-0358685","TX","PE - Midland Community Healthcare Services","Galaxy Health","Participating","Enrollment Complete",44802,"","","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",44802,"","","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",44849,"","","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","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","","","","2024-02-13","all locations - panel closed, locations are not prime credentialed. MS"]
["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-BC","1184261950","75-2656723","TX","PE - Premier Family Care, Inc","United Health Care","Participating","Enrollment Complete","2022-10-10","007330684","","2023-11-15","11/15/2023 Per email received from UHC provider is PAR and linked to group TIN effective 10/10/2022.  MPIN# 007330684.  DCannon"]
["Christian A Richardson, APRN-FNP-BC","1184261950","75-2656723","TX","PE - Premier Family Care, Inc","Rail Road Medicare","Participating","Enrollment Complete","2022-11-01","Q00346338","CE1588","2022-10-15","10/15/2022 Rcvd RR Medicare approval letter.  PTAN # Q00346338 - effective 11/1/2022.  DCannon"]
["Christian A Richardson, APRN-FNP-BC","1184261950","75-2656723","TX","PE - Premier Family Care, Inc","USA PPO","Participating","Enrollment Complete","2022-10-10","","","2023-03-24","3/24/2023 In following up with USAMCO (800-872-3860) I was told that you can confirm participating via the USA MCO website  https://providersearch.usamco.com/hwprovsearch.  Provider is PAR and linked to location/TIN effective 10/10/2022.  DCannon"]
["Christian A Richardson, APRN-FNP-BC","1184261950","75-2656723","TX","PE - Premier Family Care, Inc","Ambetter","Participating","Enrollment Complete","2022-11-01","","","2022-12-29","12/29/2022 Rcvd confirmation email from Superior that October delegation roster has been processed and provider has been loaded to delegation roster and PAR w/ group effective 11/1/2022.  DCannon"]
["Christian A Richardson, APRN-FNP-BC","1184261950","75-2656723","TX","PE - Premier Family Care, 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-BC","1184261950","75-2656723","TX","PE - Premier Family Care, Inc","CAQH","Participating","CAQH Reattested","2024-08-13","","","2024-08-13","08/13/2024 CAQH Reattested all locations current and all expirables up to date wthompson"]
["Christian A Richardson, APRN-FNP-BC","1184261950","75-2656723","TX","PE - Premier Family Care, Inc","Triwest VA","Facility Enrollment","In House Enrollment","","","","2022-09-13",""]
["Richard Glenn Eby, MD","1598260325","75-1997880","TX","PE - Andrews County Hospital District","Alliance WC","Participating","Enrollment Complete","2023-06-02","","","2023-06-09","confirmed via the website directory the provider is active. MS"]
["Richard Glenn Eby, MD","1598260325","26-3789190","TX","PE - Permian Physician Services","Multiplan","Participating","Enrollment Complete","2022-09-26","","","2023-07-25","7/25/2023 Rcvd email from Jessica Bess at Multiplan with a full roster and provider is PAR w/ group and location effective 9/26/2022.  DCannon"]
["Richard Glenn Eby, MD","1598260325","26-3789190","TX","PE - Permian Physician Services","Triwest VA","In House Enrollment","In House Enrollment","","","","2022-08-23",""]
["Richard Glenn Eby, MD","1598260325","26-3789190","TX","PE - Permian Physician Services","Corvel Healthcare Corp.","Participating","Enrollment Complete","2022-09-26","","","2023-05-02","05.02.2023  Per follow-up note - S/W Marina of Corvel Healthcare Corp @ 800-872-0820. Per rep, provider is showing PAR and link under the Group and Tax ID with an Effective date 09/26/2022. Provider ID 1341506, Recredentialing date is 09/26/2025. Service location is on file. Call ref#:Marina05022023.-Danico Gabriel Melendres"]
["Richard Glenn Eby, MD","1598260325","75-1997880","TX","PE - Andrews County Hospital District","HealthSmart PPO","Participating","Enrollment Complete","2022-09-26","","","2022-11-28","11/28/2022 Per Healthsmart website provider is PAR and loaded under TIN/location effective 9/26/2022.  DCannon"]
["Richard Glenn Eby, MD","1598260325","26-3789190","TX","PE - Permian Physician Services","Cigna","In Process","Pending Other Enrollment","","","","2024-05-01","Rep researched the issue and found the application for the provider was being closed due to there not being a group contract in place for Permian Phys. Services. Currently, the group application is in process now that they have at least 1 provider to be enrolled under that group. Once the group enrollment has been approved, this provider will be linked as well. MS"]
["Richard Glenn Eby, MD","1598260325","75-1997880","TX","PE - Andrews County Hospital District","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"]
["Richard Glenn Eby, MD","1598260325","26-3789190","TX","PE - Permian Physician Services","Sedgwick","Participating","Enrollment Complete","2024-05-21","1598260325","","2024-05-24","Approval ltr rcvd. Effective date 05/21/2024. Jen Videan"]
["Richard Glenn Eby, MD","1598260325","75-1997880","TX","","Triwest VA","Enrollment on Hold","Enrollment on Hold","","","","","RHC."]
["Richard Glenn Eby, MD","1598260325","75-1997880","TX","PE - Andrews County Hospital District","Texas Municipal League","Participating","Enrollment Complete","","","","2023-11-20","participating, please see Alliance notes. MS"]
["Richard Glenn Eby, MD","1598260325","75-1997880","TX","PE - Andrews County Hospital District","Travelers WC","Participating","Enrollment Complete","","","","2024-01-31","Per Coventry portal provider is enrolled. Jen Videan"]
["Richard Glenn Eby, MD","1598260325","75-1997880","TX","PE - Andrews County Hospital District","Gallagher","Participating","Enrollment Complete","","","","2024-01-31","Per Coventry portal provider is enrolled. Jen Videan"]
["Richard Glenn Eby, MD","1598260325","26-3789190","TX","PE - Permian Physician Services","CAQH","Participating","CAQH Reattested","2024-08-13","","","2024-08-13","08/13/2024 CAQH REattested all locations current and all expirables up to date wthompson"]
["Richard Glenn Eby, MD","1598260325","26-3789190","TX","PE - Permian Physician Services","Zurich","Delegated - Third Party","Thru Other Payor","","","","2024-02-02","Check Coventry portal for enrollment status. Provider currently not showing as active.  Jen Videan"]
["Richard Glenn Eby, MD","1598260325","75-1997880","TX","PE - Andrews County Hospital District","Broadspire Services Inc.","Enrollment Stopped","Enrollment Stopped","","","","2023-10-04","Per Melody Starcher, they would like to hold off on Broadspire WC enrollment at this time. If they start to see a large amount of patients coming in with it, then they will reassess. 10/04/2023 Jen Videan"]
["Richard Glenn Eby, MD","1598260325","26-3789190","TX","PE - Permian Physician Services","United Health Care","Participating","Enrollment Complete","2022-09-26","","","2023-09-05","9/2/2023 Per email from UHC provider is PAR and linked to group TIN/location effective 9/26/2022.  DCannon"]
["Richard Glenn Eby, MD","1598260325","75-1997880","TX","PE - Andrews County Hospital District","Texas Mutual","Participating","Enrollment Complete","2023-08-01","","","2023-08-08","Rcvd approval letter. Effective 08/01/2023. Jen Videan"]
["Kathryn A. Lagus, APRN-FNP-BC","1285983155","75-2656723","TX","PE - Premier Family Care, Inc","Caprock (CapStar)","Participating","Add Info Submitted","2022-11-28","","","2024-04-15","4/15/2024 New location added to delegated roster. FC"]
["Kathryn A. Lagus, APRN-FNP-BC","1285983155","75-2656723","TX","PE - Premier Family Care, Inc","Triwest VA","In House Enrollment","In House Enrollment","","","","2022-12-29",""]
["Kathryn A. Lagus, APRN-FNP-BC","1285983155","75-2656723","TX","PE - Premier Family Care, Inc","CAQH","Participating","CAQH Reattested","2024-08-27","","","2024-08-27","08/27/2024 CAQH Reattested updated and uploaded COI wthompson"]
["Kathryn A. Lagus, APRN-FNP-BC","1285983155","75-2656723","TX","PE - Premier Family Care, 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","1285983155","75-2656723","TX","PE - Premier Family Care, Inc","Scott&White (First Care)","Participating","Enrollment Complete",44980,"","",44985,"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, Inc","Tricare Prime","In Process","Application Submitted","","","","2024-06-28","Application via secure portal was submitted to Re-Credential this provider for Tricare Prime. MS  Ticket 2513471"]
["Kathryn A. Lagus, APRN-FNP-BC","1285983155","75-2656723","TX","PE - Premier Family Care, Inc","Rail Road Medicare","Participating","Enrollment Complete","2023-03-01","","","2023-05-24",""]
["Kathryn A. Lagus, APRN-FNP-BC","1285983155","75-2656723","TX","PE - Premier Family Care, Inc","Multiplan","Participating","Add Info Submitted","2022-11-28","","","2024-04-15","4/15/2024 New location added to delegated roster. FC"]
["Kathryn A. Lagus, APRN-FNP-BC","1285983155","75-2656723","TX","PE - Premier Family Care, Inc","Boon Chapman","Participating","Enrollment Complete","2022-11-28","","","2023-07-26","7/26/2023 Rcvd email from Jessica Bess at Multiplan with a full roster and provider is PAR w/ group and location effective 11/28/2022.  DCannon"]
["Kathryn A. Lagus, APRN-FNP-BC","1285983155","75-2656723","TX","PE - Premier Family Care, Inc","IMS","Participating","Add Info Submitted","2022-11-28","","","2024-04-15","4/15/2024 New location added to delegated roster. FC"]
["Marisela Sample, LPC","1396470357","83-0358685","TX","PE - Midland Community Healthcare Services","Scott&White (First Care)","Participating","Enrollment Complete","2022-10-31","","","2023-08-17","8/17/2023 Received email from Scott & White HPDELEGATION@BSWHealth.org that provider load from November has been completed and provider is PAR effective 10/31/2022.  DCannon"]
["Marisela Sample, LPC","1396470357","83-0358685","TX","PE - Midland Community Healthcare Services","Wellcare","Participating","Enrollment Complete","2022-12-01","","","2022-12-29","12/29/2022 Rcvd confirmation email from Superior that November delegation roster has been processed and provider has been loaded to delegation roster and PAR w/ group effective 12/1/2022.  DCannon"]
["Marisela Sample, LPC","1396470357","83-0358685","TX","PE - Midland Community Healthcare Services","Cigna","Participating","Enrollment Complete","2023-10-06","5935530","","2023-09-21","09.21.2023 S/W Dennisse of Cigna @ 1-800-882-4462. Per rep, provider is part of a behavioral program then rep advised to call the behavioral dept at 800-274-4573. Called Cigna's behavioral dept @ 800-274-4573 then S/W Heba. As per rep, provider is showing participating and link under the Group and TIN with an Effective date 02/02/2023. Provider ID 5935530. Service location is on file. Call ref#:HebaH09212023. - 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",44896,"","","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","Participating","Enrollment Complete","2023-03-13","","","2023-03-28","3/28/2023 Rcvd Tricare certified approval letter.   Provider is TRICARE-certified in Texas effective  3/13/2023.  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","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","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",44896,"","",44903,"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","Participating","Enrollment Complete","2022-10-31","","","2023-07-26","7/26/2023 Rcvd email from Jessica Bess at Multiplan with a full roster and provider is PAR w/ group and location effective 10/31/2022.  DCannon"]
["Marisela Sample, LPC","1396470357","83-0358685","TX","PE - Midland Community Healthcare Services","IMS","Participating","Enrollment Complete","2022-10-31","","","2023-01-05","1/5/2023 Per email received from German Aviles at IMS/OMNI monthly delegation roster provider load for November has been completed.  Provider is PAR and linked to group TIN effective 10/31/2022.   DCannon"]
["Marisela Sample, LPC","1396470357","83-0358685","TX","PE - Midland Community Healthcare Services","Tricare Prime","Panel Closed","Panel Closed","","","","2023-05-24","Tricare Prime panel is closed. MS"]
["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",44865,"","","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","Multiplan","Participating","Enrollment Complete","2022-10-31","","","2023-07-26","7/26/2023 Rcvd email from Jessica Bess at Multiplan with a full roster and provider is PAR w/ group and location effective 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",""]
["Taylor Allison Arrington, APRN-FNP-BC","1619603255","75-2182177","TX","PE - Debbie P. Reese, MD PA","Ambetter","Participating","Enrollment Complete",45292,"","","2024-01-12","1/12/2024 Per email rcvd from Superior, December roster is complete provider is PAR and linked to group TIN/locations effective 1/1/2024.  DCannon"]
["Taylor Allison Arrington, APRN-FNP-BC","1619603255","75-2182177","TX","PE - Debbie P. Reese, MD PA","Medicaid","Participating","Enrollment Complete","","","","2024-08-16","License has been updated and provider is showing active and linked to the group. Jen Videan"]
["Taylor Allison Arrington, APRN-FNP-BC","1619603255","75-2182177","TX","PE - Debbie P. Reese, MD PA","HealthSmart PPO","Participating","Enrollment Complete","","","","2024-02-29","Per roster received from Aleece Moerbe (Aleece.Moerbe@healthsmart.com) on 02/23/2024, provider is PAR, eff. 12/11/2023 and linked to TIN."]
["Taylor Allison Arrington, APRN-FNP-BC","1619603255","75-2182177","TX","PE - Debbie P. Reese, MD PA","Scott&White (First Care)","In Process","Payor Follow Up","","","","2024-07-26","Sent email to payor requesting enrollment status. PA."]
["Taylor Allison Arrington, APRN-FNP-BC","1619603255","75-2182177","TX","PE - Debbie P. Reese, MD PA","First Health Coventry","Participating","Enrollment Complete","2024-01-01","","","2024-06-25","As per Teresita (call ref# 1105034) Andrews Highway location is active with FirstHealth. FC"]
["Taylor Allison Arrington, APRN-FNP-BC","1619603255","75-2182177","TX","PE - Debbie P. Reese, MD PA","Humana","In Process","Payor Follow Up","","","","2024-08-27","Sent follow up email to Network Manager Erica Lee, requesting status. PA."]
["Sacha A Stanley, APRN-FNP-BC","1780399857","75-2656723","TX","PE - Premier Family Care, Inc","Humana","In Process","Payor Follow Up","","","","2024-08-27","Sent follow up email to Network Manager Erica Lee, requesting status. PA."]
["Sacha A Stanley, APRN-FNP-BC","1780399857","75-2656723","TX","PE - Premier Family Care, Inc","Boon Chapman","Thru Other Payor","Thru Other Payor","2024-03-01","","","2024-05-22","Pending Multiplan enrollment. PA."]
["Sacha A Stanley, APRN-FNP-BC","1780399857","75-2656723","TX","PE - Premier Family Care, Inc","Wellmed","Thru Other Payor","Thru Other Payor","","","","2024-03-19","Pending UHC enrollment. PA"]
["Sacha A Stanley, APRN-FNP-BC","1780399857","75-2656723","TX","PE - Premier Family Care, Inc","Cigna","Participating","Enrollment Complete","2024-02-01","4920546","","2024-03-19","Received email confirming enrollment. MS"]
["Suhail Sami Daye, MD","1639251481","26-3789190","TX","PE - Permian Physician Services","Ambetter","Participating","Enrollment Complete",45078,"","","2023-07-17","7/17/2023 Rcvd email from Superior that provider is PAR and linked to group delegated roster effective 6/1/2023.  DCannon"]
["Suhail Sami Daye, MD","1639251481","26-3789190","TX","PE - Permian Physician Services","Medicare","Participating","Enrollment Complete",44986,"2S7645","0A3812","2023-05-04","5/4/2023 Rcvd Medicare approval letter.  Provider is PAR and linked to group/locations effective 3/1/2023.  PTAN# 2S7645.  DCannon"]
["Suhail Sami Daye, MD","1639251481","26-3789190","TX","PE - Permian Physician Services","Multiplan","Participating","Enrollment Complete",42898,"","","2023-06-01","6/01/2023 S/W Latuya of MultiPlan @ 1-800-950-7040.Per rep, Provider NPI# 1639251481 is on file for the provider and is participating, effective 6-12-2017 under the group and TIN# 26-3789190. PIN: 12424933. Physical location is on file. Next credentialing is not required. no payer ID. Call ref# 8813120. - Jherimiah Medina"]
["Suhail Sami Daye, MD","1639251481","26-3789190","TX","PE - Permian Physician Services","Wellcare","Participating","Enrollment Complete",45078,"","","2023-07-17","7/17/2023 Rcvd email from Superior that provider is PAR and linked to group delegated roster effective 6/1/2023.  DCannon"]
["Suhail Sami Daye, MD","1639251481","26-3789190","TX","PE - Permian Physician Services","Hartford","Delegated - Third Party","Thru Other Payor","","","","2024-02-02","Check Coventry portal for enrollment status. Provider currently not showing as active.  Jen Videan"]
["Suhail Sami Daye, MD","1639251481","26-3789190","TX","PE - Permian Physician Services","Molina","In Process","Application Submitted","","","","2023-11-20","11/20/2023 Emailed change of information form to Molina Healthcare to add prover to group TIN/location.  DCannon"]
["Suhail Sami Daye, MD","1639251481","26-3789190","TX","PE - Permian Physician Services","Corvel Healthcare Corp.","Enrollment Stopped","Enrollment Stopped","","","","2024-01-16","Per Melody Starcher mstarcher@permianregional.com, Permian Physician Services has decided not to sign a contract at this time with Corvel. Jen Videan"]
["Suhail Sami Daye, MD","1639251481","26-3789190","TX","PE - Permian Physician Services","Rail Road Medicare","Participating","Enrollment Complete","2023-03-01","Q00516358","DS7320","2023-07-19","7/19/2023 Rcvd RR Medicare approval letter.   PTAN # Q00516358 - effective 3/1/2023.  DCannon"]
["Suhail Sami Daye, MD","1639251481","26-3789190","TX","PE - Permian Physician Services","Boon Chapman","Participating","Enrollment Complete","2017-06-12","","","2023-07-26","7/26/2023 Rcvd email from Jessica Bess at Multiplan with a full roster and provider is PAR w/ group and location effective 6/2/2017.  DCannon"]
["Suhail Sami Daye, MD","1639251481","26-3789190","TX","PE - Permian Physician Services","Omni PPO","Participating","Enrollment Complete","2023-05-08","","","2023-07-19","7/19/2023 Per email received from IMS/OMNI May delegated roster has been processed and provider is PAR and linked to group effective 5/8/2023.  DCannon"]
["David Powell Haynie, MD","1083672778","75-2656723","TX","PE - Premier Family Care, Inc","Medicaid","In Process","Payor Follow Up","","","","2024-08-21","Emailed \"Provider Relations Mailbox\" <provider.relations@tmhp.com> for update. Jen Videan"]
["David Powell Haynie, MD","1083672778","75-2656723","TX","PE - Premier Family Care, Inc","Medicaid","In Process","Payor Follow Up","","","","2024-08-21","Emailed \"Provider Relations Mailbox\" <provider.relations@tmhp.com> for update. Jen Videan"]
["David Powell Haynie, MD","1083672778","75-2656723","TX","PE - Premier Family Care, Inc","USA PPO","Participating","Enrollment Complete","2023-06-01","","","2023-07-24","7/24/2023 In following up with USAMCO (800-872-3860) I was told that you can confirm participating via the USA MCO website  https://providersearch.usamco.com/hwprovsearch.  Provider is PAR and linked to location/TIN effective 6/1/2023.  DCannon"]
["David Powell Haynie, MD","1083672778","75-2656723","TX","PE - Premier Family Care, Inc","HealthSmart PPO","Participating","Enrollment Complete","2023-06-01","","","2023-11-13","11/13/2023 Per phone conversation with Lee Kinard at Healthsmart provider is PAR and linked to group TIN/location effective 6/1/2023.  DCannon"]
["David Powell Haynie, MD","1083672778","75-2656723","TX","PE - Premier Family Care, Inc","Aetna","Participating","Enrollment Complete","2023-05-01","","","2023-05-31","05.31.2023 S/W Ria of Aetna @ 1-800-353-1232. Per rep, provider is showing participating and link under the Group and TIN with an Effective date 05/01/2023. Provider ID 4135209, Payer ID 60054 and Recredentialing date is 05/01/2026. Service location is on file. Call ref#:6149191218. - Danico Gabriel Melendres"]
["David Powell Haynie, MD","1083672778","75-2656723","TX","PE - Premier Family Care, Inc","Aetna","Participating","Enrollment Complete","2023-05-01","","","2023-05-31","05.31.2023 S/W Ria of Aetna @ 1-800-353-1232. Per rep, provider is showing participating and link under the Group and TIN with an Effective date 05/01/2023. Provider ID 4135209, Payer ID 60054 and Recredentialing date is 05/01/2026. Service location is on file. Call ref#:6149191218. - Danico Gabriel Melendres"]
["David Powell Haynie, MD","1083672778","75-2656723","TX","PE - Premier Family Care, Inc","Humana","Participating","Payor Follow Up","2023-06-01","","","2023-12-27","12/27/2023 Priscilla Albertine at MQA sent follow-up email to Marcus Wester at Humana to try and get an updated and requested a roster.  DCannon"]
["David Powell Haynie, MD","1083672778","75-2656723","TX","PE - Premier Family Care, Inc","Triwest VA","In House Enrollment","In House Enrollment","","","","2023-04-19",""]
["David Powell Haynie, MD","1083672778","75-2656723","TX","PE - Premier Family Care, Inc","Triwest VA","In House Enrollment","In House Enrollment","","","","2023-04-19",""]
["David Powell Haynie, MD","1083672778","75-2656723","TX","PE - Premier Family Care, Inc","Multiplan","Participating","Enrollment Complete","2023-06-01","","","2023-07-25","7/25/2023 Rcvd email confirmation from Jessica Bess at Multiplan that June roster has been processed and provider is PAR w/ group effective 6/1/2023.  DCannon"]
["David Powell Haynie, MD","1083672778","75-2656723","TX","PE - Premier Family Care, Inc","IMS","Participating","Enrollment Complete","2023-06-01","","","2023-07-18","7/18/2023 Per email received from IMS/OMNI June delegated roster has been processed and provider is PAR and linked to group effective 6/1/2023.  DCannon"]
["David Powell Haynie, MD","1083672778","75-2656723","TX","PE - Premier Family Care, Inc","Amerigroup","Participating","Enrollment Complete","2023-06-01","","","2023-10-18","10/18/2023 Per email received from Jessica Bess at  Multiplan provider is PAR with Amerigroup and linked to group TIN/locations thru Multiplan enrollment effective 6/1/2023.  DCannon"]
["David Powell Haynie, MD","1083672778","75-2656723","TX","PE - Premier Family Care, Inc","Medicare","Participating","Enrollment Complete","2023-05-01","2W8694","","2024-04-16","Reconsideration request for the ICR was APPROVED and the effective date was backdated to 6/18/2023. MS"]
["David Powell Haynie, MD","1083672778","75-2656723","TX","PE - Premier Family Care, Inc","Medicare","Participating","Enrollment Complete",45047,"2W8694","","2024-04-16","Reconsideration request for the ICR was APPROVED and the effective date was backdated to 6/18/2023. MS"]
["David Powell Haynie, MD","1083672778","75-2656723","TX","PE - Premier Family Care, Inc","CAQH","Participating","CAQH Reattested","2024-08-28","","","2024-08-28","08/28/2024 CAQH Reattested updated and uploaded COI wthompson"]
["David Powell Haynie, MD","1083672778","75-2656723","TX","PE - Premier Family Care, Inc","United Health Care","Participating","Enrollment Complete","2023-09-16","000887435","","2023-10-05","10/5/2023 Rcvd copy of participating network list with effective dates for provider.  Provider is PAR with UHC effective 9/16/2023.  (see copy of report uploaded in attachments) DCannon"]
["David Powell Haynie, MD","1083672778","75-2656723","TX","PE - Premier Family Care, Inc","Rail Road Medicare","Participating","Enrollment Complete","2023-05-01","","","2023-08-21","Confirmed enrollment. MS"]
["David Powell Haynie, MD","1083672778","75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","2023-04-25","","","2024-01-25","Provider has  been confirmed as credentialed and in network with Tricare. MS"]
["David Powell Haynie, MD","1083672778","75-2656723","TX","PE - Premier Family Care, Inc","Cigna","Participating","Enrollment Complete","2023-11-15","2840278","","2023-11-30","Received enrollment confirmation. MS"]
["David Powell Haynie, MD","1083672778","75-2656723","TX","PE - Premier Family Care, Inc","Omni PPO","Participating","Enrollment Complete","2023-06-01","","","2023-07-18","7/18/2023 Per email received from IMS/OMNI June delegated roster has been processed and provider is PAR and linked to group effective 6/1/2023.  DCannon"]
["David Powell Haynie, MD","1083672778","75-2656723","TX","PE - Premier Family Care, Inc","Boon Chapman","Participating","Enrollment Complete","2023-06-01","","","2023-07-25","7/25/2023 Rcvd email confirmation from Jessica Bess at Multiplan that June roster has been processed and provider is PAR w/ group effective 6/1/2023.  DCannon"]
["David Powell Haynie, MD","1083672778","75-2656723","TX","PE - Premier Family Care, Inc","Galaxy Health","Participating","Enrollment Complete","2023-06-01","","","2023-07-20","7/20/2023 Per email received from Galaxy June delegated roster has been processed and provider is PAR and linked to group effective 6/1/2023.  DCannon"]
["David Powell Haynie, MD","1083672778","75-2656723","TX","PE - Premier Family Care, Inc","Scott&White (First Care)","Participating","Enrollment Complete","2023-07-20","","","2023-08-08","Per response from hpdelegation@bswhealth.org, Dr. Hayne is effective 07/20/2023. Jen Videan"]
["David Powell Haynie, MD","1083672778","75-2656723","TX","PE - Premier Family Care, Inc","Caprock (CapStar)","Participating","Enrollment Complete",45078,"","","2023-07-26","7/26/2023 Rcvd email  confirmation from Caprock that provider is PAR and linked to group TIN/locations effective 6/1/2023.  DCannon"]
["Dana L Bell, APRN-FNP-BC","1073983193","75-2781652","TX","PE - West Texas Allergy, PA","Scott&White (First Care)","Participating","Enrollment Complete","2023-09-14","1073983193","","2023-09-29","9/29/2023 Rcvd confirmation from Scott & White that provider has been loaded at all locations effective 9/14/2023.  DCannon"]
["Dana L Bell, APRN-FNP-BC","1073983193","75-2781652","TX","PE - West Texas Allergy, PA","Scott&White (First Care)","Participating","Enrollment Complete","2023-09-14","1073983193","","2023-09-29","9/29/2023 Rcvd confirmation from Scott & White that provider has been loaded at all locations effective 9/14/2023.  DCannon"]
["Dana L Bell, APRN-FNP-BC","1073983193","75-2781652","TX","PE - West Texas Allergy, PA","Ambetter","Participating","Enrollment Complete","2023-09-01","1073983193","","2023-09-13","9/13/2023 Rcvd email from Superior confirming that the August delegated roster provider load has been completed providers are PAR and loaded under TIN/ all locations effective 9/1/2023.  DCannon"]
["Dana L Bell, APRN-FNP-BC","1073983193","75-2781652","TX","PE - West Texas Allergy, PA","CAQH","Participating","CAQH Reattested","2024-08-13","13954674","","2024-08-13","08/13/2024 CAQH REattested all locations current and all expirables up to date wthompson"]
["Dana L Bell, APRN-FNP-BC","1073983193","75-2781652","TX","PE - West Texas Allergy, PA","TriCare Standard","Participating","Enrollment Complete","2023-06-22","1073983193","","2024-08-23","Provider is active and linked to this location eff 7/9/2024. MS"]
["Dana L Bell, APRN-FNP-BC","1073983193","75-2781652","TX","PE - West Texas Allergy, PA","Boon Chapman","Participating","Enrollment Complete","2023-08-01","1073983193","","2023-09-20","9/20/2023 Per email received from Jessica Bess at Multiplan August roster has been completed.  Provider is PAR and linked to group TIN/location effective 8/1/2023.  DCannon"]
["Dana L Bell, APRN-FNP-BC","1073983193","75-2781652","TX","PE - West Texas Allergy, PA","Boon Chapman","Participating","Enrollment Complete","2023-08-01","1073983193","","2023-09-20","9/20/2023 Per email received from Jessica Bess at Multiplan August roster has been completed.  Provider is PAR and linked to group TIN/location effective 8/1/2023.  DCannon"]
["Dana L Bell, APRN-FNP-BC","1073983193","75-2781652","TX","PE - West Texas Allergy, PA","Medicaid","Participating","Enrollment Complete","2023-05-29","1073983193","","2023-08-21","Dana Bell par effective 05/29/2023 at 5000 Briarwood Ave Midland, TX 79707. Jen Videan"]
["Dana L Bell, APRN-FNP-BC","1073983193","75-2781652","TX","PE - West Texas Allergy, PA","United Health Care","Participating","Enrollment Complete","2023-08-12","006397593","","2023-11-17","11/17/2023 Per email rcvd from UHC provider is PAR and linked to group TIN and locations effective 8/12/2023.  MPIN # 006397593.  DCannon"]
["Dana L Bell, APRN-FNP-BC","1073983193","75-2781652","TX","PE - West Texas Allergy, PA","United Health Care","Participating","Enrollment Complete","2023-08-12","006397593","","2023-11-17","11/17/2023 Per email rcvd from UHC provider is PAR and linked to group TIN and locations effective 8/12/2023.  MPIN # 006397593.  DCannon"]
["Dana L Bell, APRN-FNP-BC","1073983193","75-2781652","TX","PE - West Texas Allergy, PA","Aetna","Participating","Enrollment Complete","2023-05-29","4523940","","2023-08-17","8/17/2023 Per email from Priscilla Albertine at MQA she received confirmation that provider is PAR and linked to group TIN/location effective 5/29/2023.  DCannon"]
["Dana L Bell, APRN-FNP-BC","1073983193","75-2781652","TX","PE - West Texas Allergy, PA","HealthSmart PPO","Participating","Enrollment Complete","2023-08-01","1073983193","","2023-12-15","12/15/2023 Per email rcvd from Aleece Moerbe at Healthsmart provider is PAR and linked to group TIN/location effective 8/1/2023.  DCannon"]
["Dana L Bell, APRN-FNP-BC","1073983193","75-2781652","TX","PE - West Texas Allergy, PA","HealthSmart PPO","Participating","Enrollment Complete","2023-08-01","1073983193","","2023-12-15","12/15/2023 Per email rcvd from Aleece Moerbe at Healthsmart provider is PAR and linked to group TIN/location effective 8/1/2023.  DCannon"]
["Dana L Bell, APRN-FNP-BC","1073983193","75-2781652","TX","PE - West Texas Allergy, PA","IMS","Participating","Enrollment Complete","2023-08-01","1073983193","","2023-09-05","9/5/2023 Per email received from IMS/OMNI May delegated roster has been processed and provider is PAR and linked to group effective 8/1/2023.  DCannon"]
["Dana L Bell, APRN-FNP-BC","1073983193","75-2781652","TX","PE - West Texas Allergy, PA","Galaxy Health","Participating","Enrollment Complete",45139,"1073983193","","2023-09-19","9/19/2023 Per email received from Galaxy August delegated roster has been processed and provider is PAR and linked to group/location effective 8/1/2023.  DCannon"]
["Dana L Bell, APRN-FNP-BC","1073983193","75-2781652","TX","PE - West Texas Allergy, PA","Superior","Participating","Enrollment Complete","2023-09-01","1073983193","","2023-09-13","9/13/2023 Rcvd email from Superior confirming that the August delegated roster provider load has been completed providers are PAR and loaded under TIN/locations effective 9/1/2023.  DCannon"]
["Dana L Bell, APRN-FNP-BC","1073983193","75-2781652","TX","PE - West Texas Allergy, PA","Amerigroup","Participating","Payor Follow Up","2023-08-01","19103471","","2024-01-16","1/16/2024 Sent follow-up email to Cassandra Dunagon-Smith at Amerigroup to check status of August roster.  Have not received responses from previous requests.  DCannon"]
["Dana L Bell, APRN-FNP-BC","1073983193","75-2781652","TX","PE - West Texas Allergy, PA","Amerigroup","Participating","Payor Follow Up","2023-08-01","19103471","","2024-01-16","1/16/2024 Sent follow-up email to Cassandra Dunagon-Smith at Amerigroup to check status of August roster.  Have not received responses from previous requests.  DCannon"]
["Dana L Bell, APRN-FNP-BC","1073983193","75-2781652","TX","PE - West Texas Allergy, PA","Triwest VA","Participating","Enrollment Complete","2024-02-01","667985783","","2024-01-24","1/24/2024- received email confirmation from Scarlett A. (Scarlett_Abigail@bcbstx.com), provider is par, eff. 02/01/24."]
["Dana L Bell, APRN-FNP-BC","1073983193","75-2781652","TX","PE - West Texas Allergy, PA","Medicare","Participating","Enrollment Complete",45075,"2V0556","00608K","2023-06-22","Received confirmation of COI. MS"]
["Dana L Bell, APRN-FNP-BC","1073983193","75-2781652","TX","PE - West Texas Allergy, PA","Cigna","Participating","Enrollment Complete",45075,"853821","","2024-02-12","Received completion notice. MS"]
["Dana L Bell, APRN-FNP-BC","1073983193","75-2781652","TX","PE - West Texas Allergy, PA","Wellmed","Participating","Enrollment Complete","2023-08-12","006397593","","2023-11-17","11/17/2023 Per email rcvd from UHC provider is PAR and linked to group TIN and locations effective 8/12/2023.  MPIN # 006397593.  DCannon"]
["Dana L Bell, APRN-FNP-BC","1073983193","75-2781652","TX","PE - West Texas Allergy, PA","Humana","Participating","Enrollment Complete","2023-08-10","1073983193","","2024-01-24","1/24/2024 Rcvd email from Priscilla Albertine at MQA with an updated from Humana.  Provider is PAR and linked to group TIN and both locations effective 8/10/2023.  DCannon"]
["Dana L Bell, APRN-FNP-BC","1073983193","75-2781652","TX","PE - West Texas Allergy, PA","Wellcare","Participating","Enrollment Complete","2023-09-01","1073983193","","2023-09-13","9/13/2023 Rcvd email from Superior confirming that the August delegated roster provider load has been completed providers are PAR and loaded under TIN/ all locations effective 9/1/2023.  DCannon"]
["Dana L Bell, APRN-FNP-BC","1073983193","75-2781652","TX","PE - West Texas Allergy, PA","Tricare Prime","Participating","Enrollment Complete","2023-06-22","","","2024-01-29","Received approval for 19th St. location eff 7/26/2023. MS"]
["Dana L Bell, APRN-FNP-BC","1073983193","75-2781652","TX","PE - West Texas Allergy, PA","Tricare Prime","Participating","Enrollment Complete",45099,"","","2024-01-29","Received approval for 19th St. location eff 7/26/2023. MS"]
["Dana L Bell, APRN-FNP-BC","1073983193","75-2781652","TX","PE - West Texas Allergy, PA","Tricare Prime","Participating","Enrollment Complete","2023-06-22","","","2024-01-26","Confirmed provider is credentialed and in network with Tricare for the Briarwood location. MS"]
["Dana L Bell, APRN-FNP-BC","1073983193","75-2781652","TX","PE - West Texas Allergy, PA","Tricare Prime","Participating","Confirm Par Status","2023-06-22","","","2024-07-03","Submitted a request via the secure email as Tricare is now showing the provider is not listed under the Briarwood location and the 19th St. location listed as inactive. Ticket # 2520511. MS"]
["Dana L Bell, APRN-FNP-BC","1073983193","75-2781652","TX","PE - West Texas Allergy, PA","Caprock (CapStar)","Participating","Enrollment Complete","2023-08-01","1073983193","","2023-09-12","9/12/2023 Per email received from Caprock provider is PAR and linked to group TIN/location effective 8/1/2023.  DCannon"]
["Dana L Bell, APRN-FNP-BC","1073983193","75-2781652","TX","PE - West Texas Allergy, PA","Caprock (CapStar)","Participating","Enrollment Complete","2023-08-01","1073983193","","2023-09-12","9/12/2023 Per email received from Caprock provider is PAR and linked to group TIN/location effective 8/1/2023.  DCannon"]
["Dana L Bell, APRN-FNP-BC","1073983193","75-2781652","TX","PE - West Texas Allergy, PA","Omni PPO","Participating","Enrollment Complete","2023-08-01","1073983193","","2023-09-05","9/5/2023 Per email received from IMS/OMNI May delegated roster has been processed and provider is PAR and linked to group effective 8/1/2023.  DCannon"]
["Laura Sonnenburg, PA","1003214511","84-2617748","TX","","BCBSTX","Participating","Enrollment Complete","2024-03-22","","","2024-03-21","3/21/2024 - received email confirmation provider is PAR, eff. 03/22/2024.  Provider is participating with the following BCBSTX networks:\nBAV - Blue Advantage HMO\nPMC - Medicare Advantage PPO\nBCA - BlueChoice PPO\nCHP - CHIP (Medicaid)\nHME - Health Select\nSNP - Dual Eligible Special Needs Plan\nSTR - STAR (Medicaid)\nHMO - Blue Essentials\nMCH - Medicare Advantage HMO\nSPL - STAR Plus (Medicaid)\nSTK - STAR Kids (Medicaid)\nWEL - WellMed MA HMO. PA."]
["Laura Sonnenburg, PA","1003214511","84-2617748","TX","PE - Midland Medicine PA","Gallagher","Participating","Enrollment Complete","2023-06-11","","","2024-02-02","Confirmed enrollment via Coventry portal. MS"]
["Laura Sonnenburg, PA","1003214511","84-2617748","TX","PE - Midland Medicine PA","IMS","Participating","Enrollment Complete","2023-08-01","","","2023-09-05","9/5/2023 Per email received from IMS/OMNI May delegated roster has been processed and provider is PAR and linked to group effective 8/1/2023.  DCannon"]
["Laura Sonnenburg, PA","1003214511","84-2617748","TX","","Ambetter","Participating","Enrollment Complete","2023-09-01","","","2023-10-16","10/16/2023 Rcvd email from Superior that provider is PAR and linked to group TIN/location effective 9/1/2023.  DCannon"]
["Laura Sonnenburg, PA","1003214511","84-2617748","TX","PE - Midland Medicine PA","Travelers WC","Participating","Enrollment Complete","2023-06-11","","","2024-02-02","Confirmed enrollment via Coventry portal. MS"]
["Laura Sonnenburg, PA","1003214511","84-2617748","TX","","First Health Coventry","In Process","Payor Follow Up","","","","2024-07-24","7/24/2024 Submitted First Health application via Aetna portal. FC"]
["Laura Sonnenburg, PA","1003214511","84-2617748","TX","PE - Midland Medicine PA","HealthSmart PPO","Participating","Enrollment Complete","2023-08-01","","","2023-12-15","12/15/2023 Per email rcvd from Aleece Moerbe at Healthsmart provider is PAR and linked to group TIN/location effective 8/1/2023.  DCannon"]
["Laura Sonnenburg, PA","1003214511","84-2617748","TX","","Sedgwick","Enrollment Stopped","Enrollment Stopped","","","","2023-12-19","Per MQA, I received verbal confirmation from the practice, they are currently not desiring enrollment with WC payors. Please discontinue pursuit until further notice. Jen Videan"]
["Laura Sonnenburg, PA","1003214511","84-2617748","TX","PE - Midland Medicine PA","Liberty Mutual","Participating","Enrollment Complete","2023-06-11","","","2024-02-02","Confirmed enrollment via Coventry portal. MS"]
["Laura Sonnenburg, PA","1003214511","84-2617748","TX","","Galaxy Health","Participating","Enrollment Complete","2023-08-01","","","2023-09-19","9/19/2023 Per email received from Galaxy August delegated roster has been processed and provider is PAR and linked to group/location effective 8/1/2023.  DCannon"]
["Laura Sonnenburg, PA","1003214511","84-2617748","TX","","Rail Road Medicare","Participating","Enrollment Complete",45078,"Q00537215","","2023-08-21","Confirmed enrollment. MS"]
["Laura Sonnenburg, PA","1003214511","84-2617748","TX","PE - Midland Medicine PA","Humana","Participating","Enrollment Complete",45317,"","","2024-05-22","5/22/2024 Provider participating as of 1/26/2024 listed as PCP spoke to Jen R. call Ref#2000387504047. FC"]
["Laura Sonnenburg, PA","1003214511","84-2617748","TX","","Medicare","Participating","Enrollment Complete",45078,"2W9073","","2023-08-02","Received email confirmation of approval. MS"]
["Laura Sonnenburg, PA","1003214511","84-2617748","TX","PE - Midland Medicine PA","Coventry Workers Comp","Participating","Enrollment Complete","2023-06-11","","","2024-02-02","Confirmed enrollment via Coventry portal. MS"]
["Laura Sonnenburg, PA","1003214511","84-2617748","TX","","Coventry Workers Comp","Participating","Enrollment Complete","2023-06-11","","","2024-02-02","Confirmed enrollment via Coventry portal. MS"]
["Laura Sonnenburg, PA","1003214511","84-2617748","TX","PE - Midland Medicine PA","Broadspire Services Inc.","Participating","Enrollment Complete","2023-12-18","","","2024-07-08","Contract complete. Effective 12/18/2023. Provider was listed on par provider roster submitted with contract. Jen Videan"]
["Laura Sonnenburg, PA","1003214511","84-2617748","TX","","Cigna","Participating","Enrollment Complete","2023-10-11","","","2023-10-12","Received enrollment confirmation email. MS"]
["Laura Sonnenburg, PA","1003214511","84-2617748","TX","","Medicaid","Participating","Enrollment Complete","2023-06-01","","","2024-01-05","Welcome letter rcvd. Provider effective 06/01/2023. Jen Videan"]
["Suresh K Kota, MD","1609921782","47-5554737","TX","PE - Midland Inpatient Medical Association","First Health Coventry","Participating","Enrollment Complete","2023-09-08","","","2023-11-07","11/7/2023 S/W Bridgette of First Health @ 800-226-5116. Per rep, provider is PAR and linked to group TIN and location effective 9/8/2023.  PID # 1037148.  DCannon"]
["Suresh K Kota, MD","1609921782","47-5554737","TX","PE - Midland Inpatient Medical Association","Medicare","Participating","Enrollment Complete","2023-08-01","2X6561","","2023-08-16","Received approval letter. MS"]
["Suresh K Kota, MD","1609921782","47-5554737","TX","PE - Midland Inpatient Medical Association","Superior","Participating","Enrollment Complete","2023-10-01","","","2023-10-16","10/16/2023 Rcvd email from Superior that provider is PAR and linked to group TIN/location effective 10/1/2023.  DCannon"]
["Suresh K Kota, MD","1609921782","47-5554737","TX","PE - Midland Inpatient Medical Association","Rail Road Medicare","Participating","Enrollment Complete","2023-08-01","","","2023-09-05","Received confirmation letter. MS"]
["Suresh K Kota, MD","1609921782","47-5554737","TX","PE - Midland Inpatient Medical Association","TriCare Standard","Participating","Enrollment Complete","2023-08-16","","","2023-08-24","Confirmed via Tricare portal. MS"]
["Suresh K Kota, MD","1609921782","47-5554737","TX","PE - Midland Inpatient Medical Association","HealthSmart PPO","Participating","Enrollment Complete","2023-09-08","","","2023-11-13","11/13/2023 Per phone conversation with Lee Kinard at Healthsmart provider is PAR and linked to group TIN/location effective 9/8/2023.  DCannon"]
["Tokkie Orogbemi, CPNP","1790435014","75-2133441","TX","PE - Midland Pediatric Associates, PLLC","Scott&White (First Care)","Participating","Enrollment Complete","2023-07-20","","","2023-08-17","8/17/2023 Received email from Scott & White HPDELEGATION@BSWHealth.org that provider load from June has been completed and provider is PAR effective 7/20/2023.  DCannon"]
["Tokkie Orogbemi, CPNP","1790435014","75-2133441","TX","PE - Midland Pediatric Associates, PLLC","Tricare Prime","Participating","Enrollment Complete","2019-11-27","","","2024-02-28","Re-Cred has been completed. eff 11/27/2023. MS"]
["Tokkie Orogbemi, CPNP","1790435014","75-2133441","TX","","Tricare Prime","Participating","Enrollment Complete","2019-11-27","","","2024-02-28","Re-Cred has been completed. eff 11/27/2023. MS"]
["Tokkie Orogbemi, CPNP","1790435014","75-2133441","TX","PE - Midland Pediatric Associates, PLLC","Humana","Participating","Enrollment Complete","2023-06-01","","","2024-06-21","Received email confirmation from Marcus Wester, provider is par and linked to TIN/location, eff. 06/01/2023. PA."]
["Rahul P Sinha, MD","1598182412","75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","2024-01-10","","","2024-02-13","Confirmed provider is linked to a Prime Credentialed location. MS"]
["Rahul P Sinha, MD","1598182412","75-2656723","TX","","Scott&White (First Care)","Participating","Enrollment Complete","2023-10-03","","","2023-10-09","10/9/2023 Per email received from Scott & White provider is PAR and linked to group effective 10/3/2023.  DCannon"]
["Rahul P Sinha, MD","1598182412","75-2656723","TX","PE - Premier Family Care, Inc","IMS","Participating","Enrollment Complete","2023-09-19","","","2024-01-02","1/2/2024 Rcvd email from German Avilies at IMS/OMNI that October delegation roster is complete.  Provider is PAR and linked to group TIN/location effective 9/19/2023.  DCannon"]
["Rahul P Sinha, MD","1598182412","75-2656723","TX","PE - Premier Family Care, Inc","United Health Care","Participating","Enrollment Complete","2023-09-19","007700003","","2023-11-15","11/15/2023 Per email received from UHC provider is PAR and linked to group TIN effective 9/19/2023.  MPIN# 007700003.  DCannon"]
["Rahul P Sinha, MD","1598182412","75-2656723","TX","","Omni PPO","Participating","Enrollment Complete","2023-09-19","","","2024-01-02","1/2/2024 Rcvd email from German Avilies at IMS/OMNI that October delegation roster is complete.  Provider is PAR and linked to group TIN/location effective 9/19/2023.  DCannon"]
["Rahul P Sinha, MD","1598182412","75-2656723","TX","PE - Premier Family Care, Inc","Humana","Participating","Enrollment Complete","2023-09-19","","","2024-01-29","1/29/2024 Per Humana provider portal provider is PAR and linked to group TIN/location effective 9/19/2023.  DCannon"]
["Rahul P Sinha, MD","1598182412","75-2656723","TX","","Humana","Participating","Enrollment Complete","2023-09-19","","","2024-01-29","1/29/2024 Per Humana provider portal provider is PAR and linked to group TIN/location effective 9/19/2023.  DCannon"]
["Rahul P Sinha, MD","1598182412","75-2656723","TX","PE - Premier Family Care, Inc","Medicaid","Participating","Enrollment Complete","2023-09-25","","","2024-04-22","Welcome ltr rcvd. Provider effective 09/25/2023. Jen Videan"]
["Rahul P Sinha, MD","1598182412","75-2656723","TX","PE - Premier Family Care, Inc","First Health Coventry","Pending Other Enrollment","Pending Other Enrollment","","","","2024-01-24","Pending Aetna approval. MS"]
["Rahul P Sinha, MD","1598182412","75-2656723","TX","PE - Premier Family Care, Inc","TriCare Standard","Participating","Enrollment Complete","2024-01-10","","","2024-01-19","Received confirmation of approval. MS"]
["Rahul P Sinha, MD","1598182412","75-2656723","TX","","CAQH","Participating","CAQH Reattested","2024-08-26","","","2024-08-26","08/26/2026 CAQH Reattested updated and uploaded COI wthompson"]
["Rahul P Sinha, MD","1598182412","75-2656723","TX","","Amerigroup","Participating","Enrollment Complete","2023-09-19","","","2023-11-09","11/9/2023 Per email received from Jessica Bess at  Multiplan provider is PAR with Amerigroup and linked to group TIN/locations thru Multiplan enrollment effective 9/19/2023.  DCannon"]
["Rahul P Sinha, MD","1598182412","75-2656723","TX","PE - Premier Family Care, Inc","Rail Road Medicare","Participating","Enrollment Complete","2023-09-25","Q00593564","CE1588","2023-11-06","Received confirmation eff 9/25/2023. MS"]
["Whitney E Wyers, APRN-FNP-BC","1972003119","27-4061759","TX","PE - Permian Cardiology Inc.","Tricare Prime","Panel Closed","Panel Closed","","","","2023-08-17",""]
["Whitney E Wyers, APRN-FNP-BC","1972003119","27-4061759","TX","PE - Permian Cardiology Inc.","HealthSmart PPO","Participating","Enrollment Complete","2023-09-08","","","2023-12-15","12/15/2023 Per email rcvd from Aleece Moerbe at Healthsmart provider is PAR and linked to group TIN/location effective 9/8/2023.  DCannon"]
["Whitney E Wyers, APRN-FNP-BC","1972003119","27-4061759","TX","PE - Permian Cardiology Inc.","Medicaid","Participating","Enrollment Complete","2023-11-13","1972003119","","2023-12-15","12/15/2023 Rcvd TMHP approval letter.  Provider is PAR and linked to group effective 11/13/2023.  TPI # 1972003119.  DCannon"]
["Whitney E Wyers, APRN-FNP-BC","1972003119","27-4061759","TX","PE - Permian Cardiology Inc.","Wellcare","Participating","Enrollment Complete","2023-10-01","","","2023-11-03","11/3/2023 Rcvd email from Superior that provider is PAR and linked to group TIN/location effective 10/1/2023.  DCannon"]
["Whitney E Wyers, APRN-FNP-BC","1972003119","27-4061759","TX","PE - Permian Cardiology Inc.","Triwest VA","Participating","Enrollment Complete","2024-02-15","","","2024-02-21","Received confirmation provider is par w/ Triwest VA per email from Scarlett Abigail, eff. 02/15/2024. PA."]
["Whitney E Wyers, APRN-FNP-BC","1972003119","27-4061759","TX","PE - Permian Cardiology Inc.","CAQH","Participating","CAQH Reattested","2024-08-16","","","2024-08-16","08/16/2024 CAQH Reattested all locations current and all expirables up to date wthompson"]
["Esther Ebele Ihediwa, APRN-FNP-BC","1215633011","83-0358685","TX","PE - Midland Community Healthcare Services","Tricare Prime","Panel Closed","Panel Closed","","","","2023-08-17","Unfortunately, at this time the network is closed. Humana Military thanks you for your interest in joining the TRICARE East Region network to provide care for our beneficiaries. At this time, we are not currently expanding our network based on your specialty and location within the East Region. Please understand that every market is different based on the beneficiary population and the types of services needed in a particular location. Thank you again for your inquiry.   You can monitor the link below for network opening status.    Join the TRICARE East network (humanamilitary.com)   Humana Military is currently not accepting requests to join the medical surgical network. We apologize for the inconvenience, but we hope you check back soon to see if we are accepting network providers."]
["Esther Ebele Ihediwa, APRN-FNP-BC","1215633011","83-0358685","TX","PE - Midland Community Healthcare Services","Tricare Prime","Panel Closed","Panel Closed","","","","2023-08-17","Unfortunately, at this time the network is closed. Humana Military thanks you for your interest in joining the TRICARE East Region network to provide care for our beneficiaries. At this time, we are not currently expanding our network based on your specialty and location within the East Region. Please understand that every market is different based on the beneficiary population and the types of services needed in a particular location. Thank you again for your inquiry.   You can monitor the link below for network opening status.    Join the TRICARE East network (humanamilitary.com)   Humana Military is currently not accepting requests to join the medical surgical network. We apologize for the inconvenience, but we hope you check back soon to see if we are accepting network providers."]
["Esther Ebele Ihediwa, APRN-FNP-BC","1215633011","83-0358685","TX","PE - Midland Community Healthcare Services","United Health Care","Participating","Enrollment Complete","2023-08-22","008866025","","2023-09-28","9/28/2023 Rcvd email confirmation from UHC that September delegated roster has been completed.  Provider is PAR and linked to group/location effective 8/22/2023.  DCannon"]
["Esther Ebele Ihediwa, APRN-FNP-BC","1215633011","83-0358685","TX","PE - Midland Community Healthcare Services","United Health Care","Participating","Enrollment Complete","2023-08-22","008866025","","2023-09-28","9/28/2023 Rcvd email confirmation from UHC that September delegated roster has been completed.  Provider is PAR and linked to group/location effective 8/22/2023.  DCannon"]
["Esther Ebele Ihediwa, APRN-FNP-BC","1215633011","83-0358685","TX","PE - Midland Community Healthcare Services","Cigna","Participating","Enrollment Complete","2023-10-06","","","2023-10-09","Received confirmation email. Attached. MS"]
["Esther Ebele Ihediwa, APRN-FNP-BC","1215633011","83-0358685","TX","PE - Midland Community Healthcare Services","CAQH","In House Enrollment","In House Enrollment","","","","2023-06-28","6/28/2023- per notification form, provider will maintain own CAQH - kavello"]
["Esther Ebele Ihediwa, APRN-FNP-BC","1215633011","83-0358685","TX","PE - Midland Community Healthcare Services","Scott&White (First Care)","Participating","Enrollment Complete","2023-10-15","","","2023-10-12","10/12/2023 Per email received from Scott & White provider is PAR and linked to group TIN/locations effective 10/15/2023.  DCannon"]
["Esther Ebele Ihediwa, APRN-FNP-BC","1215633011","83-0358685","TX","PE - Midland Community Healthcare Services","Scott&White (First Care)","Participating","Enrollment Complete","2023-10-15","","","2023-10-12","10/12/2023 Per email received from Scott & White provider is PAR and linked to group TIN/locations effective 10/15/2023.  DCannon"]
["Esther Ebele Ihediwa, APRN-FNP-BC","1215633011","83-0358685","TX","PE - Midland Community Healthcare Services","Wellcare","Participating","Enrollment Complete","2023-10-01","","","2023-10-16","10/16/2023 Rcvd email from Superior that provider is PAR and linked to group TIN/location effective 10/1/2023.  DCannon"]
["Esther Ebele Ihediwa, APRN-FNP-BC","1215633011","83-0358685","TX","PE - Midland Community Healthcare Services","HealthSmart PPO","Participating","Enrollment Complete","2023-08-22","","","2023-12-15","12/15/2023 Per email rcvd from Aleece Moerbe at Healthsmart provider is PAR and linked to group TIN/location effective 8/22/2023.  DCannon"]
["Esther Ebele Ihediwa, APRN-FNP-BC","1215633011","83-0358685","TX","PE - Midland Community Healthcare Services","Boon Chapman","Participating","Enrollment Complete","2023-08-22","","","2023-10-12","10/12/2023 Per email received from Jessica Bess at  Multiplan provider is PAR and linked to group TIN/locations effective 8/22/2023.  DCannon"]
["Esther Ebele Ihediwa, APRN-FNP-BC","1215633011","83-0358685","TX","PE - Midland Community Healthcare Services","Boon Chapman","Participating","Enrollment Complete","2023-08-22","","","2023-10-12","10/12/2023 Per email received from Jessica Bess at  Multiplan provider is PAR and linked to group TIN/locations effective 8/22/2023.  DCannon"]
["Esther Ebele Ihediwa, APRN-FNP-BC","1215633011","83-0358685","TX","PE - Midland Community Healthcare Services","IMS","Participating","Enrollment Complete","2023-08-22","","","2023-10-09","10/9/2023 Per email received from G. Aviles at IMS/OMNI September delegation roster has been completed.  Provider is PAR and linked to group/location effective 8/22/2023.  DCannon"]
["Esther Ebele Ihediwa, APRN-FNP-BC","1215633011","83-0358685","TX","PE - Midland Community Healthcare Services","TriCare Standard","Participating","Enrollment Complete","2023-09-14","","","2023-09-26","Provider has been loaded to the Andrews Hwy location effective 9/14/23. MS"]
["Esther Ebele Ihediwa, APRN-FNP-BC","1215633011","83-0358685","TX","PE - Midland Community Healthcare Services","TriCare Standard","Participating","Enrollment Complete","2023-09-14","","","2023-09-26","Provider has been loaded to the Andrews Hwy location effective 9/14/23. MS"]
["Esther Ebele Ihediwa, APRN-FNP-BC","1215633011","83-0358685","TX","PE - Midland Community Healthcare Services","TriCare Standard","Participating","Enrollment Complete","2023-09-14","","","2023-09-26","Provider has been loaded to the Andrews Hwy location effective 9/14/23. MS"]
["Esther Ebele Ihediwa, APRN-FNP-BC","1215633011","83-0358685","TX","PE - Midland Community Healthcare Services","TriCare Standard","Participating","Enrollment Complete","2023-09-14","","","2023-09-26","Provider has been loaded to the Andrews Hwy location effective 9/14/23. MS"]
["Esther Ebele Ihediwa, APRN-FNP-BC","1215633011","83-0358685","TX","PE - Midland Community Healthcare Services","TriCare Standard","Participating","Enrollment Complete","2023-09-14","","","2023-10-20","Provider is linked to the Rosalind location. MS"]
["Esther Ebele Ihediwa, APRN-FNP-BC","1215633011","83-0358685","TX","PE - Midland Community Healthcare Services","Aetna","Participating","Enrollment Complete","2023-08-22"," 8574198","","2023-10-19","10.16.2023 S/W Anthony of Aetna @ 1-800-353-1232. Per rep, provider is showing participating and link under the Group and TIN with an Effective date 08/22/2023. Provider ID 8574198. Service location is on file. Call ref#:6166954339.-Danico Gabriel Melendres"]
["Esther Ebele Ihediwa, APRN-FNP-BC","1215633011","83-0358685","TX","PE - Midland Community Healthcare Services","Humana","Participating","Enrollment Complete","2023-08-22","","","2023-12-28","12/28/2023 Per Humana online web portal provider is PAR and linked to group TIN/location effective 8/22/2023.  DCannon"]
["Esther Ebele Ihediwa, APRN-FNP-BC","1215633011","83-0358685","TX","PE - Midland Community Healthcare Services","Humana","Participating","Enrollment Complete","2023-08-22","","","2023-12-28","12/28/2023 Per Humana online web portal provider is PAR and linked to group TIN/location effective 8/22/2023.  DCannon"]
["Esther Ebele Ihediwa, APRN-FNP-BC","1215633011","83-0358685","TX","PE - Midland Community Healthcare Services","Caprock (CapStar)","Participating","Enrollment Complete","2023-08-22","","","2023-09-27","9/27/2023 Rcvd email confirmation from Caprock that the September roster has been completed.  Provider is PAR and linked to group/location effective 8/22/2023.  DCannon"]
["Esther Ebele Ihediwa, APRN-FNP-BC","1215633011","83-0358685","TX","PE - Midland Community Healthcare Services","Multiplan","Participating","Enrollment Complete","2023-08-22","","","2023-10-12","10/12/2023 Per email received from Jessica Bess at  Multiplan provider is PAR and linked to group TIN/locations effective 8/22/2023.  DCannon"]
["Esther Ebele Ihediwa, APRN-FNP-BC","1215633011","83-0358685","TX","PE - Midland Community Healthcare Services","Multiplan","Participating","Enrollment Complete","2023-08-22","","","2023-10-12","10/12/2023 Per email received from Jessica Bess at  Multiplan provider is PAR and linked to group TIN/locations effective 8/22/2023.  DCannon"]
["Esther Ebele Ihediwa, APRN-FNP-BC","1215633011","83-0358685","TX","PE - Midland Community Healthcare Services","Superior","Participating","Enrollment Complete","2023-10-01","","","2023-10-16","10/16/2023 Rcvd email from Superior that provider is PAR and linked to group TIN/location effective 10/1/2023.  DCannon"]
["Esther Ebele Ihediwa, APRN-FNP-BC","1215633011","83-0358685","TX","PE - Midland Community Healthcare Services","Amerigroup","Participating","Enrollment Complete","2023-08-22","","","2023-12-27","12/27/2023 Per Amerigroup web portal provider is PAR and linked to group TIN/location effective 8/22/2023.  DCannon"]
["Esther Ebele Ihediwa, APRN-FNP-BC","1215633011","83-0358685","TX","PE - Midland Community Healthcare Services","Amerigroup","Participating","Enrollment Complete","2023-08-22","","","2023-12-27","12/27/2023 Per Amerigroup web portal provider is PAR and linked to group TIN/location effective 8/22/2023.  DCannon"]
["Madhusmita Panda, MD","1134756364","75-2656723","TX","PE - Premier Family Care, Inc","Triwest VA","In House Enrollment","In House Enrollment","","","","2023-08-24",""]
["Madhusmita Panda, MD","1134756364","75-2656723","TX","PE - Premier Family Care, Inc","Aetna","Participating","Enrollment Complete","2023-09-08","8997443","","2023-10-24","10.24.2023 S/W PhilC of Aetna @ 1-800-353-1232. Per rep, Provider is in network with Aetna and linked to the group and TIN# effective 09/08/2023. Next recredentialing date is 09/08/2026. PIN: 8997443. Servicing location is on file. Payer# 60054. Call ref# 6167813673. - Willie Ravas"]
["Madhusmita Panda, MD","1134756364","75-2656723","TX","","Tricare Prime","Participating","Enrollment Complete","2023-09-29","","","2024-02-28","Re-Cred has been completed. eff 9/23/23. MS"]
["Madhusmita Panda, MD","1134756364","75-2656723","TX","PE - Premier Family Care, Inc","USA PPO","Participating","Enrollment Complete",45177,"","","2024-01-11","1/11/2024 Per email from USA MCO - LaNetricia Myart provider is PAR and linked to group TIN/location effective 9/8/2023.  Provider is also listed on the online provider directory.  DCannon"]
["Madhusmita Panda, MD","1134756364","75-2656723","TX","PE - Premier Family Care, Inc","TriCare Standard","Participating","Enrollment Complete","2023-09-29","0037","","2023-10-19","10.18.2023 S/W Kathy of TriCare Standard @ 1-800-444-5445 and transferred me over to the WPS Department and spoke to Shay. Per rep, Provider is certified with TriCare on 09/28/2023 and in network with Tricare and linked to the group and TIN# effective 02/20/2013. No next recredentialing date available. PIN: 0037. Servicing location is on file. Payer# trest. Call ref# Shay10182023."]
["Madhusmita Panda, MD","1134756364","75-2656723","TX","PE - Premier Family Care, Inc","Galaxy Health","Participating","Enrollment Complete","2023-09-08","","","2023-10-11","10/11/2023 Per email received from Galaxy September delegated roster has been processed and provider is PAR and linked to group/location effective 9/8/2023.  DCannon"]
["Abbie Estes, PA","1952088411","46-0950925","TX","PE - Urgent Orthopedic Specialists, PLLC","IMS","Participating","Enrollment Complete","2023-09-08","","","2023-10-09","10/9/2023 Per email received from G. Aviles at IMS/OMNI September delegation roster has been completed.  Provider is PAR and linked to group/location effective 9/8/2023.  DCannon"]
["Abbie Estes, PA","1952088411","46-0950925","TX","PE - Urgent Orthopedic Specialists, PLLC","Zurich","Delegated - Third Party","Enrollment Complete","2024-03-01","","","2024-07-16","7/16/2024 Provider participating as of 3/1/2024 notified via email. FC"]
["Abbie Estes, PA","1952088411","46-0950925","TX","PE - Urgent Orthopedic Specialists, PLLC","Scott&White (First Care)","Participating","Enrollment Complete",45214,"","","2023-10-12","10/12/2023 Per email received from Scott & White provider is PAR and linked to group TIN/locations effective 10/15/2023.  DCannon"]
["Abbie Estes, PA","1952088411","46-0950925","TX","PE - Urgent Orthopedic Specialists, PLLC","Omni PPO","Participating","Enrollment Complete","2023-09-08","","","2023-10-09","10/9/2023 Per email received from G. Aviles at IMS/OMNI September delegation roster has been completed.  Provider is PAR and linked to group/location effective 9/8/2023.  DCannon"]
["Abbie Estes, PA","1952088411","46-0950925","TX","PE - Urgent Orthopedic Specialists, PLLC","Liberty Mutual","Participating","Enrollment Complete","2023-08-07","","","2024-02-02","Per Coventry portal provider is enrolled. Jen Videan"]
["Abbie Estes, PA","1952088411","46-0950925","TX","PE - Urgent Orthopedic Specialists, PLLC","Ambetter","Participating","Enrollment Complete",45200,"","","2023-10-16","10/16/2023 Rcvd email from Superior that provider is PAR and linked to group TIN/location effective 10/1/2023.  DCannon"]
["Abbie Estes, PA","1952088411","46-0950925","TX","PE - Urgent Orthopedic Specialists, PLLC","TriCare Standard","Participating","Enrollment Complete","2023-11-09","","","2023-12-07","Provider is linked to this location eff 11/9/23. MS"]
["Abbie Estes, PA","1952088411","46-0950925","TX","PE - Urgent Orthopedic Specialists, PLLC","First Health Coventry","Participating","Enrollment Complete","2023-09-02","3746308","","2023-11-20","11/20/2023 S/W James of First Health @ 800-226-5116, per rep provider is showing participating and link under the Group and TIN with an Effective date 9/8/2023. Provider ID 3746308. Physical locations are on file. Call ref#:773110. - DCannon"]
["Rony Ninan, MD","1750526182","75-2656723","TX","PE - Premier Family Care, Inc","Galaxy Health","Participating","Enrollment Complete","2023-10-09","","","2023-11-07","11/7/2023 Per email received from Galaxy October delegated roster has been processed and provider is PAR and linked to group/location effective 10/9/2023.  DCannon"]
["Rony Ninan, MD","1750526182","75-2656723","TX","PE - Premier Family Care, Inc","Rail Road Medicare","Participating","Enrollment Complete","2023-09-01","Q00658585","CE1588","2024-02-07","Received approval letter. MS"]
["Rony Ninan, MD","1750526182","75-2656723","TX","PE - Premier Family Care, Inc","Cigna","Participating","Enrollment Complete","2023-09-01","2554745","","2023-11-03","Received confirmation . W202310263491837. MS"]
["Rony Ninan, MD","1750526182","75-2656723","TX","PE - Premier Family Care, Inc","Scott&White (First Care)","Participating","Enrollment Complete","2023-10-03","","","2023-10-09","10/9/2023 Per email received from Scott & White provider is PAR and linked to group effective 10/3/2023.  DCannon"]
["Rony Ninan, MD","1750526182","75-2656723","TX","PE - Premier Family Care, Inc","Humana","Participating","Enrollment Complete",45208,"","","2024-01-29","1/29/2024 Per Humana provider portal provider is PAR and linked to group TIN/location effective 10/9/2023.  DCannon"]
["Rony Ninan, MD","1750526182","75-2656723","TX","PE - Premier Family Care, Inc","CAQH","Participating","CAQH Reattested","2024-07-09","","","2024-07-09","07/09/2024 CAQH Reattested all locations current and all expirables up to date wthompson"]
["Rajnarsing R Chennamaneni, MD","1164689634","47-5554737","TX","PE - Midland Inpatient Medical Association","Amerigroup","Participating","Enrollment Complete","2023-11-06","","","2024-06-19","Provider participating as of 11/6/2023 via roster. FC"]
["Rajnarsing R Chennamaneni, MD","1164689634","47-5554737","TX","PE - Midland Inpatient Medical Association","Cigna","Participating","Enrollment Complete","2023-12-05","9594034","","2024-01-02","Received confirmation of enrollment. MS"]
["Rajnarsing R Chennamaneni, MD","1164689634","47-5554737","TX","PE - Midland Inpatient Medical Association","United Health Care","Participating","Enrollment Complete","2023-11-06","003305120","","2023-12-27","12/27/2023 Per email rcvd from UHC provider is PAR and linked to group TIN and locations effective 11/6/2023.  MPIN # 003305120.  DCannon"]
["Rajnarsing R Chennamaneni, MD","1164689634","47-5554737","TX","PE - Midland Inpatient Medical Association","HealthSmart PPO","Participating","Enrollment Complete","","","","2024-02-29","Per roster received from Aleece Moerbe (Aleece.Moerbe@healthsmart.com) on 02/23/2024, provider is PAR, eff. 11/06/2023, and linked to TIN."]
["Rajnarsing R Chennamaneni, MD","1164689634","47-5554737","TX","PE - Midland Inpatient Medical Association","Caprock (CapStar)","Participating","Enrollment Complete","2023-11-06","","","2023-11-30","11/30/2023 Per email received from Caprock, November Delegated roster has been completed.  Provider is PAR and linked to group TIN effective 11/6/2023.  DCannon"]
["Rajnarsing R Chennamaneni, MD","1164689634","47-5554737","TX","PE - Midland Inpatient Medical Association","Superior","Participating","Enrollment Complete","2023-12-01","","","2023-12-08","12/8/2023 Rcvd roster from Superior Health Plan confirming provider is PAR and linked to group TIN/location effective 12/1/2023.  DCannon"]
["Amanda Dee Flores, APRN-FNP-BC","1083394977","75-2781652","TX","PE - West Texas Allergy, PA","Medicaid","Participating","Enrollment Complete","2023-08-14","1083394977","","2023-12-13","Amanda Flores NPI is a performing provider of the group for any location of the group. Jen Videan"]
["Amanda Dee Flores, APRN-FNP-BC","1083394977","75-2781652","TX","PE - West Texas Allergy, PA","IMS","Participating","Enrollment Complete","2023-09-08","1083394977","","2023-10-09","10/9/2023 Per email received from G. Aviles at IMS/OMNI September delegation roster has been completed.  Provider is PAR and linked to group/location effective 9/8/2023.  DCannon"]
["Amanda Dee Flores, APRN-FNP-BC","1083394977","75-2781652","TX","PE - West Texas Allergy, PA","Cigna","Participating","Enrollment Complete","2024-05-03","5056023","","2024-05-06","Received confirmation of enrollment. MS"]
["Amanda Dee Flores, APRN-FNP-BC","1083394977","75-2781652","TX","","Tricare Prime","Participating","Enrollment Complete",45229,"","","2024-03-05","Provider has been linked to this location. MS"]
["Amanda Dee Flores, APRN-FNP-BC","1083394977","75-2781652","TX","PE - West Texas Allergy, PA","Medicaid","Participating","Enrollment Complete","2023-08-14","1083394977","","2024-03-06","License has been updated with new expiration date. Jen Videan"]
["Amanda Dee Flores, APRN-FNP-BC","1083394977","75-2781652","TX","PE - West Texas Allergy, PA","Triwest VA","Participating","Enrollment Complete","2024-02-01","953232543","","2024-01-24","1/24/2024- received email confirmation from Scarlett A. (Scarlett_Abigail@bcbstx.com), provider is par, eff. 02/01/24."]
["Amanda Dee Flores, APRN-FNP-BC","1083394977","75-2781652","TX","PE - West Texas Allergy, PA","Triwest VA","Participating","Enrollment Complete","2024-02-01","953232543","","2024-01-24","1/24/2024- received email confirmation from Scarlett A. (Scarlett_Abigail@bcbstx.com), provider is par, eff. 02/01/24."]
["Amanda Dee Flores, APRN-FNP-BC","1083394977","75-2781652","TX","PE - West Texas Allergy, PA","IMS","Participating","Enrollment Complete",45177,"1083394977","","2024-01-02","1/2/2024 Rcvd email from German Avilies at IMS/OMNI that November delegation roster is complete.  Provider is PAR and linked to group TIN/location effective 9/8/2023.  DCannon"]
["Amanda Dee Flores, APRN-FNP-BC","1083394977","75-2781652","TX","PE - West Texas Allergy, PA","Amerigroup","Participating","Add Info Submitted","2023-09-08","1083399477","","2024-04-19","4/19/2024- Submitted Lubbock address via delegated roster on 4/15/2024. FC"]
["Amanda Dee Flores, APRN-FNP-BC","1083394977","75-2781652","TX","PE - West Texas Allergy, PA","Medicare","Participating","Enrollment Complete","2023-08-14","6B7029","","2023-10-25","10/25/2023 Per PECOS provider is PAR and linked to group effective 8/14/2023.  PTAN # 6B7029.  DCannon"]
["Amanda Dee Flores, APRN-FNP-BC","1083394977","75-2781652","TX","PE - West Texas Allergy, PA","Caprock (CapStar)","Participating","Enrollment Complete","2023-09-08","1083394977","","2023-09-27","9/27/2023 Rcvd email confirmation from Caprock that the September roster has been completed.  Provider is PAR and linked to group/location effective 9/8/2023.  DCannon"]
["Amanda Dee Flores, APRN-FNP-BC","1083394977","75-2781652","TX","PE - West Texas Allergy, PA","CAQH","Participating","CAQH Reattested",45518,"16016463","","2024-08-14","08/14/2024 CAQH Reattested all locations current and all expirables up to date wthompson"]
["Amanda Dee Flores, APRN-FNP-BC","1083394977","75-2781652","TX","PE - West Texas Allergy, PA","Triwest VA","Participating","Enrollment Complete",45323,"953232543","","2024-01-24","1/24/2024- received email confirmation from Scarlett A. (Scarlett_Abigail@bcbstx.com), provider is par, eff. 02/01/24."]
["Amanda Dee Flores, APRN-FNP-BC","1083394977","75-2781652","TX","PE - West Texas Allergy, PA","TriCare Standard","In Process","Payor Follow Up",45229,"","","2024-08-28","Received email from Triwest: Your group has a net sub BlueCross BlueShield of TX. BlueCross BlueShield of TX handles all of our CCN contracting/credentialing/data updates for TriWest. BlueCross BlueShield of TX can be contacted on by their email vatriwest@bcbstx.com or office phone 1-877-891-3327.\nAn inquiry email was sent. MS"]
["Amanda Dee Flores, APRN-FNP-BC","1083394977","75-2781652","TX","PE - West Texas Allergy, PA","HealthSmart PPO","Participating","Enrollment Complete","","","","2024-02-29","Per roster received from Aleece Moerbe (Aleece.Moerbe@healthsmart.com) on 02/23/2024, provider is PAR, eff. 09/08/2023  and linked to location 5424 19th, suite 300. PA."]
["Ankit Ashwin Patel, MD","1083979322","75-2656723","TX","PE - Premier Family Care, Inc","HealthSmart PPO","Participating","Enrollment Complete","","","","2024-02-29","Per roster received from Aleece Moerbe (Aleece.Moerbe@healthsmart.com) on 02/23/2024, provider is PAR, eff.  11/08/2023 and linked to TIN. PA"]
["Ankit Ashwin Patel, MD","1083979322","75-2656723","TX","PE - Premier Family Care, Inc","Galaxy Health","Participating","Enrollment Complete","2023-11-08","","","2023-12-18","12/18/2023 Per email from Karen Avalos at Galaxy November delegated roster is complete.  Provider is PAR and linked to group TIN/locations effective 11/6/2023.  DCannon"]
["Ankit Ashwin Patel, MD","1083979322","75-2656723","TX","PE - Premier Family Care, Inc","Medicaid","Participating","Enrollment Complete","2014-08-01","1083979322","","2023-12-06","12/6/2023 Per TMHP web portal application has been approved.  Provider is PAR and linked to group/location effective 8/1/2014.  Revalidation date 10/16/2028.  TPI # 1083979322.  DCannon"]
["Ankit Ashwin Patel, MD","1083979322","75-2656723","TX","PE - Premier Family Care, Inc","United Health Care","Participating","Enrollment Complete","2023-11-08","004473172","","2023-12-28","12/28/2023 Per email from UHC provider is PAR and linked to group TIN/location effective 11/8/2023. \nMPIN # 004473172.  DCannon"]
["Ankit Ashwin Patel, MD","1083979322","75-2656723","TX","PE - Premier Family Care, Inc","Humana","Participating","Enrollment Complete","2023-11-08","","","2023-12-21","12/21/2023 Per Humana online directory provider is PAR and linked to group TIN and  all locations effective 11/8/2023.  DCannon"]
["Billy S Gao, MD","1699092304","75-2656723","TX","PE - Premier Family Care, Inc","HealthSmart PPO","Participating","Enrollment Complete","","","","2024-02-29","Per roster received from Aleece Moerbe (Aleece.Moerbe@healthsmart.com) on 02/23/2024, provider is PAR, eff.  11/06/2023 and linked to TIN. PA"]
["Billy S Gao, MD","1699092304","75-2656723","TX","PE - Premier Family Care, Inc","Superior","Participating","Enrollment Complete","2023-12-01","","","2023-12-08","12/8/2023 Rcvd roster from Superior Health Plan confirming provider is PAR and linked to group TIN/location effective 12/1/2023.  DCannon"]
["Billy S Gao, MD","1699092304","75-2656723","TX","PE - Premier Family Care, Inc","Multiplan","Participating","Enrollment Complete","2023-11-06","","","2023-12-20","12/20/2023 Per email from Jessica Bess at Multiplan November delegated roster provider load is complete.  Provider is PAR and linked to group TIN/location effective 11/6/2023.  DCannon"]
["Billy S Gao, MD","1699092304","75-2656723","TX","PE - Premier Family Care, Inc","Amerigroup","Participating","Enrollment Complete","2023-11-06","","","2023-12-27","12/27/2023 Per Amerigroup web portal provider is PAR and linked to group TIN/location effective 11/6/2023.  DCannon"]
["Billy S Gao, MD","1699092304","75-2656723","TX","PE - Premier Family Care, Inc","United Health Care","Participating","Enrollment Complete","2023-11-06","","","2023-12-27","12/27/2023 Per email rcvd from UHC provider is PAR and linked to group TIN and locations effective 11/6/2023.  MPIN # 006259813.  DCannon"]
["Sudhir K Chiluka, MD","1912452053","47-5554737","TX","PE - Midland Inpatient Medical Association","Tricare Prime","Panel Closed","Panel Closed","","","","2023-11-15","Per the payor, the panel is closed for new enrollments. MS"]
["Sudhir K Chiluka, MD","1912452053","47-5554737","TX","PE - Midland Inpatient Medical Association","Omni PPO","Participating","Enrollment Complete","2023-12-04","","","2024-01-02","1/2/2024 Rcvd email from German Avilies at IMS/OMNI that December delegation roster is complete.  Provider is PAR and linked to group TIN/location effective 12/4/2023.  DCannon"]
["Sudhir K Chiluka, MD","1912452053","47-5554737","TX","PE - Midland Inpatient Medical Association","CAQH","Participating","CAQH Reattested","2024-08-30","","","2024-08-30","08/30/2024 CAQH Reattested updated and uploaded COI wthompson"]
["Sudhir K Chiluka, MD","1912452053","47-5554737","TX","PE - Midland Inpatient Medical Association","First Health Coventry","Participating","Enrollment Complete","2024-01-01","","","2024-06-25","As per Teresita (call ref# 1105034) provider participating as of 1/1/2024, listed as Family Practice. FC"]
["Sudhir K Chiluka, MD","1912452053","47-5554737","TX","PE - Midland Inpatient Medical Association","Cigna","Participating","Enrollment Complete","2023-12-06","6700596","","2024-02-14","Received welcome email. MS"]
["Sudhir K Chiluka, MD","1912452053","47-5554737","TX","PE - Midland Inpatient Medical Association","Wellmed","Participating","Enrollment Complete",45264,"00010938653","","2024-01-22","1/22/2024 Per UHC portal provider is PAR and linked to group TIN/location effective 12/4/2023. MPIN# 00010938653.  DCannon"]
["Briana Janene Smith, APRN-FNP-BC","1215488754","83-0358685","TX","PE - Midland Community Healthcare Services","TriCare Standard","Participating","Enrollment Complete",45194,"","","2023-10-27","Provider linked to Rosalind and Andrews Hwy location eff 9/28/2023. MS"]
["Briana Janene Smith, APRN-FNP-BC","1215488754","83-0358685","TX","PE - Midland Community Healthcare Services","TriCare Standard","Participating","Enrollment Complete",45194,"","","2023-10-27","Provider linked to Rosalind and Andrews Hwy location eff 9/28/2023. MS"]
["Briana Janene Smith, APRN-FNP-BC","1215488754","83-0358685","TX","PE - Midland Community Healthcare Services","CAQH","In House Enrollment","In House Enrollment","","","","2023-09-18","9/18/13-Per notification form - provider will maintain - kavello"]
["Briana Janene Smith, APRN-FNP-BC","1215488754","83-0358685","TX","PE - Midland Community Healthcare Services","CAQH","In House Enrollment","In House Enrollment","","","","2023-09-18","9/18/13-Per notification form - provider will maintain - kavello"]
["Briana Janene Smith, APRN-FNP-BC","1215488754","83-0358685","TX","PE - Midland Community Healthcare Services","Omni PPO","Participating","Enrollment Complete",45236,"","","2024-01-02","1/2/2024 Rcvd email from German Avilies at IMS/OMNI that November delegation roster is complete.  Provider is PAR and linked to group TIN/location effective 11/6/2023.  DCannon"]
["Briana Janene Smith, APRN-FNP-BC","1215488754","83-0358685","TX","PE - Midland Community Healthcare Services","Omni PPO","Participating","Enrollment Complete",45236,"","","2024-01-02","1/2/2024 Rcvd email from German Avilies at IMS/OMNI that November delegation roster is complete.  Provider is PAR and linked to group TIN/location effective 11/6/2023.  DCannon"]
["Briana Janene Smith, APRN-FNP-BC","1215488754","83-0358685","TX","PE - Midland Community Healthcare Services","Aetna","Participating","Enrollment Complete",45236,"","","2023-12-28","12/28/2023 S/W Paul of Aetna @ 1-800-353-1232. Per rep, Provider is in network with Aetna for the state of TX and linked to the group TIN and locations effective 11/06/2023.  DCannon"]
["Briana Janene Smith, APRN-FNP-BC","1215488754","83-0358685","TX","PE - Midland Community Healthcare Services","United Health Care","Participating","Enrollment Complete","2023-11-06","006258398","","2023-12-28","12/28/2023 Per email from UHC provider is PAR and linked to group TIN/location effective 11/6/2023. \nMPIN # 006258398.  DCannon"]
["Briana Janene Smith, APRN-FNP-BC","1215488754","83-0358685","TX","PE - Midland Community Healthcare Services","United Health Care","Participating","Enrollment Complete",45236,"006258398","","2023-12-28","12/28/2023 Per email from UHC provider is PAR and linked to group TIN/location effective 11/6/2023. \nMPIN # 006258398.  DCannon"]
["Briana Janene Smith, APRN-FNP-BC","1215488754","83-0358685","TX","PE - Midland Community Healthcare Services","Humana","Participating","Enrollment Complete","2023-11-06","","","2023-12-21","12/21/2023 Per Humana online directory provider is PAR and linked to group TIN and  all locations effective 11/6/2023.  DCannon"]
["Briana Janene Smith, APRN-FNP-BC","1215488754","83-0358685","TX","PE - Midland Community Healthcare Services","Cigna","Participating","Enrollment Complete","2023-11-29","8412605","","2023-12-06","Received confirmation email of approval effective 11/29/23. MS"]
["Briana Janene Smith, APRN-FNP-BC","1215488754","83-0358685","TX","PE - Midland Community Healthcare Services","Cigna","Participating","Enrollment Complete","2023-11-29","8412605","","2023-12-06","Received confirmation email of approval effective 11/29/23. MS"]
["Briana Janene Smith, APRN-FNP-BC","1215488754","83-0358685","TX","PE - Midland Community Healthcare Services","Superior","Participating","Enrollment Complete","2023-12-01","","","2023-12-08","12/8/2023 Rcvd roster from Superior Health Plan confirming provider is PAR and linked to group TIN/location effective 12/1/2023.  DCannon"]
["Briana Janene Smith, APRN-FNP-BC","1215488754","83-0358685","TX","PE - Midland Community Healthcare Services","Tricare Prime","Panel Closed","Panel Closed","","","","2023-09-20","Per the website, the panel is closed to new providers at this time. MS"]
["Briana Janene Smith, APRN-FNP-BC","1215488754","83-0358685","TX","PE - Midland Community Healthcare Services","Wellmed","Thru Other Payor","Pending Other Enrollment","","","","2024-01-30","1/30/2024 Per UHC portal provider load in Wellmed is still pending.  Will check back in a few days.  DCannon"]
["Briana Janene Smith, APRN-FNP-BC","1215488754","83-0358685","TX","PE - Midland Community Healthcare Services","Wellmed","Thru Other Payor","Pending Other Enrollment","","","","2024-01-30","1/30/2024 Per UHC portal provider load in Wellmed is still pending.  Will check back in a few days.  DCannon"]
["Briana Janene Smith, APRN-FNP-BC","1215488754","83-0358685","TX","PE - Midland Community Healthcare Services","Boon Chapman","Participating","Enrollment Complete","2023-11-06","","","2023-12-20","12/20/2023 Per email from Jessica Bess at Multiplan November delegated roster provider load is complete.  Provider is PAR and linked to group TIN/location effective 11/6/2023.  DCannon"]
["Briana Janene Smith, APRN-FNP-BC","1215488754","83-0358685","TX","PE - Midland Community Healthcare Services","Multiplan","Participating","Enrollment Complete",45236,"","","2023-12-20","12/20/2023 Per email from Jessica Bess at Multiplan November delegated roster provider load is complete.  Provider is PAR and linked to group TIN/location effective 11/6/2023.  DCannon"]
["Briana Janene Smith, APRN-FNP-BC","1215488754","83-0358685","TX","PE - Midland Community Healthcare Services","HealthSmart PPO","Participating","Enrollment Complete","2023-11-06","","","2024-02-29","Per roster received from Aleece Moerbe (Aleece.Moerbe@healthsmart.com) on 02/23/2024, provider is PAR, eff. 11/06/2023, linked to TIN and the following locations 4214 Andrews HWY, 801 E Florida Ave, and 400 Rosalind Redfern.  PA"]
["Briana Janene Smith, APRN-FNP-BC","1215488754","83-0358685","TX","PE - Midland Community Healthcare Services","HealthSmart PPO","Participating","Enrollment Complete","2023-11-06","","","2024-02-29","Per roster received from Aleece Moerbe (Aleece.Moerbe@healthsmart.com) on 02/23/2024, provider is PAR, eff. 11/06/2023, linked to TIN and the following locations 4214 Andrews HWY, 801 E Florida Ave, and 400 Rosalind Redfern.  PA"]
["Briana Janene Smith, APRN-FNP-BC","1215488754","83-0358685","TX","PE - Midland Community Healthcare Services","HealthSmart PPO","Participating","Enrollment Complete","2023-11-06","","","2024-02-29","Per roster received from Aleece Moerbe (Aleece.Moerbe@healthsmart.com) on 02/23/2024, provider is PAR, eff. 11/06/2023, linked to TIN and the following locations 4214 Andrews HWY, 801 E Florida Ave, and 400 Rosalind Redfern.  PA"]
["Briana Janene Smith, APRN-FNP-BC","1215488754","83-0358685","TX","PE - Midland Community Healthcare Services","Scott&White (First Care)","Participating","Enrollment Complete",45236,"","","2024-01-11","1/11/2024 Per email from Scott & White November roster has been completed.  Provider is PAR and linked to group TIN/location effective 11/6/2023.  DCannon"]
["Briana Janene Smith, APRN-FNP-BC","1215488754","83-0358685","TX","PE - Midland Community Healthcare Services","Scott&White (First Care)","Participating","Enrollment Complete",45236,"","","2024-01-11","1/11/2024 Per email from Scott & White November roster has been completed.  Provider is PAR and linked to group TIN/location effective 11/6/2023.  DCannon"]
["Briana Janene Smith, APRN-FNP-BC","1215488754","83-0358685","TX","PE - Midland Community Healthcare Services","Amerigroup","Participating","Enrollment Complete",45236,"","","2024-05-20","5/20/2024 Provider participating as of 11/6/2023 via April roster. FC"]
["Briana Janene Smith, APRN-FNP-BC","1215488754","83-0358685","TX","PE - Midland Community Healthcare Services","Amerigroup","Participating","Enrollment Complete",45236,"","","2024-05-20","5/20/2024 Provider participating as of 11/6/2023 via April roster. FC"]
["Briana Janene Smith, APRN-FNP-BC","1215488754","83-0358685","TX","PE - Midland Community Healthcare Services","IMS","Participating","Enrollment Complete","2023-11-06","","","2024-01-02","1/2/2024 Rcvd email from German Avilies at IMS/OMNI that November delegation roster is complete.  Provider is PAR and linked to group TIN/location effective 11/6/2023.  DCannon"]
["Neel N Shah, MD","1861752529","75-2656723","TX","PE - Premier Family Care, Inc","Medicare","Participating","Enrollment Complete","2024-04-01","6K7156","0008AH","2024-02-27","Received welcome letter. MS"]
["Neel N Shah, MD","1861752529","75-2656723","TX","PE - Premier Family Care, Inc","Humana","Participating","Enrollment Complete","2023-11-01","","","2024-06-21","Received email confirmation from Marcus Wester, provider is par and linked to TIN/location, eff. 11/01/2023. PA."]
["Neel N Shah, MD","1861752529","75-2656723","TX","PE - Premier Family Care, Inc","Boon Chapman","Participating","Enrollment Complete","2024-02-05","","","2024-04-02","3/20/2024 Received confirmation from Jessica Bess via email, provider effective with Multiplan 2/5/2024. FC."]
["Neel N Shah, MD","1861752529","75-2656723","TX","PE - Premier Family Care, Inc","Galaxy Health","Participating","Enrollment Complete","2024-02-05","","","2024-03-21","03/21/2024 - received email confirmation from Karen Avalos (kavalos@ghn-mci.com), provider is PAR, eff. 02/05/2024. PA"]
["Neel N Shah, MD","1861752529","75-2656723","TX","PE - Premier Family Care, Inc","Medicaid","Participating","Payor Follow Up",45383,"","","2024-08-21","Application submitted to correct primary taxonomy code from 2084N0400X to 2084V0102X.  Application still in PE Review status. Jen Videan"]
["Neel N Shah, MD","1861752529","75-2656723","TX","","Medicaid","Participating","Payor Follow Up",45383,"","","2024-08-21","Application submitted to correct primary taxonomy code from 2084N0400X to 2084V0102X.  Application still in PE Review status. Jen Videan"]
["Neel N Shah, MD","1861752529","75-2656723","TX","PE - Premier Family Care, Inc","Amerigroup","Participating","Enrollment Complete","2024-02-05","","","2024-05-20","5/202/24 Provider participating as of 2/5/2024 via April wellpoint roster. FC"]
["Bailey Bergman, PA","1447851639","75-2656723","TX","PE - Premier Family Care, Inc","TriCare Standard","Participating","Enrollment Complete","2024-02-27","","","2024-03-13","Re-Cred completed. MS"]
["Bailey Bergman, PA","1447851639","75-2656723","TX","PE - Premier Family Care, Inc","USA PPO","In Process","Payor Follow Up","2024-02-09","","","2024-07-30","Sent email to payor requesting enrollment status update. PA."]
["Bailey Bergman, PA","1447851639","75-2656723","TX","PE - Premier Family Care, Inc","Boon Chapman","Participating","Enrollment Complete","2024-03-11","","","2024-05-24","Par through Multiplan enrollment, eff. 03/11/2024. PA"]
["Bailey Bergman, PA","1447851639","75-2656723","TX","PE - Premier Family Care, Inc","Medicare","Participating","Enrollment Complete","2024-02-01","6K7369","0008AH","2024-02-27","Received welcome letter. MS"]
["Bailey Bergman, PA","1447851639","75-2656723","TX","PE - Premier Family Care, Inc","HealthSmart PPO","Participating","Enrollment Complete","2024-03-11","","","2024-07-04","7/4/2024 provider participating as of 3/11/2024 as per Aleece Moerbe from HealthSmart via email confirmation. FC"]
["Bailey Bergman, PA","1447851639","75-2656723","TX","PE - Premier Family Care, Inc","Multiplan","Participating","Enrollment Complete","2024-03-11","","","2024-05-24","Received email confirmation from Multiplan rep Jessica Bess (jessica.bess@multiplan.com), provider is PAR, eff. 03/11/2024. PA."]
["Bailey Bergman, PA","1447851639","75-2656723","TX","PE - Premier Family Care, Inc","Galaxy Health","Participating","Enrollment Complete",45362,"","","2024-04-16","Received email confirmation from Karen Avalos, roster completed;  Provider is PAR, eff. 03/11/2024. PA."]
["Brittany P Price, RD","1922875160","75-2656723","TX","PE - Premier Family Care, Inc","Superior","Participating","Enrollment Complete",45323,"","","2024-04-29","Per email from Sebastian Flores (sebastian.flores@superiorhealthplan.com), provider is PAR and linked to TIN/location, eff 02/01/2024, with TX CHIP and TX CHIP RSA. PA."]
["Brittany P Price, RD","1922875160","75-2656723","TX","PE - Premier Family Care, Inc","Cigna","Participating","Enrollment Complete","2024-03-05","9348170","","2024-03-06","Received welcome letter via email. MS"]
["Brittany P Price, RD","1922875160","75-2656723","TX","PE - Premier Family Care, Inc","HealthSmart PPO","Participating","Enrollment Complete","2024-01-08","","","2024-07-04","7/4/2024 provider participating as of 1/8/2024 as per Aleece Moerbe from HealthSmart via email confirmation. FC"]
["Brittany P Price, RD","1922875160","75-2656723","TX","PE - Premier Family Care, Inc","Medicaid","In Process","Payor Follow Up","2023-12-13","6J8407","","2024-08-21","Application in PE Review status. Emailed TMHP PE for status. Jen Videan"]
["Brittany P Price, RD","1922875160","75-2656723","TX","PE - Premier Family Care, Inc","Amerigroup","Participating","Enrollment Complete","2024-01-08","","","2024-03-21","3/21/2024 Provider participating as of 1/8/2024 with Wellpoint via roster. FC"]
["Carrie M Watson, APRN-NP","1700513504","75-2656723","TX","PE - Premier Family Care, Inc","Ambetter","Participating","Enrollment Complete","2024-03-01","","","2024-04-29","Per email from Sebastian Flores (sebastian.flores@superiorhealthplan.com), provider is PAR and linked to TIN/location, eff 03/01/2024. PA."]
["Carrie M Watson, APRN-NP","1700513504","75-2656723","TX","PE - Premier Family Care, Inc","Aetna","Participating","Enrollment Complete","2024-02-20","8405143","","2024-06-18","S/W Claire of Aetna @ 1-800-353-1232. Per rep, Provider is in network with Aetna for the state of TX and linked to the group and TIN effective 02/01/2024. Next recredentialing date is 02/20/2024. PIN: 8405143. Servicing location is on file. Payer# 60054. Call ref# 6194640428."]
["Carrie M Watson, APRN-NP","1700513504","75-2656723","TX","PE - Premier Family Care, Inc","Amerigroup","Participating","Enrollment Complete","2024-02-05","","","2024-05-20","5/20/2024 Provider participating as of 2/5/2024 via April roster. FC"]
["Carrie M Watson, APRN-NP","1700513504","75-2656723","TX","PE - Premier Family Care, Inc","United Health Care","Participating","Enrollment Complete","2024-02-05","","","2024-06-11","Received enrollment confirmation from UHC, illustrating provider is PAR, listed as PCP, and linked to TIN & location, eff. 02/05/2024. PA."]
["Carrie M Watson, APRN-NP","1700513504","75-2656723","TX","PE - Premier Family Care, Inc","Wellcare","Participating","Enrollment Complete","2024-03-01","","","2024-04-29","Per email from Sebastian Flores (sebastian.flores@superiorhealthplan.com), provider is PAR and linked to TIN/location, eff 03/01/2024. PA."]
["Carrie M Watson, APRN-NP","1700513504","75-2656723","TX","PE - Premier Family Care, Inc","TriCare Standard","Participating","Enrollment Complete","2024-01-15","","","2024-01-19","Received confirmation of approval. MS"]
["Carrie M Watson, APRN-NP","1700513504","75-2656723","TX","PE - Premier Family Care, Inc","Humana","In Process","Payor Follow Up","","","","2024-08-27","Sent follow up email to Network Manager Erica Lee, requesting status. PA."]
["Alberto Fernandez, PA","1912697970","46-3131679","TX","PE - Midland Texas Orthopedic Group Inc","Broadspire Services Inc.","Participating","Enrollment Complete","2024-01-11","","","2024-07-08","Contract complete. Effective 01/11/2024. Provider was listed on par provider roster submitted with contract. Jen Videan"]
["Alberto Fernandez, PA","1912697970","46-3131679","TX","PE - Midland Texas Orthopedic Group Inc","TriCare Standard","Participating","Enrollment Complete","2024-01-23","","","2024-02-07","Received approval letter. MS"]
["Alberto Fernandez, PA","1912697970","46-3131679","TX","PE - Midland Texas Orthopedic Group Inc","Triwest VA","In Process","Payor Follow Up","","","","2024-08-19","Requested status update on enrollment via email to Scarlett Abigail. PA."]
["Alberto Fernandez, PA","1912697970","46-3131679","TX","PE - Midland Texas Orthopedic Group Inc","Caprock (CapStar)","Participating","Enrollment Complete","2024-02-05","","","2024-03-26","Received email from Mary Rodriguez (mary.rodriguez@90degreebenefits.com) on 03/25/2024  provider is PAR, eff. 02/05/2024. Location on file: 5615 Deauville BLVD, Suite 220. PA"]
["Alberto Fernandez, PA","1912697970","46-3131679","TX","PE - Midland Texas Orthopedic Group Inc","Sedgwick","Participating","Enrollment Complete","2024-06-19","1912697970","","2024-06-28","Approval ltr rcvd. Provider eff 06/19/2024. Jen Videan"]
["Alberto Fernandez, PA","1912697970","46-3131679","TX","PE - Midland Texas Orthopedic Group Inc","USA PPO","In Process","Payor Follow Up","","","","2024-07-30","Sent email to payor requesting enrollment status update. PA."]
["Alberto Fernandez, PA","1912697970","46-3131679","TX","PE - Midland Texas Orthopedic Group Inc","Zurich","Delegated - Third Party","Thru Other Payor","","","","2024-01-27","Check Coventry portal for enrollment status. MS"]
["Alberto Fernandez, PA","1912697970","46-3131679","TX","PE - Midland Texas Orthopedic Group Inc","Coventry Workers Comp","Participating","Enrollment Complete","2024-03-01","","","2024-08-06","8/6/2024 Spoke to Paul R. call ref# 17821445, provider participating as of 3/1/2024. FC"]
["Alberto Fernandez, PA","1912697970","46-3131679","TX","PE - Midland Texas Orthopedic Group Inc","Wellmed","Thru Other Payor","Pending Other Enrollment","","","","2024-01-30","1/30/2024 Pending UHC enrollment.  DCannon"]
["Nikolas V St Cyr, MD","1538659487","75-2656723","TX","","United Health Care","In Process","Application Submitted","","","","2024-08-15","Application submitted through delegated roster. PA."]
["Nikolas V St Cyr, MD","1538659487","75-2656723","TX","PE - Premier Family Care, Inc","TriCare Standard","Participating","Enrollment Complete","2024-06-25","","","2024-06-28","Provider has been linked to this location 6/25/2024. MS"]
["Nikolas V St Cyr, MD","1538659487","75-2656723","TX","PE - Premier Family Care, Inc","Ambetter","In Process","Application Submitted","","","","2024-08-15","Application submitted through delegated roster. PA."]
["Nikolas V St Cyr, MD","1538659487","75-2656723","TX","","CAQH","Participating","CAQH Reattested","2024-08-26","","","2024-08-26","08/26/2024 CAQH Reattested Updated and uploaded COI wthompson"]
["Nikolas V St Cyr, MD","1538659487","75-2656723","TX","PE - Premier Family Care, Inc","Medicaid","Participating","Enrollment Complete","2024-07-29","","","2024-07-29","Approval ltr rcvd. Effective 07/29/2024. Jen Videan"]
["Nikolas V St Cyr, MD","1538659487","75-2656723","TX","","PPHP","Participating","Enrollment Complete","2024-08-05","","","2024-08-30","Received email confirmation provider is PAR and linked to TIN/location, eff. 08/05/2024. PA."]
["Nikolas V St Cyr, MD","1538659487","75-2656723","TX","PE - Premier Family Care, Inc","Scott&White (First Care)","In Process","Application Submitted","","","","2024-08-15","Application submitted through delegated roster. PA."]
["Nikolas V St Cyr, MD","1538659487","75-2656723","TX","","Caprock (CapStar)","In Process","Application Submitted","","","","2024-08-19","Submitted via delegated roster on 8/15/2024. FC"]
["Nikolas V St Cyr, MD","1538659487","75-2656723","TX","PE - Premier Family Care, Inc","Rail Road Medicare","Participating","Enrollment Complete","2024-07-29","Q00774162","CE1588","2024-07-01","Provider has been approved. MS"]
["Nikolas V St Cyr, MD","1538659487","75-2656723","TX","PE - Premier Family Care, Inc","Aetna","Participating","Enrollment Complete","2024-06-03","8313945","","2024-06-18","S/W Claire of Aetna @ 1-800-353-1232. Per rep, Provider is in network with Aetna for the state of TX and linked to the group and TIN effective 06/03/2024. No next recredentialing date provided. PIN: 8313945. Servicing location is on file. Payer# 60054. Call ref# 6194640428."]
["Nikolas V St Cyr, MD","1538659487","75-2656723","TX","","Aetna","Participating","Enrollment Complete","2024-06-03","8313945","","2024-06-18","S/W Claire of Aetna @ 1-800-353-1232. Per rep, Provider is in network with Aetna for the state of TX and linked to the group and TIN effective 06/03/2024. No next recredentialing date provided. PIN: 8313945. Servicing location is on file. Payer# 60054. Call ref# 6194640428."]
["Nikolas V St Cyr, MD","1538659487","75-2656723","TX","PE - Premier Family Care, Inc","First Health Coventry","In Process","Application Submitted","","","","2024-08-08","Application submitted online. MS"]
["Rathnavali Katragadda, MD","1750885075","75-2656723","TX","","Medicare","Participating","Enrollment Complete","","","","2024-08-23","Provider is linked to this TIN and location is already on file. MS"]
["Rathnavali Katragadda, MD","1750885075","75-2656723","TX","PE - Premier Family Care, Inc","Cigna","In Process","Payor Receipt Validated","","","","2024-06-21","Application has been received and is processing. MS Ref #13741394. MS"]
["Rathnavali Katragadda, MD","1750885075","75-2656723","TX","","Cigna","In Process","Payor Receipt Validated","","","","2024-06-21","Application has been received and is processing. MS Ref #13741394. MS"]
["Rathnavali Katragadda, MD","1750885075","75-2656723","TX","","Medicaid","In Process","Payor Follow Up","","","","2024-08-21","Application still in PE Review status. Jen Videan"]
["Rathnavali Katragadda, MD","1750885075","75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","In Process","Payor Receipt Validated","","","","2024-05-21",""]
["Rathnavali Katragadda, MD","1750885075","75-2656723","TX","","TriCare Standard","In Process","Application Submitted","","","","2024-08-23","Submitted request to add provider to this location. MS"]
["Rathnavali Katragadda, MD","1750885075","75-2656723","TX","PE - Premier Family Care, Inc","CAQH","Active","CAQH Reattested","2024-08-27","","","2024-08-27","08/01/2024 CAQH Reattested updated and uploaded COI wthompson"]
["Rathnavali Katragadda, MD","1750885075","75-2656723","TX","","Rail Road Medicare","Participating","Enrollment Complete","2024-07-01","Q00774557","CE1588","2024-07-01","Provider has been approved and linked. MS"]
["Robert John Cornell, MD","1457331803","75-1997880","TX","PE - Andrews County Hospital District","HealthSmart PPO","In Process","Payor Follow Up","","","","2024-08-22","Emailed Aleece and Lee for an update. FC"]
["Robert John Cornell, MD","1457331803","75-1997880","TX","PE - Andrews County Hospital District","Cigna Healthspring","Pending Other Enrollment","Pending Contracting","","","","2024-05-01","Payor has requested not to send follow up requests as they will review the need for at the group level first. If they want to contract, they will reach out and request a roster of all providers under TIN. MS"]
["Robert John Cornell, MD","1457331803","75-1997880","TX","PE - Andrews County Hospital District","Rail Road Medicare","In Process","Pending Info/Document","","","","2024-07-24","Pending confirmation from client. The Medicare approval letter that was provided is for another group, not Andrews. MS"]
["Robert John Cornell, MD","1457331803","75-1997880","TX","PE - Andrews County Hospital District","Omni PPO","In Process","Application Submitted","","","","2024-08-19","Submitted via delegated roster on 8/15/2024. FC"]
["Robert John Cornell, MD","1457331803","75-1997880","TX","PE - Andrews County Hospital District","USA PPO","In Process","Application Submitted","","","","2024-07-15","Submitted application via delegated roster submission. PA."]
["Robert John Cornell, MD","1457331803","75-1997880","TX","PE - Andrews County Hospital District","Omni PPO","In Process","Application Submitted","","","","2024-07-17","Submitted via delegated roster on 7/15/2024. FC"]
["Robert John Cornell, MD","1457331803","75-1997880","TX","PE - Andrews County Hospital District","TriCare Standard","Participating","Enrollment Complete","2024-04-12","","","2024-08-23",""]
["Robert John Cornell, MD","1457331803","75-1997880","TX","PE - Andrews County Hospital District","Medicare","In House Enrollment","In House Enrollment","","","","2024-04-16","Practice confirmed the office will enroll the provider. MS"]
["Patrick M Brennan, DO","1295354264","46-3131679","TX","PE - Midland Texas Orthopedic Group Inc","Medicare","Participating","Enrollment Complete","2024-08-11","6T6690","320497","2024-07-10","Received welcome letter. MS"]
["Patrick M Brennan, DO","1295354264","46-3131679","TX","PE - Midland Texas Orthopedic Group Inc","Sedgwick","In Process","Payor Follow Up","2024-05-20","","","2024-09-20","Per spneast@sedgwickcms.com, your provider's credentialing has been completed & is on the September 2024 credentialing meeting.  It is tentatively scheduled for 9/18/2024. Jen Videan"]
["Patrick M Brennan, DO","1295354264","46-3131679","TX","","BCBSTX","Participating","Enrollment Complete","2024-07-12","8WL530","","2024-07-11","Received email confirmation provider is PAR and linked to TIN/location, eff. 7/12/2024. Provider is participating with the following products: BAV - Blue Advantage HMO\nHMO - Blue Essentials\nBCA - BlueChoice PPO\nHME - Health Select\nMCH - Medicare Advantage HMO\nPMC - Medicare Advantage PPO\nWEL - WellMed MA HMO\nSNP - Dual Eligible Special Needs Plan. PA."]
["Patrick M Brennan, DO","1295354264","46-3131679","TX","PE - Midland Texas Orthopedic Group Inc","Corvel Healthcare Corp.","Participating","Enrollment Complete",45498,"","",45499,"Approval ltr rcvd. Effective 07/25/2024. Jen Videan"]
["Patrick M Brennan, DO","1295354264","46-3131679","TX","","Texas Municipal League","Participating","Enrollment Complete","2024-06-28","","","2024-07-24","Please see status updates under Alliance WC payor line. Jen Videan"]
["Patrick M Brennan, DO","1295354264","46-3131679","TX","PE - Midland Texas Orthopedic Group Inc","Alliance WC","Participating","Enrollment Complete",45471,"","","2024-07-24","Approval Ltr rcvd. Effective 06/28/2024. Jen Videan"]
["Patrick M Brennan, DO","1295354264","46-3131679","TX","","Alliance WC","Participating","Enrollment Complete",45471,"","","2024-07-24","Approval Ltr rcvd. Effective 06/28/2024. Jen Videan"]
["Patrick M Brennan, DO","1295354264","46-3131679","TX","PE - Midland Texas Orthopedic Group Inc","Broadspire Services Inc.","Participating","Enrollment Complete","2024-01-11","","","2024-07-25","Per Broadspire, Moving forward please send all update requests to Updates@primehealthservices.com only. Please note, that our team will no longer be providing direct responses to update requests. We understand the importance of updated provider information and rest assured, your request is in our system, and our dedicated team will handle it promptly.  Our team will reach out should any additional information be needed. But, no further updates will be given on requests and no confirmation of completion will be given. Effective date is date of contract 01/11/2024. Jen Videan"]
["Patrick M Brennan, DO","1295354264","46-3131679","TX","","Coventry Workers Comp","In Process","Add Info Submitted","","","","2024-08-19","8/19/2024 Submitted via roster to Coventry. FC"]
["Laura V Salcido, PA","1669755906","75-2656723","TX","PE - Premier Family Care, Inc","Wellmed","Thru Other Payor","Thru Other Payor","","","","2024-06-17","Pending UHC enrollment. PA."]
["Laura V Salcido, PA","1669755906","75-2656723","TX","PE - Premier Family Care, Inc","TriCare Standard","Participating","Enrollment Complete","2024-05-20","","","2024-07-02","Provider is Tricare  certified and linked to this location eff 5/20/24. MS"]
["Laura V Salcido, PA","1669755906","75-2656723","TX","PE - Premier Family Care, Inc","USA PPO","In Process","Payor Follow Up","","","","2024-07-30","Sent email to payor requesting enrollment status update. PA."]
["Laura V Salcido, PA","1669755906","75-2656723","TX","PE - Premier Family Care, Inc","Scott&White (First Care)","In Process","Payor Follow Up","","","","2024-07-26","Sent email to payor requesting enrollment status. PA."]
["Laura V Salcido, PA","1669755906","75-2656723","TX","PE - Premier Family Care, Inc","CAQH","Provider Load","CAQH Reattested","2024-08-27","","","2024-08-27","08/27/2024 CAQH Reattested updated and uploaded COI wthompson"]
["Kwame B Agyeman, MD","1285863753","47-5554737","TX","PE - Midland Inpatient Medical Association","Medicare","Participating","Enrollment Complete",45469,"6S8965","","2024-07-01","PECOS confirmed enrollment. MS"]
["Kwame B Agyeman, MD","1285863753","47-5554737","TX","PE - Midland Inpatient Medical Association","CAQH","Provider Load","CAQH Reattested",45518,"","","2024-08-14","08/14/2024 CAQH Reattested all locations current and all expirables up to date wthompson"]
["Emma E Patterson, PA","1922775287","83-0358685","TX","PE - Midland Community Healthcare Services","CAQH","Provider Load","DO NOT ENROLL","2024-06-14","","","2024-06-14",""]
["Emma E Patterson, PA","1922775287","83-0358685","TX","PE - Midland Community Healthcare Services","Wellmed","In Process","Application Submitted","","","","2024-07-15","Submitted application via delegated roster submission. PA."]
["Emma E Patterson, PA","1922775287","83-0358685","TX","PE - Midland Community Healthcare Services","Wellmed","In Process","Application Submitted","","","","2024-07-15","Submitted application via delegated roster submission. PA."]
["Emma E Patterson, PA","1922775287","83-0358685","TX","PE - Midland Community Healthcare Services","Superior","Participating","Enrollment Complete","2024-08-01","","","2024-08-06","Provider is par, effective 8/1/2024, per the August SHP Validation report, participating in the following lines of business: STAR, STAR PLUS, STAR HEALTH (Foster Care), Star Kids, CHIP, CHIP RSA, CHIP Perinate, Medicare Advantage, Medicare Medicaid Program (MMP), Medicare Part D, Ambetter (Commercial-Exchange). PA"]
["Emma E Patterson, PA","1922775287","83-0358685","TX","PE - Midland Community Healthcare Services","Superior","Participating","Enrollment Complete",45505,"","","2024-08-06","Provider is par, effective 8/1/2024, per the August SHP Validation report, participating in the following lines of business: STAR, STAR PLUS, STAR HEALTH (Foster Care), Star Kids, CHIP, CHIP RSA, CHIP Perinate, Medicare Advantage, Medicare Medicaid Program (MMP), Medicare Part D, Ambetter (Commercial-Exchange). PA"]
["Emma E Patterson, PA","1922775287","83-0358685","TX","PE - Midland Community Healthcare Services","United Health Care","In Process","Payor Follow Up","","","","2024-08-19","Provider not yet added per UHC rep Nai, ref# 04697226, via online chat. Please allow more time. PA."]
["Emma E Patterson, PA","1922775287","83-0358685","TX","PE - Midland Community Healthcare Services","United Health Care","In Process","Payor Follow Up","","","","2024-08-19","Provider not yet added per UHC rep Nai, ref# 04697226, via online chat. Please allow more time. PA."]
["Emma E Patterson, PA","1922775287","83-0358685","TX","PE - Midland Community Healthcare Services","Ambetter","Participating","Enrollment Complete","2024-08-01","","","2024-08-06","Provider is par, effective 8/1/2024, per the August SHP Validation report, participating in the following lines of business: STAR, STAR PLUS, STAR HEALTH (Foster Care), Star Kids, CHIP, CHIP RSA, CHIP Perinate, Medicare Advantage, Medicare Medicaid Program (MMP), Medicare Part D, Ambetter (Commercial-Exchange). PA"]
["Emma E Patterson, PA","1922775287","83-0358685","TX","PE - Midland Community Healthcare Services","TriCare Standard","In Process","Payor Follow Up","","","","2024-07-24","Emailed the rep to get status. Ticket 2557739. MS"]
["Emma E Patterson, PA","1922775287","83-0358685","TX","PE - Midland Community Healthcare Services","TriCare Standard","In Process","Payor Follow Up","","","","2024-07-24","Emailed the rep to get status. Ticket 2557739. MS"]
["Emma E Patterson, PA","1922775287","83-0358685","TX","PE - Midland Community Healthcare Services","Wellcare","Participating","Enrollment Complete","2024-08-01","","","2024-08-06","Provider is par, effective 8/1/2024, per the August SHP Validation report, participating in the following lines of business: STAR, STAR PLUS, STAR HEALTH (Foster Care), Star Kids, CHIP, CHIP RSA, CHIP Perinate, Medicare Advantage, Medicare Medicaid Program (MMP), Medicare Part D, Ambetter (Commercial-Exchange). PA"]
["Emma E Patterson, PA","1922775287","83-0358685","TX","PE - Midland Community Healthcare Services","Wellcare","Participating","Enrollment Complete","2024-08-01","","","2024-08-06","Provider is par, effective 8/1/2024, per the August SHP Validation report, participating in the following lines of business: STAR, STAR PLUS, STAR HEALTH (Foster Care), Star Kids, CHIP, CHIP RSA, CHIP Perinate, Medicare Advantage, Medicare Medicaid Program (MMP), Medicare Part D, Ambetter (Commercial-Exchange). PA"]
["Emma E Patterson, PA","1922775287","83-0358685","TX","PE - Midland Community Healthcare Services","Humana","In Process","Payor Follow Up","","","","2024-08-27","Sent follow up email to Network Manager Erica Lee, requesting status. PA."]
["Emma E Patterson, PA","1922775287","83-0358685","TX","PE - Midland Community Healthcare Services","Tricare Prime","Panel Closed","Panel Closed","","","","2024-06-17","None of the 3 locations are Tricare credentialed, and since the panel is closed to new enrollments there is nothing else needed at this time. MS"]
["Emma E Patterson, PA","1922775287","83-0358685","TX","PE - Midland Community Healthcare Services","Scott&White (First Care)","In Process","Application Submitted","","","","2024-07-15","Submitted application via delegated roster submission. PA."]
["Emma E Patterson, PA","1922775287","83-0358685","TX","PE - Midland Community Healthcare Services","Scott&White (First Care)","In Process","Application Submitted","","","","2024-07-15","Submitted application via delegated roster submission. PA."]
["Emma E Patterson, PA","1922775287","83-0358685","TX","PE - Midland Community Healthcare Services","Cigna","Participating","Enrollment Complete","2024-07-10","4469357","","2024-07-12","Received confirmation of enrollment MS"]
["Audrey K Allen, APRN-FNP-C","1598517369","75-2781652","TX","PE - West Texas Allergy, PA","Caprock (CapStar)","In Process","Application Submitted","","","","2024-08-19","Submitted via delegated roster on 8/15/2024. FC"]
["Audrey K Allen, APRN-FNP-C","1598517369","75-2781652","TX","PE - West Texas Allergy, PA","Caprock (CapStar)","In Process","Application Submitted","","","","2024-08-19","Submitted via delegated roster on 8/15/2024. FC"]
["Audrey K Allen, APRN-FNP-C","1598517369","75-2781652","TX","PE - West Texas Allergy, PA","Wellmed","In Process","Application Submitted","","","","2024-08-15","Application submitted through delegated roster. PA."]
["Audrey K Allen, APRN-FNP-C","1598517369","75-2781652","TX","PE - West Texas Allergy, PA","Superior","In Process","Application Submitted","","","","2024-08-15","Application submitted through delegated roster. PA."]
["Audrey K Allen, APRN-FNP-C","1598517369","75-2781652","TX","PE - West Texas Allergy, Lubbock, PLLC","Superior","In Process","Application Submitted","","","","2024-08-15","Application submitted through delegated roster. PA."]
["Audrey K Allen, APRN-FNP-C","1598517369","75-2781652","TX","PE - West Texas Allergy, Lubbock, PLLC","Rail Road Medicare","Participating","Enrollment Complete","2024-05-28","","","2024-09-03","Received confirmation. MS"]
["Audrey K Allen, APRN-FNP-C","1598517369","75-2781652","TX","PE - West Texas Allergy, Lubbock, PLLC","Omni PPO","In Process","Application Submitted","","","","2024-08-19","Submitted via delegated roster on 8/15/2024. FC"]
["Audrey K Allen, APRN-FNP-C","1598517369","75-2781652","TX","PE - West Texas Allergy, PA","Humana","In Process","Payor Follow Up","","","","2024-08-27","Received confirmation of receipt from payor: \"We are in receipt of your request. Your update has been routed to the coordinator that manages this agreement.You will need to allow anywhere from 45-60 days for a task to be submitted to update our Humana systems.Once the task has been submitted the coordinator will reach out to you with a transmittal # and advise of the turnaround time for completion of your task. If you have not received your transmittal # in 60 days, you can reach out  to the coordinator directly to check the status (Erica Lee ELee22@humana.com). Please do not send a duplicate inquiry to our department mailbox or a request to check the status.\" PA."]
["Audrey K Allen, APRN-FNP-C","1598517369","75-2781652","TX","PE - West Texas Allergy, PA","TriCare Standard","In Process","Payor Follow Up","","","","2024-08-28","Received email from Triwest: Your group has a net sub BlueCross BlueShield of TX. BlueCross BlueShield of TX handles all of our CCN contracting/credentialing/data updates for TriWest. BlueCross BlueShield of TX can be contacted on by their email vatriwest@bcbstx.com or office phone 1-877-891-3327.\nAn inquiry email was sent. MS"]
["Audrey K Allen, APRN-FNP-C","1598517369","75-2781652","TX","PE - West Texas Allergy, Lubbock, PLLC","TriCare Standard","In Process","Payor Follow Up","","","","2024-08-28","Received email from Triwest: Your group has a net sub BlueCross BlueShield of TX. BlueCross BlueShield of TX handles all of our CCN contracting/credentialing/data updates for TriWest. BlueCross BlueShield of TX can be contacted on by their email vatriwest@bcbstx.com or office phone 1-877-891-3327.\nAn inquiry email was sent. MS"]
["Audrey K Allen, APRN-FNP-C","1598517369","75-2781652","TX","PE - West Texas Allergy, Lubbock, PLLC","Ambetter","In Process","Application Submitted","","","","2024-08-15","Application submitted through delegated roster. PA."]
["Audrey K Allen, APRN-FNP-C","1598517369","75-2781652","TX","PE - West Texas Allergy, Lubbock, PLLC","Cigna","Participating","Enrollment Complete",45490,"1691234","","2024-07-18","Received enrollment confirmation. MS"]
["Audrey K Allen, APRN-FNP-C","1598517369","75-2781652","TX","PE - West Texas Allergy, Lubbock, PLLC","United Health Care","In Process","Application Submitted","","","","2024-08-15","Application submitted through delegated roster. PA."]
["Audrey K Allen, APRN-FNP-C","1598517369","75-2781652","TX","PE - West Texas Allergy, PA","Medicaid","Pending Other Enrollment","Pending Other Enrollment","","","","2024-08-13","Per Lily Flynn at Allervie they submitted an enrollment for Audrey under TIN at Allergy & Asthma Clinic of West Texas. (3502 22nd Street Lubbock, TX 79410 and 10607 Quaker Ave., Suite 102 Lubbock, TX 79424). Until this is completed I am unable to add her as a performing provider to West Texas Allergy. (See attachment) Jen Videan"]
["Audrey K Allen, APRN-FNP-C","1598517369","75-2781652","TX","PE - West Texas Allergy, Lubbock, PLLC","Amerigroup","In Process","Application Submitted","","","","2024-08-19","Submitted via delegated roster on 8/15/2024. FC"]
["Audrey K Allen, APRN-FNP-C","1598517369","75-2781652","TX","PE - West Texas Allergy, Lubbock, PLLC","CAQH","Provider Load","In House Enrollment","2024-06-26","","","2024-06-26",""]
["Audrey K Allen, APRN-FNP-C","1598517369","75-2781652","TX","PE - West Texas Allergy, Lubbock, PLLC","IMS","In Process","Application Submitted","","","","2024-08-19","Submitted via delegated roster on 8/15/2024. FC"]
["Audrey K Allen, APRN-FNP-C","1598517369","75-2781652","TX","PE - West Texas Allergy, Lubbock, PLLC","Boon Chapman","Pending Other Enrollment","Pending Other Enrollment","","","","",""]
["Audrey K Allen, APRN-FNP-C","1598517369","75-2781652","TX","PE - West Texas Allergy, Lubbock, PLLC","Tricare Prime","Panel Closed","Panel Closed","","","","2024-06-27","Panel is closed to new providers. Nothing else is needed at this time. MS"]
["Audrey K Allen, APRN-FNP-C","1598517369","75-2781652","TX","PE - West Texas Allergy, Lubbock, PLLC","First Health Coventry","In Process","Application Submitted","","","","2024-08-19","Submitted via delegated roster on 8/15/2024. FC"]
["Audrey K Allen, APRN-FNP-C","1598517369","75-2781652","TX","PE - West Texas Allergy, Lubbock, PLLC","Galaxy Health","In Process","Application Submitted","","","","2024-08-15","Application submitted through delegated roster. PA."]
["Audrey K Allen, APRN-FNP-C","1598517369","75-2781652","TX","PE - West Texas Allergy, PA","Galaxy Health","In Process","Application Submitted","","","","2024-08-15","Application submitted through delegated roster. PA."]
["Audrey K Allen, APRN-FNP-C","1598517369","75-2781652","TX","PE - West Texas Allergy, Lubbock, PLLC","Aetna","In Process","Application Submitted","","","","2024-08-19","Submitted via delegated roster on 8/15/2024. FC"]
["Audrey K Allen, APRN-FNP-C","1598517369","75-2781652","TX","PE - West Texas Allergy, Lubbock, PLLC","USA PPO","In Process","Application Submitted","","","","2024-08-15","Application submitted through delegated roster. PA."]
["Audrey K Allen, APRN-FNP-C","1598517369","75-2781652","TX","PE - West Texas Allergy, PA","Scott&White (First Care)","In Process","Application Submitted","","","","2024-08-15","Application submitted through delegated roster. PA."]
["Audrey K Allen, APRN-FNP-C","1598517369","75-2781652","TX","PE - West Texas Allergy, Lubbock, PLLC","Multiplan","In Process","Application Submitted","","","","2024-08-19","Submitted via delegated roster on 8/15/2024. FC"]
["Audrey K Allen, APRN-FNP-C","1598517369","75-2781652","TX","PE - West Texas Allergy, Lubbock, PLLC","Multiplan","In Process","Application Submitted","","","","2024-08-19","Submitted via delegated roster on 8/15/2024. FC"]
["Jennifer F Blackerby, PA","1144933367","75-2781652","TX","PE - West Texas Allergy, PA","Wellmed","In Process","Application Submitted","","","","2024-08-15","Application submitted through delegated roster. PA."]
["Jennifer F Blackerby, PA","1144933367","75-2781652","TX","PE - West Texas Allergy, PA","Tricare Prime","Panel Closed","Panel Closed","","","","2024-07-03","This location is not Tricare credentialed, and the panel is closed at this time. Nothing further is needed. MS"]
["Jennifer F Blackerby, PA","1144933367","75-2781652","TX","PE - West Texas Allergy, PA","Tricare Prime","Panel Closed","Panel Closed","","","","2024-07-03","This location is not Tricare credentialed, and the panel is closed at this time. Nothing further is needed. MS"]
["Jennifer F Blackerby, PA","1144933367","75-2781652","TX","PE - West Texas Allergy, PA","Boon Chapman","Pending Other Enrollment","Pending Other Enrollment","","","","",""]
["Jennifer F Blackerby, PA","1144933367","75-2781652","TX","PE - West Texas Allergy, PA","Caprock (CapStar)","In Process","Application Submitted","","","","2024-08-19","Submitted via delegated roster on 8/15/2024. FC"]
["Jennifer F Blackerby, PA","1144933367","75-2781652","TX","PE - West Texas Allergy, PA","Caprock (CapStar)","In Process","Application Submitted","","","","2024-08-19","Submitted via delegated roster on 8/15/2024. FC"]
["Jennifer F Blackerby, PA","1144933367","75-2781652","TX","PE - West Texas Allergy, PA","Wellcare","In Process","Application Submitted","","","","2024-08-16","Application submitted through delegated roster. PA."]
["Jennifer F Blackerby, PA","1144933367","75-2781652","TX","PE - West Texas Allergy, PA","Humana","In Process","Payor Follow Up","","","","2024-08-27","Received confirmation of receipt from payor: \"We are in receipt of your request. Your update has been routed to the coordinator that manages this agreement.You will need to allow anywhere from 45-60 days for a task to be submitted to update our Humana systems.Once the task has been submitted the coordinator will reach out to you with a transmittal # and advise of the turnaround time for completion of your task. If you have not received your transmittal # in 60 days, you can reach out  to the coordinator directly to check the status (Erica Lee ELee22@humana.com). Please do not send a duplicate inquiry to our department mailbox or a request to check the status.\" PA."]
["Jennifer F Blackerby, PA","1144933367","75-2781652","TX","PE - West Texas Allergy, PA","Medicare","Participating","Enrollment Complete",45474,"","","2024-07-22","Received welcome letter. MS"]
["Jennifer F Blackerby, PA","1144933367","75-2781652","TX","PE - West Texas Allergy, PA","Superior","In Process","Application Submitted","","","","2024-08-15","Application submitted through delegated roster. PA."]
["Jennifer F Blackerby, PA","1144933367","75-2781652","TX","PE - West Texas Allergy, PA","Superior","In Process","Application Submitted","","","","2024-08-15","Application submitted through delegated roster. PA."]
["Jennifer F Blackerby, PA","1144933367","75-2781652","TX","PE - West Texas Allergy, PA","United Health Care","In Process","Application Submitted","","","","2024-08-15","Application submitted through delegated roster. PA."]
["Jennifer F Blackerby, PA","1144933367","75-2781652","TX","PE - West Texas Allergy, PA","TriCare Standard","Enrollment Stopped","Enrollment Denied","","","","2024-08-08","Enrollment denied due to issue with the supervising physician. Please see attached denial letter. MS"]
["Jennifer F Blackerby, PA","1144933367","75-2781652","TX","PE - West Texas Allergy, PA","First Health Coventry","In Process","Application Submitted","","","","2024-08-19","Submitted via delegated roster on 8/15/2024. FC"]
["Jennifer F Blackerby, PA","1144933367","75-2781652","TX","PE - West Texas Allergy, PA","IMS","In Process","Application Submitted","","","","2024-08-19","Submitted via delegated roster on 8/15/2024. FC"]
["Jennifer F Blackerby, PA","1144933367","75-2781652","TX","PE - West Texas Allergy, PA","CAQH","Provider Load","In House Enrollment","2024-07-02","","","2024-07-02",""]
["Jennifer F Blackerby, PA","1144933367","75-2781652","TX","PE - West Texas Allergy, PA","Cigna","Participating","Enrollment Complete","2024-07-01","4357405","","2024-07-30","Received confirmation of enrollment. MS"]
["Jennifer F Blackerby, PA","1144933367","75-2781652","TX","PE - West Texas Allergy, PA","Omni PPO","In Process","Application Submitted","","","","2024-08-19","Submitted via delegated roster on 8/15/2024. FC"]
["Jennifer F Blackerby, PA","1144933367","75-2781652","TX","PE - West Texas Allergy, PA","Amerigroup","In Process","Application Submitted","","","","2024-08-19","Submitted via delegated roster on 8/15/2024. FC"]
["Jennifer F Blackerby, PA","1144933367","75-2781652","TX","PE - West Texas Allergy, PA","Scott&White (First Care)","In Process","Application Submitted","","","","2024-08-15","Application submitted through delegated roster. PA."]
["Jennifer F Blackerby, PA","1144933367","75-2781652","TX","PE - West Texas Allergy, PA","USA PPO","In Process","Application Submitted","","","","2024-08-15","Application submitted through delegated roster. PA."]
["Jennifer F Blackerby, PA","1144933367","75-2781652","TX","PE - West Texas Allergy, PA","Ambetter","In Process","Application Submitted","","","","2024-08-15","Application submitted through delegated roster. PA."]
["Jennifer F Blackerby, PA","1144933367","75-2781652","TX","PE - West Texas Allergy, PA","Ambetter","In Process","Application Submitted","","","","2024-08-15","Application submitted through delegated roster. PA."]
["Jennifer F Blackerby, PA","1144933367","75-2781652","TX","PE - West Texas Allergy, PA","Rail Road Medicare","Participating","Enrollment Complete",45474,"1144933367","CF8499","2024-09-03","Received confirmation. MS"]
["Jennifer F Blackerby, PA","1144933367","75-2781652","TX","PE - West Texas Allergy, PA","Medicaid","In Process","Payor Follow Up","","","","2024-08-21","Application still in PE Review status. Jen Videan"]
["James H Barnett, MD","1356484497","27-4061759","TX","PE - Permian Cardiology Inc.","Amerigroup","Participating","Re-Credentialing","2019-07-30","1356484497","","2024-02-20","2/20/2024- Submitted recred status via delegated monthly roster on 2/15/2024. FC."]
["James H Barnett, MD","1356484497","27-4061759","TX","","Humana","Participating","Enrollment Complete",41222,"","","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","","HealthSmart PPO","Participating","Re-Credentialing",40575,"1356484497","","2024-02-20","2/20/2024- Submitted recred status via delegated monthly roster on 2/15/2024. FC."]
["James H Barnett, MD","1356484497","27-4061759","TX","PE - Permian Cardiology Inc.","Superior","Participating","Enrollment Complete",43739,"1356484497","","2020-07-14","07/14/2020 - Rec'd email from the payer stating this provider is EFF under PRIMED DELEGATED agreement - Stacey Hudak"]
["James H Barnett, MD","1356484497","27-4061759","TX","","USA PPO","Participating","Enrollment Complete","2010-12-29","1356484497","274061759","2020-08-19","Confirmed provider is participating with PPO, H&W and WIN networks (list of networks attached). Kimberly Frazier"]
["James H Barnett, MD","1356484497","27-4061759","TX","PE - Permian Cardiology Inc.","CAQH","Participating","CAQH Reattested","2024-08-14","12124562","","2024-08-14","08/14/2024 CAQH REattested all locations current and all expirables up to date wthompson"]
["James H Barnett, MD","1356484497","27-4061759","TX","","Cigna","Participating","Enrollment Complete","2010-08-01","1356484497","","2020-08-26","08/26/2020 - Moved to completed status after reviewing Follow UP Complete note - Stacey Hudak"]
["James H Barnett, MD","1356484497","27-4061759","TX","PE - Permian Cardiology Inc.","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.","Scott&White (First Care)","Participating","Enrollment Complete","2019-07-29","1356484497","","2020-08-19","08/29/2020 - Rec'd spreadsheet back from the payer confirming that this provider is affiliated with the delegated PRIMED AGREEMENT under this TIN/Service Location. This provider is networked with: \nFirstCare MyChoice PPO\nCHIP\nFirstCare Select Benefit Network\nHMO Enhanced Benefit Network\nMedicaid (FC)\nPPO Limited Benefit Network\n- Stacey Hudak"]
["James H Barnett, MD","1356484497","27-4061759","TX","","United Health Care","Participating","Enrollment Complete","2020-01-01","1356484497","","2020-08-31","08/31/2020 - moved to completed status after reviewing follow up complete status - Stacey Hudak"]
["James H Barnett, MD","1356484497","27-4061759","TX","PE - Permian Cardiology Inc.","Multiplan","Participating","Re-Credentialing",42087,"1356484497","","2024-02-20","2/20/2024- Submitted recred status via delegated monthly roster on 2/15/2024. FC."]
["James H Barnett, MD","1356484497","27-4061759","TX","","Medicaid","Participating","Enrollment Complete","","","","2024-08-21","TMHP Revalidation Approval Ltr rcvd. Jen Videan"]
["Pankaj J Patel, MD","1124009766","75-2784378","TX","PE - Pankaj N. Patel, MD PA","Wellcare","Participating","Enrollment Complete",44501,"","","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"]
["Pankaj J Patel, MD","1124009766","75-2784378","TX","PE - Pankaj N. Patel, MD PA","Galaxy Health","Participating","Enrollment Complete","2019-09-01","1124009766","","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"]
["Pankaj J Patel, MD","1124009766","75-2784378","TX","PE - Pankaj N. Patel, MD PA","Multiplan","Participating","Add Info Submitted","2011-07-15","1124009766","Individual contract","2024-08-19","Submitted reapplication via delegated roster on 8/15/2024. FC"]
["Pankaj J Patel, MD","1124009766","75-2784378","TX","","Caprock (CapStar)","Participating","Enrollment Complete","2012-03-01","1124009766","","2020-09-16","09/16/2020 - Reviewed a spreadsheet rec'd from the payer stating this provider/service location has been affiliated with our PRIMED delegated roster - Stacey Hudak"]
["Pankaj J Patel, MD","1124009766","75-2784378","TX","PE - Pankaj N. Patel, MD PA","IMS","Participating","Enrollment Complete","2001-09-01","1124009766","","2020-06-22","06/22/2020- Rec'd email from the payer confirming this provider is PAR with this group/service location - Stacey Hudak"]
["Pankaj J Patel, MD","1124009766","75-2784378","TX","","IMS","Participating","Enrollment Complete","2001-09-01","1124009766","","2020-06-22","06/22/2020- Rec'd email from the payer confirming this provider is PAR with this group/service location - Stacey Hudak"]
["Pankaj J Patel, MD","1124009766","75-2784378","TX","PE - Pankaj N. Patel, MD PA","HealthSmart PPO","Participating","Add Info Submitted",40909,"1124009766","","2024-08-19","Submitted reapplication via delegated roster on 8/15/2024. FC"]
["Pankaj J Patel, MD","1124009766","75-2784378","TX","","Aetna","Participating","Enrollment Complete",41030,"1124009766","","2020-04-15","04/15/2020 - Rec'd response from follow up team stating \"S/W Nina of Aetna @ 8003531232, provider NPI is on file for the provider and participating effective 05/01/12 under the group and TIN with delegated contract with Primed health network. Physical location is on file. Call ref# 5225848462. \" - Stacey HUdak"]
["Pankaj J Patel, MD","1124009766","75-2784378","TX","PE - Pankaj N. Patel, MD PA","First Health Coventry","Participating","Enrollment Complete","2008-09-01","1124009766","","2020-06-12","06/12/2020 - Rec'd email from the payer stating this provider is EFF - PID# 1620242 - Stacey Hudak"]
["Pankaj J Patel, MD","1124009766","75-2784378","TX","","First Health Coventry","Participating","Enrollment Complete","2008-09-01","1124009766","","2020-06-12","06/12/2020 - Rec'd email from the payer stating this provider is EFF - PID# 1620242 - Stacey Hudak"]
["John M McKenna, MD","1225170103","75-2656723","TX","","Rail Road Medicare","Participating","Enrollment Complete",44531,"Q00181145","CE1588","2021-12-30","12/30/2021 Rcvd RR Medicare approval letter. RR Medicare PTAN #  Q00181145 - effective 12/1/2021.  DCannon"]
["John M McKenna, MD","1225170103","75-2656723","TX","","CAQH","Participating","CAQH Reattested","2024-08-14","","","2024-08-14","CAQH Reattested all locations current and all expirables up to date wthompson"]
["John M McKenna, MD","1225170103","75-2656723","TX","","HealthSmart PPO","Participating","Re-Credentialing","2021-12-06","10122396","","2024-05-16","5/16/2024- Submitted recred status via delegated monthly roster on 5/15/2024. FC."]
["John M McKenna, MD","1225170103","75-2656723","TX","PE - Premier Family Care, Inc","TriCare Standard","Participating","Enrollment Complete",45293,"","","2024-01-09","Confirmed provider is linked to Ste. 271 via the self service portal. MS"]
["John M McKenna, MD","1225170103","75-2656723","TX","","Amerigroup","Participating","Re-Credentialing",44665,"","","2024-05-16","5/16/2024- Submitted recred status via delegated monthly roster on 5/15/2024. FC."]
["John M McKenna, MD","1225170103","75-2656723","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","75-2656723","TX","","Aetna","Participating","Enrollment Complete",44515,"4361906","","2021-12-29","12/29/2021 Per F/U Notes - S/W Christine of Aetna @ 8003531232, NPI# for the provider is on file, shows linked and PAR under the group and TIN# ( Individual contract ) effective 11/15/2021, the physical location is on file, The provider ID is 4361906.   DCannon"]
["John M McKenna, MD","1225170103","75-2656723","TX","PE - Premier Family Care, Inc","United Health Care","Participating","Enrollment Complete",367,"000466442","","2022-01-03","1/3/2022 Recevied email from asampat4@uhc.com, provider/group updates complete. Assigned reference number PR-6284499. Cbankston"]
["John M McKenna, MD","1225170103","75-2656723","TX","","Wellmed","Participating","Enrollment Complete",44562,"","","2023-03-23","3/23/2023 Rcvd roster from UHC w/ all Wellmed participating providers.  Provider is PAR effective 1/1/2022.  DCannon"]
["John M McKenna, MD","1225170103","75-2656723","TX","","Omni PPO","Participating","Re-Credentialing",44536,"","","2024-05-16","5/16/2024- Submitted recred status via delegated monthly roster on 5/15/2024. FC."]
["John M McKenna, MD","1225170103","75-2656723","TX","PE - Premier Family Care, Inc","First Health Coventry","Participating","Re-Credentialing",44515,"1902363","","2024-05-16","5/16/2024- Submitted recred status via delegated monthly roster on 5/15/2024. FC."]
["John M McKenna, MD","1225170103","75-2656723","TX","","First Health Coventry","Participating","Re-Credentialing",44515,"1902363","","2024-05-16","5/16/2024- Submitted recred status via delegated monthly roster on 5/15/2024. FC."]
["John M McKenna, MD","1225170103","75-2656723","TX","","Scott&White (First Care)","Participating","Enrollment Complete","2021-11-05","","","2022-01-11","1/11/2022 Rcvd approval letter from Scott and White.  Provider is PAR and linked to group/TIN effective 11/05/2021.  DCannon"]
["John M McKenna, MD","1225170103","75-2656723","TX","","Ambetter","Participating","Enrollment Complete",44713,"","","2022-06-13","6/13/2022 Per roster received from Superior provider is PAR and linked to group delegation roster effective 6/1/2022."]
["John M McKenna, MD","1225170103","75-2656723","TX","PE - Premier Family Care, Inc","USA PPO","Participating","Enrollment Complete",44536,"","","2022-02-25","2/25/2022 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 12/6/2021.  DCannon"]
["John M McKenna, MD","1225170103","75-2656723","TX","PE - Premier Family Care, Inc","Humana","Participating","Enrollment Complete","2021-12-06","","","2022-04-21","4/21/2022 Per email received from VYoung at Humana delegated roster for December has been completed and providers loaded in Humana effective 12/6/2021.  DCannon"]
["John M McKenna, MD","1225170103","75-2656723","TX","","Humana","Participating","Enrollment Complete","2021-12-06","","","2022-04-21","4/21/2022 Per email received from VYoung at Humana delegated roster for December has been completed and providers loaded in Humana effective 12/6/2021.  DCannon"]
["John M McKenna, MD","1225170103","75-2656723","TX","PE - Premier Family Care, Inc","Multiplan","Participating","Re-Credentialing",44545,"","","2024-05-16","5/16/2024- Submitted recred status via delegated monthly roster on 5/15/2024. FC."]
["John M McKenna, MD","1225170103","75-2656723","TX","","Caprock (CapStar)","Participating","Re-Credentialing","2021-12-06","","",45428,"5/16/2024- Submitted recred status via delegated monthly roster on 5/15/2024. FC."]
["John M McKenna, MD","1225170103","75-2656723","TX","","Caprock (CapStar)","Participating","Re-Credentialing","2021-12-06","","",45428,"5/16/2024- Submitted recred status via delegated monthly roster on 5/15/2024. FC."]
["John M McKenna, MD","1225170103","75-2656723","TX","","Triwest VA","Facility Enrollment","Facility Enrollment","","","","2022-10-17","10/17/2022 - Received roster from Scarlett of TriWest VA; provider status: \"No Action.  TIN is CCN participating under own DCN.\""]
["John M McKenna, MD","1225170103","75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","2024-01-02","","","2024-01-26","Confirmed provider is credentialed and in network with Tricare. MS"]
["John M McKenna, MD","1225170103","75-2656723","TX","","Tricare Prime","Participating","Enrollment Complete","2024-01-02","","","2024-01-26","Confirmed provider is credentialed and in network with Tricare. MS"]
["John M McKenna, MD","1225170103","75-2656723","TX","","Tricare Prime","Participating","Enrollment Complete","2024-01-02","","","2024-02-28","Re-Cred has been completed. eff 1/2/2024. MS"]
["John M McKenna, MD","1225170103","75-2656723","TX","PE - Premier Family Care, Inc","Cigna","Participating","Enrollment Complete","2022-01-22","8020391","","2021-11-25","11/25/21 received letter from pdmcogz@cigna.com, enrollment complete. PID 8020391 eff 1/22/2022"]
["John M McKenna, MD","1225170103","75-2656723","TX","","Medicare","Participating","Enrollment Complete","2021-12-01","1X1311","","2021-12-08","12/8/21 Provider approved 12/01/2021. PTAN 1X1311 Cbankston"]
["Michael J Dragun, MD","1679574099","75-2656723","TX","PE - Premier Family Care, Inc","Omni PPO","Participating","Enrollment Complete","2024-07-01","","","2024-08-30","Received confirmation via email from German Aviles provider participating eff date 7/1/2024. FC"]
["Michael J Dragun, MD","1679574099","75-2656723","TX","PE - Premier Family Care, Inc","Wellmed","In Process","Application Submitted","","","","2024-07-15","Submitted application via delegated roster submission. PA."]
["Michael J Dragun, MD","1679574099","75-2656723","TX","PE - Premier Family Care, Inc","CAQH","Provider Load","CAQH Reattested","2024-07-09","","","2024-07-09","07/09/2024 CAQH Reattested All locations current and all expirables up to date wthompson"]
["Michael J Dragun, MD","1679574099","75-2656723","TX","PE - Premier Family Care, Inc","Galaxy Health","Participating","Enrollment Complete","2024-07-05","","","2024-07-29","Received email confirmation provider is PAR and linked to TIN/location, eff. 07/05/2024. PA."]
["Michael J Dragun, MD","1679574099","75-2656723","TX","PE - Premier Family Care, Inc","Amerigroup","In Process","Payor Follow Up","","","","2024-08-22","Emailed Cassandra Dunagon requesting network status. FC"]
["Michael J Dragun, MD","1679574099","75-2656723","TX","PE - Premier Family Care, Inc","Ambetter","Participating","Enrollment Complete","2024-08-01","","","2024-08-06","Provider is par, effective 8/1/2024, per the August SHP Validation report, participating in the following lines of business: STAR, STAR PLUS, STAR HEALTH (Foster Care), Star Kids, CHIP, CHIP RSA, CHIP Perinate, Medicare Advantage, Medicare Medicaid Program (MMP), Medicare Part D, Ambetter (Commercial-Exchange). PA"]
["Mrunal C Patel, MD","1528000734","74-2348334","TX","PE - Permian Gastroenterology PA","Amerigroup","Participating","Enrollment Complete","2016-08-04","1528000734","","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"]
["Mrunal C Patel, MD","1528000734","74-2348334","TX","PE - Permian Gastroenterology PA","Medicaid","Participating","In House Enrollment","","080363701","Unknown","2020-10-23","10/23/2020 - Rec'd email from the clinic stating \"I spoke with Swapna Patel, the office manager for Dr. Mrunal and Dr. Govind Patel. \nYes, they participate in Medicaid but they will be taking care of it themselves.\n\nTheir TPI # is 0803637-01.\n\nShe doesn’t know the effective date because they’ve had it so long.\"  - Stacey Hudak"]
["Mrunal C Patel, MD","1528000734","74-2348334","TX","PE - Permian Gastroenterology PA","Medicare","Participating","Enrollment Complete",36039,"83461K","00320K","2020-04-20","04/20/2020 - Rec'd email stating this recred application was approved - Stacey Hudak"]
["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","Aetna","Participating","Enrollment Complete",43392,"1528000734","","2020-03-25","3/25/2020--S/W Ella of Aetna 8003531232, provider NPI# is on file for the provider and is participating effective 10/19/2018 under the group and TIN#. Physical location is on file. DIRECT CONTRACT--Call ref#: 5194745657. \ntisha rader"]
["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","Caprock (CapStar)","Participating","Enrollment Complete","2012-04-01","1659366433","","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"]
["Willie Clyde Watson, III, MD","1659366433","75-2133441","TX","PE - Midland Pediatric Associates, PLLC","Scott&White (First Care)","Participating","Enrollment Complete","2018-01-01","1659366433","","2020-04-16","04/16/2020 - Rec'd confirmation from the payer stating this provider is EFF under the DELEGATED PRIMED agreement with HMO/PPO only products with this TIN/Service Location- Stacey Hudak"]
["Willie Clyde Watson, III, MD","1659366433","75-2133441","TX","PE - Midland Pediatric Associates, PLLC","Cigna","Participating","Enrollment Complete","2012-07-01","1659366433","","2020-04-22","04/22/2020--SW Monic of Cigna @ 8008824462, Provider NPI# is on file and participating under the group and TIN# effective 7/1/2012. Location is on file. Call ref# Monic4202020.\n-copied note from spreadsheet-tisha rader"]
["Lawrence A Wilson, MD","1518951342","75-2656723","TX","PE - Premier Family Care, Inc","Ambetter","Participating","Enrollment Complete","2022-04-01","","","2022-06-13","6/13/2022 Per roster received from Superior provider is PAR and linked to group delegation roster effective 4/1/2022."]
["Lawrence A Wilson, MD","1518951342","75-6000608","TX","PE - City of Midland Health Department","HealthSmart PPO","Participating","Add Info Submitted","2021-01-07","","","2024-08-19","Submitted reapplication via delegated roster on 8/15/2024. FC"]
["Lawrence A Wilson, MD","1518951342","75-6000608","TX","","Amerigroup","Participating","Add Info Submitted","2021-08-01","12731150","","2024-08-19","Submitted reapplication via delegated roster on 8/15/2024. FC"]
["Lawrence A Wilson, MD","1518951342","75-6000608","TX","","Caprock (CapStar)","Participating","Enrollment Complete","2021-01-07","","","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","1518951342","75-2656723","TX","","Omni PPO","Participating","Enrollment Complete","2021-01-07","","","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","1518951342","75-2656723","TX","PE - Premier Family Care, Inc","Wellmed","Participating","Enrollment Complete",44562,"","","2023-03-23","3/23/2023 Rcvd roster from UHC w/ all Wellmed participating providers.  Provider is PAR effective 1/1/2022.  DCannon"]
["Lawrence A Wilson, MD","1518951342","75-2656723","TX","PE - Premier Intensive Cardiac Rehabilitation","Wellmed","Participating","Enrollment Complete",44562,"","","2023-03-23","3/23/2023 Rcvd roster from UHC w/ all Wellmed participating providers.  Provider is PAR effective 1/1/2022.  DCannon"]
["Lawrence A Wilson, MD","1518951342","75-2656723","TX","PE - Premier Intensive Cardiac Rehabilitation","Multiplan","Participating","Enrollment Complete",44203,"","","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","75-6000608","TX","PE - City of Midland Health Department","Multiplan","Participating","Enrollment Complete",44203,"","","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","75-2656723","TX","PE - Premier Family Care, Inc","Coventry Workers Comp","Participating","Enrollment Complete","","","","2021-10-08","10/8/21 Recevied email from CoventryProvider@cvty.us.com, provider effective 8/1/2021. Cbankston"]
["Lawrence A Wilson, MD","1518951342","75-2656723","TX","PE - Premier Family Care, Inc","Rail Road Medicare","Participating","Enrollment Complete","","Q00021661","CE1588","2021-02-09","2/9/2021 - Rcvd RR Medicare Welcome letter.  DCannon"]
["Lawrence A Wilson, MD","1518951342","75-2656723","TX","PE - Premier Family Care, Inc","IMS","Participating","Add Info Submitted","2021-01-07","","","2024-08-19","Submitted reapplication via delegated roster on 8/15/2024. FC"]
["Lawrence A Wilson, MD","1518951342","75-2656723","TX","PE - Premier Family Care, Inc","Superior","Participating","Enrollment Complete","","","","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","1518951342","75-2656723","TX","PE - Premier Family Care, Inc","HealthSmart PPO","Participating","Enrollment Complete","2002-04-01","","","2021-04-11","4/11/2021 Rcvd email 4/11/2021 from HealthSmart <mdipsupport@healthsmart.com> confirming participation of provider under TIN and location effective 4/1/2002.  DCannon"]
["Lawrence A Wilson, MD","1518951342","75-2656723","TX","","HealthSmart PPO","Participating","Enrollment Complete",37347,"","","2021-04-11","4/11/2021 Rcvd email 4/11/2021 from HealthSmart <mdipsupport@healthsmart.com> confirming participation of provider under TIN and location effective 4/1/2002.  DCannon"]
["Lawrence A Wilson, MD","1518951342","75-2656723","TX","PE - Premier Intensive Cardiac Rehabilitation","HealthSmart PPO","Participating","Add Info Submitted","2021-01-07","","","2024-08-19","Submitted reapplication via delegated roster on 8/15/2024. FC"]
["Lawrence A Wilson, MD","1518951342","75-6000608","TX","PE - City of Midland Health Department","CAQH","Delegated - Third Party","CAQH Reattested","2024-07-09","","","2024-07-09","07/09/2024 CAQH Reattested all locations current and all expirables up to date wthompson"]
["Lawrence A Wilson, MD","1518951342","75-2656723","TX","PE - Premier Family Care, Inc","Multiplan","Participating","Add Info Submitted",44203,"","","2024-08-19","Submitted reapplication via delegated roster on 8/15/2024. FC"]
["Lawrence A Wilson, MD","1518951342","75-2656723","TX","","Multiplan","Participating","Add Info Submitted","2021-01-07","","","2024-08-19","Submitted reapplication via delegated roster on 8/15/2024. FC"]
["Lawrence A Wilson, MD","1518951342","75-6000608","TX","PE - City of Midland Health Department","Aetna","Participating","Enrollment Complete","2021-01-07","","","2021-06-28","6/28/2021 Received email response from aetnaproviderservices@aetna.com confirming provider is participating under group Tax ID and location effective 1/7/2021. KFrazier"]
["Lawrence A Wilson, MD","1518951342","75-6000608","TX","PE - City of Midland Health Department","Boon Chapman","Participating","Enrollment Complete",44203,"","","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","75-2656723","TX","","Amerigroup","Participating","Add Info Submitted","2021-01-07","","","2024-08-19","Submitted reapplication via delegated roster on 8/15/2024. FC"]
["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","75-6000608","TX","","IMS","Participating","Enrollment Complete",44203,"","","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 Family Care, Inc","Amerigroup","Participating","Add Info Submitted","2021-01-07","","","2024-08-19","Submitted reapplication via delegated roster on 8/15/2024. FC"]
["Lawrence A Wilson, MD","1518951342","75-2656723","TX","PE - Premier Intensive Cardiac Rehabilitation","Ambetter","Participating","Enrollment Complete","2022-04-01","","","2022-06-13","6/13/2022 Per roster received from Superior provider is PAR and linked to group delegation roster effective 4/1/2022."]
["Lawrence A Wilson, MD","1518951342","75-2656723","TX","PE - Premier Family Care, Inc","Humana","Participating","Enrollment Complete","2021-09-01","","","2021-11-18","11/18/2021 Rcvd full roster from Humana listing provider as PAR and linked to group TIN/location effective 9/1/2021.  DCannon"]
["Lawrence A Wilson, MD","1518951342","75-6000608","TX","","Omni PPO","Participating","Add Info Submitted",44203,"","","2024-08-19","Submitted reapplication via delegated roster on 8/15/2024. FC"]
["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","75-6000608","TX","PE - City of Midland Health Department","TriCare Standard","Participating","Enrollment Complete",44377,"","","2021-07-29","7/29/2021 Upon review of the Self-Service portal, confirmed provider is certified under the group Tax ID effective 6/30/2021. KFrazier"]
["Lawrence A Wilson, MD","1518951342","75-6000608","TX","PE - City of Midland Health Department","First Health Coventry","Participating","Enrollment Complete",44203,"","","2022-08-10","8/10/2022 Per First Health web portal provider is PAR and linked to group TIN/location effective 1/7/2021.  PID # 1103233.  DCannon"]
["Lawrence A Wilson, MD","1518951342","75-2656723","TX","PE - Premier Family Care, Inc","Caprock (CapStar)","Participating","Add Info Submitted",44203,"","","2024-08-19","Submitted reapplication via delegated roster on 8/15/2024. FC"]
["Debbie P Reese, MD","1629074984","75-2182177","TX","PE - Debbie P. Reese, MD PA","IMS","Participating","Enrollment Complete",45271,"","","2024-01-02","1/2/2024 Rcvd email from German Avilies at IMS/OMNI that December delegation roster is complete.  Provider is PAR and linked to group TIN/location effective 12/11/2023.  DCannon"]
["Debbie P Reese, MD","1629074984","75-2182177","TX","PE - Debbie P. Reese, MD PA","Wellcare","Participating","Enrollment Complete","2024-01-01","","","2024-01-12","1/12/2024 Per email rcvd from Superior, December roster is complete provider is PAR and linked to group TIN/locations effective 1/1/2024.  DCannon"]
["Debbie P Reese, MD","1629074984","75-2133441","TX","PE - Midland Pediatric Associates, PLLC","Cigna","Participating","Enrollment Complete",44075,"1629074984","","2020-07-20","07/20/2020 - 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","Medicaid","Participating","Enrollment Complete","","132863503","212775501","2020-09-25","09/25/2020 - Rec'd email from the clinic with TPI (provider and group only) typed in. No actual letter from the payer naming the group - Stacey Hudak"]
["Debbie P Reese, MD","1629074984","75-2182177","TX","PE - Debbie P. Reese, MD PA","Aetna","Participating","Enrollment Complete","2023-12-11","","","2024-01-22","1/22/2024 Per Aetna online portal provider is PAR and linked to group TIN/locations effective 12/11/2023.  DCannon"]
["Debbie P Reese, MD","1629074984","75-2133441","TX","PE - Midland Pediatric Associates, PLLC","CAQH","Participating","CAQH Reattested","2024-08-14","","","2024-08-14","08/14/2024 CAQH REattested all locations current and all expirables up to date wthompson"]
["Debbie P Reese, MD","1629074984","75-2182177","TX","PE - Debbie P. Reese, MD PA","CAQH","Participating","CAQH Reattested",45518,"","","2024-08-14","08/14/2024 CAQH REattested all locations current and all expirables up to date wthompson"]
["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","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"]
["Debbie P Reese, MD","1629074984","75-2182177","TX","PE - Debbie P. Reese, MD PA","Humana","Participating","Enrollment Complete","","","","2024-02-29","Per roster received from Aleece Moerbe (Aleece.Moerbe@healthsmart.com) on 02/23/2024, provider is PAR, eff. 12/11/2023 and linked to TIN & location 4214 Andrews HWY, suite 205. PA."]
["Debbie P Reese, MD","1629074984","75-2133441","TX","PE - Midland Pediatric Associates, PLLC","Tricare Prime","Participating","Enrollment Complete",35331,"","","2021-09-14","9/14/2021 Per Tricare portal, provider is participating under the Tax ID as of 9/23/96. Cbankston"]
["Donald W Floyd, MD","1942216122","46-0950925","TX","PE - Urgent Orthopedic Specialists, PLLC","Scott&White (First Care)","Participating","Enrollment Complete",43544,"1942216122","","2020-08-19","08/19/2020 - Rec'd spreadsheet confirmation from the payer stating this provider is linked to the PRIMED DELEGATED CONTRACT with this TIN/Service Location and networked with the following: \nCHIP\nFirstCare Select Benefit Network\nHMO Enhanced Benefit Network\nMedicaid (FC)\nMedicare (FC)\nPPO Limited Benefit Network\n- Stacey Hudak"]
["Donald W Floyd, MD","1942216122","46-0950925","TX","PE - Urgent Orthopedic Specialists, PLLC","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","Coventry Workers Comp","Participating","Enrollment Complete","2011-04-01","","","2024-02-23","Per roster received on 02/01/2024, provider is par, effective 4/1/2011. PA"]
["Donald W Floyd, MD","1942216122","46-0950925","TX","PE - Urgent Orthopedic Specialists, PLLC","Humana","Participating","Enrollment Complete","2017-05-01","","","2021-11-18","11/18/2021 Rcvd full roster from Humana listing provider as PAR and linked to group TIN/location effective 5/1/2017.  DCannon"]
["Govind B Patel, MD","1073555249","74-2348334","TX","","Rail Road Medicare","Participating","Enrollment Complete",37104,"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","First Health Coventry","Participating","Application Resubmitted",39692,"1902426","","2024-07-22","Submitted reapplication via delegated roster on 7/15/2024. FC"]
["Govind B Patel, MD","1073555249","74-2348334","TX","","USA PPO","Participating","Enrollment Complete",37575,"1073555249","742348334","2020-08-19","Confirmed provider is participating with PPO, H&W and WIN networks (list of networks attached). Kimberly Frazier"]
["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","","Caprock (CapStar)","Participating","Application Resubmitted",40969,"1073555249","","","Submitted reapplication via delegated roster on 7/15/2024. FC"]
["Govind B Patel, MD","1073555249","74-2348334","TX","","Medicare","Participating","Enrollment Complete",37104,"83462K","00320K","2020-03-10","03/10/2020 - Signed into  PECOS and confirmed that this provider is linked to Permian Gastroenterology Pa 74-2348334 (EIN) as of 8-1-2001 - Stacey Hudak"]
["Govind B Patel, MD","1073555249","74-2348334","TX","PE - Permian Gastroenterology PA","HealthSmart PPO","Participating","Application Resubmitted","2011-02-01","1073555249","","2024-07-22","Submitted reapplication via delegated roster on 7/15/2024. FC"]
["Govind B Patel, MD","1073555249","74-2348334","TX","","HealthSmart PPO","Participating","Application Resubmitted","2011-02-01","1073555249","","2024-07-22","Submitted reapplication via delegated roster on 7/15/2024. FC"]
["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","","Multiplan","Participating","Application Resubmitted","1996-10-01","1073555249","","2024-07-22","Submitted reapplication via delegated roster on 7/15/2024. FC"]
["Govind B Patel, MD","1073555249","74-2348334","TX","PE - Permian Gastroenterology PA","Superior","Participating","Enrollment Complete","2020-08-01","1073555249","","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"]
["Govind B Patel, MD","1073555249","74-2348334","TX","","Superior","Participating","Enrollment Complete",44044,"1073555249","","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"]
["Govind B Patel, MD","1073555249","74-2348334","TX","","Amerigroup","Participating","Enrollment Complete",41356,"1073555249","","2020-03-19","03/19/2020 - Rec'd email from this payer (multiplan/texas true choice)  stating this provider is effective at this service location with Amerigroup - Stacey Hudak"]
["Govind B Patel, MD","1073555249","74-2348334","TX","PE - Permian Gastroenterology PA","Aetna","Participating","Application Resubmitted",38671,"","","2024-07-22","Submitted reapplication via delegated roster on 7/15/2024. FC"]
["Joseph J Shayeb, MD","1528049590","75-2656723","TX","","IMS","Participating","Re-Credentialing",45078,"","","2024-03-18","3/18/2024- Submitted recred status via delegated monthly roster on 3/15/2024. FC."]
["Joseph J Shayeb, MD","1528049590","75-2656723","TX","PE - Premier Family Care, Inc","Medicare","Participating","Enrollment Complete",45017,"","","2023-06-21","Received COI application confirmation. Reference # 3231460484  MS"]
["Joseph J Shayeb, MD","1528049590","75-2656723","TX","","Boon Chapman","Participating","Enrollment Complete",45078,"","","2023-07-25","7/25/2023 Rcvd email confirmation from Jessica Bess at Multiplan that June roster has been processed and provider is PAR w/ group effective 6/1/2023.  DCannon"]
["Joseph J Shayeb, MD","1528049590","75-2656723","TX","PE - Premier Family Care, Inc","Aetna","Participating","Enrollment Complete","2023-06-01","4513524","","2023-08-16","8/16/2023 Per follow-up note - provider NPI# is on file for the provider and is participating effective 06/01/23 under the group and TIN#. Location address is on file. PIN# 4513524.   DCannon"]
["Joseph J Shayeb, MD","1528049590","75-2656723","TX","","TriCare Standard","Participating","Enrollment Complete",45071,"","","2023-08-23","Confirmed provider is active and linked to location. MS"]
["Joseph J Shayeb, MD","1528049590","75-2656723","TX","","Cigna","Participating","Enrollment Complete",45217,"3453380","","2023-10-19","Received enrollment confirmation. MS"]
["Joseph J Shayeb, MD","1528049590","75-2656723","TX","PE - Premier Family Care, Inc","Medicaid","Participating","Enrollment Complete","2023-04-01","1528049590","","2023-10-06","Rcvd welcome ltr from TMHP. Provider is effective 04/01/2023. Jen Videan"]
["Joseph J Shayeb, MD","1528049590","75-2656723","TX","","First Health Coventry","Participating","Enrollment Complete","2023-06-01","1119106","","2023-09-20","9/20/2023 Per First Health web portal provider is PAR and linked to group TIN/location effective 6/1/2023.  PID #1119106.  DCannon"]
["Joseph J Shayeb, MD","1528049590","75-2656723","TX","PE - Premier Family Care, Inc","Scott&White (First Care)","Participating","Enrollment Complete",45127,"","","2023-09-12","9/12/2023 Received email from Scott & White that provider is PAR and linked to group TIN/location effective 7/20/2023.  DCannon"]
["Joseph J Shayeb, MD","1528049590","75-2656723","TX","","Scott&White (First Care)","Participating","Enrollment Complete",45127,"","","2023-09-12","9/12/2023 Received email from Scott & White that provider is PAR and linked to group TIN/location effective 7/20/2023.  DCannon"]
["Joseph J Shayeb, MD","1528049590","75-2656723","TX","PE - Premier Family Care, Inc","Caprock (CapStar)","Participating","Re-Credentialing",45078,"","","2024-03-18","3/18/2024- Submitted recred status via delegated monthly roster on 3/15/2024. FC."]
["Joseph J Shayeb, MD","1528049590","75-2656723","TX","PE - Premier Family Care, Inc","Omni PPO","Participating","Re-Credentialing","2023-06-01","","","2024-03-18","3/18/2024- Submitted recred status via delegated monthly roster on 3/15/2024. FC."]
["Joseph J Shayeb, MD","1528049590","75-2656723","TX","","Galaxy Health","Participating","Enrollment Complete",45078,"","","2023-07-20","7/20/2023 Per email received from Galaxy June delegated roster has been processed and provider is PAR and linked to group effective 6/1/2023.  DCannon"]
["John C Dean, MD","1013923291","46-3131679","TX","PE - Midland Texas Orthopedic Group Inc","Medicare","Participating","Enrollment Complete",41487,"321613YV2D","320497","2020-01-30","01/30/2020 - Found that this provider is EFF thorugh PECOS group application - Stacey Hudak"]
["John C Dean, MD","1013923291","46-3131679","TX","PE - Midland Texas Orthopedic Group Inc","Wellcare","Participating","Enrollment Complete",44501,"","","2022-11-15","11/15/2022 Per roster received from Wellcare provider is PAR and linked to group TIN/location effective 11/1/2021.  DCannon"]
["John C Dean, MD","1013923291","46-3131679","TX","PE - Midland Texas Orthopedic Group Inc","United Health Care","Participating","Enrollment Complete",43831,"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","Triwest VA","Participating","Enrollment Complete","2022-08-01","","","2022-11-14","11/14/22 Per Scarlett Abigail, provider effective from 8/1/22"]
["John C Dean, MD","1013923291","46-3131679","TX","PE - Midland Texas Orthopedic Group Inc","Wellmed","Participating","Enrollment Complete","2022-01-01","","","2023-03-23","3/23/2023 Rcvd roster from UHC w/ all Wellmed participating providers.  Provider is PAR effective 1/1/2022.  DCannon"]
["John C Dean, MD","1013923291","46-3131679","TX","PE - Midland Texas Orthopedic Group Inc","Cigna Healthspring","Pending Other Enrollment","Pending Other Enrollment","","","","2024-07-23","Group letter of interest was submitted. They payer has received it and after reviewing if they want to contract, they will be reaching out to me for additional info and the roster. Nothing is needed until then. MS"]
["John C Dean, MD","1013923291","46-3131679","TX","PE - Midland Texas Orthopedic Group Inc","Humana","Participating","Enrollment Complete","2020-01-01","1013923291","","2020-07-19","7/19/2020 - Received email spreadsheet from the payor confirming that this provider is EFF at this service location and PAR with the PRIMED DELEGATED agreement - Pam Porter"]
["John C Dean, MD","1013923291","46-3131679","TX","PE - Midland Texas Orthopedic Group Inc","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",43252,"","","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"]
["Srikanth R Deme, MD","1124103338","75-2949900","TX","PE - Srikanth Deme MD PA","CAQH","Participating","CAQH Reattested","2024-08-14","","","2024-08-14","08/14/2024 CAQH Reattested all locations current and all expirables up to date wthompson"]
["Srikanth R Deme, MD","1124103338","75-2949900","TX","PE - Srikanth Deme MD PA","United Health Care","Participating","Enrollment Complete",45188,"001806789","","2023-11-15","11/15/2023 Per email received from UHC provider is PAR and linked to group TIN effective 9/19/2023.  MPIN# 001806789.  DCannon"]
["Shylesh R Ganta, MD","1811900657","20-8658501","TX","PE - Shylesh Ganta, MD, PA","Rail Road Medicare","Participating","Enrollment Complete","2007-11-01","P00663946","DO2096","2020-03-10","03/10/2020 - Found EFF info through payer portal - Stacey Hudak"]
["Shylesh R Ganta, MD","1811900657","20-8658501","TX","PE - Shylesh Ganta, MD, PA","Caprock (CapStar)","Participating","Enrollment Complete","2019-09-01","1811900657","","2020-09-23","09/23/2020 - rec'd confirmation from the payer that this August 2020 roster was completed. This provider/service location was added to PriMed Agreement - OK to move to completed status. - Stacey Hudak"]
["Shylesh R Ganta, MD","1811900657","20-8658501","TX","PE - Shylesh Ganta, MD, PA","Liberty Mutual","Participating","Enrollment Complete",40109,"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","Aetna","Participating","Enrollment Complete","2020-03-12","","","2024-08-27","As per Anj R (call ref# 62012556) provider participating as of 3/1/2020, listed as PCP. FC"]
["Shylesh R Ganta, MD","1811900657","20-8658501","TX","PE - Shylesh Ganta, MD, PA","Medicare","Participating","Enrollment Complete",39387,"8F6462","00Y323","2020-03-10","03/10/2020 - signed into PECOS and verified that this provider is linked to this group: SHYLESH GANTA ,MD , PA (group TPAN 00Y323) as of 11-1-2007 - Stacey Hudak"]
["Shylesh R Ganta, MD","1811900657","20-8658501","TX","PE - Shylesh Ganta, MD, PA","Wellmed","Participating","Enrollment Complete","2022-01-01","","","2023-03-23","3/23/2023 Rcvd roster from UHC w/ all Wellmed participating providers.  Provider is PAR effective 1/1/2022.  DCannon"]
["Bhuvana Balasekaran, MD","1770564080","46-1602172","TX","PE - Bhuvana Balasekaran, MD PA","Boon Chapman","Participating","Enrollment Complete","2008-12-10","12705210","","2022-02-24","2/224/2022 - Per follow-up note on 2/18/2022 - Provider NPI# is on file for the provider and participating effective 12/10/2008 under the group and TIN#. Provider ID#  12705210. Physical location is on file. Call ref# 7919804 -Marielle Pacheco"]
["Bhuvana Balasekaran, MD","1770564080","46-1602172","TX","PE - Bhuvana Balasekaran, MD PA","CAQH","In House Enrollment","In House Enrollment",44075,"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","Wellmed","Participating","Enrollment Complete","2022-01-01","","","2023-03-23","3/23/2023 Rcvd roster from UHC w/ all Wellmed participating providers.  Provider is PAR effective 1/1/2022.  DCannon"]
["Eric J Venegas, MD","1760485502","75-2930500","TX","PE - Eric J. Venegas, MD, PA","United Health Care","Participating","Enrollment Complete","2020-01-01","1760485502","","2020-08-31","08/31/2020 - Moved to completed status after reviewing Follow Up Completed note - Stacey Hudak"]
["Eric J Venegas, MD","1760485502","75-2930500","TX","PE - Eric J. Venegas, MD, PA","Galaxy Health","Participating","Enrollment Complete","2019-09-01","1760485502","","2020-08-21",""]
["Eric J Venegas, MD","1760485502","75-2930500","TX","PE - Eric J. Venegas, MD, PA","Superior","Participating","Enrollment Complete","2019-05-01","1760485502","","2020-07-14","07/14/2020 - Rec'd email from the payer stating this provider is EFF under PRIMED DELEGATED agreement - Stacey Hudak"]
["Eric J Venegas, MD","1760485502","75-2930500","TX","PE - Eric J. Venegas, MD, PA","First Health Coventry","Participating","Enrollment Complete","2008-09-01","1760485502","","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","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","TX","PE - Premier Family Care, Inc","Medicare","Participating","Enrollment Complete","2011-08-25","TXB134311","0008AH","2020-01-29","01/29/2020 - confirmed EFF through PECOS group enrollment - Stacey Hudak"]
["Kirit N Patel, MD","1295724698","75-2656723","TX","PE - Premier Family Care, Inc","CAQH","Active","CAQH Reattested",45531,"10776779","","2024-08-27","08/27/2024 CAQH Reattested updated and uploaded COI wthompson"]
["Kirit N Patel, MD","1295724698","75-2656723","TX","PE - Premier Family Care, Inc","Multiplan","Participating","Enrollment Complete",37530,"1295724698","Multiple Group Affiliations","2020-04-09","04/09/2020 - Rec'd response from the payer stating:\n\"Thank you for contacting our Service Department at Multiplan/PHCS and Beech Street. Here is the following information we have on file for Patel, Kirit:\n\nNetwork: Multiplan\nNetwork Participation effective: 10/01/2004\nContract Source Group contract through: West Texas Physicians Alliance \n\nNetwork: PHCS\nNetwork Participation effective: 10/01/2002\nContract Source Group contract through: West Texas Physicians Alliance \n\nNetwork: Beech Street\nNetwork Participation effective: 01/01/2008\nContract Source Group contract through: West Texas Physicians Alliance\n\nNetwork: Multiplan and PHCS\nNetwork Participation effective: 02/28/2017\nContract Source Group contract through: Permian Basin Healthcare Network-Midlevel\n\nNetwork: Multiplan, PHCS, and Beech Street \nNetwork Participation effective: 11/01/2010\nContract Source : Individual\"\n\nStacey Hudak"]
["Kirit N Patel, MD","1295724698","75-2656723","TX","","Multiplan","Participating","Application Resubmitted","2002-10-01","1295724698","Multiple Group Affiliations","2024-07-18","Submitted reapplication via delegated roster on 7/15/2024. FC"]
["Kirit N Patel, MD","1295724698","75-2656723","TX","PE - Premier Family Care, Inc","Aetna","Participating","Enrollment Complete","2016-01-01","1295724698","","2020-02-03","02/03/2020  - Rec'd confirmation from the payer that this provider is on file and EFF 1-1-2016 under a DIRECT CONTRACT. Provider is linked to 600 Washington Ave location - Stacey Hudak"]
["Kirit N Patel, MD","1295724698","75-2656723","TX","PE - Premier Family Care, Inc","Wellcare","Participating","Enrollment Complete","2021-11-01","","","2022-12-01","12/1/2022 Per roster received from Wellcare provider is PAR and linked to group TIN/location effective 11/1/2021.  DCannon"]
["Kirit N Patel, MD","1295724698","75-2656723","TX","PE - Premier Family Care, Inc","Ambetter","Participating","Enrollment Complete","2022-06-01","","","2022-06-13","6/13/2022 Per roster received from Superior provider is PAR and linked to group delegation roster effective 6/1/2022."]
["Kirit N Patel, MD","1295724698","75-2656723","TX","PE - Premier Family Care, Inc","Ambetter","Participating","Enrollment Complete","2022-06-01","","","2022-06-13","6/13/2022 Per roster received from Superior provider is PAR and linked to group delegation roster effective 6/1/2022."]
["Kirit N Patel, MD","1295724698","75-2656723","TX","PE - Premier Family Care, Inc","Wellmed","Participating","Enrollment Complete","2022-01-01","","","2023-03-23","3/23/2023 Rcvd roster from UHC w/ all Wellmed participating providers.  Provider is PAR effective 1/1/2022.  DCannon"]
["Kirit N Patel, MD","1295724698","75-2656723","TX","PE - Premier Family Care, Inc","IMS","Participating","Enrollment Complete","2019-09-01","1295724698","","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"]
["Kirit N Patel, MD","1295724698","75-2656723","TX","PE - Premier Family Care, Inc","IMS","Participating","Enrollment Complete","2019-09-01","1295724698","","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"]
["Kirit N Patel, MD","1295724698","75-2656723","TX","PE - Premier Family Care, Inc","Caprock (CapStar)","Participating","Enrollment Complete",43040,"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","TX","PE - Premier Family Care, Inc","Medicare","Participating","Enrollment Complete","2011-08-25","TXB134311","0008AH","2020-01-29","01/29/2020 - confirmed EFF through PECOS group enrollment - Stacey Hudak"]
["Kirit N Patel, MD","1295724698","75-2656723","TX","PE - Premier Family Care, Inc","Scott&White (First Care)","Participating","Enrollment Complete","2018-12-01","1295724698","","2020-10-02","10/02/2020 - moved to completed status after reviewing follow up complete note - Stacey Hudak"]
["Kirit N Patel, MD","1295724698","75-2656723","TX","PE - Premier Family Care, Inc","Liberty Mutual","Participating","Enrollment Complete","2011-09-01","1295724698","752656723","2020-08-19","Confirmed provider is participating with WIN network which includes this payor (list of networks attached). Kimberly Frazier"]
["Kirit N Patel, MD","1295724698","75-2656723","TX","PE - Premier Family Care, Inc","Medicaid","Participating","Enrollment Complete","","046690605","","2020-01-29","01/29/2020 - Found provider PAR through payer portal and linked to correct service location. Proivder 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"]
["Kirit N Patel, MD","1295724698","75-2656723","TX","PE - Premier Family Care, Inc","Triwest VA","Facility Enrollment","Facility Enrollment","","","","2022-10-17","10/17/2022 - Received roster from Scarlett of TriWest VA; provider status: \"No Action.  TIN is CCN participating under own DCN.\""]
["Kirit N Patel, MD","1295724698","75-2656723","TX","","Omni PPO","Participating","Application Resubmitted","2019-09-01","1295724698","","2024-07-18","Submitted reapplication via delegated roster on 7/15/2024. FC"]
["Dario Beltran, MD","1912100850","75-2656723","TX","PE - Premier Family Care, Inc","HealthSmart PPO","Participating","Enrollment Complete",44498,"1912100850","","2023-07-11","Received confirmation from Client. MS"]
["Dario Beltran, MD","1912100850","75-2656723","TX","PE - Premier Family Care, Inc","Medicaid","Participating","Enrollment Complete",45011,"121276305","079837301","2024-05-01","Rcvd Medicaid approval ltr. Provider effective 03/26/2023. Jen Videan"]
["Dario Beltran, MD","1912100850","75-2656723","TX","PE - Premier Family Care, Inc","Aetna","Participating","Enrollment Complete","2011-01-17","1912100850","","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","1912100850","75-2656723","TX","PE - Premier Family Care, Inc","IMS","Participating","Enrollment Complete",44498,"1922008234","","2023-08-24","8/24/2023 Per email received from IMS/Omni provider is PAR and linked to group TIN/location effective 10/29/2021.  DCannon"]
["Dario Beltran, MD","1912100850","75-2656723","TX","PE - Premier Family Care, Inc","Galaxy Health","Participating","Enrollment Complete","2021-10-29","1912100850","","2023-08-15","8/15/2023 Per email received for Karen Avalos at Galaxy Health provider is PAR and linked to group TIN effective 10/29/2021.  DCannon"]
["Dario Beltran, MD","1912100850","75-2656723","TX","PE - Premier Family Care, Inc","Superior","Participating","Enrollment Complete","2021-12-01","1912100850","","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"]
["P Douglas Cochran, MD","1316026396","20-0212181","TX","P. Douglas Cochran, MD, PA","HealthSmart PPO","Participating","Enrollment Complete",45047,"","","2023-11-13","11/13/2023 Per phone conversation with Lee Kinard at Healthsmart provider is PAR and linked to group TIN/location effective 5/1/2023.  DCannon"]
["P Douglas Cochran, MD","1316026396","20-0212181","TX","P. Douglas Cochran, MD, PA","Cigna","Participating","Enrollment Complete",45047,"","","2023-11-03","Received confirmation of update. W202310193478451 MS"]
["Jose G Delgado, MD","1578557468","75-2656723","TX","PE - Premier Family Care, Inc","Medicaid","In Process","Enrollment Complete",38261,"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","75-2656723","TX","PE - Premier Family Care, Inc","Medicaid","In Process","Enrollment Complete",38261,"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","75-2656723","TX","PE - Premier Family Care, Inc","First Health Coventry","Participating","Enrollment Complete","2022-11-01","3637766","","2023-05-02","5/2/2023 Per confirm par status note -   Per rep, provider is participating with an effective date 11/01/2022 and link under the Group and TIN. Provider ID 3637766. As per Donna from there Credentialing Dept they don't have the provider's next recredentialing date then advised that their Network Team will inform the provider if the recredentialing Date is available. Service location is on file. Call ref#:610340.  DCannon"]
["Jose G Delgado, MD","1578557468","75-2656723","TX","PE - Premier Family Care, Inc","Ambetter","Participating","Enrollment Complete",44866,"","","2022-12-29","12/29/2022 Rcvd confirmation email from Superior that October delegation roster has been processed and provider has been loaded to delegation roster and PAR w/ group effective 11/1/2022.  DCannon"]
["Jose G Delgado, MD","1578557468","75-2656723","TX","PE - Premier Family Care, Inc","United Health Care","Participating","Enrollment Complete","2022-09-12","","","2023-05-04","5/4/2023 Per email from UHC delegated roster from February has been processed.  Provider is PAR and linked to group TIN effective 9/12/2022.  DCannon"]
["Jose G Delgado, MD","1578557468","75-2656723","TX","PE - Premier Family Care, Inc","Rail Road Medicare","Participating","Enrollment Complete",44816,"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","75-2656723","TX","PE - Premier Family Care, Inc","IMS","Participating","Enrollment Complete",44816,"","","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","75-2656723","TX","PE - Premier Family Care, Inc","Triwest VA","Facility Enrollment","In House Enrollment","","","","2022-09-13",""]
["Jose G Delgado, MD","1578557468","75-2656723","TX","PE - Premier Family Care, Inc","Cigna","Participating","Enrollment Complete",44816,"3714369","","2022-11-08","11/8/2022 Rcvd email from Cigna that provider is PAR and linked to group TIN/location effective 9/12/2022.  PID # 3714369.  DCannon"]
["Jose G Delgado, MD","1578557468","75-2656723","TX","PE - Premier Family Care, Inc","Cigna","Participating","Enrollment Complete",44816,"3714369","","2022-11-08","11/8/2022 Rcvd email from Cigna that provider is PAR and linked to group TIN/location effective 9/12/2022.  PID # 3714369.  DCannon"]
["Jose G Delgado, MD","1578557468","75-2656723","TX","PE - Premier Family Care, Inc","Superior","Participating","Enrollment Complete","2022-11-01","","","2022-12-08","12/08/2022 Rcvd confirmation email from Superior that October delegation roster has been processed and provider has been loaded to delegation roster and PAR w/ group effective 11/1/2022.  DCannon"]
["Jose G Delgado, MD","1578557468","75-2656723","TX","PE - Premier Family Care, Inc","HealthSmart PPO","Participating","Enrollment Complete","2022-09-12","","","2022-11-28","11/28/2022 Per Healthsmart website provider is PAR and loaded under TIN/location effective 9/12/2022.  DCannon"]
["Jose G Delgado, MD","1578557468","75-2656723","TX","PE - Premier Family Care, Inc","USA PPO","Participating","Enrollment Complete","2021-09-12","","","2023-03-24","3/24/2023 In following up with USAMCO (800-872-3860) I was told that you can confirm participating via the USA MCO website  https://providersearch.usamco.com/hwprovsearch.  Provider is PAR and linked to location/TIN effective 9/12/2022.  DCannon"]
["Jose G Delgado, MD","1578557468","75-2656723","TX","PE - Premier Family Care, Inc","USA PPO","Participating","Enrollment Complete","2021-09-12","","","2023-03-24","3/24/2023 In following up with USAMCO (800-872-3860) I was told that you can confirm participating via the USA MCO website  https://providersearch.usamco.com/hwprovsearch.  Provider is PAR and linked to location/TIN effective 9/12/2022.  DCannon"]
["Jose G Delgado, MD","1578557468","75-2656723","TX","PE - Premier Family Care, Inc","TriCare Standard","Participating","Enrollment Complete","2022-09-13","","","2023-05-24","Confirmed via HM portal. MS"]
["Jose G Delgado, MD","1578557468","75-2656723","TX","PE - Premier Family Care, Inc","Multiplan","Participating","Enrollment Complete","2022-09-12","","","2023-07-26","7/26/2023 Rcvd email from Jessica Bess at Multiplan with a full roster and provider is PAR w/ group and location effective 9/12/2022.  DCannon"]
["Jose G Delgado, MD","1578557468","75-2656723","TX","PE - Premier Family Care, Inc","Scott&White (First Care)","Participating","Enrollment Complete",44841,"","","2022-10-28","10/28/2022 Rcvd email from Scott & White that provider is PAR and linked to group TIN/locations effective 10/7/2022.  DCannon"]
["Jose G Delgado, MD","1578557468","75-2656723","TX","PE - Premier Family Care, Inc","Scott&White (First Care)","Participating","Enrollment Complete",44841,"","","2022-10-28","10/28/2022 Rcvd email from Scott & White that provider is PAR and linked to group TIN/locations effective 10/7/2022.  DCannon"]
["Jose G Delgado, MD","1578557468","75-2656723","TX","PE - Premier Family Care, Inc","Aetna","Participating","Enrollment Complete","2022-09-12","7423546","","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 # 7423546.  DCannon"]
["Jose G Delgado, MD","1578557468","75-2656723","TX","PE - Premier Family Care, Inc","Amerigroup","Participating","Enrollment Complete","2022-10-10","","","2023-02-01","2/1/2023 Per email response from Amerigroup Provider Relations-Texas provider is PAR and linked to group effective 10/10/2022.  PID# 14614726.  DCannon"]
["Jose G Delgado, MD","1578557468","75-2656723","TX","PE - Premier Family Care, Inc","CAQH","Participating","CAQH Reattested",45532,"","","2024-08-28","08/28/2024 CAQH Reattested updated and uploaded COI wthompson"]
["Jose G Delgado, MD","1578557468","75-2656723","TX","PE - Premier Family Care, Inc","Medicare","Participating","Enrollment Complete",44816,"2I8228","0008AH","2022-09-21","9/21/2022 Rcvd Medicare approval letter from Candace Wynne.  PTAN # 2I8228 - effective 9/12/2022.  DCannon"]
["Jose G Delgado, MD","1578557468","75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","2022-09-13","","","2024-01-25","During the Tricare audit, it was found this provider is credentialed and is in network with Tricare. MS"]
["Jose G Delgado, MD","1578557468","75-2656723","TX","PE - Premier Family Care, 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","75-2656723","TX","PE - Premier Family Care, Inc","Humana","Participating","Enrollment Complete","2022-09-12","","","2023-02-17","2/17/2023 Per email received from Priscilla Albertine at MQA she received confirmation from Humana that provider is PAR and linked to group TIN/location effective 9/12/2022.  DCannon"]
["Vincent P Rascon, DPM","1346236924","91-1559006","TX","PE - Vincent P. Rascon","IMS","Participating","Re-Credentialing","2012-01-01","","","2024-03-18","3/18/2024- Submitted recred status via delegated monthly roster on 3/15/2024. FC."]
["Vincent P Rascon, DPM","1346236924","91-1559006","TX","PE - Vincent P. Rascon","Amerigroup","Participating","Re-Credentialing","2015-12-09","1346236924","","2024-03-18","3/18/2024- Submitted recred status via delegated monthly roster on 3/15/2024. FC."]
["Vincent P Rascon, DPM","1346236924","91-1559006","TX","PE - Vincent P. Rascon","Medicare","Participating","Enrollment Complete","1998-06-01","00147E","N/A - no group enrollment/PTAN","2020-03-10","03/10/2020 - Logged onto provider account through PECOS and found that this provider only has an individual enrollment. Is not reassigned to group - Stacey Hudak"]
["Vincent P Rascon, DPM","1346236924","91-1559006","TX","PE - Vincent P. Rascon","HealthSmart PPO","Participating","Re-Credentialing","2011-02-01","1346236924","","2024-03-18","3/18/2024- Submitted recred status via delegated monthly roster on 3/15/2024. FC."]
["Vincent P Rascon, DPM","1346236924","91-1559006","TX","PE - Vincent P. Rascon","Cigna","Participating","Enrollment Complete","2010-08-01","1346236924","","2020-04-22","04/22/2020--S/W Rica of Cigna @ 8008824462, provider NPI# is on file for the provider and is participating effective 8/1/2010 under the group and TIN#. Physical location is on file. Call ref# Rica04202020.\ncopied note from spreadsheet-tisha rader"]
["Rand E Waddingham, M.D.","1730181389","26-3789190","TX","","Medicare","Participating","Enrollment Complete","2021-01-01","1M9652","","2021-04-27","4/26/2021 Per email confirmation received from Stacy Salazar, provider has been assigned PTAN 1M9652 under group effective 1/1/2021. KFrazier"]
["Rand E Waddingham, M.D.","1730181389","75-1997880","TX","PE - Andrews County Hospital District","Tricare Prime","Participating","Enrollment Complete","2004-11-01","","","2024-01-26","Confirmed provider is credentialed and in network with Tricare. MS"]
["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","","Gallagher","Participating","Enrollment Complete","","","","2024-02-02","Per Coventry portal provider is enrolled. Jen Videan"]
["Rand E Waddingham, M.D.","1730181389","26-3789190","TX","PE - Permian Physician Services","Coventry Workers Comp","Participating","Enrollment Complete","","","","2024-02-02","Per Coventry portal provider is enrolled. Jen Videan"]
["Rand E Waddingham, M.D.","1730181389","75-1997880","TX","","United Health Care","Participating","Enrollment Complete","2020-06-01","1730181389","","2020-09-01","09/01/2020 - moved to completed status after reviewing follow up complete note - Stacey Hudak"]
["Rand E Waddingham, M.D.","1730181389","75-1997880","TX","PE - Andrews County Hospital District","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","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","75-1997880","TX","PE - Andrews County Hospital District","HealthSmart PPO","Participating","Enrollment Complete","2011-02-01","1730181389","","2020-07-01","07/01/2020 - rec'd email confirmation from the payer that this provider is EFF - 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","75-1997880","TX","","Broadspire Services Inc.","Enrollment Stopped","Enrollment Stopped","","","","2023-10-04","Per Melody Starcher, they would like to hold off on Broadspire WC enrollment at this time. If they start to see a large amount of patients coming in with it, then they will reassess. 10/04/2023 Jen Videan"]
["Rand E Waddingham, M.D.","1730181389","26-3789190","TX","PE - Permian Physician Services","Multiplan","Participating","Enrollment Complete","2021-09-02","","","2022-07-23","7/23/2022 Per email from Marcie Eckhart-Haven at Multiplan provider is PAR and linked to group TIN effective 9/2/2021.  DCannon"]
["Rand E Waddingham, M.D.","1730181389","26-3789190","TX","","TriCare Standard","Participating","Enrollment Complete","","","","2021-09-15","9/15/2021 Per non network portal, provider is certified under this location. Cbankston"]
["Rand E Waddingham, M.D.","1730181389","75-1997880","TX","PE - Andrews County Hospital District","USA PPO","Participating","Enrollment Complete","2003-02-11","1730181389","751997880","2020-08-19","Confirmed provider is participating with PPO, H&W and WIN networks (list of networks attached). Kimberly Frazier"]
["Rand E Waddingham, M.D.","1730181389","26-3789190","TX","","Galaxy Health","Participating","Enrollment Complete","2019-09-01","1730181389","","2020-08-21","08/21/2020 - Rec'd email confirmation that this roster was processed and this provider was made effective with the requested eff date of 9-1-2019 - Stacey Hudak"]
["Rand E Waddingham, M.D.","1730181389","26-3789190","TX","PE - Permian Physician Services","Caprock (CapStar)","Participating","Enrollment Complete",43709,"","","2021-04-09","4/9/2020 Rcvd roster from Mary Rodriguez <mary.rodriguez@90degreebenefits.com> at Caprock listing provider as participating under TIN.  DCannon"]
["Rand E Waddingham, M.D.","1730181389","26-3789190","TX","","Ambetter","Participating","Enrollment Complete","2022-04-01","","","2022-06-13","6/13/2022 Per roster received from Superior provider is PAR and linked to group delegation roster effective 4/1/2022."]
["Rand E Waddingham, M.D.","1730181389","75-1997880","TX","","Humana","Participating","Enrollment Complete","2011-03-01","1730181389","","2021-11-18","11/18/2021 Rcvd full roster from Humana listing provider as PAR and linked to group TIN/location effective 3/1/2011.  DCannon"]
["Rand E Waddingham, M.D.","1730181389","26-3789190","TX","PE - Permian Physician Services","CAQH","Active","CAQH Reattested","2024-08-14","10778944","","2024-08-14","08/14/2024 CAQH Reattested all locations current and all expirables up to date wthompson"]
["Rand E Waddingham, M.D.","1730181389","26-3789190","TX","PE - Permian Physician Services","CAQH","Active","CAQH Reattested","2024-08-14","10778944","","2024-08-14","08/14/2024 CAQH Reattested all locations current and all expirables up to date wthompson"]
["Rand E Waddingham, M.D.","1730181389","75-1997880","TX","PE - Andrews County Hospital District","Triwest VA","Participating","Enrollment Complete","2022-08-01","","","2022-11-14","11/14/22- TIN is active and has direct contract, provider in network due to association with TIN"]
["Rand E Waddingham, M.D.","1730181389","75-1997880","TX","","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","75-1997880","TX","PE - Andrews County Hospital District","Texas Municipal League","Participating","Enrollment Complete","2023-11-03","","","2023-11-20","Enrollment through Alliance WC. Rcvd approval ltr. Provider effective 11/03/2023. See Alliance WC payor line. Jen Videan"]
["Rand E Waddingham, M.D.","1730181389","75-1997880","TX","PE - Andrews County Hospital District","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","75-1997880","TX","","Coventry Workers Comp","Participating","Enrollment Complete","2023-08-02","","","2024-04-25","4/25/2024 provider enrolled as of 8/2/2023 via roster. FC"]
["Rand E Waddingham, M.D.","1730181389","26-3789190","TX","PE - Permian Physician Services","Humana","Participating","Enrollment Complete",44440,"","","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","75-1997880","TX","","TriCare Standard","Participating","Enrollment Complete","2004-11-01","1730181389","","2020-07-31","7/31/2020 - Rec'd email from the payer stating \"I also show Rand attached to Permian, effective 11/1/04. \" - Stacey Hudak"]
["Rand E Waddingham, M.D.","1730181389","75-1997880","TX","PE - Andrews County Hospital District","Gallagher","Participating","Enrollment Complete","","","","2024-01-27","Confirmed provider is enrolled via the Integrated Network. MS"]
["Rand E Waddingham, M.D.","1730181389","26-3789190","TX","","Amerigroup","Participating","Enrollment Complete","2012-03-01","","","2021-02-13","2/13/2021 - Rcvd complete roster from Amerigroup provider is participating and linked to TIN and location for the following plans STAR - eff 3/1/2012, MEDICARE - eff 8/1/2012, C-SNP - eff 1/1/2017, OTHER - eff 1/1/2021, OTHER - eff 1/1/2020,  PLUS - eff 3/1/2012, Star_Kids - eff 11/1/2016.  DCannon"]
["Rajanikant P Pandya, MD","1316965403","56-2697415","TX","PE - Rajanikant P. Pandya","TriCare Standard","Participating","Enrollment Complete","1991-09-01","1316965403","","2020-05-01","05/01/2020 - Rec'd access to the TIN through the portal and was able to confirm that this provider is EFF and IN NETWORK with this payer - Stacey Hudak"]
["Rajanikant P Pandya, MD","1316965403","56-2697415","TX","","IMS","Participating","Enrollment Complete","2001-01-15","1316965403","","2020-06-22","06/22/2020- Rec'd email from the payer confirming this provider is PAR with this group/service location - Stacey Hudak"]
["Rajanikant P Pandya, MD","1316965403","56-2697415","TX","PE - Rajanikant P. Pandya","HealthSmart PPO","Participating","Enrollment Complete","2011-02-01","1316965403","","2020-06-10","06/10/2020 - rec'd email from the payer stating this provider is EFF - Stacey Hudak"]
["Rajanikant P Pandya, MD","1316965403","56-2697415","TX","PE - Rajanikant P. Pandya","HealthSmart PPO","Participating","Add Info Submitted",40575,"1316965403","","2024-08-19","Submitted reapplication via delegated roster on 8/15/2024. FC"]
["Rajanikant P Pandya, MD","1316965403","56-2697415","TX","","Multiplan","Participating","Enrollment Complete","1999-09-23","1316965403","","2020-02-12","02/12/2020 - Rec'd cofnirmation through payer portal that this provider is EFF 9-23-1999 under an INDIVIDUAL CONTRACT. Provider is networked with Multiplan - Stacey  Hudak"]
["Rajanikant P Pandya, MD","1316965403","56-2697415","TX","PE - Rajanikant P. Pandya","Wellcare","Participating","Enrollment Complete",44501,"","","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"]
["Rajanikant P Pandya, MD","1316965403","56-2697415","TX","PE - Rajanikant P. Pandya","Superior","Participating","Enrollment Complete",44075,"1316965403","","2020-09-02","09/02/2020 - Rec'd email from the payer stating this delegated update has been made - Stacey Hudak"]
["Rajanikant P Pandya, MD","1316965403","56-2697415","TX","PE - Rajanikant P. Pandya","Omni PPO","Participating","Enrollment Complete",36906,"1316965403","","2020-06-25",""]
["Rajanikant P Pandya, MD","1316965403","56-2697415","TX","PE - Rajanikant P. Pandya","Scott&White (First Care)","Participating","Enrollment Complete","2016-06-01","1316965403","","2020-04-16","04/16/2020 - Rec'd spreadsheet from the payer confirming this provider is EFF with all products under the PRIMED DELEGATED agreement at this TIN/Service Location. - Stacey Hudak"]
["Rajanikant P Pandya, MD","1316965403","56-2697415","TX","PE - Rajanikant P. Pandya","Amerigroup","Participating","Add Info Submitted","2020-04-15","01449395","","2024-08-19","Submitted reapplication via delegated roster on 8/15/2024. FC"]
["Cheryl J. Vallie, APRN-FNP-BC","1417941410","20-4063608","TX","PE - C Vallie CFNP Limited Partnership","Triwest VA","In House Enrollment","In House Enrollment","","","","2021-01-14","1/6/2021 MQA Team is working with Representatives at BCBS-TX to ensure all providers are enrolled and loaded to participate with the VACCN network in a timely manner. However, we are currently awaiting a full roster of providers currently participating and will update all records accordingly upon receipt. Kfrazier"]
["Cheryl J. Vallie, APRN-FNP-BC","1417941410","20-4063608","TX","PE - C Vallie CFNP Limited Partnership","HealthSmart PPO","Participating","Enrollment Complete","2021-02-08","","","2021-04-11","4/11/2021 Rcvd email from HealthSmart <mdipsupport@healthsmart.com> confirming participation of provider under TIN and location effective 2/8/2021.  DCannon"]
["Cheryl J. Vallie, APRN-FNP-BC","1417941410","75-2656723","TX","PE - Premier Family Care, Inc","Cigna","Participating","Enrollment Complete",45571,"3219215","","2024-08-23","Provider has been linked and is active with this TIN. MS"]
["Cheryl J. Vallie, APRN-FNP-BC","1417941410","75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","Panel Closed","Panel Closed","","","","2024-08-23","Panel is closed. MS"]
["Cheryl J. Vallie, APRN-FNP-BC","1417941410","20-4063608","TX","PE - C Vallie CFNP Limited Partnership","USA PPO","Participating","Enrollment Complete","2021-02-08","","","2021-05-04","5/4/2021  In following up with USAMCO (800-872-3860) I was told that you can confirm participating via the USA MCO website  https://providersearch.usamco.com/hwprovsearch.  Provider is PAR and linked to location/TIN effective 2/8/2021.  DCannon"]
["Cheryl J. Vallie, APRN-FNP-BC","1417941410","20-4063608","TX","PE - C Vallie CFNP Limited Partnership","Multiplan","Participating","Enrollment Complete","2021-02-08","","","2022-07-24","7/24/2022 Per email from Marcie Eckhart-Havens Multiplan July delegated roster has been completed  and provider is PAR and linked to group TIN effective 2/8/2021.  DCannon"]
["Cheryl J. Vallie, APRN-FNP-BC","1417941410","20-4063608","TX","PE - C Vallie CFNP Limited Partnership","Cigna","Participating","Enrollment Complete","2018-11-22","","","2020-12-23",""]
["Joseph M Damiani, MD","1093821274","39-9526391","TX","PE - Joseph Damiani","Humana","Participating","Enrollment Complete","2021-09-01","","","2021-11-18","11/18/2021 Rcvd full roster from Humana listing provider as PAR and linked to group TIN/location effective 9/1/2021.  DCannon"]
["Joseph M Damiani, MD","1093821274","39-9526391","TX","PE - Joseph Damiani","First Health Coventry","Participating","Re-Credentialing","2016-07-01","1093821274","","2024-03-18","3/18/2024- Submitted recred status via delegated monthly roster on 3/15/2024. FC."]
["Joseph M Damiani, MD","1093821274","39-9526391","TX","PE - Joseph Damiani","Galaxy Health","Participating","Enrollment Complete","2019-09-01","1093821274","","2020-08-24","08/21/2020 - Rec'd email confirmation that this roster was processed and this provider was made effective with the requested eff date of 9-1-2019 - Stacey Hudak"]
["Joseph M Damiani, MD","1093821274","39-9526391","TX","PE - Joseph Damiani","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","Re-Credentialing","2014-11-15","1093821274","","2024-03-18","3/18/2024- Submitted recred status via delegated monthly roster on 3/15/2024. FC."]
["Joseph M Damiani, MD","1093821274","39-9526391","TX","PE - Joseph Damiani","HealthSmart PPO","Participating","Re-Credentialing","2014-10-31","1093821274","","2024-03-18","3/18/2024- Submitted recred status via delegated monthly roster on 3/15/2024. FC."]
["Anand C Reddy, MD","1780892760","81-3411343","TX","","Galaxy Health","Participating","Enrollment Complete","2019-09-01","1780892760","","2020-08-21","08/21/2020 - Rec'd email confirmation that this roster was processed and this provider was made effective with the requested eff date of 9-1-2019 - Stacey Hudak"]
["Anand C Reddy, MD","1780892760","81-3411343","TX","PE - Permian Basin Kidney Center Inc","Wellcare","Participating","Enrollment Complete",44501,"","","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","TX","","Scott&White (First Care)","Participating","Enrollment Complete",44102,"","","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","TX","PE - Permian Basin Kidney Center Inc","IMS","Participating","Enrollment Complete",43586,"1780892760","","2020-06-22","06/22/2020- Rec'd email from the payer confirming this provider is PAR with this group/service location - Stacey Hudak"]
["Anand C Reddy, MD","1780892760","81-3411343","TX","","IMS","Participating","Enrollment Complete","2019-05-01","1780892760","","2020-06-22","06/22/2020- Rec'd email from the payer confirming this provider is PAR with this group/service location - Stacey Hudak"]
["Anand C Reddy, MD","1780892760","81-3411343","TX","PE - Permian Basin Kidney Center Inc","Triwest VA","Participating","Enrollment Complete","2021-05-15","","","2021-05-31","5/31/2021 Received forwarded email from Rebecca Pontaski with confirmation provider is participating with VACCN (TriWest) effective 5/15/2021. KFrazier"]
["Anand C Reddy, MD","1780892760","81-3411343","TX","","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","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","TX","PE - Permian Basin Kidney Center Inc","Caprock (CapStar)","Participating","Enrollment Complete","2019-09-01","1780892760","","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"]
["Anand C Reddy, MD","1780892760","81-3411343","TX","","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","TX","PE - Permian Basin Kidney Center Inc","United Health Care","Participating","Enrollment Complete",43586,"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","TX","","United Health Care","Participating","Enrollment Complete",43586,"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","TX","PE - Permian Basin Kidney Center Inc","Medicare","Participating","Enrollment Complete","2019-05-01","791813","791814","2020-05-01","05/01/2020 - Rec'd this information from the providers staff - Stacey Hudak"]
["Anand C Reddy, MD","1780892760","81-3411343","TX","","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"]
["Melissa D Alworth, DO","1942454525","75-2656723","TX","","Wellcare","In Process","Application Submitted","","","","2024-08-15","Application submitted through delegated roster. PA."]
["Melissa D Alworth, DO","1942454525","75-2656723","TX","","USA PPO","In Process","Application Submitted","","","","2024-08-15","Application submitted through delegated roster. PA."]
["Melissa D Alworth, DO","1942454525","75-2656723","TX","PE - Premier Family Care, Inc","CAQH","Provider Load","CAQH Reattested","2024-08-12","","","2024-08-12","08/12/2024 CAQH Reattested updated specialty wthompson"]
["Melissa D Alworth, DO","1942454525","75-2656723","TX","","HealthSmart PPO","In Process","Application Submitted","","","","2024-08-19","Submitted via delegated roster on 8/15/2024. FC"]
["Melissa D Alworth, DO","1942454525","75-2656723","TX","","PPHP","In Process","Payor Follow Up","","","","2024-08-29","Sent email to payor requesting status. PA."]
["Melissa D Alworth, DO","1942454525","75-2656723","TX","","PPHP","In Process","Payor Follow Up","","","","2024-08-29","Sent email to payor requesting status. PA."]
["Melissa D Alworth, DO","1942454525","75-2656723","TX","","Superior","In Process","Application Submitted","","","","2024-08-15","Application submitted through delegated roster. PA."]
["Melissa D Alworth, DO","1942454525","75-2656723","TX","","Amerigroup","In Process","Application Submitted","","","","2024-08-19","Submitted via delegated roster on 8/15/2024. FC"]
["Melissa D Alworth, DO","1942454525","75-2656723","TX","PE - Premier Family Care, Inc","TriCare Standard","Pending Other Enrollment","Pending Other Enrollment","","","","2024-08-23","group app still pending to have this location added to the record. MS"]
["Melissa D Alworth, DO","1942454525","75-2656723","TX","","TriCare Standard","Pending Other Enrollment","Pending Other Enrollment","","","","2024-08-23","group app still pending to have this location added to the record. MS"]
["Melissa D Alworth, DO","1942454525","75-2656723","TX","PE - Premier Family Care, Inc","Humana","In Process","Payor Follow Up","","","","2024-08-27","Received confirmation of receipt from payor: \"We are in receipt of your request. Your update has been routed to the coordinator that manages this agreement.You will need to allow anywhere from 45-60 days for a task to be submitted to update our Humana systems.Once the task has been submitted the coordinator will reach out to you with a transmittal # and advise of the turnaround time for completion of your task. If you have not received your transmittal # in 60 days, you can reach out  to the coordinator directly to check the status (Erica Lee ELee22@humana.com). Please do not send a duplicate inquiry to our department mailbox or a request to check the status.\" PA."]
["Melissa D Alworth, DO","1942454525","75-2656723","TX","","Wellmed","In Process","Application Submitted","","","","2024-08-15","Application submitted through delegated roster. PA."]
["Melissa D Alworth, DO","1942454525","75-2656723","TX","","IMS","In Process","Application Submitted","","","","2024-08-19","Submitted via delegated roster on 8/15/2024. FC"]
["Melissa D Alworth, DO","1942454525","75-2656723","TX","","IMS","In Process","Application Submitted","","","","2024-08-19","Submitted via delegated roster on 8/15/2024. FC"]
["Melissa D Alworth, DO","1942454525","75-2656723","TX","PE - Premier Family Care, Inc","Ambetter","In Process","Application Submitted","","","","2024-08-15","Application submitted through delegated roster. PA."]
["Melissa D Alworth, DO","1942454525","75-2656723","TX","","Medicare","In Process","Payor Follow Up","","","","2024-09-01","Still in process. MS"]
["Melissa D Alworth, DO","1942454525","75-2656723","TX","PE - Premier Family Care, Inc","Multiplan","In Process","Application Submitted","","","","2024-08-19","Submitted via delegated roster on 8/15/2024. FC"]
["Melissa D Alworth, DO","1942454525","75-2656723","TX","","Multiplan","In Process","Application Submitted","","","","2024-08-19","Submitted via delegated roster on 8/15/2024. FC"]
["Melissa D Alworth, DO","1942454525","75-2656723","TX","PE - Premier Family Care, Inc","First Health Coventry","Pending Other Enrollment","Pending Other Enrollment","","","","2024-06-27","Pending Aetna enrollment MS"]
["Chandan Mazumder, MD","1093928913","83-0358685","TX","PE - Midland Community Healthcare Services","Amerigroup","Participating","Enrollment Complete","2020-02-12","","","2021-12-02","12/2/2021 Per Amerigroup roster received Joe Rodriguez for MCHS TIN 83-0358685 provider is PAR under group TIN/location effective 2/12/2020.   DCannon"]
["Chandan Mazumder, MD","1093928913","83-0358685","TX","PE - Midland Community Healthcare Services","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","Wellcare","Participating","Enrollment Complete","2021-11-01","","","2022-12-01","12/1/2022 Per roster received from Wellcare provider is PAR and linked to group TIN/location effective 11/1/2021.  DCannon"]
["Chandan Mazumder, MD","1093928913","83-0358685","TX","PE - Midland Community Healthcare Services","Wellmed","Participating","Enrollment Complete","2022-01-01","","","2023-03-23","3/23/2023 Rcvd roster from UHC w/ all Wellmed participating providers.  Provider is PAR effective 1/1/2022.  DCannon"]
["Chandan Mazumder, MD","1093928913","83-0358685","TX","PE - Midland Community Healthcare Services","Wellmed","Participating","Enrollment Complete",44562,"","","2023-03-23","3/23/2023 Rcvd roster from UHC w/ all Wellmed participating providers.  Provider is PAR effective 1/1/2022.  DCannon"]
["Chandan Mazumder, MD","1093928913","83-0358685","TX","PE - Midland Community Healthcare Services","Wellmed","Participating","Enrollment Complete",44562,"","","2023-03-23","3/23/2023 Rcvd roster from UHC w/ all Wellmed participating providers.  Provider is PAR effective 1/1/2022.  DCannon"]
["Chandan Mazumder, MD","1093928913","83-0358685","TX","PE - Midland Community Healthcare Services","Ambetter","Participating","Enrollment Complete",44652,"","","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","Ambetter","Participating","Enrollment Complete",44652,"","","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","TriCare Standard","Participating","Enrollment Complete",44140,"","","2021-03-31","3/31/2021 Confirmed provider certified via Humana-Military portal effective 11/05/2020.  DCannon"]
["Chandan Mazumder, MD","1093928913","83-0358685","TX","PE - Midland Community Healthcare Services","Scott&White (First Care)","Participating","Enrollment Complete",44102,"","","2021-01-29","1/29/2021 - Rcvd roster from Scott&White (First Care) confirming participation of provider with TIN and location effective dates.  DCannon"]
["Chandan Mazumder, MD","1093928913","83-0358685","TX","PE - Midland Community Healthcare Services","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","Caprock (CapStar)","Participating","Enrollment Complete",44348,"","","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"]
["Chandan Mazumder, MD","1093928913","83-0358685","TX","PE - Midland Community Healthcare Services","United Health Care","Participating","Enrollment Complete","2020-07-29","1093928913","","2020-08-06","8/6/2020 - Rec'd email from the payer stating \"Good news! We’ve completed the provider/group updates you requested on Jul 29, 2020 9:56:56 AM. Your request was assigned reference number PR-5410028 .\" - Stacey Hudak"]
["Chandan Mazumder, MD","1093928913","83-0358685","TX","PE - Midland Community Healthcare Services","Amerigroup","Participating","Enrollment Complete","2020-02-12","","","2021-08-26","8/26/2021 Rcvd full roster from Joe Rodriguez at Amerigroup listing provider as PAR w/ group TIN and location effective 2/12/2020.  DCannon"]
["Chandan Mazumder, MD","1093928913","83-0358685","TX","PE - Midland Community Healthcare Services","Omni PPO","Participating","Enrollment Complete","2020-08-01","","","2020-08-25","Confirmed provider is participating at this location as of 8/1/2020. Kimberly Frazier"]
["Chandan Mazumder, MD","1093928913","83-0358685","TX","PE - Midland Community Healthcare Services","United Health Care","Participating","Enrollment Complete","2020-07-29","1093928913","","2020-08-06","8/6/2020 - Rec'd email from the payer stating \"Good news! We’ve completed the provider/group updates you requested on Jul 29, 2020 9:56:56 AM. Your request was assigned reference number PR-5410028 .\" - Stacey Hudak"]
["Chandan Mazumder, MD","1093928913","83-0358685","TX","PE - Midland Community Healthcare Services","Superior","Participating","Enrollment Complete","2023-12-01","","","2023-12-08","12/8/2023 Rcvd roster from Superior Health Plan confirming provider is PAR and linked to group TIN/location effective 12/1/2023.  DCannon"]
["Chandan Mazumder, MD","1093928913","83-0358685","TX","PE - Midland Community Healthcare Services","Cigna","Participating","Enrollment Complete","2020-09-01","4341928","","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"]
["Chandan Mazumder, MD","1093928913","83-0358685","TX","PE - Midland Community Healthcare Services","HealthSmart PPO","Participating","Enrollment Complete","2012-10-29","","","2021-04-11","4/11/2021 Rcvd email from HealthSmart <mdipsupport@healthsmart.com> confirming participation of provider under TIN and location effective 10/29/2012.  DCannon"]
["Chandan Mazumder, MD","1093928913","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"]
["Chandan Mazumder, MD","1093928913","83-0358685","TX","PE - Midland Community Healthcare Services","Superior","Participating","Enrollment Complete",45261,"1093928913","","2023-12-08","12/8/2023 Rcvd roster from Superior Health Plan confirming provider is PAR and linked to group TIN/location effective 12/1/2023.  DCannon"]
["Chandan Mazumder, MD","1093928913","83-0358685","TX","PE - Midland Community Healthcare Services","Multiplan","Participating","Enrollment Complete",43873,"","","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"]
["Marcy L Askins, APRN-FNP-BC","1831441385","27-4061759","TX","PE - Permian Cardiology Inc.","HealthSmart PPO","Participating","Enrollment Complete","2023-05-08","","","2023-12-15","12/15/2023 Per email rcvd from Aleece Moerbe at Healthsmart provider is PAR and linked to group TIN/location effective 5/8/2023.  DCannon"]
["Marcy L Askins, APRN-FNP-BC","1831441385","27-4061759","TX","PE - Permian Cardiology Inc.","Aetna","Participating","Enrollment Complete",45054,"4810470","","2023-09-19","09.19.2023 S/W Abby of Aetna @ 1-800-353-1232. Per rep, provider is in network with Aetna for the state of TX and participating under the group and TIN# effective 05/08/2023. PIN: 4810470. Physical location is on file. No next recredentialing date available. Payer# 60054. Call ref# 6163772542. - Willie Ravas"]
["Marcy L Askins, APRN-FNP-BC","1831441385","27-4061759","TX","PE - Permian Cardiology Inc.","Scott&White (First Care)","Participating","Enrollment Complete",45054,"","","2023-08-17","8/17/2023 Received email from Scott & White HPDELEGATION@BSWHealth.org that provider load from May has been completed and provider is PAR effective 5/8/2023.  DCannon"]
["Marcy L Askins, APRN-FNP-BC","1831441385","27-4061759","TX","PE - Permian Cardiology Inc.","First Health Coventry","Participating","Enrollment Complete",45047," 2868832","","2023-10-19","10.17.2023 S/W Bridgette of First Health @ 800-226-5116. Per rep, provider is showing as participating and link under the Group and TIN with an Effective date 05/01/2023. Provider ID 2868832. Service location is on file. Call ref#:788770.-Danico Gabriel Melendres"]
["Marcy L Askins, APRN-FNP-BC","1831441385","27-4061759","TX","PE - Permian Cardiology Inc.","Galaxy Health","Participating","Enrollment Complete",45054,"","","2023-07-20","7/20/2023 Per email received from Galaxy May delegated roster has been processed and provider is PAR and linked to group effective 5/8/2023.  DCannon"]
["Khadijah A. Abdurrazaq, MD","1336304120","83-0358685","TX","PE - Midland Community Healthcare Services","First Health Coventry","Participating","Enrollment Complete",44348,"","","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"]
["Khadijah A. Abdurrazaq, MD","1336304120","83-0358685","TX","PE - Midland Community Healthcare Services","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"]
["Khadijah A. Abdurrazaq, MD","1336304120","83-0358685","TX","PE - Midland Community Healthcare Services","Cigna","Participating","Enrollment Complete",41808,"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",44348,"","","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","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"]
["Khadijah A. Abdurrazaq, MD","1336304120","83-0358685","TX","PE - Midland Community Healthcare Services","United Health Care","Participating","Enrollment Complete","2019-12-01","1336304120","","2020-08-31","08/31/2020 - moved to completed status after reviewing follow up complete note - Stacey Hduak"]
["Khadijah A. Abdurrazaq, MD","1336304120","83-0358685","TX","PE - Midland Community Healthcare Services","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",44652,"","","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","United Health Care","Participating","Enrollment Complete","2019-12-01","1336304120","","2020-10-02","10/02/2020 - moved to completed status after reviewing follow up complete note - Stacey Hudak"]
["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","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",44091,"","","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","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","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","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",42605,"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","Humana","Participating","Enrollment Complete","2020-01-01","1306167309","","2020-07-15","7/15/2020 - 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"]
["Maung K Hlaing, MD","1306167309","47-5554737","TX","PE - Midland Inpatient Medical Association","Galaxy Health","Participating","Enrollment Complete","2020-04-15","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","Triwest VA","Enrollment Stopped","Enrollment Stopped","","","","","Practice is hospital-based; not eligible for TriWest VA enrollment"]
["Maung K Hlaing, MD","1306167309","47-5554737","TX","PE - Midland Inpatient Medical Association","USA PPO","Participating","Enrollment Complete",44222,"","","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"]
["Maung K Hlaing, MD","1306167309","47-5554737","TX","PE - Midland Inpatient Medical Association","United Health Care","Participating","Enrollment Complete","2020-09-03","1306167309","","2020-09-18","09/18/2020 - Rec'd email from the payer stating \"Good news! We’ve completed the provider/group updates you requested on Sep 3, 2020 12:32:40 PM. Your request was assigned reference number PR-5476170 .\" - Stacey Hudak"]
["Leo D Villaroman, MD","1073796330","26-3413331","TX","PE - Leo Villaroman, MD, PA","Amerigroup","In Process","Payor Follow Up","","","","2024-08-22","Emailed Cassandra Dunagon requesting network status. FC"]
["Leo D Villaroman, MD","1073796330","26-3413331","TX","","USA PPO","Participating","Enrollment Complete",44935,"","","2023-03-24","3/24/2023 In following up with USAMCO (800-872-3860) I was told that you can confirm participating via the USA MCO website  https://providersearch.usamco.com/hwprovsearch.  Provider is PAR and linked to location/TIN effective 1/9/2023.  DCannon"]
["Leo D Villaroman, MD","1073796330","26-3413331","TX","PE - Leo Villaroman, MD, PA","IMS","Participating","Enrollment Complete",44935,"","","2023-01-31","1/31/2023 Per email received from German Aviles at IMS/OMNI monthly delegation roster provider load for December has been completed.  Provider is PAR and linked to group TIN effective 1/9/2023.   DCannon"]
["Leo D Villaroman, MD","1073796330","26-3413331","TX","","IMS","Participating","Enrollment Complete",44935,"","","2023-01-31","1/31/2023 Per email received from German Aviles at IMS/OMNI monthly delegation roster provider load for December has been completed.  Provider is PAR and linked to group TIN effective 1/9/2023.   DCannon"]
["Leo D Villaroman, MD","1073796330","26-3413331","TX","","HealthSmart PPO","Participating","Enrollment Complete",44935,"","","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","Cigna","Participating","Enrollment Complete","2023-09-19","","","2023-10-12","Contract has been signed and executed. MS"]
["Leo D Villaroman, MD","1073796330","26-3413331","TX","","Scott&White (First Care)","Participating","Enrollment Complete",45245,"","","2024-01-11","1/11/2024 Per email from Scott & White November roster has been completed.  Provider is PAR and linked to group TIN/location effective 11/15/2023.  DCannon"]
["Leo D Villaroman, MD","1073796330","26-3413331","TX","PE - Leo Villaroman, MD, PA","Galaxy Health","Participating","Enrollment Complete",44935,"","","2023-03-09","3/9/2023 Per email rcvd from Karen Avalos at Galaxy, January monthly roster has been completed.  Provider is PAR and linked to group effective 1/9/2023.  DCannon"]
["Leo D Villaroman, MD","1073796330","26-3413331","TX","","Caprock (CapStar)","Participating","Enrollment Complete",44935,"","","2023-01-20","1/20/2023 Rcvd email  confirmation from Caprock that provider is PAR and linked to group TIN/locations effective 1/9/2023.  DCannon"]
["Leo D Villaroman, MD","1073796330","26-3413331","TX","PE - Leo Villaroman, MD, PA","Triwest VA","In House Enrollment","In House Enrollment","","","","2023-01-14",""]
["Leela K Lella, MD","1306162557","27-4061759","TX","PE - Permian Cardiology Inc.","Humana","Participating","Enrollment Complete","2020-01-01","1306162557","","2020-08-31","08/31/2020 - moved to completed status after reviewing follow up complete status - Stacey Hudak"]
["Leela K Lella, MD","1306162557","27-4061759","TX","PE - Permian Cardiology Inc.","Wellcare","Participating","Enrollment Complete","2021-11-01","","","2022-12-01","12/1/2022 Per roster received from Wellcare provider is PAR and linked to group TIN/location effective 11/1/2021.  DCannon"]
["Leela K Lella, MD","1306162557","27-4061759","TX","PE - Permian Cardiology Inc.","Galaxy Health","Participating","Enrollment Complete","2018-10-15","1306162557","","2020-07-17","07/17/2020 Received a spreadsheet from the payer stating this provider is effective as of 10/15/2018. – Archie Candiasan"]
["Leela K Lella, MD","1306162557","27-4061759","TX","PE - Permian Cardiology Inc.","IMS","Participating","Enrollment Complete","2018-10-15","1306162557","","2020-06-22","06/22/2020- Rec'd email from the payer confirming this provider is PAR with this group/service location - Stacey Hudak"]
["Leela K Lella, MD","1306162557","27-4061759","TX","PE - Permian Cardiology Inc.","Omni PPO","Participating","Enrollment Complete","2018-10-15","1306162557","","2020-06-29","06/29/2020 - confirmed that IMS is effective, therefore this is also participating - Stacey Hudak"]
["Leela K Lella, MD","1306162557","27-4061759","TX","PE - Permian Cardiology Inc.","Scott&White (First Care)","Participating","Enrollment Complete",43675,"1306162557","","2020-08-19","8/19/2020 - Rec'd spreadsheet from the payer stating this provider is affiliated with the PRIMED DELEGATED AGREEMENT under this TIN/Service location. This provider is networked with: \nFirstCare MyChoice PPO\nCHIP\nFirstCare Select Benefit Network\nHMO Enhanced Benefit Network\nMedicaid (FC)\nMedicare (FC)\nPPO Limited Benefit Network\n- Stacey Hudak"]
["Asif AK Ansari, MD","1528299872","81-3411343","TX","PE - Permian Basin Kidney Center Inc","HealthSmart PPO","Participating","Enrollment Complete",43740,"10-2-2019","","2020-07-21","07/21/2020 - Rec'd email from the payer stating this provider is EFF with this TIN/service location under the WEST TEXAS PHYSICIANS ALLIANCE MDDO\ndelegation - Stacey Hudak"]
["Asif AK Ansari, MD","1528299872","81-3411343","tx","PE - Permian Basin Kidney Center Inc","HealthSmart PPO","Participating","Enrollment Complete","2019-10-02","10-2-2019","","2020-07-21","07/21/2020 - Rec'd email from the payer stating this provider is EFF with this TIN/service location under the WEST TEXAS PHYSICIANS ALLIANCE MDDO\ndelegation - Stacey Hudak"]
["Asif AK Ansari, MD","1528299872","81-3411343","TX","","Amerigroup","Participating","Enrollment Complete","2020-03-18","07416220","","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"]
["Asif AK Ansari, MD","1528299872","81-3411343","TX","","Superior","Participating","Enrollment Complete","2020-04-13","","","2020-10-02","10/2/2020 - Rec'd response from the payer stating \"•\tProviders marked as \" Delegated Contract With SHP” have an active delegated contract with another entity by the same NPI & TIN through Superior Health Plan. Please note that these providers will not be accepted as part of your Delegated Opt-in. \" \nWe cannot add this provider to the PriMed delegation, as they are already with another delegated group- Stacey Hudak"]
["Asif AK Ansari, MD","1528299872","81-3411343","TX","PE - Permian Basin Kidney Center Inc","Boon Chapman","Participating","Enrollment Complete",43922,"1528299872","","2020-10-05","Enrollment thru PHCS"]
["Asif AK Ansari, MD","1528299872","81-3411343","TX","","United Health Care","Participating","Enrollment Complete","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","Amerigroup","Participating","Enrollment Complete","2020-03-18","","","2023-08-31","8/31/2023 Per Amerigroup portal provider has been added to new location.  Provider effective date 3/18/2020.  DCannon"]
["Asif AK Ansari, MD","1528299872","81-3411343","TX","","TriCare Standard","Participating","Enrollment Complete","2019-08-28","1528299872","","2020-09-04","09/04/2020 - Rec'd access to this TIN and was able to confirm through the payer site that this provider/service location are effective and NON Networked as of 8-28-2019 - Stacey Hudak"]
["Asif AK Ansari, MD","1528299872","81-3411343","TX","","Humana","Participating","Enrollment Complete","2019-06-04","1528299872","","2020-08-31","08/31/2020 - moved to completed status after reviewing follow up complete note - Stacey Hudak"]
["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","","Superior","Participating","Enrollment Complete","2023-08-01","","","2023-08-15","8/15/2023 Rcvd confirmation email from Superior that July delegation roster has been processed and provider has been loaded to delegation roster and PAR w/ group/location effective 8/1/2023.  DCannon"]
["Asif AK Ansari, MD","1528299872","81-3411343","TX","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","PE - Permian Basin Kidney Center Inc","Wellmed","Participating","Enrollment Complete","2023-03-24","","","2023-03-23","3/23/2023 Rcvd roster from UHC w/ all Wellmed participating providers.  Provider is PAR effective 3/24/2023.  DCannon"]
["Asif AK Ansari, MD","1528299872","81-3411343","TX","PE - Permian Basin Kidney Center Inc","Wellmed","Participating","Enrollment Complete","2023-03-24","","","2023-03-23","3/23/2023 Rcvd roster from UHC w/ all Wellmed participating providers.  Provider is PAR effective 3/24/2023.  DCannon"]
["Asif AK Ansari, MD","1528299872","81-3411343","TX","PE - Permian Basin Kidney Center Inc","Ambetter","Participating","Enrollment Complete","2023-08-01","","","2023-08-15","8/15/2023 Rcvd confirmation email from Superior that July delegation roster has been processed and provider has been loaded to delegation roster and PAR w/ group/location effective 8/1/2023.  DCannon"]
["Asif AK Ansari, MD","1528299872","81-3411343","TX","PE - Permian Basin Kidney Center Inc","Scott&White (First Care)","Participating","Enrollment Complete","2020-04-03","","","2021-03-29","3/29/2021 - Rcvd roster from Scott&White (First Care) confirming participation of provider with TIN and location effective 4/3/2020.  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","Caprock (CapStar)","Participating","Enrollment Complete","2019-09-01","1528299872","","2020-09-14","09/14/2020 - 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"]
["Asif AK Ansari, MD","1528299872","81-3411343","TX","","Rail Road Medicare","Participating","Enrollment Complete","2019-05-01","P02323200","DZ2789","2020-05-04","05/04/2020 - verified through portal and moved to completed status - Stacey Hudak"]
["Alaaedin Alhomosh, MD","1063709913","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"]
["Alaaedin Alhomosh, MD","1063709913","47-5554737","TX","PE - Midland Inpatient Medical Association","Rail Road Medicare","Participating","Enrollment Complete","2016-11-27","P01782054","DW7662","2020-12-31","11/31/2020 Confirmed provider is already participating and assigned RR PTAN P01782054 effective 11/27/2016. KFrazier"]
["Alaaedin Alhomosh, MD","1063709913","47-5554737","TX","PE - Midland Inpatient Medical Association","IMS","Participating","Enrollment Complete","2021-01-07","","","2021-04-01","4/1/2021 Rcvd confirmation email from payor that providers have been loaded according to the monthly delegation roster.  DCannon"]
["Alaaedin Alhomosh, MD","1063709913","47-5554737","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 01/07/2021.  DCannon"]
["Alaaedin Alhomosh, MD","1063709913","47-5554737","TX","PE - Midland Inpatient Medical Association","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"]
["Samuel L Baumguardner, PA","1295109510","75-2656723","TX","PE - Premier Family Care, Inc","Aetna","Participating","Enrollment Complete","2019-09-01","1295109510","","2020-06-09","06/09/2020 - SW Keith of Aetna @ 8003531232. Provider NPI# is on file and in-network participating under the group and TIN# effective 9/1/2019. Location is on file. Call ref# 5309861800. - Stacey Hudak"]
["Samuel L Baumguardner, PA","1295109510","75-2656723","TX","PE - Premier Family Care, Inc","Omni PPO","Participating","Enrollment Complete","2019-09-01","1295109510","","2020-07-27","IMS complete"]
["Samuel L Baumguardner, PA","1295109510","75-2656723","TX","PE - Premier Family Care, Inc","Ambetter","Participating","Enrollment Complete","2022-06-01","","","2022-06-13","6/13/2022 Per roster received from Superior provider is PAR and linked to group delegation roster effective 6/1/2022."]
["Samuel L Baumguardner, PA","1295109510","75-2656723","TX","PE - Premier Family Care, Inc","TriCare Standard","Participating","Enrollment Complete","2018-01-11","","","2020-10-23","10/23/2020 Provider is participating with TriCare Prime; therefore, remains certified as a non-network effective 1/11/2018. Kimberly Frazier"]
["Samuel L Baumguardner, PA","1295109510","75-2656723","TX","PE - Premier Family Care, Inc","Wellmed","Participating","Enrollment Complete","2022-01-01","","","2023-03-23","3/23/2023 Rcvd roster from UHC w/ all Wellmed participating providers.  Provider is PAR effective 1/1/2022.  DCannon"]
["Samuel L Baumguardner, PA","1295109510","75-2656723","TX","PE - Premier Family Care, Inc","Medicaid","Participating","Enrollment Complete","","361608801","079837301","2020-08-10","08/10/2020 -  Rec'd notification that the recred has been approved for this provider - Stacey Hudak"]
["Samuel L Baumguardner, PA","1295109510","75-2656723","TX","PE - Premier Family Care, Inc","Humana","Participating","Enrollment Complete","2020-01-01","1295109510","","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"]
["Samuel L Baumguardner, PA","1295109510","75-2656723","TX","PE - Premier Family Care, Inc","Cigna","Participating","Enrollment Complete",44342,"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","TX","PE - Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete",43111,"","","2020-10-08","10/8/2020 Confirmed via Self-Service Portal provider is participating under Tax ID and location. Kimberly Frazier"]
["Samuel L Baumguardner, PA","1295109510","75-2656723","TX","PE - Premier Family Care, Inc","Superior","Participating","Enrollment Complete",42736,"1295109510","","2020-07-14","07/14/2020 - Rec'd email from the payer stating this provider is EFF under PRIMED DELEGATED agreement - Stacey Hudak"]
["Samuel L Baumguardner, PA","1295109510","75-2656723","TX","PE - Premier Family Care, Inc","TriCare Standard","Participating","Enrollment Complete","2024-02-13","","","2024-07-02","Provider is linked to this location eff 2/13/24. MS"]
["Samuel L Baumguardner, PA","1295109510","75-2656723","TX","PE - Premier Family Care, Inc","Aetna","Participating","Enrollment Complete","2019-03-01","1295109510","","2020-03-24","3/24/2020--S/W Cris of Aetna @ 18003531232, provider NPI# is on file for the provider and is participating effective 03/01/2019 under the group and TIN#. Physical location is on file. DIRECT CONTRACT-- Call ref# 5192774121.\ntisha rader"]
["Samuel L Baumguardner, PA","1295109510","75-2656723","TX","PE - Premier Family Care, Inc","Wellcare","Participating","Enrollment Complete","2021-11-01","","","","11/15/2022 Per roster received from Wellcare provider is PAR and linked to group TIN/location effective 11/1/2021.  DCannon"]
["Samuel L Baumguardner, PA","1295109510","75-2656723","TX","PE - Premier Family Care, Inc","Wellcare","Participating","Enrollment Complete","2021-11-01","","","","11/15/2022 Per roster received from Wellcare provider is PAR and linked to group TIN/location effective 11/1/2021.  DCannon"]
["Samuel L Baumguardner, PA","1295109510","75-2656723","TX","PE - Premier Family Care, 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","CAQH","Participating","CAQH Reattested","2024-07-10","12803191","","2024-07-10","07/10/2024 CAQH Reattested all locations current and all expirables up to date wthompson"]
["Jessie J Dickens, MD","1215254156","46-3131679","TX","PE - Midland Texas Orthopedic Group Inc","Alliance WC","Participating","Enrollment Complete","2017-04-28","","","2024-07-24","Approval ltr rcvd. Effective 04/28/2017. Jen Videan"]
["Jessie J Dickens, MD","1215254156","46-3131679","TX","PE - Midland Texas Orthopedic Group Inc","Cigna","Participating","Enrollment Complete","2016-12-14","1215254156","","2020-02-20","02/20/2020 - Had the follow up team call Cigna to verify provider enrollment with this TIN. They were advised that this provider is EFF as of 12-14-2016 under a DIRECT CONTRACT at this service location. - Stacey Hudak"]
["Jessie J Dickens, MD","1215254156","46-3131679","TX","PE - Midland Texas Orthopedic Group Inc","Corvel Healthcare Corp.","Participating","Enrollment Complete",44411,"1215254156","","2024-05-07","Provider active with Corvel. Jen Videan"]
["Jessie J Dickens, MD","1215254156","46-3131679","TX","PE - Midland Texas Orthopedic Group Inc","Texas Mutual","Participating","Enrollment Complete",43838,"","","2021-01-23","11/25/2020-Confirmed provider is participating under group Tax ID and practice location. Rafael Calixtro"]
["Jessie J Dickens, MD","1215254156","46-3131679","TX","PE - Midland Texas Orthopedic Group Inc","HealthSmart PPO","Participating","Re-Credentialing","2019-05-10","1215254156","","2024-04-19","4/19/2024- Submitted recred status via delegated monthly roster on 4/15/2024. FC"]
["Jessie J Dickens, MD","1215254156","46-3131679","TX","PE - Midland Texas Orthopedic Group Inc","USA PPO","Participating","Enrollment Complete","2016-10-26","1215254156","463131679","2020-08-21","Confirmed provider is participating with PPO and H&W networks (list of networks attached). Kimberly Frazier"]
["Jessie J Dickens, MD","1215254156","46-3131679","TX","PE - Midland Texas Orthopedic Group Inc","Sedgwick","Participating","Enrollment Complete","2024-06-19","1215254156","","2024-06-28","Approval ltr rcvd. Provider effective 06/19/2024. Jen Videan"]
["Adenike T Esho, MD","1467745240","75-2656723","TX","PE - Premier Family Care, 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","","Amerigroup","Participating","Enrollment Complete","2019-08-30","1467745240","","2020-02-11","2/11/2020 – Received Roster from Amerigroup and provider is now PAR- Tisha Rader\n\n3/18/2020 - Also rec'd email confirmation from Multiplan/Texas True Choice confirming that this EFF information is true - Stacey Hudak"]
["Adenike T Esho, MD","1467745240","75-2656723","TX","","Amerigroup","Participating","Application Resubmitted","2019-08-30","1467745240","","2024-07-18","Submitted reapplication via delegated roster on 7/15/2024. FC"]
["Adenike T Esho, MD","1467745240","75-2656723","TX","PE - Premier Family Care, Inc","HealthSmart PPO","Participating","Enrollment Complete","2019-06-12","13535050","","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","1467745240","75-2656723","TX","","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, Inc","First Health Coventry","Participating","Enrollment Complete","2019-08-01","2739018","","2020-03-24","3/24/2020-receieved email with roster stating provider PAR 8/1/2019 PID # 2739018\ntisha rader"]
["Adenike T Esho, MD","1467745240","75-2656723","TX","","First Health Coventry","Participating","Enrollment Complete","2019-08-01","2739018","","2020-03-24","3/24/2020-receieved email with roster stating provider PAR 8/1/2019 PID # 2739018\ntisha rader"]
["Adenike T Esho, MD","1467745240","75-2656723","TX","PE - Premier Family Care, Inc","Multiplan","Participating","Application Resubmitted","2019-08-14","1467745240","","2024-07-18","Submitted reapplication via delegated roster on 7/15/2024. FC"]
["Adenike T Esho, MD","1467745240","75-2656723","TX","","Ambetter","Participating","Enrollment Complete","2022-06-01","","","2022-06-13","6/13/2022 Per roster received from Superior provider is PAR and linked to group delegation roster effective 6/1/2022."]
["Adenike T Esho, MD","1467745240","75-2656723","TX","","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, 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"]
["Adenike T Esho, MD","1467745240","75-2656723","TX","","Cigna","Participating","Enrollment Complete","2019-08-28","1467745240","","2020-02-20","02/20/2020 - Rec'd verification from the payer that this provider is EFF 2-20-2020 and linked to this service location under a DIRECT CONTRACT with this payer - Stacey Hudak"]
["Adenike T Esho, MD","1467745240","75-2656723","TX","PE - Premier Family Care, 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","","Triwest VA","In House 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.\""]
["Adenike T Esho, MD","1467745240","75-2656723","TX","PE - Premier Family Care, Inc","CAQH","Active","CAQH Reattested","2024-08-28","13510925","","2024-08-28","08/28/2024 CAQH Reattested updated and uploaded COI wthompson"]
["Adenike T Esho, MD","1467745240","75-2656723","TX","","Tricare Prime","Participating","Enrollment Complete","2020-01-01","","","2024-02-28","Re-Cred has been completed. eff 1/1/2020. MS"]
["Christopher Ryan Vela, PA","1366728909","27-4061759","TX","PE - Permian Cardiology Inc.","CAQH","Participating","CAQH Reattested","2024-06-06","","","2024-06-06","06/06/2024 CAQH Reattested updated and uploaded board and DEA wthompson"]
["Christopher Ryan Vela, PA","1366728909","27-4061759","TX","PE - Permian Cardiology Inc.","Humana","Participating","Enrollment Complete","2023-05-30","","","2023-09-15","9/15/2023 Per email received from Humana provider is PAR and linked to group TIN/locations effective 5/30/2023.  DCannon"]
["Christopher Ryan Vela, PA","1366728909","27-4061759","TX","PE - Permian Cardiology Inc.","Boon Chapman","Participating","Enrollment Complete","2023-02-01","","","2023-07-25","7/25/2023 Rcvd email from Jessica Bess at Multiplan with a full roster and provider is PAR w/ group effective 2/1/2023.  DCannon"]
["Christopher Ryan Vela, PA","1366728909","27-4061759","TX","PE - Permian Cardiology Inc.","IMS","Participating","Application Resubmitted","2023-05-30","","","2024-06-17","Submitted reapplication via delegated roster on 6/14/2024. FC"]
["Christopher Ryan Vela, PA","1366728909","27-4061759","TX","PE - Permian Cardiology Inc.","Omni PPO","Participating","Application Resubmitted",45076,"","","2024-06-17","Submitted reapplication via delegated roster on 6/14/2024. FC"]
["Haritha Bellam, MD","1770883191","75-2656723","TX","PE - Premier Family Care, 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","","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","","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","1770883191","75-2656723","TX","PE - Premier Family Care, Inc","Humana","Participating","Enrollment Complete","2020-01-01","1770883191","","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","1770883191","75-2656723","TX","","TriCare Standard","Participating","Enrollment Complete","2018-04-14","","","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","1770883191","75-2656723","TX","PE - Premier Family Care, Inc","Wellmed","Participating","Enrollment Complete",44562,"","","2023-03-23","3/23/2023 Rcvd roster from UHC w/ all Wellmed participating providers.  Provider is PAR effective 1/1/2022.  DCannon"]
["Haritha Bellam, MD","1770883191","75-2656723","TX","","Ambetter","Participating","Enrollment Complete",44713,"","","2022-06-13","6/13/2022 Per roster received from Superior provider is PAR and linked to group delegation roster effective 6/1/2022."]
["Haritha Bellam, MD","1770883191","75-2656723","TX","PE - Premier Family Care, Inc","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","","Medicaid","Participating","Enrollment Complete","","1770883191","","2024-06-20","Revalidation approval letter rcvd. Jen Videan"]
["Haritha Bellam, MD","1770883191","75-2656723","TX","PE - Premier Family Care, Inc","Galaxy Health","Participating","Enrollment Complete","2015-11-19","1770883191","","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","1770883191","75-2656723","TX","PE - Premier Family Care, Inc","Aetna","Participating","Enrollment Complete","2015-07-01","1770883191","","2020-02-03","02/03/2020 - Confirmed with the payer that this provider is EFF as of 7-1-2015 under a DIRECT CONTRACT. No reval information was provided - Stacey Hudak"]
["Haritha Bellam, MD","1770883191","75-2656723","TX","","Medicare","Participating","Enrollment Complete","2015-05-11","415412YPVD","0008AH","2020-01-29","01/29/2020 - confirmed EFF through PECOS group enrollment - Stacey Hudak"]
["Haritha Bellam, MD","1770883191","75-2656723","TX","PE - Premier Family Care, Inc","United Health Care","Participating","Enrollment Complete",43831,"1770883191","","2020-08-31","08/31/2020 - moved to completed status after reviewing follow up completed note - Stacey Hudak"]
["Haritha Bellam, MD","1770883191","75-2656723","TX","","United Health Care","Participating","Enrollment Complete",43831,"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","TX","PE - Premier Family Care, Inc","Medicaid","Participating","Enrollment Complete","","384181902","079837301","2024-02-21","Rcvd revalidation approval letter. Jen Videan"]
["Michael J Hester, APRN-AGACNP","1275044422","75-2656723","TX","PE - Premier Family Care, Inc","Wellmed","Participating","Enrollment Complete","2022-01-01","","","2023-03-23","3/23/2023 Rcvd roster from UHC w/ all Wellmed participating providers.  Provider is PAR effective 1/1/2022.  DCannon"]
["Michael J Hester, APRN-AGACNP","1275044422","75-2656723","TX","PE - Premier Family Care, Inc","Superior","Participating","Enrollment Complete","2018-09-01","1275044422","","2020-07-14","07/14/2020 - Rec'd email from the payer stating this provider is EFF under PRIMED DELEGATED agreement - Stacey Hudak"]
["Michael J Hester, APRN-AGACNP","1275044422","75-2656723","TX","PE - Premier Family Care, Inc","Rail Road Medicare","Participating","Enrollment Complete","2018-04-01","P02124304","","2020-03-25","3/25/2020--3/25/2020-Per online check, provider is now PAR effective 04/01/2018 with provider number P02124304. Attached welcome letter to payor line.-Elonah Grace B.Gelig"]
["Michael J Hester, APRN-AGACNP","1275044422","75-2656723","TX","PE - Premier Family Care, 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"]
["Michael J Hester, APRN-AGACNP","1275044422","75-2656723","TX","PE - Premier Family Care, Inc","Scott&White (First Care)","Participating","Enrollment Complete","2020-02-13","1275044422","","2020-10-02","10/02/2020 - moved to completed status after reviewing follow up complete note - Stacey Hudak"]
["Michael J Hester, APRN-AGACNP","1275044422","75-2656723","TX","PE - Premier Family Care, Inc","HealthSmart PPO","Participating","Enrollment Complete",43308,"1275044422","","2020-06-05","06/05/2020 - Rec'd email from the payer stating this provider is EFF - Stacey HUdak"]
["Michael J Hester, APRN-AGACNP","1275044422","75-2656723","TX","PE - Premier Family Care, Inc","Amerigroup","Participating","Enrollment Complete",43305,"1275044422","","2020-02-11","2/11/2020 – Received Roster from Amerigroup and provider is now PAR- ---roster also shows effective date: 1/1/20--Tisha Rader"]
["Michael J Hester, APRN-AGACNP","1275044422","75-2656723","TX","PE - Premier Family Care, Inc","Medicare","Participating","Enrollment Complete","2018-04-01","662202","0008AH","2020-01-29","01/29/2020 - confirmed EFF through PECOS group enrollment - Stacey Hudak"]
["Michael J Hester, APRN-AGACNP","1275044422","75-2656723","TX","PE - Premier Family Care, Inc","Wellcare","Participating","Enrollment Complete","2021-11-01","","","2022-12-01","12/1/2022 Per roster received from Wellcare provider is PAR and linked to group TIN/location effective 11/1/2021.  DCannon"]
["Michael J Hester, APRN-AGACNP","1275044422","75-2656723","TX","PE - Premier Family Care, Inc","HealthSmart PPO","Participating","Enrollment Complete","2018-07-27","1275044422","","2020-06-05","06/05/2020 - Rec'd email from the payer stating this provider is EFF - Stacey Hudak"]
["Michael J Hester, APRN-AGACNP","1275044422","75-2656723","TX","PE - Premier Family Care, Inc","Ambetter","Participating","Enrollment Complete","2022-06-01","","","2022-06-01","6/13/2022 Per roster received from Superior provider is PAR and linked to group delegation roster effective 6/1/2022."]
["Michael J Hester, APRN-AGACNP","1275044422","75-2656723","TX","PE - Premier Family Care, Inc","Amerigroup","Participating","Enrollment Complete",43305,"","","2021-10-21","10/21/2021  Rcvd full roster from Joe Rodriguez at Amerigroup listing provider as PAR w/ group TIN and location effective 7/24/2018.  DCannon"]
["Eliseo Rivera, MD","1013990761","83-0358685","TX","PE - Midland Community Healthcare Services","Aetna","Participating","Enrollment Complete",38534,"","","2020-12-04","12/4/2020 - Rcvd completed PRIMED ROSTER back from the payer. This provider is PAR at this service location eff 9/1/2020.  DCannon"]
["Eliseo Rivera, MD","1013990761","83-0358685","TX","PE - Midland Community Healthcare Services","Scott&White (First Care)","Participating","Enrollment Complete","2021-06-01","","","2021-10-06","10/6/2021 Rcvd confirmaton email from S & W that July delegated roster has been complete and provider is PAR w/ TIN and location effective 6/1/2021.  DCannon"]
["Eliseo Rivera, MD","1013990761","83-0358685","TX","PE - Midland Community Healthcare Services","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","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","Wellmed","Participating","Enrollment Complete","2022-01-01","","","2023-03-23","3/23/2023 Rcvd roster from UHC w/ all Wellmed participating providers.  Provider is PAR effective 1/1/2022.  DCannon"]
["Eliseo Rivera, MD","1013990761","83-0358685","TX","PE - Midland Community Healthcare Services","Wellmed","Participating","Enrollment Complete","2022-01-01","","","2023-03-23","3/23/2023 Rcvd roster from UHC w/ all Wellmed participating providers.  Provider is PAR effective 1/1/2022.  DCannon"]
["Eliseo Rivera, MD","1013990761","83-0358685","TX","PE - Midland Community Healthcare Services","Wellmed","Participating","Enrollment Complete",44562,"","","2023-03-23","3/23/2023 Rcvd roster from UHC w/ all Wellmed participating providers.  Provider is PAR effective 1/1/2022.  DCannon"]
["Eliseo Rivera, MD","1013990761","83-0358685","TX","PE - Midland Community Healthcare Services","TriCare Standard","Participating","Enrollment Complete","2015-07-11","1013990761","","2020-09-24","09/24/2020 - moved to completed status after reviewing follow up complete - stacey Hudak"]
["Eliseo Rivera, MD","1013990761","83-0358685","TX","PE - Midland Community Healthcare Services","Rail Road Medicare","Participating","Enrollment Complete",37970,"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","Cigna","Participating","Enrollment Complete",44348,"6653474","","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 6653474. KFrazier"]
["Eliseo Rivera, MD","1013990761","83-0358685","TX","PE - Midland Community Healthcare Services","Galaxy Health","Participating","Enrollment Complete",43952,"","","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"]
["Eliseo Rivera, MD","1013990761","83-0358685","TX","PE - Midland Community Healthcare Services","Caprock (CapStar)","Participating","Enrollment Complete",44348,"","","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","Humana","Participating","Enrollment Complete",42346,"","","2021-11-18","11/18/2021 Rcvd full roster from Humana listing provider as PAR and linked to group TIN/location effective 12/8/2015.  DCannon"]
["Eliseo Rivera, MD","1013990761","83-0358685","TX","PE - Midland Community Healthcare Services","United Health Care","Participating","Enrollment Complete",42942,"2125916","","2020-07-30","7/30/2020 - moved to completed status after reviewing follow up complete note - Stacey Hudak"]
["Eliseo Rivera, MD","1013990761","83-0358685","TX","PE - Midland Community Healthcare Services","Cigna","Participating","Enrollment Complete",44034,"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","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","HealthSmart PPO","Participating","Enrollment Complete",40575,"1013990761","","2020-06-05",""]
["Eliseo Rivera, MD","1013990761","83-0358685","TX","PE - Midland Community Healthcare Services","First Health Coventry","Participating","Enrollment Complete","2011-09-01","1099473","","2020-03-20","3/20/2020-receieved email with roster stating provider PAR 9/1/2011 PID # 1099473\n-tisha rader"]
["Eliseo Rivera, MD","1013990761","83-0358685","TX","PE - Midland Community Healthcare Services","Wellcare","Participating","Enrollment Complete","2021-11-01","","","2022-12-01","12/1/2022 Per roster received from Wellcare provider is PAR and linked to group TIN/location effective 11/1/2021.  DCannon"]
["Eliseo Rivera, MD","1013990761","83-0358685","TX","PE - Midland Community Healthcare Services","HealthSmart PPO","Participating","Enrollment Complete","2021-06-01","","","2021-08-05","8/5/2021 Per Healthsmart website provider is PAR and loaded under TIN/location effective 6/1/2021.  DCannon"]
["Karen Ward, APRN-NP, 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, APRN-NP, RNFA","1790831493","47-5554737","TX","PE - Midland Inpatient Medical Association","Cigna","Participating","Enrollment Complete",44322,"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, APRN-NP, RNFA","1790831493","47-5554737","TX","PE - Midland Inpatient Medical Association","Caprock (CapStar)","Participating","Re-Credentialing",44299,"","","2024-02-20","2/20/2024- Submitted recred status via delegated monthly roster on 2/15/2024. FC."]
["Karen Ward, APRN-NP, RNFA","1790831493","47-5554737","TX","PE - Midland Inpatient Medical Association","CAQH","Participating","Pending Info/Document",45257,"","","2024-05-29","username and password still incorrect"]
["Karen Ward, APRN-NP, RNFA","1790831493","47-5554737","TX","PE - Midland Inpatient Medical Association","Medicaid","Participating","Enrollment Complete","2020-12-19","367241202","364596201","2021-04-12","4/12/2021 Upon review of group TMHP portal, provider has been approved effective 12/19/2020 with assigned TPI 367241202. KFrazier"]
["Karen Ward, APRN-NP, RNFA","1790831493","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."]
["Karen Ward, APRN-NP, RNFA","1790831493","47-5554737","TX","PE - Midland Inpatient Medical Association","Boon Chapman","Participating","Enrollment Complete",44299,"","","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 4/13/2021.   DCannon"]
["Karen Ward, APRN-NP, RNFA","1790831493","47-5554737","TX","PE - Midland Inpatient Medical Association","United Health Care","Participating","Enrollment Complete",44280,"1163117","","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 3/25/2021 and assigned provider ID 1163117. KFrazier"]
["Stephen P Dodd, PA","1598976011","46-0950925","TX","PE - Urgent Orthopedic Specialists, PLLC","Wellmed","Participating","Enrollment Complete","2022-01-01","","","2023-03-23","3/23/2023 Rcvd roster from UHC w/ all Wellmed participating providers.  Provider is PAR effective 1/1/2022.  DCannon"]
["Stephen P Dodd, PA","1598976011","46-0950925","TX","PE - Urgent Orthopedic Specialists, PLLC","Cigna","Participating","Enrollment Complete","2013-11-01","1598976011","","2020-04-22","04/22/2020--S/W Rica of Cigna @ 8008824462, provider NPI# is on file for the provider and is participating effective 11/01/2013 under the group and TIN#. Physical location is on file. Call ref# Rica04202020.\ncopied note from spreadsheet-tisha rader"]
["Stephen P Dodd, PA","1598976011","46-0950925","TX","PE - Urgent Orthopedic Specialists, PLLC","Sedgwick","Participating","Enrollment Complete","2014-07-29","","","2021-05-06","5/6/2021  In following up with USAMCO (800-872-3860) I was told that you can confirm participating via the USA MCO website  https://providersearch.usamco.com/hwprovsearch.  Provider is PAR and linked to location/TIN effective 7/29/2014.  DCannon"]
["Stephen P Dodd, PA","1598976011","46-0950925","TX","PE - Urgent Orthopedic Specialists, PLLC","Caprock (CapStar)","Participating","Application Resubmitted","2014-08-01","1598976011","","2024-06-17","Submitted reapplication via delegated roster on 6/14/2024. FC"]
["Stephen P Dodd, PA","1598976011","46-0950925","TX","PE - Urgent Orthopedic Specialists, PLLC","Humana","Participating","Enrollment Complete",42856,"1598976011","","2020-08-31","08/31/2020 - moved to completed status afer reviewing follow up complete note - under PRIMED - Stacey Hudak"]
["Stephen P Dodd, PA","1598976011","46-0950925","TX","PE - Urgent Orthopedic Specialists, PLLC","Multiplan","Participating","Application Resubmitted","2015-04-16","1598976011","West Texas Physicians Alliance","2024-06-17","Submitted reapplication via delegated roster on 6/14/2024. FC"]
["Nanette R Paredes, PA","1437175163","75-2656723","TX","PE - Premier Family Care, Inc","Caprock (CapStar)","Participating","Application Resubmitted","2018-10-03","1437175163","","2024-06-17","Submitted reapplication via delegated roster on 6/14/2024. FC"]
["Nanette R Paredes, PA","1437175163","75-2656723","TX","PE - Premier Family Care, Inc","Triwest VA","Facility Enrollment","Enrollment Complete","2020-12-01","","","2023-03-24","03/17/2023- Per Triwest VA  email confirmation, provider participating under practice DCN, eff. 12/01/2020. PA"]
["Nanette R Paredes, PA","1437175163","75-2656723","TX","PE - Premier Family Care, Inc","Multiplan","Participating","Application Resubmitted","2018-10-29","1437175163","52669: West Texas Physicians Alliance Group Cntrct","2024-06-17","Submitted reapplication via delegated roster on 6/14/2024. FC"]
["Nanette R Paredes, PA","1437175163","75-2656723","TX","PE - Premier Family Care, Inc","Wellmed","Participating","Enrollment Complete",44562,"","","2023-03-23","3/23/2023 Rcvd roster from UHC w/ all Wellmed participating providers.  Provider is PAR effective 1/1/2022.  DCannon"]
["Nanette R Paredes, PA","1437175163","75-2656723","TX","PE - Premier Family Care, Inc","Medicare","Participating","Enrollment Complete",43344,"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","1437175163","75-2656723","TX","PE - Premier Family Care, Inc","Galaxy Health","Participating","Enrollment Complete","2018-11-20","1437175163","","2020-07-17","07/17/2020 Received a spreadsheet from the payer stating this provider is effective as of 11/20/2018 – Archie Candiasan"]
["Frank O McGehee, IV, MD","1134151756","27-0950535","TX","","Boon Chapman","Enrollment Stopped","Enrollment Stopped","","","","2023-09-25","9/25/2023 Per email from Priscilla Albertine at MQA provider does not wish to enroll in Multiplan.  Therefore, enrollment for Boon Chapman will be stopped at this time.  DCannon"]
["Frank O McGehee, IV, MD","1134151756","27-0950535","TX","PE - McGehee Medical, PA","United Health Care","Participating","Enrollment Complete","2015-12-14","2748091","","2020-07-30","7/30/2020 - moved to completed status after reviewing follow up complete note - Stacey Hudak"]
["Frank O McGehee, IV, MD","1134151756","27-0950535","TX","","Galaxy Health","Participating","Enrollment Complete",40284,"1619213386","","2020-07-17","7/17/2020- Received a spreadsheet from the payer stating this provider is effective as of 4/16/2010. – Jerha Gayorgor"]
["Frank O McGehee, IV, MD","1134151756","27-0950535","TX","PE - McGehee Medical, PA","First Health Coventry","Participating","Enrollment Complete",43862,"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","","Wellmed","Participating","Enrollment Complete",44562,"","","2023-03-23","3/23/2023 Rcvd roster from UHC w/ all Wellmed participating providers.  Provider is PAR effective 1/1/2022.  DCannon"]
["Premila L. S. Johnson, MD","1184727562","90-0858471","TX","PE - Premila Johnson, MD, LP","Scott&White (First Care)","Participating","Enrollment Complete",43101,"1184727562","","2020-04-16","04/16/2020 - Rec'd confirmation from the payer stating this provider is EFF under the DELEGATED PRIMED agreement with PPO only products with this TIN/Service Location- Stacey Hudak"]
["Premila L. S. Johnson, MD","1184727562","90-0858471","TX","PE - Premila Johnson, MD, LP","USA PPO","Participating","Enrollment Complete",43910,"","","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","","Wellcare","Participating","Enrollment Complete",44501,"","","2022-12-01","12/1/2022 Per roster received from Wellcare provider is PAR and linked to group TIN/location effective 11/1/2021.  DCannon"]
["Premila L. S. Johnson, MD","1184727562","90-0858471","TX","PE - Premila Johnson, MD, LP","IMS","Participating","Enrollment Complete",41153,"1184727562","","2020-06-22","06/22/2020- Rec'd email from the payer confirming this provider is PAR with this group/service location - Stacey Hudak"]
["Premila L. S. Johnson, MD","1184727562","90-0858471","TX","","IMS","Participating","Enrollment Complete",41153,"1184727562","","2020-06-22","06/22/2020- Rec'd email from the payer confirming this provider is PAR with this group/service location - Stacey Hudak"]
["Premila L. S. Johnson, MD","1184727562","90-0858471","TX","PE - Premila Johnson, MD, LP","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"]
["Johnny L Flitton, PA","1437356730","84-2617748","TX","PE - Midland Medicine PA","Cigna","Participating","Enrollment Complete","2024-03-08","9560591","","2024-05-01","Received confirmation email. MS"]
["Johnny L Flitton, PA","1437356730","84-2617748","TX","PE - Midland Medicine PA","Wellcare","Participating","Enrollment Complete","2024-06-01","","","2024-06-04","Per SHP validation report, provider is PAR, linked to TIN and location, eff. 06/01/2024. PA."]
["Johnny L Flitton, PA","1437356730","84-2617748","TX","PE - Midland Medicine PA","Aetna","Participating","Enrollment Complete","2024-02-05","","","2024-07-18","Spoke to Kim B call ref#6198188640, provider participating as of 2/5/2024 as PCP. FC"]
["Johnny L Flitton, PA","1437356730","84-2617748","TX","PE - Midland Medicine PA","Triwest VA","In Process","Application Submitted","","","","2024-08-19","Received BCBSTX enrollment confirmation. Application, along with COI, submitted via email to Scarlett Abigail. PA."]
["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","HealthSmart PPO","Participating","Re-Credentialing","2016-09-15","1912068446","","2024-02-20","2/20/2024- Submitted recred status via delegated monthly roster on 2/15/2024. FC."]
["Allen E Gibson, MD","1912068446","47-5554737","TX","PE - Midland Inpatient Medical Association","Cigna","Participating","Enrollment Complete","2016-08-23","1912068446","","2020-02-20","02/20/2020 - Payer confirmed that this provider is EFF as of 8-23-2016 at this service location under a DIRECT CONTRACT with this payer - Stacey Hudak"]
["Allen E Gibson, MD","1912068446","47-5554737","TX","PE - Midland Inpatient Medical Association","Galaxy Health","Participating","Enrollment Complete","2020-04-15","1912068446","","2020-08-21",""]
["Allen E Gibson, MD","1912068446","47-5554737","TX","PE - Midland Inpatient Medical Association","Aetna","Participating","Re-Credentialing","2020-08-01","1912068446","","2024-02-20","2/20/2024- Submitted recred status via delegated monthly roster on 2/15/2024. FC."]
["Allen E Gibson, MD","1912068446","47-5554737","TX","PE - Midland Inpatient Medical Association","Humana","Participating","Enrollment Complete",43831,"1912068446","","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"]
["Allen E Gibson, MD","1912068446","47-5554737","TX","","Humana","Participating","Enrollment Complete",43831,"1912068446","","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"]
["Gerardo M Catalasan, MD","1760501720","75-2656723","TX","PE - Premier Family Care, Inc","United Health Care","Participating","Enrollment Complete","2020-01-01","1760501720","","2020-08-31","08/31/2020 - Moved to completed status after reviewing follow up completed note - Stacey Hudak"]
["Gerardo M Catalasan, MD","1760501720","75-2656723","TX","","CAQH","Active","CAQH Reattested","2024-08-15","13752595","","2024-08-15","08/15/2024 CAQH Reattested all locations current and all expirables up to date wthompson"]
["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","","Aetna","Participating","Enrollment Complete",44166,"","","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, Inc","Boon Chapman","Participating","Enrollment Complete",43924,"","","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","","Multiplan","Participating","Enrollment Complete","2020-04-03","","","2022-07-24","7/24/2022 Per email from Marcie Eckhart-Havens Multiplan July delegated roster has been completed  and provider is PAR and linked to group TIN effective 4/3/2020.   DCannon"]
["Gerardo M Catalasan, MD","1760501720","75-2656723","TX","PE - Premier Family Care, Inc","Wellcare","Participating","Enrollment Complete",44501,"","","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","","Wellcare","Participating","Enrollment Complete",44501,"","","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","PE - Premier Family Care, Inc","Scott&White (First Care)","Participating","Enrollment Complete","2018-04-20","1760501720","","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","1760501720","75-2656723","TX","","HealthSmart PPO","Participating","Enrollment Complete",40575,"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","","Superior","Participating","Enrollment Complete","2017-01-01","1760501720","","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","1760501720","75-2656723","TX","","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 Prime","Participating","Enrollment Complete","2014-11-04","","","2024-01-25","Confirmed provider is credentialed and in network with Tricare. MS"]
["Gerardo M Catalasan, MD","1760501720","75-2656723","TX","","Cigna","Participating","Enrollment Complete",40441,"1760501720","","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","1760501720","75-2656723","TX","PE - Premier Family Care, Inc","Wellmed","Participating","Enrollment Complete",44562,"","","2023-03-23","3/23/2023 Rcvd roster from UHC w/ all Wellmed participating providers.  Provider is PAR effective 1/1/2022.  DCannon"]
["Gerardo M Catalasan, MD","1760501720","75-2656723","TX","","Wellmed","Participating","Enrollment Complete","2022-01-01","","","2023-03-23","3/23/2023 Rcvd roster from UHC w/ all Wellmed participating providers.  Provider is PAR effective 1/1/2022.  DCannon"]
["Gerardo M Catalasan, MD","1760501720","75-2656723","TX","PE - Premier Family Care, Inc","Medicaid","In Process","Application Submitted","","","","2024-08-21","Your application has been submitted and is now under review. Your request number is: 20536827. Jen Videan"]
["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","","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","1760501720","75-2656723","TX","PE - Premier Family Care, Inc","Humana","Participating","Enrollment Complete","2020-01-01","","","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"]
["Nikolay A Azarov, MD","1093937948","75-2656723","TX","PE - Premier Family Care, Inc","Superior","Participating","Enrollment Complete","2017-01-01","1093937948","","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"]
["Nikolay A Azarov, MD","1093937948","75-2656723","TX","","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","TX","PE - Premier Family Care, Inc","Scott&White (First Care)","Participating","Enrollment Complete","2018-12-01","1093937948","","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"]
["Nikolay A Azarov, MD","1093937948","75-2656723","TX","","Scott&White (First Care)","Participating","Enrollment Complete","2018-12-01","1093937948","","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"]
["Nikolay A Azarov, MD","1093937948","75-2656723","TX","PE - Premier Family Care, Inc","Amerigroup","Participating","Enrollment Complete","2012-03-01","01448885","","2020-02-11","2/11/2020 – Received Roster from Amerigroup and provider is now PAR- additional effective dates listed on roster are:  1/1/17, 11/1/16, 8/1/12, & 1/1/2020--Tisha Rader"]
["Nikolay A Azarov, MD","1093937948","75-2656723","TX","PE - Premier Family Care, Inc","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","TX","","First Health Coventry","Participating","Enrollment Complete","2011-02-01","1594366","","2020-03-20","3/20/2020-receieved email with roster stating provider PAR 8/1/2018 2/1/2011 PID # 1594366-tisha rader"]
["Nikolay A Azarov, MD","1093937948","75-2656723","TX","PE - Premier Family Care, 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","TX","","Medicaid","Participating","Enrollment Complete","2009-03-24","194906703","079837301","2020-03-13","03/13/2020 - Clinic forwarded Medicaid TMHP approval letter showing where the provider was linked to the group - Stacey Hudak"]
["Nikolay A Azarov, MD","1093937948","75-2656723","TX","PE - Premier Family Care, Inc","Superior","Participating","Enrollment Complete","2017-01-01","1093937948","","2020-07-14","07/14/2020 - Rec'd email from the payer stating this provider is EFF under PRIMED DELEGATED agreement - Stacey Hudak"]
["Nikolay A Azarov, MD","1093937948","75-2656723","TX","","First Health Coventry","Participating","Enrollment Complete","2011-02-01","1594366","","2020-03-20","3/20/2020-receieved email with roster stating provider PAR 8/1/2018 2/1/2011 PID # 1594366-tisha rader"]
["Nikolay A Azarov, MD","1093937948","75-2656723","TX","PE - Premier Family Care, Inc","Triwest VA","Participating","Enrollment Complete","2020-12-01","","","2023-03-24","03/17/2023- Per Triwest VA  email confirmation, provider participating under practice DCN, eff. 12/01/2020. PA"]
["Nikolay A Azarov, MD","1093937948","75-2656723","TX","","Rail Road Medicare","Participating","Enrollment Complete","2008-11-01","P00716501","","2020-03-30","3/25/2020--3/25/2020-Per online check, provider is now PAR effective 11/01/2008 with provider number P00716501. Attached welcome letter to payor line.-Elonah Grace B.Gelig"]
["Nikolay A Azarov, MD","1093937948","75-2656723","TX","","Boon Chapman","Participating","Enrollment Complete","2018-06-07","","","2021-08-06","8/6/2021 Boon Chapman falls under the Multiplan umbrella, received roster from Multiplan provider is listed on roster under TIN/location as PAR effective 6/7/2018.  DCannon"]
["Nikolay A Azarov, MD","1093937948","75-2656723","TX","PE - Premier Family Care, Inc","Cigna","Participating","Enrollment Complete","2020-02-26","6493392","","2021-11-15","11/15/2021 Per f/u note S/W Steven of Cigna @ 800-882-4462. NPI# for the provider is on file  shows LINKED and  Par under the group and TIN#,  effective 2/26/2020 , the physical location is on file and the Provider ID is 6493392.   DCannon"]
["Nikolay A Azarov, MD","1093937948","75-2656723","TX","","Cigna","Participating","Enrollment Complete","2020-02-26","6493392","","2021-11-15","11/15/2021 Per f/u note S/W Steven of Cigna @ 800-882-4462. NPI# for the provider is on file  shows LINKED and  Par under the group and TIN#,  effective 2/26/2020 , the physical location is on file and the Provider ID is 6493392.   DCannon"]
["Nikolay A Azarov, MD","1093937948","75-2656723","TX","PE - Premier Family Care, Inc","Cigna","Participating","Enrollment Complete","2020-02-26","6493392","","2021-11-15","11/15/2021 Per f/u note S/W Steven of Cigna @ 800-882-4462. NPI# for the provider is on file  shows LINKED and  Par under the group and TIN#,  effective 2/26/2020 , the physical location is on file and the Provider ID is 6493392.   DCannon"]
["Nikolay A Azarov, MD","1093937948","75-2656723","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","TX","PE - Premier Family Care, Inc","Wellcare","Participating","Enrollment Complete","2021-11-01","","","2022-11-15","11/15/2022 Per roster received from Wellcare provider is PAR and linked to group TIN/location effective 11/1/2021.  DCannon"]
["Nikolay A Azarov, MD","1093937948","75-2656723","TX","PE - Premier Family Care, Inc","Wellcare","Participating","Enrollment Complete","2021-11-01","","","2022-11-15","11/15/2022 Per roster received from Wellcare provider is PAR and linked to group TIN/location effective 11/1/2021.  DCannon"]
["Nikolay A Azarov, MD","1093937948","75-2656723","TX","PE - Premier Family Care, Inc","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","TX","PE - Premier Family Care, Inc","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"]
["Nikolay A Azarov, MD","1093937948","75-2656723","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"]
["Jeffrey Limbacher, PA-C","1376723361","75-2656723","TX","PE - Premier Family Care, Inc","Cigna","Participating","Enrollment Complete","2020-05-13","8867748","","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","1376723361","75-2656723","TX","","Amerigroup","Participating","Enrollment Complete",41971,"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",43831,"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, Inc","Scott&White (First Care)","Participating","Enrollment Complete","2018-05-11","1376723361","","2020-02-19","2/19/2020--Per payer roster received from Irma Henson, this provider is participating with this service location and TIN--tisha rader"]
["Jeffrey Limbacher, PA-C","1376723361","75-2656723","TX","","Scott&White (First Care)","Participating","Enrollment Complete","2018-05-11","1376723361","","2020-02-19","2/19/2020--Per payer roster received from Irma Henson, this provider is participating with this service location and TIN--tisha rader"]
["Jeffrey Limbacher, PA-C","1376723361","75-2656723","TX","","CAQH","Participating","CAQH Reattested","2024-08-27","13780299","","2024-08-27","08/27/2024 CAQH Reattested updated and uploaded COI wthompson"]
["Jeffrey Limbacher, PA-C","1376723361","75-2656723","TX","PE - Premier Family Care, Inc","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","","Caprock (CapStar)","Participating","Enrollment Complete","2014-12-01","1376723361","","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","1376723361","75-2656723","TX","PE - Premier Family Care, Inc","United Health Care","Participating","Enrollment Complete","2020-01-01","1376723361","","2020-08-31","08/31/2020 - moved to completed status after reviewing follow up completed note - Stacey Hudak"]
["Jeffrey Limbacher, PA-C","1376723361","75-2656723","TX","","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","","Wellmed","Participating","Enrollment Complete","2022-01-01","","","2023-03-23","3/23/2023 Rcvd roster from UHC w/ all Wellmed participating providers.  Provider is PAR effective 1/1/2022.  DCannon"]
["Jeffrey Limbacher, PA-C","1376723361","75-2656723","TX","","HealthSmart PPO","Participating","Enrollment Complete",42576,"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","","HealthSmart PPO","Participating","Enrollment Complete",42576,"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",44564,"","","","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, Inc","Galaxy Health","Participating","Enrollment Complete","2016-05-18","1376723361","","2020-07-10","07/10/2020 - updated payer line to enrollment complete status instead of \"Delegated status\" for report running purposes - Stacey Hudak"]
["Sapna Chilka, MD","1790972610","20-8658501","TX","PE - Shylesh Ganta, MD, PA","Galaxy Health","Participating","Enrollment Complete","2008-04-09","1790972610","","2020-07-17","7/17/2020 - Received a spreadsheet from the payer stating this provider is effective as of 4/9/2008 - Jesriel Segovia"]
["Sapna Chilka, MD","1790972610","20-8658501","TX","PE - Shylesh Ganta, MD, PA","CAQH","Participating","CAQH Reattested","2024-08-15","12137263","","2024-08-15","08/15/2024 CAQH Reattested all locations current and all expirables up to date wthompson"]
["Sapna Chilka, MD","1790972610","20-8658501","TX","PE - Shylesh Ganta, MD, PA","Caprock (CapStar)","Participating","Enrollment Complete","2012-03-01","1790972610","","2020-06-02","06/02/2020 - rec'd spreadsheet back from the payer Mary Rodriguez <MRodriguez@caprockhp.com> confirming this provider/service location is EFF with this payer - Stacey Hudak"]
["Sapna Chilka, MD","1790972610","20-8658501","TX","PE - Shylesh Ganta, MD, PA","Multiplan","Participating","Enrollment Complete","2020-03-20","","","2022-07-24","7/24/2022 Per email from Marcie Eckhart-Havens Multiplan July delegated roster has been completed  and provider is PAR and linked to group TIN effective 3/20/2020.   DCannon"]
["Sapna Chilka, MD","1790972610","20-8658501","TX","PE - Shylesh Ganta, MD, PA","USA PPO","Participating","Enrollment Complete","2009-10-23","","","2020-09-09","Confirmed provider is participating with PPO, H&W and WIN networks (list of networks attached). Kimberly Frazier"]
["Sapna Chilka, MD","1790972610","20-8658501","TX","PE - Shylesh Ganta, MD, PA","Omni PPO","Participating","Enrollment Complete","2008-04-09","1790972610","","2020-06-25",""]
["Ajay K Vaikuntam, MD","1447415476","47-5554737","TX","PE - Midland Inpatient Medical Association","HealthSmart PPO","Participating","Re-Credentialing","2020-04-15","","","2024-05-16","5/16/2024- Submitted recred status via delegated monthly roster on 5/15/2024. FC."]
["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","Re-Credentialing","2020-04-15","","","2024-05-16","5/16/2024- Submitted recred status via delegated monthly roster on 5/15/2024. FC."]
["Ajay K Vaikuntam, MD","1447415476","47-5554737","TX","PE - Midland Inpatient Medical Association","IMS","Participating","Re-Credentialing","2019-09-01","1447415476","","2024-05-16","5/16/2024- Submitted recred status via delegated monthly roster on 5/15/2024. FC."]
["Ajay K Vaikuntam, MD","1447415476","47-5554737","TX","PE - Midland Inpatient Medical Association","Medicare","Participating","Enrollment Complete",42926,"468835ZV0W","519061","2020-02-19","02/19/2020 - Signed into PECOS and confirmed that this provider is EFF with Medicare group PTAN 519061  as of 7-10-2017 - 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","2024-08-15","11035862","","2024-08-15","08/15/2024 CAQH Reattested all locations current and all expirables up to date wthompson"]
["Wayne L Sager, MD","1225182314","75-2133441","TX","PE - Midland Pediatric Associates, PLLC","Cigna","Participating","Enrollment Complete","2012-07-01","1225182314","","2020-04-22","04/22/2020--SW Monic of Cigna @ 8008824462, Provider NPI# is on file and participating under the group and TIN# effective 7/1/2012. Location is on file. Call ref# Monic4202020.\n-copied note from spreadsheet-tisha rader"]
["Wayne L Sager, MD","1225182314","75-2133441","TX","PE - Midland Pediatric Associates, PLLC","Multiplan","Participating","Enrollment Complete","2017-04-15","1225182314","","2020-08-27","08/27/2020 -Rec'd email from the payer stating \"\nThank you for contacting our Customer Service Department with Multiplan/PHCS. We received your request have confirmed that the following providers are participating with Multiplan and PHCS through Midland Pediatric Associates: - Wayne Sager-Effective 04/15/2017\" - Stacey Hudak"]
["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","HealthSmart PPO","Participating","Enrollment Complete","2011-02-01","1194813709","","2020-06-10","06/10/2020 - Rec'd email from the payer stating this provider is EFF - Stacey Hudak"]
["Adriana E Nur, MD","1619982584","75-2656723","TX","","Medicare","Participating","Enrollment Complete","2024-03-18","","","2024-05-13","Group record has been updated with this location eff 3/18/24. MS"]
["Adriana E Nur, MD","1619982584","75-2656723","TX","PE - Premier Family Care, Inc","Medicaid","In Process","Payor Follow Up","","","","2024-08-21","Application in PE Review status. Jen Videan"]
["Adriana E Nur, MD","1619982584","75-2656723","TX","","Aetna","Participating","Enrollment Complete","2024-03-18","9630068","","2024-06-18","S/W Claire of Edward @ 1-800-353-1232. Per rep, Provider is in network with Aetna for the state of TX and linked to the group and TIN effective 03/18/2024. No next recredentialing date provided. PIN: 9630068. Servicing location is on file. Payer# 60054. Call ref# 6194642485."]
["Adriana E Nur, MD","1619982584","75-2656723","TX","PE - Premier Family Care, Inc","Rail Road Medicare","Participating","Enrollment Complete","","","","2024-07-24","RR MCR does not add more than 1 location to their group record. They only need notified if the new location is replacing the main location on the record. MS"]
["Adriana E Nur, MD","1619982584","75-2656723","TX","","Tricare Prime","Participating","Enrollment Complete","2024-05-31","","","2024-06-28","Location is Tricare Credentialed. Provider is active eff 5/31/2024. MS"]
["Shailesh Jain, MD","1215922802","75-2656723","TX","PE - Premier Family Care, Inc","TriCare Standard","Participating","Enrollment Complete","2023-11-27","","","2023-12-12","Provider is linked to location. MS"]
["Shailesh Jain, MD","1215922802","75-2656723","TX","PE - Premier Family Care, Inc","Scott&White (First Care)","Participating","Enrollment Complete","2024-01-18","","","2024-01-08","1/8/2024 Rcvd email from Scott & White that provider is PAR and linked to group TIN/location effective 1/18/2024.  DCannon"]
["Shailesh Jain, MD","1215922802","75-2656723","TX","","Scott&White (First Care)","Participating","Enrollment Complete","2024-01-18","","","2024-01-08","1/8/2024 Rcvd email from Scott & White that provider is PAR and linked to group TIN/location effective 1/18/2024.  DCannon"]
["Shailesh Jain, MD","1215922802","75-2656723","TX","PE - Premier Family Care, Inc","Superior","Participating","Enrollment Complete","2024-01-01","","","2024-06-10","Received email confirmation provider's enrollment date has been backdated to 01/01/2024. PA."]
["Shailesh Jain, MD","1215922802","75-2656723","TX","","Ambetter","Participating","Enrollment Complete","2024-01-01","","","2024-06-10","Received confirmation provider's enrollment date is now backdated to 01/01/2024."]
["Shailesh Jain, MD","1215922802","75-2656723","TX","PE - Premier Family Care, Inc","CAQH","Provider Load","CAQH Reattested",45481,"","","2024-07-08","07/08/2024 CAQH Sweep. All locations current and up to date. ALl expirables up to date and uploaded wthompson"]
["Shailesh Jain, MD","1215922802","75-2656723","TX","","CAQH","Provider Load","CAQH Reattested",45481,"","","2024-07-08","07/08/2024 CAQH Sweep. All locations current and up to date. ALl expirables up to date and uploaded wthompson"]
["Shailesh Jain, MD","1215922802","75-2656723","TX","PE - Premier Family Care, Inc","Cigna","Participating","Enrollment Complete",45371,"60308","","2024-03-22","03.22.2024 WR: Called Cigna@ 1-800-882-4462 to obtain PNP/FU status for the provider and spoke to PaulaM. Per rep, Provider is in network with Cigna for the state of TX and linked to the group and TIN# effective 03/20/2024. Next recredentialing date is on 03/20/2027. PIN: 0998740. Servicing location is on file. Payer# 60308. Call ref# PaulaM03242024."]
["Shailesh Jain, MD","1215922802","75-2656723","TX","","IMS","Participating","Enrollment Complete","2023-12-04","","","2024-01-02","1/2/2024 Rcvd email from German Avilies at IMS/OMNI that December delegation roster is complete.  Provider is PAR and linked to group TIN/location effective 12/4/2023.  DCannon"]
["Shailesh Jain, MD","1215922802","75-2656723","TX","","Amerigroup","Participating","Enrollment Complete","2023-12-04","","","2024-02-01","2/1/2024 Per Amerigroup web portal provider is PAR and linked to group TIN/location effective 12/4/2023.  DCannon"]
["Shailesh Jain, MD","1215922802","75-2656723","TX","PE - Premier Family Care, Inc","Wellcare","Participating","Enrollment Complete","2024-01-01","","","2024-06-10","Received email confirmation provider's enrollment date has been backdated to 01/01/2024. PA."]
["Shailesh Jain, MD","1215922802","75-2656723","TX","","First Health Coventry","Participating","Enrollment Complete","2024-01-01","","","2024-04-24","4/24/2024 Spoke to Shannon call ref#1025129 provider effective as of 1/1/2024 under Child & Adolescent Psychiatry/Psychiatry. FC"]
["Staton Awtrey, MD","1376556019","75-2656723","TX","PE - Premier Family Care, Inc","Ambetter","Participating","Enrollment Complete",44713,"","","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","TX","PE - Premier Family Care, Inc","United Health Care","Participating","Enrollment Complete",43838,"1376556019","","2020-09-08","09/08/2020 - Reviewed last note and moved to completed status - Stacey Hudak"]
["Staton Awtrey, MD","1376556019","75-2656723","TX","PE - Premier Family Care, Inc","Superior","Participating","Enrollment Complete","2017-01-01","1376556019","","2020-07-14","07/14/2020 - Rec'd email back from the delegated team stating this provider has been linked to this TIN since 1-1-2017 **see the other Enrollment Complete line for details about specific products and when they became EFF** - Stacey Hudak"]
["Staton Awtrey, MD","1376556019","75-2656723","TX","PE - Premier Family Care, Inc","HealthSmart PPO","Participating","Enrollment Complete","2017-11-01","1376556019","","2020-06-10","06/10/2020 - Rec'd email from the payer stating this provider is EFF - stacey hudak"]
["Staton Awtrey, MD","1376556019","75-2656723","TX","PE - Premier Family Care, Inc","Wellmed","Participating","Enrollment Complete",44562,"","","2023-03-23","3/23/2023 Rcvd roster from UHC w/ all Wellmed participating providers.  Provider is PAR effective 1/1/2022.  DCannon"]
["Staton Awtrey, MD","1376556019","75-2656723","TX","PE - Premier Family Care, Inc","Amerigroup","Participating","Enrollment Complete",41274,"","","2021-08-26","8/26/2021 Rcvd full roster from Joe Rodriguez at Amerigroup listing provider as PAR w/ group TIN and location effective 12/31/2012.  DCannon"]
["Staton Awtrey, MD","1376556019","75-2656723","TX","PE - Premier Family Care, Inc","Medicaid","Participating","Enrollment Complete",40154,"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","TX","PE - Premier Family Care, 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","TX","PE - Premier Family Care, Inc","Wellcare","Participating","Enrollment Complete","2021-11-01","","","2022-11-15","11/15/2022 Per roster received from Wellcare provider is PAR and linked to group TIN/location effective 11/1/2021.  DCannon"]
["Staton Awtrey, MD","1376556019","75-2656723","TX","PE - Premier Family Care, Inc","USA PPO","Participating","Enrollment Complete","2011-09-01","","","2020-09-09","Confirmed provider is participating with PPO and H&W networks (list of networks attached). Kimberly Frazier"]
["Staton Awtrey, MD","1376556019","75-2656723","TX","PE - Premier Family Care, 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"]
["Staton Awtrey, MD","1376556019","75-2656723","TX","PE - Premier Family Care, Inc","CAQH","Participating","CAQH Reattested","2024-08-15","11351930","","2024-08-15","08/15/2024 CAQH Reattested all locations current and all expirables up to date wthompson"]
["Staton Awtrey, MD","1376556019","75-2656723","TX","PE - Premier Family Care, Inc","Galaxy Health","Participating","Enrollment Complete",43709,"1376556019","","2020-08-21","08/21/2020 - Rec'd email confirmation that this roster was processed and this provider was made effective with the requested eff date of 9-1-2019 - Stacey Hudak"]
["Juan C Gil, MD","1558392779","75-2656723","TX","PE - Premier Family Care, Inc","Galaxy Health","Participating","Enrollment Complete","2013-09-28","1558392779","","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","1558392779","75-2656723","TX","PE - Premier Family Care, Inc","Amerigroup","Participating","Re-Credentialing","2020-06-29","1558392779","","2024-03-18","3/18/2024- Submitted recred status via delegated monthly roster on 3/15/2024. FC."]
["Juan C Gil, MD","1558392779","75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","2009-01-01","","","2024-01-26","Confirmed provider is credentialed and in network with Tricare. MS"]
["Juan C Gil, MD","1558392779","75-2656723","TX","PE - Premier Family Care, Inc","Medicaid","Participating","Enrollment Complete","","187586602","079837301","2024-07-26","Approval ltr rcvd for 2402 W Wall St. Effective 05/29/2023. Jen Videan"]
["Juan C Gil, MD","1558392779","75-2656723","TX","PE - Premier Family Care, Inc","Medicaid","Participating","Enrollment Complete","","187586602","079837301","2024-07-26","Approval ltr rcvd for 2402 W Wall St. Effective 05/29/2023. Jen Videan"]
["Juan C Gil, MD","1558392779","75-2656723","TX","PE - Premier Family Care, Inc","Boon Chapman","Participating","Enrollment Complete",42522,"","","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"]
["Rebecca A Sanchez, PA","1174846364","46-3131679","TX","PE - Midland Texas Orthopedic Group Inc","Zurich","Participating","Enrollment Complete",43910,"","","2022-12-15","12/15/2022 Per Coventry WC website provider is PAR in Zurich WC and linked to TIN/locations effective 3/20/2020.  DCannon"]
["Rebecca A Sanchez, PA","1174846364","46-3131679","TX","PE - Midland Texas Orthopedic Group Inc","Multiplan","Participating","Enrollment Complete",44197,"","","2021-02-20","2/20/2021 Rcvd approval letter from MultiPlan for WesTexas OrthoPedics providers effective 1/1/2021.  DCannon"]
["Rebecca A Sanchez, PA","1174846364","46-3131679","TX","PE - Midland Texas Orthopedic Group Inc","Wellmed","Participating","Enrollment Complete",44562,"","","2023-03-23","3/23/2023 Rcvd roster from UHC w/ all Wellmed participating providers.  Provider is PAR effective 1/1/2022.  DCannon"]
["Rebecca A Sanchez, PA","1174846364","46-3131679","TX","PE - Midland Texas Orthopedic Group Inc","Caprock (CapStar)","Participating","Enrollment Complete",43894,"1174846364","","2020-06-02","06/02/2020 - rec'd spreadsheet back from the payer Mary Rodriguez <MRodriguez@caprockhp.com> confirming this provider/service location is EFF with this payer - Stacey Hudak"]
["Rebecca A Sanchez, PA","1174846364","46-3131679","TX","PE - Midland Texas Orthopedic Group Inc","Superior","Participating","Enrollment Complete",44044,"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","Cigna","Participating","Enrollment Complete",43739,"0186460","","2020-02-27","02/27/2020 - rec'd email from the payer stating \"This is to confirm that your request has been completed\" Completion Notice - Cigna Internal Reference # W20200226902641\nHCP Name: Rebecca Sanchez\nPID: 0186460\nEffective date: 10/01/2019  - Stacey Hudak"]
["Rebecca A Sanchez, PA","1174846364","46-3131679","TX","PE - Midland Texas Orthopedic Group Inc","Wellcare","Participating","Enrollment Complete","2021-11-01","","","2022-12-01","12/1/2022 Per roster received from Wellcare provider is PAR and linked to group TIN/location effective 11/1/2021.  DCannon"]
["Rebecca A Sanchez, PA","1174846364","46-3131679","TX","PE - Midland Texas Orthopedic Group Inc","Humana","Participating","Enrollment Complete","2020-01-01","1174846364","","2020-07-19","7/19/2020 - Received email spreadsheet from the payor confirming that this provider is EFF at this service location and PAR with the PRIMED DELEGATED agreement - Pam Porter"]
["Rebecca A Sanchez, PA","1174846364","46-3131679","TX","PE - Midland Texas Orthopedic Group Inc","Omni PPO","Participating","Enrollment Complete",43709,"1174846364","","2020-07-27","IMS complete"]
["Michael P Wolbert, MD","1881711778","75-2781652","TX","PE - West Texas Allergy, PA","Aetna","Participating","Add Info Submitted",42339,"9826163","","2024-08-19","Submitted reapplication via delegated roster on 8/15/2024. FC"]
["Michael P Wolbert, MD","1881711778","75-2781652","TX","","United Health Care","Terminated","Terminated","2021-08-01","002904472","","2023-10-25","10/25/2023 Per email received from Priscilla Albertine at MQA, Dr. Wolbert's UHC contracted terminated effective 8/23/2023.  DCannon"]
["Michael P Wolbert, MD","1881711778","75-2781652","TX","PE - West Texas Allergy, PA","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","75-2781652","TX","PE - West Texas Allergy, PA","Wellmed","Terminated","Terminated","2022-01-01","1881711778","","2023-10-25","10/25/2023 Per email received from Priscilla Albertine at MQA, Dr. Wolbert's UHC contracted terminated effective 8/23/2023.  DCannon"]
["Michael P Wolbert, MD","1881711778","75-2781652","TX","PE - West Texas Allergy, PA","First Health Coventry","Participating","Add Info Submitted","2010-08-01","1945548","","2024-08-19","Submitted reapplication via delegated roster on 8/15/2024. FC"]
["Michael P Wolbert, MD","1881711778","75-2781652","TX","PE - West Texas Allergy, PA","Tricare Prime","Participating","Enrollment Complete","2022-12-13","","","2024-01-26","Confirmed provider is credentialed and in network with Tricare. MS"]
["Michael P Wolbert, MD","1881711778","75-2781652","TX","","Tricare Prime","Participating","Enrollment Complete","2022-12-13","","","2024-01-26","Confirmed provider is credentialed and in network with Tricare. MS"]
["Michael P Wolbert, MD","1881711778","75-2781652","TX","PE - West Texas Allergy, PA","United Health Care","Terminated","Terminated","2016-05-19","002904472","","2023-10-25","10/25/2023 Per email received from Priscilla Albertine at MQA, Dr. Wolbert's UHC contracted terminated effective 8/23/2023.  DCannon"]
["Michael P Wolbert, MD","1881711778","75-2781652","TX","","HealthSmart PPO","Participating","Add Info Submitted","2021-08-02","1881711778","","2024-08-19","Submitted reapplication via delegated roster on 8/15/2024. FC"]
["Michael P Wolbert, MD","1881711778","75-2781652","TX","PE - West Texas Allergy, PA","Boon Chapman","Participating","Enrollment Complete","2020-07-02","1881711778","","2021-08-06","8/6/2021 Boon Chapman falls under the Multiplan umbrella, received roster from Multiplan provider is listed on roster under TIN/location as PAR effective 7/2/2020.  DCannon"]
["Michael P Wolbert, MD","1881711778","75-2781652","TX","PE - West Texas Allergy, PA","Amerigroup","Participating","Add Info Submitted","2020-04-15","1881711778","","2024-08-19","Submitted reapplication via delegated roster on 8/15/2024. FC"]
["Michael P Wolbert, MD","1881711778","75-2781652","TX","","Amerigroup","Participating","Enrollment Complete","2020-04-15","01618929","","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"]
["Michael P Wolbert, MD","1881711778","75-2781652","TX","PE - West Texas Allergy, PA","Aetna","Participating","Add Info Submitted","2021-08-02","9826163","","2024-08-19","Submitted reapplication via delegated roster on 8/15/2024. FC"]
["Michael P Wolbert, MD","1881711778","75-2781652","TX","","Galaxy Health","Participating","Enrollment Complete",44410,"1881711778","","2021-10-06","10/6/2021 Rcvd email from Karen Avalos at Galaxy confirming that the August delegated roser provider load has been completed and providers are loaded under TIN/locations effective 8/2/2021.  DCannon"]
["Michael P Wolbert, MD","1881711778","75-2781652","TX","PE - West Texas Allergy, PA","TriCare Standard","Participating","Enrollment Complete",45461,"1881711778","","2023-08-23","Confirmation received of provider linked to this location. MS"]
["Michael P Wolbert, MD","1881711778","75-2781652","TX","","Ambetter","Participating","Enrollment Complete","2022-04-01","1881711778","","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","Add Info Submitted","2021-08-13","1881711778","","2024-08-19","Submitted reapplication via delegated roster on 8/15/2024. FC"]
["Michael P Wolbert, MD","1881711778","75-2781652","TX","","Omni PPO","Participating","Add Info Submitted","2021-08-02","1881711778","","2024-08-19","Submitted reapplication via delegated roster on 8/15/2024. FC"]
["Michael P Wolbert, MD","1881711778","75-2781652","TX","","Medicare","Participating","Enrollment Complete","2010-07-25","TXB111410","00608K","2020-05-04","05/04/2020 - was able to find/confirm PTAN through PECOS login - Stacey Hudak"]
["Michael P Wolbert, MD","1881711778","75-2781652","TX","PE - West Texas Allergy, PA","Medicare","Participating","Enrollment Complete","2010-07-25","TXB111410","00608K","2021-09-15","9/15/2021 Rcvd Medicare approval letter.   PTAN # TXB111410.  DCannon"]
["Michael P Wolbert, MD","1881711778","75-2781652","TX","","Cigna","Participating","Enrollment Complete","2010-08-01","9097673","","2020-04-22","04/22/2020--S/W Rica of Cigna @ 8008824462, provider NPI# is on file for the provider and is participating effective 8/1/2010 under the group and TIN#. Physical location is on file. Call ref# Rica04202020.\ncopied note from spreadsheet-tisha rader"]
["Michael P Wolbert, MD","1881711778","75-2781652","TX","PE - West Texas Allergy, PA","Omni PPO","Participating","Add Info Submitted","2010-07-14","1881711778","","2024-08-19","Submitted reapplication via delegated roster on 8/15/2024. FC"]
["Michael P Wolbert, MD","1881711778","75-2781652","TX","","Omni PPO","Participating","Add Info Submitted","2010-07-14","1881711778","","2024-08-19","Submitted reapplication via delegated roster on 8/15/2024. FC"]
["Michael P Wolbert, MD","1881711778","75-2781652","TX","PE - West Texas Allergy, PA","IMS","Participating","Enrollment Complete","2021-08-02","1881711778","","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 8/2/2021.  DCannon"]
["Michael P Wolbert, MD","1881711778","75-2781652","TX","","HealthSmart PPO","Participating","Enrollment Complete","2011-02-01","1881711778","","2020-06-10","06/10/2020 - Rec'd email from the payer stating this provider is EFF - Stacey Hudak"]
["Michael P Wolbert, MD","1881711778","75-2781652","TX","","Multiplan","Participating","Add Info Submitted","2020-07-02","1881711778","","2024-08-19","Submitted reapplication via delegated roster on 8/15/2024. FC"]
["Michael P Wolbert, MD","1881711778","75-2781652","TX","PE - West Texas Allergy, PA","Caprock (CapStar)","Participating","Enrollment Complete","2012-03-01","1881711778","","2020-06-02","06/02/2020 - rec'd spreadsheet back from the payer Mary Rodriguez <MRodriguez@caprockhp.com> confirming this provider/service location is EFF with this payer - Stacey Hudak"]
["Michael P Wolbert, MD","1881711778","75-2781652","TX","","Superior","Participating","Enrollment Complete","2021-09-01","1881711778","","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","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","PE - West Texas Allergy, PA","Triwest VA","Participating","Enrollment Complete","2024-02-01","387297379","","2024-01-24","1/24/2024- received email confirmation from Scarlett A. (Scarlett_Abigail@bcbstx.com), provider is par, eff. 02/01/24."]
["Michael P Wolbert, MD","1881711778","75-2781652","TX","PE - West Texas Allergy, PA","Scott&White (First Care)","Participating","Enrollment Complete","2017-09-14","1881711778","","2020-08-19","8/19/2020 - Rec'd confirmation that this provider is affiliated with the PRIMED DELEGATED ROSTER under this TIN/Service Location. This provider is networked with: \nFirstCare MyChoice PPO\nCHIP\nFirstCare Select Benefit Network\nHMO Enhanced Benefit Network\nMedicaid (FC)\nPPO Limited Benefit Network\n- Stacey Hudak"]
["Michael P Wolbert, MD","1881711778","75-2781652","TX","","Scott&White (First Care)","Participating","Enrollment Complete","2021-08-02","1881711778","","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","Participating","Enrollment Complete","2024-02-01","387297379","","2024-01-24","1/24/2024- received email confirmation from Scarlett A. (Scarlett_Abigail@bcbstx.com), provider is par, eff. 02/01/24."]
["Ayodele Olowookere, MD","1124350442","49-4110931","TX","PE - Ayodele O Olowookere MD, PA","United Health Care","Participating","Enrollment Complete","2014-07-01","1124350442","","2020-07-30","07/30/2020 - Rec'd email confirmation from the payer that this provider is effective at this service location and linked with this TIN - Stacey Hudak"]
["Ayodele Olowookere, MD","1124350442","49-4110931","TX","PE - Ayodele O Olowookere MD, PA","Wellcare","Participating","Enrollment Complete","2021-11-01","","","2022-12-01","12/1/2022 Per roster received from Wellcare provider is PAR and linked to group TIN/location effective 11/1/2021.  DCannon"]
["Ayodele Olowookere, MD","1124350442","49-4110931","TX","","Amerigroup","Participating","Re-Credentialing","2020-07-02","1124350442","","2024-05-15","5/15/2024- Submitted recred status via delegated monthly roster. FC."]
["Ayodele Olowookere, MD","1124350442","49-4110931","TX","PE - Ayodele O Olowookere MD, PA","Boon Chapman","Participating","Re-Credentialing","2016-05-16","1124350442","","2024-05-15","5/15/2024- Submitted recred status via delegated monthly roster. FC."]
["Ayodele Olowookere, MD","1124350442","49-4110931","TX","PE - Ayodele O Olowookere MD, PA","HealthSmart PPO","Participating","Re-Credentialing","2011-02-01","1124350442","","2024-05-15","5/15/2024- Submitted recred status via delegated monthly roster. FC."]
["Ayodele Olowookere, MD","1124350442","49-4110931","TX","PE - Ayodele O Olowookere MD, PA","Wellmed","Participating","Enrollment Complete","2022-01-01","","","2023-03-23","3/23/2023 Rcvd roster from UHC w/ all Wellmed participating providers.  Provider is PAR effective 1/1/2022.  DCannon"]
["Rosanna Y Catalasan, MD","1487837712","75-2656723","TX","PE - Premier Family Care, Inc","IMS","Participating","Re-Credentialing","2010-02-26","1487837712","","2024-05-16","5/16/2024- Submitted recred status via delegated monthly roster on 5/15/2024. FC."]
["Rosanna Y Catalasan, MD","1487837712","75-2656723","TX","PE - Premier Family Care, Inc","Ambetter","Participating","Enrollment Complete","2022-06-01","","","2022-06-13","6/13/2022 Per roster received from Superior provider is PAR and linked to group delegation roster effective 6/1/2022."]
["Rosanna Y Catalasan, MD","1487837712","75-2656723","TX","PE - Premier Family Care, Inc","Medicare","Participating","Enrollment Complete","2010-01-01","8L23968","0008AH","2020-01-29","01/29/2020 - confirmed EFF through PECOS group enrollment - Stacey Hudak"]
["Rosanna Y Catalasan, MD","1487837712","75-2656723","TX","PE - Premier Family Care, Inc","First Health Coventry","Participating","Re-Credentialing","2020-04-01","2122957","","2024-05-16","5/16/2024- Submitted recred status via delegated monthly roster on 5/15/2024. FC."]
["Rosanna Y Catalasan, MD","1487837712","75-2656723","TX","PE - Premier Family Care, Inc","Wellcare","Participating","Enrollment Complete","2021-11-01","","","2022-11-15","11/15/2022 Per roster received from Wellcare provider is PAR and linked to group TIN/location effective 11/1/2021.  DCannon"]
["Aaron B Stike, MD","1366652315","75-2656723","TX","PE - Premier Family Care, Inc","HealthSmart PPO","In Process","Application Submitted","","","","2024-08-19","Submitted via delegated roster on 8/15/2024. FC"]
["Aaron B Stike, MD","1366652315","75-2656723","TX","PE - Premier Family Care, Inc","Superior","In Process","Application Resubmitted","","","","2024-08-15","Application submitted through delegated roster. PA."]
["Aaron B Stike, MD","1366652315","75-2656723","TX","PE - Premier Family Care, Inc","Wellmed","In Process","Application Submitted","","","","2024-08-15","Application submitted through delegated roster. PA."]
["Aaron B Stike, MD","1366652315","75-2656723","TX","PE - Premier Family Care, Inc","Scott&White (First Care)","In Process","Application Submitted","","","","2024-08-15","Application submitted through delegated roster. PA."]
["Aaron B Stike, MD","1366652315","75-2656723","TX","PE - Premier Family Care, Inc","CAQH","Active","CAQH Reattested","2024-08-02","","","2024-08-02","08/02/2024 CAQH Sweep Updated demo tab, specialty, location, cred contact and confirmed docs are uploaded wthompson"]
["Aaron B Stike, MD","1366652315","75-2656723","TX","PE - Premier Family Care, Inc","Multiplan","In Process","Application Submitted","","","","2024-08-19","Submitted via delegated roster on 8/15/2024. FC"]
["Matthew A Sanchez, APRN-NP","1437402278","75-2656723","TX","PE - Premier Family Care, Inc","Omni PPO","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"]
["Matthew A Sanchez, APRN-NP","1437402278","75-2656723","TX","PE - Premier Family Care, Inc","USA PPO","Participating","Enrollment Complete","2022-07-01","","","2023-03-24","3/24/2023 In following up with USAMCO (800-872-3860) I was told that you can confirm participating via the USA MCO website  https://providersearch.usamco.com/hwprovsearch.  Provider is PAR and linked to location/TIN effective 7/1/2022.  DCannon"]
["Matthew A Sanchez, APRN-NP","1437402278","75-2656723","TX","PE - Premier Family Care, 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"]
["Matthew A Sanchez, APRN-NP","1437402278","75-2656723","TX","PE - Premier Family Care, Inc","Ambetter","Participating","Enrollment Complete","2022-09-01","","","2022-12-29","12/29/2022 Rcvd email from Superior Delegation that August delegation roster has been completed and providers are loaded under appropriate group TIN/locations effective 9/1/2022.  DCannon"]
["Matthew A Sanchez, APRN-NP","1437402278","75-2656723","TX","PE - Premier Family Care, Inc","Medicare","Participating","Enrollment Complete","2016-03-21","299111YPVD","0008AH","2021-11-15","11/15/2021 Per PECOS provider is PAR and linked to group PTAN/location.  PTAN # 2991117PVD - effective 3/21/2016.  DCannon"]
["Matthew A Sanchez, APRN-NP","1437402278","75-2656723","TX","PE - Premier Family Care, Inc","United Health Care","Participating","Enrollment Complete",43910,"","","2022-08-01","8/1/2022 Rcvd email from UHC that provider is PAR and linked to group/location effective 3/20.2020.  DCannon"]
["Matthew A Sanchez, APRN-NP","1437402278","75-2656723","TX","PE - Premier Family Care, Inc","Caprock (CapStar)","Participating","Enrollment Complete",42559,"1437402278","","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, APRN-NP","1437402278","75-2656723","TX","PE - Premier Family Care, Inc","Scott&White (First Care)","Participating","Enrollment Complete",44657,"","","2022-07-14","7/14/2022 Received email from HPEXPEDITES@BSWHealth.org, provider is in process and has an effective date of 4/6/2022.   DCannon"]
["Matthew A Sanchez, APRN-NP","1437402278","75-2656723","TX","PE - Premier Family Care, Inc","Superior","Participating","Enrollment Complete",42583,"1437402278","","2020-07-14","07/14/2020 - Rec'd spreadsheet from the delegated team stating this provider has been linked to the PriMed contract since 8-1-2016 **see the other enrollment complete line to see details about when this provider became effective with various specific products** - stacey Hudak"]
["Matthew A Sanchez, APRN-NP","1437402278","75-2656723","TX","PE - Premier Family Care, Inc","Medicaid","Participating","Enrollment Complete","2022-12-13","1437402278","","2024-01-03","Rcvd revalidation approval letter. 1805 S County Rd is effective 12/13/2022. Jen Videan"]
["Matthew A Sanchez, APRN-NP","1437402278","75-2656723","TX","PE - Premier Family Care, Inc","Boon Chapman","Participating","Enrollment Complete","2022-01-03","13489266","","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 13489266.  Case ref#7920144. - DCannon"]
["Matthew A Sanchez, APRN-NP","1437402278","75-2656723","TX","PE - Premier Family Care, Inc","Galaxy Health","Participating","Enrollment Complete","2016-07-08","1437402278","","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, APRN-NP","1437402278","75-2656723","TX","PE - Premier Family Care, Inc","HealthSmart PPO","Participating","Enrollment Complete","2024-02-01","","","2024-07-04","7/4/2024 provider participating as of 2/1/2024 as per Aleece Moerbe from HealthSmart via email confirmation. FC"]
["Matthew A Sanchez, APRN-NP","1437402278","75-2656723","TX","PE - Premier Family Care, Inc","Wellmed","Participating","Enrollment Complete","2022-01-01","","","2023-03-23","3/23/2023 Rcvd roster from UHC w/ all Wellmed participating providers.  Provider is PAR effective 1/1/2022.  DCannon"]
["Matthew A Sanchez, APRN-NP","1437402278","75-2656723","TX","PE - Premier Family Care, Inc","CAQH","Active","CAQH Reattested","2024-08-27","12567903","","2024-08-27","08/27/2024 CAQH Reattested updated and uploaded COI wthompson"]
["Matthew A Sanchez, APRN-NP","1437402278","75-2656723","TX","PE - Premier Family Care, Inc","United Health Care","Participating","Enrollment Complete","2018-09-25","1437402278","","2020-07-30","7/30/2020 - moved to completed status after reviewing follow up complete note - Stacey Hudak"]
["Matthew A Sanchez, APRN-NP","1437402278","75-2656723","TX","PE - Premier Family Care, Inc","Caprock (CapStar)","Participating","Enrollment Complete","2020-01-01","","","2022-10-12","10/12/2022 Per email from Priscilla Albertine she rcvd confirmation from Mary Rodriguez at Caprock that provider is PAR and linked to group TIN/locations effective 1/1/2020.  DCannon"]
["Matthew A Sanchez, APRN-NP","1437402278","75-2656723","TX","PE - Premier Family Care, 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"]
["Mohammed H Aljarwi, MD","1013320050","75-2656723","TX","PE - Premier Family Care, Inc","CAQH","Participating","CAQH Reattested","2024-08-28","","","2024-08-28","08/28/2024 CAQH Reattested updated and uploaded COI wthompson"]
["Mohammed H Aljarwi, MD","1013320050","75-2656723","TX","","First Health Coventry","Participating","Enrollment Complete",44866,"","","2023-07-27","07.27.2023 S/W Bridgett of First Health @800-226-5116. Per rep, provider is showing participating and link under the Group and TIN with an Effective date 11/01/2022. Provider ID 2906417. Service location is on file. Call ref#:709557. - Danico Gabriel Melendres"]
["Mohammed H Aljarwi, MD","1013320050","75-2656723","TX","PE - Premier Family Care, Inc","Rail Road Medicare","Participating","Enrollment Complete",44896,"Q00375443","CE1588","2022-11-30","11/30/2022 Rcvd RR Medicare approval letter.  PTAN # Q00375443 - effective 12/1/2022.  DCannon"]
["Mohammed H Aljarwi, MD","1013320050","92-0675116","TX","","Scott&White (First Care)","In Process","Payor Follow Up","2024-06-07","","","2024-07-26","Sent email to payor requesting enrollment status. PA."]
["Mohammed H Aljarwi, MD","1013320050","92-0675116","TX","PE - Delight Pediatrics","Amerigroup","Participating","Enrollment Complete",45434,"","","2024-08-29","Received confirmation from Cassandra Dunagon provider participating as of 5/22/2024 listed as Pediatric Specialty. FC"]
["Mohammed H Aljarwi, MD","1013320050","75-2656723","TX","","TriCare Standard","Participating","Enrollment Complete","2022-09-14","","","2022-10-28","10/28/2022 Per Tricare/Humana Military portal provider is PAR and linked to group TIN/location effective 9/14/2022.  DCannon"]
["Mohammed H Aljarwi, MD","1013320050","75-2656723","TX","","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"]
["Mohammed H Aljarwi, MD","1013320050","92-0675116","TX","PE - Delight Pediatrics","Omni PPO","Participating","Enrollment Complete","2024-05-22","","","2024-08-27","As per Kodi Cox provider participating as of 5/22/2024 received via email. FC"]
["Mohammed H Aljarwi, MD","1013320050","75-2656723","TX","","Multiplan","Participating","Enrollment Complete","2022-10-10","","","2023-09-01","9/1/2023 Per email received from Multiplan provider is PAR and linked to group TIN/locations effective 10/10/2022.  DCannon"]
["Mohammed H Aljarwi, MD","1013320050","92-0675116","TX","PE - Delight Pediatrics","HealthSmart PPO","In Process","Payor Follow Up","2024-06-07","","","2024-08-22","Emailed Aleece and Lee for an update. FC"]
["Mohammed H Aljarwi, MD","1013320050","92-0675116","TX","","HealthSmart PPO","In Process","Payor Follow Up","2024-06-07","","","2024-08-22","Emailed Aleece and Lee for an update. FC"]
["Mohammed H Aljarwi, MD","1013320050","75-2656723","TX","PE - Premier Family Care, Inc","Superior","Participating","Enrollment Complete",44866,"","","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"]
["Mohammed H Aljarwi, MD","1013320050","92-0675116","TX","","Ambetter","In Process","Thru Other Payor","","","","2024-08-27","Sent email to payor requesting status. PA."]
["Mohammed H Aljarwi, MD","1013320050","92-0675116","TX","","Caprock (CapStar)","In Process","Payor Follow Up","2024-06-07","","","2024-08-22","Emailed mary.rodriguez@90degreebenefits.com & Provider_Services_Shared.T8@90degreebenefits.com for network status. FC"]
["Mohammed H Aljarwi, MD","1013320050","75-2656723","TX","PE - Premier Family Care, Inc","United Health Care","Participating","Enrollment Complete","2022-10-10","006200573","","2023-09-12","9/12/2023 Rcvd email from UHC that provider is PAR and linked to group TIN/location effective 10/10/2022.  DCannon"]
["Mohammed H Aljarwi, MD","1013320050","92-0675116","TX","","Multiplan","Provider Load","Provider Load","2024-06-07","","","2024-06-07","new group"]
["Mohammed H Aljarwi, MD","1013320050","92-0675116","TX","PE - Delight Pediatrics","Tricare Prime","Pending Other Enrollment","Pending Other Enrollment","","","","2024-07-23","Pending Tricare certification. MS"]
["Mohammed H Aljarwi, MD","1013320050","75-2656723","TX","","Boon Chapman","Participating","Enrollment Complete","2022-10-10","","","2023-09-01","9/1/2023 Per email received from Multiplan provider is PAR and linked to group TIN/locations effective 10/10/2022.  DCannon"]
["Mohammed H Aljarwi, MD","1013320050","75-2656723","TX","PE - Premier Family Care, 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"]
["Mohammed H Aljarwi, MD","1013320050","92-0675116","TX","","Boon Chapman","Provider Load","Provider Load","2024-06-07","","","2024-06-07","new group"]
["Mohammed H Aljarwi, MD","1013320050","75-2656723","TX","","Tricare Prime","Participating","Enrollment Complete","2022-09-14","","","2024-01-25","Confirmed provider is credentialed and in network with Tricare. MS"]
["Mohammed H Aljarwi, MD","1013320050","92-0675116","TX","PE - Delight Pediatrics","Cigna","In Process","Application Submitted","","","","2024-07-23","Application submitted via email to Medical Onboarding. MS"]
["Mohammed H Aljarwi, MD","1013320050","92-0675116","TX","","Cigna","In Process","Application Submitted","","","","2024-07-23","Application submitted via email to Medical Onboarding. MS"]
["Mohammed H Aljarwi, MD","1013320050","92-0675116","TX","PE - Delight Pediatrics","BCBSTX","In Process","Payor Follow Up","2024-06-07","","","2024-08-27","Case# 09703342 pending per portal. PA."]
["Mohammed H Aljarwi, MD","1013320050","75-2656723","TX","","Amerigroup","Participating","Enrollment Complete",44844,"","","2024-02-29","02/29/2024 - per roster received from Cassandra Dunagon (CassandraJ.Dunagon@wellpoint.com) on 02/29/2024, provider is PAR, effective 10/10/2022, and linked to TIN and location 4214 Andrews HWY, suite 102. PA."]
["Michael T Caglia, MD","1568789550","85-3162122","TX","PE - Basin Dermatology","Medicare","Participating","Enrollment Complete","2021-04-28","1T8899","1T8900","2021-09-15","9/9/2021 Received approval from Medicare that provider and group have been approved.  Group PTAN # 1T8900 and Individual Provider PTAN # 1T8899 - effective 4/28/2021.  DCannon"]
["Michael T Caglia, MD","1568789550","85-3162122","TX","PE - Basin Dermatology","TriCare Standard","Participating","Enrollment Complete","2021-03-25"," 853162122 79703 A002"," 853162122 79703 A001","","4/5/2021 Received an email from Latisha Green at Latisha.Green@wpsic.com confirming group and providers are Certified as non-network providers effective 3/25/2021 with assigned ID's as follows:\n\nGROUP                 853162122 79703 A001\nM. CAGLIA          853162122 79703 A002\nM. SIMS               853162122 79703 A003\n\nKFrazier"]
["Michael T Caglia, MD","1568789550","85-3162122","TX","PE - Basin Dermatology","Cigna","Participating","Enrollment Complete","2021-05-01","6008373","","2021-09-08","9/8/2021 Received an email from 9psscent@cigna.com confirming provider is now participating under group Tax ID effective 5/1/2021 with basic lines of business OAP, PPO and HMO with assigned provider ID 6008373, which was communicated to Rebecca Pontaski via email. KFrazier"]
["Michael T Caglia, MD","1568789550","85-3162122","TX","PE - Basin Dermatology","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","Amerigroup","Enrollment Stopped","Enrollment Stopped","","","","2021-08-05","8/5/2021 Provider will not be accepting Medicaid therefore, Amerigroup enrollment will not be persued.  DCannon"]
["Joan S R Petalcorin, MD","1619008141","75-2656723","TX","PE - Premier Family Care, Inc","HealthSmart PPO","Participating","Enrollment Complete","2016-10-05","1619008141","","2020-06-10","06/10/2020 - Rec'd email from the payer stating this provider is EFF - Stacey Hudak"]
["Joan S R Petalcorin, MD","1619008141","75-2656723","TX","PE - Premier Family Care, 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, Inc","Cigna","Participating","Enrollment Complete",44286,"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, Inc","Boon Chapman","Participating","Enrollment Complete",42655,"","","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","1619008141","75-2656723","TX","PE - Premier Family Care, Inc","CAQH","Active","CAQH Reattested",45531,"11857339","","2024-08-27","08/27/2024 CAQH Reattested updated and uploaded COI wthompson"]
["Joan S R Petalcorin, MD","1619008141","75-2656723","TX","PE - Premier Family Care, Inc","Medicaid","Participating","Enrollment Complete","","361391101","079837301","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"]
["Alim M Ladha, MD","1093935975","45-3020135","TX","PE - Alim M. Ladha, MD","Humana","Participating","Enrollment Complete",44440,"","","2021-11-18","11/18/2021 Rcvd full roster from Humana listing provider as PAR and linked to group TIN/location effective 9/1/2021.  DCannon"]
["Alim M Ladha, MD","1093935975","45-3020135","TX","PE - Alim M. Ladha, MD","Superior","Participating","Enrollment Complete",41153,"1093935975","","2020-07-14","07/14/2020 - Rec'd email from the payer stating this provider is EFF with this TIN under PRIMED DELEGATED agreement - Stacey Hudak"]
["Alim M Ladha, MD","1093935975","45-3020135","TX","PE - Alim M. Ladha, MD","Cigna","Terminated","Terminated",44244,"1093935975","","2021-07-09","7/9/2021 Per Rep Joe, the payor received a written request to terminate the provider's participation in December, 2020, and he was officially terminated with the networks as of 2/17/2021. Notice to payor was received by kbakas@echd.org. Emailed this information to MQA for clarification if they wish for us to initiate new enrollment and pending response. KFrazier"]
["Alim M Ladha, MD","1093935975","45-3020135","TX","PE - Alim M. Ladha, MD","Cigna","Participating","Enrollment Complete","2021-06-01","6313275","","2021-09-13","9/13/2021 Received email from pdmcogz@cigna.com, Their  records indicate that your provider was credentialed as of 06/01/21 under the below tax ID with assigned provider ID 6313275. Cbankston"]
["Leela Sharath Pillarisetty, MD","1235484114","86-3825791","TX","PE - West Texas Ob/Gyn","Wellmed","Participating","Enrollment Complete","2022-05-13","","","2023-03-23","3/23/2023 Rcvd roster from UHC w/ all Wellmed participating providers.  Provider is PAR effective 5/13/2022.  DCannon"]
["Leela Sharath Pillarisetty, MD","1235484114","86-3825791","TX","PE - West Texas Ob/Gyn","Omni PPO","Participating","Application Resubmitted",44571,"","","2024-06-17",""]
["Leela Sharath Pillarisetty, MD","1235484114","86-3825791","TX","PE - West Texas Ob/Gyn","Triwest VA","In House Enrollment","In House Enrollment","","","","2022-02-23",""]
["Leela Sharath Pillarisetty, MD","1235484114","86-3825791","TX","PE - West Texas Ob/Gyn","CAQH","Participating","CAQH Reattested","2024-06-10","","","2024-06-10","06/10/2024 CAQH Reattested updated and uploaded board wthompson"]
["Leela Sharath Pillarisetty, MD","1235484114","86-3825791","TX","PE - West Texas Ob/Gyn","TriCare Standard","Participating","Enrollment Complete",44561,"","","2022-02-25","2/25/2022 Per Tricare portal, provider is linked to location eff 12/31/2021. Cbankston"]
["Leela Sharath Pillarisetty, MD","1235484114","86-3825791","TX","PE - West Texas Ob/Gyn","Scott&White (First Care)","Participating","Enrollment Complete","2022-02-15","","","2022-05-05","5/5/2022 Rcvd email from Scott & White confirming that the February delegation roster has been completed and the provider are now loaded and PAR w/ group TIN/locations effective 2/15/2022.  DCannon"]
["Leela Sharath Pillarisetty, MD","1235484114","86-3825791","TX","PE - West Texas Ob/Gyn","Medicare","Participating","Enrollment Complete","2021-04-17","1S4718","1S4719","2022-05-03","5/3/2022 Rcvd email from Candace with confirmation of group and provider's individual Medicare PTANS.  Group PTAN # 1S4719 and Individual PTAN # 1S4718 - effective 4/17/2021. \nDCannon"]
["Leela Sharath Pillarisetty, MD","1235484114","86-3825791","TX","PE - West Texas Ob/Gyn","IMS","Participating","Application Resubmitted",44571,"","","2024-06-17","Submitted reapplication via delegated roster on 6/14/2024. FC"]
["Leela Sharath Pillarisetty, MD","1235484114","86-3825791","TX","PE - West Texas Ob/Gyn","Aetna","Participating","Application Resubmitted","2022-01-10","","","2024-06-17","Submitted reapplication via delegated roster on 6/14/2024. FC"]
["Leela Sharath Pillarisetty, MD","1235484114","86-3825791","TX","PE - West Texas Ob/Gyn","Multiplan","Participating","Application Resubmitted","2017-09-01","","","2024-06-17","Submitted reapplication via delegated roster on 6/14/2024. FC"]
["Leela Sharath Pillarisetty, MD","1235484114","86-3825791","TX","PE - West Texas Ob/Gyn","Multiplan","Participating","Application Resubmitted","2017-09-01","","","2024-06-17","Submitted reapplication via delegated roster on 6/14/2024. FC"]
["Leela Sharath Pillarisetty, MD","1235484114","86-3825791","TX","PE - West Texas Ob/Gyn","USA PPO","Participating","Enrollment Complete","2022-01-10","","","2022-03-29","3/29/2022  In following up with USAMCO (800-872-3860) I was told that you can confirm participating via the USA MCO website  https://providersearch.usamco.com/hwprovsearch.  Provider is PAR and linked to location/TIN effective 1/10/2022.  DCannon"]
["Leela Sharath Pillarisetty, MD","1235484114","86-3825791","TX","PE - West Texas Ob/Gyn","Amerigroup","Participating","Application Resubmitted",44571,"12802966","","2024-06-17","Submitted reapplication via delegated roster on 6/14/2024. FC"]
["Leela Sharath Pillarisetty, MD","1235484114","86-3825791","TX","PE - West Texas Ob/Gyn","Wellcare","Participating","Enrollment Complete",44501,"","","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 Sharath Pillarisetty, MD","1235484114","86-3825791","TX","PE - West Texas Ob/Gyn","Wellcare","Participating","Enrollment Complete",44501,"","","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 Sharath Pillarisetty, MD","1235484114","86-3825791","TX","PE - West Texas Ob/Gyn","Humana","Participating","Enrollment Complete","2022-01-10","","","2022-06-19","6/19/2022 Per email received from V. Thomas at Humana provider is PAR and linked to group TIN effective 1/10/2022.  DCannon"]
["Leela Sharath Pillarisetty, MD","1235484114","86-3825791","TX","PE - West Texas Ob/Gyn","Superior","Participating","Enrollment Complete",44593,"","","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 Sharath Pillarisetty, MD","1235484114","86-3825791","TX","PE - West Texas Ob/Gyn","United Health Care","Participating","Enrollment Complete","2022-01-10","","","2022-06-11","6/11/2022 Per email from Janice Edwards @ UHC delegated roster provider load has been completed and providers PAR and linked to group TIN effective 1/10/2022.  DCannon"]
["Leela Sharath Pillarisetty, MD","1235484114","86-3825791","TX","PE - West Texas Ob/Gyn","United Health Care","Participating","Enrollment Complete",44571,"","","2022-06-11","6/11/2022 Per email from Janice Edwards @ UHC delegated roster provider load has been completed and providers PAR and linked to group TIN effective 1/10/2022.  DCannon"]
["Leela Sharath Pillarisetty, MD","1235484114","86-3825791","TX","PE - West Texas Ob/Gyn","Boon Chapman","Participating","Enrollment Complete","2017-09-01","","","2022-03-10","3/10/2022 Rcvd roster from Multiplan listing provider as PAR and listed under group TIN/location effective 9/1/2017.  DCannon"]
["Kavitha Bagadi, MD","1871782961","47-5554737","TX","PE - Midland Inpatient Medical Association","Omni PPO","Participating","Enrollment Complete","2019-09-01","1871782961","","2020-07-27","IMS approved"]
["Kavitha Bagadi, MD","1871782961","47-5554737","TX","PE - Midland Inpatient Medical Association","IMS","Participating","Enrollment Complete","2019-09-01","1871782961","","2020-07-27","07/27/2020 - Rec'd roster response back from the payer regarding 7/15/2020 submission stating that all requested providers/service locations have been added to PriMed agreement - Stacey Hudak"]
["Kavitha Bagadi, MD","1871782961","47-5554737","TX","PE - Midland Inpatient Medical Association","Caprock (CapStar)","Participating","Enrollment Complete","2020-03-01","1871782961","","",""]
["Kavitha Bagadi, MD","1871782961","47-5554737","TX","PE - Midland Inpatient Medical Association","CAQH","Participating","CAQH Reattested","2024-08-29","","","2024-08-29","08/29/2024 CAQH Reattested updated and uploaded COI wthompson"]
["Kavitha Bagadi, MD","1871782961","47-5554737","TX","PE - Midland Inpatient Medical Association","Triwest VA","Enrollment Stopped","Enrollment Stopped","","","","","Practice is hospital-based; not eligible for TriWest VA enrollment"]
["Anju B Varanasi, MD","1407070162","47-5554737","TX","PE - Midland Inpatient Medical Association","Rail Road Medicare","Participating","Enrollment Complete",42629,"P01752760","DW7662","2024-08-20","Provider is enrolled and linked to this group. MS"]
["Anju B Varanasi, MD","1407070162","47-5554737","TX","","Rail Road Medicare","Participating","Enrollment Complete",42629,"P01752760","DW7662","2024-08-20","Provider is enrolled and linked to this group. MS"]
["Anju B Varanasi, MD","1407070162","47-5554737","TX","PE - Midland Inpatient Medical Association","TriCare Standard","Participating","Enrollment Complete","2018-12-09","","","2024-08-23","Provider is linked to this location. MS"]
["Anju B Varanasi, MD","1407070162","47-5554737","TX","","CAQH","Provider Load","CAQH Reattested","2024-08-12","","","2024-08-12","08/12/2024 CAQH Sweep, updated board, COI, practice location, cred contact, and email. uploaded docs wthompson"]
["Tiffany D Cossey, MD","1053601344","75-2656723","TX","PE - Premier Family Care, Inc","Superior","Participating","Enrollment Complete","2020-08-01","1053601344","","2020-08-06","8/6/2020 - Rec'd an email from the payer stating this provider was added to their database EFF: 8-1-2020 after receiving/processing the July roster - Stacey Hudak"]
["Tiffany D Cossey, MD","1053601344","75-2656723","TX","PE - Premier Family Care, Inc","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"]
["Tiffany D Cossey, MD","1053601344","75-2656723","TX","","IMS","Participating","Application Resubmitted","2019-05-21","1053601344","","2024-07-18","Submitted reapplication via delegated roster on 7/15/2024. FC"]
["Tiffany D Cossey, MD","1053601344","75-2656723","TX","PE - Premier Family Care, Inc","HealthSmart PPO","Participating","Application Resubmitted","2019-05-31","1053601344","","2024-07-18","Submitted reapplication via delegated roster on 7/15/2024. FC"]
["Tiffany D Cossey, MD","1053601344","75-2656723","TX","PE - Premier Family Care, Inc","Omni PPO","Participating","Enrollment Complete","2019-05-21","1053601344","","2020-06-26",""]
["Tiffany D Cossey, MD","1053601344","75-2656723","TX","","Omni PPO","Participating","Enrollment Complete",43606,"1053601344","","2020-06-26",""]
["Tiffany D Cossey, MD","1053601344","75-2656723","TX","PE - Premier Family Care, Inc","Caprock (CapStar)","Participating","Application Resubmitted",43559,"1053601344","","2024-07-18","Submitted reapplication via delegated roster on 7/15/2024. FC"]
["Tiffany D Cossey, MD","1053601344","75-2656723","TX","","Multiplan","Participating","Enrollment Complete",43559,"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","1053601344","75-2656723","TX","","Multiplan","Participating","Application Resubmitted","2019-04-04","1053601344","52669: West Texas Physicians Alliance Group Cntrct","2024-07-18","Submitted reapplication via delegated roster on 7/15/2024. FC"]
["Evbu O Enakpene, MD","1972816189","27-4061759","TX","PE - Permian Cardiology Inc.","Omni PPO","Participating","Enrollment Complete","2019-02-28","1972816189","","2020-06-29","06/29/2020 - confirmed IMS is par - therefore this enrollment is also effective - Stacey Hudak"]
["Evbu O Enakpene, MD","1972816189","27-4061759","TX","","HealthSmart PPO","Participating","Enrollment Complete","2018-02-28","1972816189","","2020-06-05","06/05/2020  - Rec'd email from the payer stating this provider is EFF - Stacey Hudak"]
["Evbu O Enakpene, MD","1972816189","27-4061759","TX","PE - Permian Cardiology Inc.","Rail Road Medicare","Participating","Enrollment Complete","2017-09-01"," P02260538","DS1746","2020-10-09","10/9/2020 - double checked the PTAN and found it was reveresed in the payer line. Found working/effective RRMCRPTAN and updated payer line - Stacey Hudak"]
["Evbu O Enakpene, MD","1972816189","27-4061759","TX","","Galaxy Health","Participating","Enrollment Complete","2018-02-28","1972816189","","2020-07-17","7/17/20- Received a spreadsheet from the payer stating this provider is effective as of 2/28/2018. – Jerha Gayorgor"]
["Evbu O Enakpene, MD","1972816189","27-4061759","TX","PE - Permian Cardiology Inc.","USA PPO","Participating","Enrollment Complete",43341,"","","2020-09-09","Confirmed provider is participating with PPO and H&W networks (list of networks attached). Kimberly Frazier"]
["Evbu O Enakpene, MD","1972816189","27-4061759","TX","","Triwest VA","Facility Enrollment","Facility Enrollment","","","","2022-10-17","10/17/2022 - Received roster from Scarlett; provider status: \"No Action.  TIN is CCN participating under own DCN.\""]
["Evbu O Enakpene, MD","1972816189","27-4061759","TX","PE - Permian Cardiology Inc.","Wellmed","Participating","Enrollment Complete","2022-01-01","","","2023-03-23","3/23/2023 Rcvd roster from UHC w/ all Wellmed participating providers.  Provider is PAR effective 1/1/2022.  DCannon"]
["Evbu O Enakpene, MD","1972816189","27-4061759","TX","PE - Permian Cardiology Inc.","Boon Chapman","Participating","Enrollment Complete","2018-01-30","","","2021-08-06",""]
["Evbu O Enakpene, MD","1972816189","27-4061759","TX","","Boon Chapman","Participating","Enrollment Complete","2018-01-30","","","2021-08-06",""]
["Evbu O Enakpene, MD","1972816189","27-4061759","TX","PE - Permian Cardiology Inc.","Wellcare","Participating","Enrollment Complete",44501,"","","2022-11-15","11/15/2022 Per roster received from Wellcare provider is PAR and linked to group TIN/location effective 11/1/2021.  DCannon"]
["Evbu O Enakpene, MD","1972816189","27-4061759","TX","","Multiplan","Participating","Enrollment Complete","2018-01-30","1972816189","","2020-02-12","02/12/2020 - rec'd confirmation from the payer stating \" Provider:Evbu Enakpene \nNetwork: MPI\nNetwork Participation effective:1/30/2018\nContract Source Group contract through DELEGATED PARTY: West Texas Physicians Alliance\" - Stacey Hudak"]
["Chelsea N Luebke, APRN-FNP-BC","1427452945","46-3131679","TX","PE - Midland Texas Orthopedic Group Inc","CAQH","Participating","CAQH Reattested","2024-07-10","","","2024-07-10","07/10/2024 CAQH Reattested all locations current and all expirables up to date wthompson"]
["Chelsea N Luebke, APRN-FNP-BC","1427452945","46-3131679","TX","PE - Midland Texas Orthopedic Group Inc","Molina","Pending Other Enrollment","Pending Contracting","","","","2024-08-07","Contract request form for the group and provider was submitted to mhtcontractrequest@molinahealthcare.com MS"]
["Chelsea N Luebke, APRN-FNP-BC","1427452945","46-3131679","TX","PE - Midland Texas Orthopedic Group Inc","United Health Care","Participating","Enrollment Complete","2018-01-01","5396301","","2020-07-30","7/30/2020 - moved to completed status after reviewing follow up complete note - Stacey Hudak"]
["Chelsea N Luebke, APRN-FNP-BC","1427452945","46-3131679","TX","PE - Midland Texas Orthopedic Group Inc","Medicaid","Participating","Enrollment Complete","2017-11-27","343965503","","2020-06-25","06/25/2020 - Rec'd proof of enrollment from the clinic and updated payer line - Stacey Hudak"]
["Chelsea N Luebke, APRN-FNP-BC","1427452945","46-3131679","TX","PE - Midland Texas Orthopedic Group Inc","Rail Road Medicare","Participating","Enrollment Complete","2017-11-27","P02027037","DU5783","2020-03-10","03/10/2020 - Found EFF info through payer portal - Stacey Hudak"]
["Chelsea N Luebke, APRN-FNP-BC","1427452945","46-3131679","TX","","Rail Road Medicare","Participating","Enrollment Complete",43066,"P02027037","DU5783","2020-03-10","03/10/2020 - Found EFF info through payer portal - Stacey Hudak"]
["Chelsea N Luebke, APRN-FNP-BC","1427452945","46-3131679","TX","PE - Midland Texas Orthopedic Group Inc","First Health Coventry","Participating","Enrollment Complete","2018-08-01","2878466","","2020-03-20","03/20/2020 - Rec'd from the payer stating this provider is EFF under PID# 2878466 - Stacey Hudak"]
["Chelsea N Luebke, APRN-FNP-BC","1427452945","46-3131679","TX","PE - Midland Texas Orthopedic Group Inc","Alliance WC","In Process","Payor Follow Up","","","","2024-08-13","Per michelle.killough@pswca.org, provider has been approved to join network. Submit Provider Data Form with license, DEA, Cert, COI and W9. \nEmailed above to michelle.killough@pswca.org. Jen Videan"]
["Chelsea N Luebke, 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, APRN-FNP-BC","1427452945","46-3131679","TX","PE - Midland Texas Orthopedic Group Inc","Multiplan","Participating","Enrollment Complete","2018-01-03","1427452945","Midland Texas Orthopedic Group Inc.","2020-09-24","09/24/2020 -moved to completed status after reviewing follow up complete note - Stacey Hudak"]
["Chelsea N Luebke, APRN-FNP-BC","1427452945","46-3131679","TX","PE - Midland Texas Orthopedic Group Inc","Gallagher","Participating","Enrollment Complete","","","","2024-01-27","Confirmed via Coventry portal the provider is enrolled via the WC Integrated Network MS"]
["Jeffrey Hunter Atkins, MD","1760860720","75-2656723","TX","PE - Premier Family Care, Inc","IMS","Participating","Enrollment Complete","2023-11-01","","","2024-01-02","1/2/2024 Rcvd email from German Avilies at IMS/OMNI that October delegation roster is complete.  Provider is PAR and linked to group TIN/location effective 11/1/2023.  DCannon"]
["Jeffrey Hunter Atkins, MD","1760860720","84-2617748","TX","PE - Midland Medicine PA","CAQH","Participating","CAQH Reattested","2024-08-28","","","2024-08-28","08/28/2024 CAQH Reattested updated and uploaded COI wthompson"]
["Jeffrey Hunter Atkins, MD","1760860720","84-2617748","TX","PE - Premier Family Care, Inc","CAQH","Participating","CAQH Reattested","2024-08-28","","","2024-08-28","08/28/2024 CAQH Reattested updated and uploaded COI wthompson"]
["Jeffrey Hunter Atkins, MD","1760860720","47-5554737","TX","PE - Midland Inpatient Medical Association","Caprock (CapStar)","Participating","Enrollment Complete","2018-07-24","1760860720","","2020-06-02","06/02/2020 - rec'd spreadsheet back from the payer Mary Rodriguez <MRodriguez@caprockhp.com> confirming this provider/service location is EFF with this payer - Stacey Hudak"]
["Jeffrey Hunter Atkins, MD","1760860720","75-2656723","TX","PE - Premier Family Care, Inc","Wellmed","Participating","Enrollment Complete","2023-11-01","0040519489","","2023-11-15","11/15/2023 Per email received from UHC provider is PAR and linked to group TIN effective 11/1/2023.  MPIN# 0040519489.  DCannon"]
["Jeffrey Hunter Atkins, MD","1760860720","75-2656723","TX","PE - Premier Family Care, Inc","Multiplan","Participating","Enrollment Complete",45231,"","","2023-11-09","11/9/2023 Rcvd email confirmation from Jessica Bess at Multiplan that October roster has been processed and provider is PAR w/ group effective 11/1/2023.  DCannon"]
["Jeffrey Hunter Atkins, MD","1760860720","84-2617748","TX","PE - Midland Medicine PA","IMS","Participating","Enrollment Complete","2022-06-01","","","2022-07-05","7/5/2022 Rcvd email from G.Aviles at IMS/OMNI that delegation roster provider load for June has been completed.  Provider is PAR and linked to group effective 6/1/2022.  DCannon"]
["Jeffrey Hunter Atkins, MD","1760860720","47-5554737","TX","PE - Midland Inpatient Medical Association","IMS","Participating","Enrollment Complete","2018-07-24","1760860720","","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 Hunter Atkins, MD","1760860720","84-2617748","TX","PE - Midland Medicine PA","Aetna","Participating","Enrollment Complete","2022-06-01","6107649","","2022-06-02","6/2/2022 Per Aetna provider directory provider is PAR and linked to group TIN/location effective 6/1/2022.   DCannon"]
["Jeffrey Hunter Atkins, MD","1760860720","75-2656723","TX","PE - Premier Family Care, Inc","First Health Coventry","Participating","Enrollment Complete","2023-11-01","3165776","","2023-12-06","12/6/2023 S/W Kim of First Health @ 800-226-5116 and transferred me over to Courtney. Per rep, Provider is in network with First Health and linked to the group and TIN# effective 11/1/2023.  PIN: 3165776. Servicing location is on file. No payer# available. DCannon"]
["Jeffrey Hunter Atkins, MD","1760860720","47-5554737","TX","PE - Midland Inpatient Medical Association","TriCare Standard","Participating","Enrollment Complete","2018-07-11","1760860720","","2020-03-03","03/03/2020 - This provider is linked to this group and service location, however, this group/provdier is NON NETWORK. This payer is not currently open to accepting new groups/providers in network.  - Stacey HUdak"]
["Jeffrey Hunter Atkins, MD","1760860720","75-2656723","TX","PE - Premier Family Care, Inc","Triwest VA","In House Enrollment","In House Enrollment","","","","2023-10-09",""]
["Jeffrey Hunter Atkins, MD","1760860720","84-2617748","TX","PE - Midland Medicine PA","Ambetter","Participating","Enrollment Complete","2022-06-01","","","2022-06-13","6/13/2022 Per roster received from Superior provider is PAR and linked to group delegation roster effective 6/1/2022."]
["Jeffrey Hunter Atkins, MD","1760860720","84-2617748","TX","PE - Midland Medicine PA","Multiplan","Participating","Enrollment Complete","2022-06-01","","","2022-07-24","7/24/2022 Per email from Marcie Eckhart-Havens Multiplan July delegated roster has been completed  and provider is PAR and linked to group TIN effective 6/1/2022.  DCannon"]
["Jeffrey Hunter Atkins, MD","1760860720","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","75-2656723","TX","PE - Premier Family Care, Inc","Amerigroup","Participating","Enrollment Complete","2023-11-01","","","2023-11-09","11/9/2023 Per email received from Jessica Bess at  Multiplan provider is PAR with Amerigroup and linked to group TIN/locations thru Multiplan enrollment effective 11/1/2023.  DCannon"]
["Jeffrey Hunter Atkins, MD","1760860720","47-5554737","TX","PE - Midland Inpatient Medical Association","Boon Chapman","Participating","Enrollment Complete","2020-03-20","","","2022-09-13","9/13/2022 Per roster received from Multiplan provider is PAR and linked to group TIN/location effective 3/20/2020.  DCannon"]
["Jeffrey Hunter Atkins, MD","1760860720","75-2656723","TX","PE - Premier Family Care, Inc","HealthSmart PPO","Participating","Enrollment Complete","2023-11-01","","","2023-12-15","12/15/2023 Per email rcvd from Aleece Moerbe at Healthsmart provider is PAR and linked to group TIN/location effective 11/1/2023.  DCannon"]
["Jeffrey Hunter Atkins, MD","1760860720","47-5554737","TX","PE - Midland Inpatient Medical Association","Rail Road Medicare","Participating","Enrollment Complete","2018-08-01","P02179382","DW7662","2020-05-04","05/04/2020 -verified and moved to completed status - Stacey Hudak"]
["Jeffrey Hunter Atkins, MD","1760860720","47-5554737","TX","PE - Midland Inpatient Medical Association","Scott&White (First Care)","Participating","Enrollment Complete","2018-08-01","1760860720","","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\n\n**verified the provider is networked with: \nCHIP\nHMO Enhanced Benefit Network\nMedicaid (FC)\nMedicare (FC)"]
["Amber J White, PA","1255614970","47-5554737","TX","PE - Midland Inpatient Medical Association","United Health Care","Participating","Enrollment Complete","2017-08-15","1255614970","","2020-06-09","06/09/2020 - Rec'd email from the payer stating \"Provider is a hospital based provider – no cred process necessary. provider is part of a direct group contract\" - Stacey Hudak"]
["Amber J White, PA","1255614970","47-5554737","TX","PE - Midland Inpatient Medical Association","CAQH","Participating","CAQH Reattested","2024-08-30","12614131","","2024-08-30","08/30/2024 CAQH Reattested updated and uploaded COI wthompson"]
["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","Boon Chapman","Participating","Enrollment Complete","2020-04-03","","","2022-07-24","7/24/2022 Per email from Marcie Eckhart-Havens Multiplan July delegated roster has been completed  and provider is PAR and linked to group TIN effective 4/3/2020.   DCannon"]
["Amber J White, PA","1255614970","47-5554737","TX","PE - Midland Inpatient Medical Association","Cigna","Participating","Enrollment Complete",43709,"3709059","","2020-04-06","04/06/2020 - Rec'd email from the payer stating \"Thank you for your submission. This is to conform that your request has been completed.\"\nThis provider was linked to this group as a hospitalist - Stacey Hudak"]
["Amber J White, PA","1255614970","47-5554737","TX","PE - Midland Inpatient Medical Association","Caprock (CapStar)","Participating","Enrollment Complete",43891,"1255614970","","",""]
["Luis F Hernandez, DO","1447412895","47-5554737","TX","","Cigna","Participating","Enrollment Complete",42724,"6703681","","2020-06-25","6-25-2020 - Moved to completed status based on info rec'd during follow up complete call - Stacey Hudak"]
["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",43709,"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",43724,"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","Wellmed","Participating","Enrollment Complete",44562,"","","2023-03-23","3/23/2023 Rcvd roster from UHC w/ all Wellmed participating providers.  Provider is PAR effective 1/1/2022.  DCannon"]
["Luis F Hernandez, DO","1447412895","47-5554737","TX","PE - Midland Inpatient Medical Association","TriCare Standard","Participating","Enrollment Complete",43991,"1447412895","","2020-09-09","09/09/2020 - moved to completed status after reviewing previous note - Stacey Hudak"]
["Indira Donepudi, MD","1447406137","81-1031742","TX","PE - Permian Digestive Disease Center PA","Humana","Participating","Enrollment Complete",43376,"","","2024-06-21","Received confirmation from Marcus Wester provider is PAR and linked to TIN/location, eff. 10/03/2018. PA"]
["Indira Donepudi, MD","1447406137","81-1031742","TX","","TriCare Standard","Participating","Enrollment Complete","2024-01-19","","","2024-02-07","Confirmed provider is enrolled at this location. MS"]
["Indira Donepudi, MD","1447406137","81-1031742","TX","PE - Permian Digestive Disease Center PA","BCBSTX","Participating","Enrollment Complete","2016-02-12","","","2024-07-31","Received email confirmation, provider is par and linked to TIN & locations. Participating LOBs: Blue Advantage HMO eff. 02/12/2016, Blue Choice PPO, eff. 02/12/2016, Health Select eff 04/01/2017, Blue Essentials HMO eff. 02/20/2016, TriWest, eff 10/01/2016. PA."]
["Indira Donepudi, MD","1447406137","81-1031742","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","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 Hudak"]
["Indira Donepudi, MD","1447406137","81-1031742","TX","PE - Permian Digestive Disease Center PA","Ambetter","Participating","Enrollment Complete",44652,"","","2024-04-29","Per email from Sebastian Flores (sebastian.flores@superiorhealthplan.com), provider is PAR and linked to TIN/location, eff 04/01/2022. PA."]
["Indira Donepudi, MD","1447406137","81-1031742","TX","","Ambetter","Participating","Enrollment Complete",44652,"","","2024-04-29","Per email from Sebastian Flores (sebastian.flores@superiorhealthplan.com), provider is PAR and linked to TIN/location, eff 04/01/2022. PA."]
["Indira Donepudi, MD","1447406137","81-1031742","TX","PE - Permian Digestive Disease Center PA","USA PPO","Participating","Enrollment Complete",42460,"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","TX","","HealthSmart PPO","Participating","Enrollment Complete","2024-01-01","","","2024-05-28","Spoke to Yvonne call ref#110778 provider participating with new location as of 1/1/2024. FC"]
["Indira Donepudi, MD","1447406137","81-1031742","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","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","TX","","Omni PPO","Participating","Application Resubmitted","2024-01-01","","","2024-07-18","Submitted reapplication via delegated roster on 7/15/2024. FC"]
["Indira Donepudi, MD","1447406137","81-1031742","TX","PE - Permian Digestive Disease Center PA","Caprock (CapStar)","Participating","Application Resubmitted","2024-01-01","","","2024-07-18","Submitted reapplication via delegated roster on 7/15/2024. FC"]
["Indira Donepudi, MD","1447406137","81-1031742","TX","","Multiplan","Participating","Enrollment Complete","2024-01-01","","","2024-06-20","Spoke to Bri W. (call ref# 10514349) 3409 Andrews Hwy location participating as of 1/1/2024. FC"]
["Indira Donepudi, MD","1447406137","81-1031742","TX","PE - Permian Digestive Disease Center PA","Multiplan","Participating","Application Resubmitted","2024-01-01","","","2024-07-18","Submitted reapplication via delegated roster on 7/15/2024. FC"]
["Indira Donepudi, MD","1447406137","81-1031742","TX","","IMS","Participating","Application Resubmitted",45292,"","","2024-07-18","Submitted reapplication via delegated roster on 7/15/2024. FC"]
["Indira Donepudi, MD","1447406137","81-1031742","TX","","Triwest VA","Participating","Enrollment Complete",44774,"","","2022-11-14","11/14/22 Per Scarlett Abigail, provider effective 8/1/22"]
["Indira Donepudi, MD","1447406137","81-1031742","TX","PE - Permian Digestive Disease Center PA","Omni PPO","Participating","Enrollment Complete",44075,"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","TX","","Omni PPO","Participating","Enrollment Complete",44075,"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","TX","PE - Permian Digestive Disease Center PA","First Health Coventry","Participating","Application Resubmitted",45335,"","","2024-07-18","Submitted reapplication via delegated roster on 7/15/2024. FC"]
["Indira Donepudi, MD","1447406137","81-1031742","TX","","Aetna","Participating","Application Resubmitted",43709,"1447406137","","2024-07-18","Submitted reapplication via delegated roster on 7/15/2024. FC"]
["Indira Donepudi, MD","1447406137","81-1031742","TX","PE - Permian Digestive Disease Center PA","Boon Chapman","Thru Other Payor","Pending Other Enrollment","","","","2024-01-12","1/12/2024 Pending Multiplan enrollment.  DCannon"]
["Indira Donepudi, MD","1447406137","81-1031742","TX","","IMS","Participating","Application Resubmitted","2019-09-01","1447406137","","2024-07-18","Submitted reapplication via delegated roster on 7/15/2024. FC"]
["Indira Donepudi, MD","1447406137","81-1031742","TX","PE - Permian Digestive Disease Center PA","Aetna","Participating","Enrollment Complete","2024-01-01","","","2024-05-20","5/20/2024- Spoke to Dan R. call ref #6192810917 3409 Andrews Hwy address effective as of 1/1/2024, provider listed as a SPEC. FC"]
["Indira Donepudi, MD","1447406137","81-1031742","TX","","Aetna","Participating","Enrollment Complete","2024-01-01","","","2024-05-20","5/20/2024- Spoke to Dan R. call ref #6192810917 3409 Andrews Hwy address effective as of 1/1/2024, provider listed as a SPEC. FC"]
["Indira Donepudi, MD","1447406137","81-1031742","TX","PE - Permian Digestive Disease Center PA","Aetna","Participating","Application Resubmitted","2024-01-01","","","2024-07-18","Submitted reapplication via delegated roster on 7/15/2024. FC"]
["Indira Donepudi, MD","1447406137","81-1031742","TX","","Aetna","Participating","Application Resubmitted","2024-01-01","","","2024-07-18","Submitted reapplication via delegated roster on 7/15/2024. FC"]
["Indira Donepudi, MD","1447406137","81-1031742","TX","PE - Permian Digestive Disease Center PA","Scott&White (First Care)","Participating","Enrollment Complete","2024-02-01","","","2024-07-26","Received email confirmation provider is PAR and linked to location, eff. 02/01/2024. PA."]
["Indira Donepudi, MD","1447406137","81-1031742","TX","","Scott&White (First Care)","Participating","Enrollment Complete","2024-02-01","","","2024-07-26","Received email confirmation provider is PAR and linked to location, eff. 02/01/2024. PA."]
["Indira Donepudi, MD","1447406137","81-1031742","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","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","TX","PE - Permian Digestive Disease Center PA","Amerigroup","Participating","Application Resubmitted","2018-05-03","","","2024-07-18","Submitted reapplication via delegated roster on 7/15/2024. FC"]
["Indira Donepudi, MD","1447406137","81-1031742","TX","","Amerigroup","Participating","Application Resubmitted","2018-05-03","","","2024-07-18","Submitted reapplication via delegated roster on 7/15/2024. FC"]
["Indira Donepudi, MD","1447406137","81-1031742","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","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","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","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","TX","PE - Permian Digestive Disease Center PA","Caprock (CapStar)","Participating","Application Resubmitted","2016-05-01","1447406137","","2024-07-18","Submitted reapplication via delegated roster on 7/15/2024. FC"]
["Indira Donepudi, MD","1447406137","81-1031742","TX","","Caprock (CapStar)","Participating","Application Resubmitted",42491,"1447406137","","2024-07-18","Submitted reapplication via delegated roster on 7/15/2024. FC"]
["Indira Donepudi, MD","1447406137","81-1031742","TX","PE - Permian Digestive Disease Center PA","Rail Road Medicare","Participating","Enrollment Complete",42378,"P01708900","DW5495","2024-03-06","Provider is enrolled. MS"]
["Indira Donepudi, MD","1447406137","81-1031742","TX","","Rail Road Medicare","Participating","Enrollment Complete",42378,"P01708900","DW5495","2024-03-06","Provider is enrolled. MS"]
["Indira Donepudi, MD","1447406137","81-1031742","TX","PE - Permian Digestive Disease Center PA","Medicare","Participating","Enrollment Complete","","","","2024-02-07","Received confirmation from the group enrollment that all information has been updated. There is no individual enrollment needed for the provider. MS"]
["Indira Donepudi, MD","1447406137","81-1031742","TX","","Medicare","Participating","Enrollment Complete","","","","2024-02-07","Received confirmation from the group enrollment that all information has been updated. There is no individual enrollment needed for the provider. MS"]
["Indira Donepudi, MD","1447406137","81-1031742","TX","PE - Permian Digestive Disease Center PA","USA PPO","In Process","Enrollment Complete","","","","2024-03-07","Received email confirmation provider is PAR and linked to TIN & location, eff. 01/01/2024. PA."]
["Indira Donepudi, MD","1447406137","81-1031742","TX","","USA PPO","In Process","Enrollment Complete","","","","2024-03-07","Received email confirmation provider is PAR and linked to TIN & location, eff. 01/01/2024. PA."]
["Indira Donepudi, MD","1447406137","81-1031742","TX","PE - Permian Digestive Disease Center PA","Galaxy Health","Participating","Enrollment Complete",43709,"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","TX","","Galaxy Health","Participating","Enrollment Complete",43709,"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"]
["Tiffany B Hansen, APRN-FNP-BC","1750794749","20-8658501","TX","PE - Shylesh Ganta, MD, PA","Rail Road Medicare","Participating","Enrollment Complete",41800,"P02417404","DO2096","2020-08-31","08/31/2020 - moved to completed status after reviewing follow up complete note and downloading EFF letter - Stacey Hudak"]
["Tiffany B Hansen, APRN-FNP-BC","1750794749","20-8658501","TX","PE - Shylesh Ganta, MD, PA","Humana","Participating","Enrollment Complete","2021-09-01","","","2021-11-18","11/18/2021 Rcvd full roster from Humana listing provider as PAR and linked to group TIN/location effective 9/1/2021.  DCannon"]
["Tiffany B Hansen, APRN-FNP-BC","1750794749","20-8658501","TX","PE - Shylesh Ganta, MD, PA","IMS","Participating","Enrollment Complete","2019-09-01","1750794749","","2020-07-27","07/27/2020 - Rec'd roster response back from the payer regarding 7/15/2020 submission stating that all requested providers/service locations have been added to PriMed agreement - Stacey Hudak"]
["Tiffany B Hansen, APRN-FNP-BC","1750794749","20-8658501","TX","PE - Shylesh Ganta, MD, PA","Scott&White (First Care)","Participating","Enrollment Complete","2020-09-28","","","2021-01-29","1/29/2021 - Rcvd roster from Scott&White (First Care) confirming participation of provider with TIN and location effective dates.  DCannon"]
["Tiffany B Hansen, APRN-FNP-BC","1750794749","20-8658501","TX","PE - Shylesh Ganta, MD, PA","Multiplan","Participating","Enrollment Complete","2020-04-03","","","2022-07-24","7/24/2022 Per email from Marcie Eckhart-Havens Multiplan July delegated roster has been completed  and provider is PAR and linked to group TIN effective 4/3/2020.   DCannon"]
["Tiffany B Hansen, APRN-FNP-BC","1750794749","20-8658501","TX","PE - Shylesh Ganta, MD, PA","Caprock (CapStar)","Participating","Enrollment Complete","2019-09-01","1750794749","","2020-09-23","09/23/2020 - rec'd confirmation from the payer that this August 2020 roster was completed. This provider/service location was added to PriMed Agreement - OK to move to completed status. - Stacey Hudak"]
["Tiffany B Hansen, APRN-FNP-BC","1750794749","20-8658501","TX","PE - Shylesh Ganta, MD, PA","HealthSmart PPO","Participating","Enrollment Complete","2020-04-03","","","2022-02-26","2/26/2022 Per Healthsmart website provider is PAR and loaded under TIN/location effective 4/3/2020.  DCannon"]
["Tiffany B Hansen, APRN-FNP-BC","1750794749","20-8658501","TX","PE - Shylesh Ganta, MD, PA","USA PPO","Participating","Enrollment Complete","2021-01-26","1312309","","2021-03-13","3/12/2021 Per verification on payor website USAMCO.com provider is loaded as participating.  Rcvd Roster LeNetrice Myart with provider numbers and effective dates for providers.  DCannon"]
["Tiffany B Hansen, APRN-FNP-BC","1750794749","20-8658501","TX","PE - Shylesh Ganta, MD, PA","Triwest VA","In House Enrollment","In House Enrollment","","","","2021-01-13","1/6/2021 MQA Team is working with Representatives at BCBS-TX to ensure all providers are enrolled and loaded to participate with the VACCN network in a timely manner. However, we are currently awaiting a full roster of providers currently participating and will update all records immediately upon receipt. KFrazier"]
["Tiffany B Hansen, APRN-FNP-BC","1750794749","20-8658501","TX","PE - Shylesh Ganta, MD, PA","Cigna","Participating","Enrollment Complete","2020-09-15","5009460","","2020-09-18","09/18/2020 - Your effective date is 09/15/2020. Your provider identification number is 5009460.  - Stacey Hudak"]
["Tiffany B Hansen, APRN-FNP-BC","1750794749","20-8658501","TX","PE - Shylesh Ganta, MD, PA","Aetna","Participating","Enrollment Complete","2020-08-01","","","2024-08-27","Provider participating as of 8/1/2020, listed as PCP, received via roster from Brandy Smith. FC"]
["Tiffany B Hansen, APRN-FNP-BC","1750794749","20-8658501","TX","PE - Shylesh Ganta, MD, PA","Boon Chapman","Participating","Enrollment Complete","2020-04-03","","","2022-07-24","7/24/2022 Per email from Marcie Eckhart-Havens Multiplan July delegated roster has been completed  and provider is PAR and linked to group TIN effective 4/3/2020.   DCannon"]
["Tiffany B Hansen, APRN-FNP-BC","1750794749","20-8658501","TX","PE - Shylesh Ganta, MD, PA","Medicare","Participating","Enrollment Complete","2014-06-10","363200ZH9T","00Y323","2020-03-10","03/10/2020 - Confimed through PECOS that this provider is linked to the corect group and EFF 6-10-2014 - Stacey Hudak"]
["Tiffany B Hansen, APRN-FNP-BC","1750794749","20-8658501","TX","PE - Shylesh Ganta, MD, PA","Wellmed","Participating","Enrollment Complete","2022-01-01","","","2023-03-23","3/23/2023 Rcvd roster from UHC w/ all Wellmed participating providers.  Provider is PAR effective 1/1/2022.  DCannon"]
["Tiffany B Hansen, APRN-FNP-BC","1750794749","20-8658501","TX","PE - Shylesh Ganta, MD, PA","United Health Care","Participating","Enrollment Complete","2019-12-01","1750794749","","2020-07-30","7/30/2020 - moved to completed status after reviewing follow up complete note - Stacey Hudak"]
["Tiffany B Hansen, APRN-FNP-BC","1750794749","20-8658501","TX","PE - Shylesh Ganta, MD, PA","Galaxy Health","Participating","Enrollment Complete","2019-09-01","1750794749","","2020-08-24","08/21/2020 - Rec'd email confirmation that this roster was processed and this provider was made effective with the requested eff date of 9-1-2019 - Stacey Hudak"]
["Tiffany B Hansen, APRN-FNP-BC","1750794749","20-8658501","TX","PE - Shylesh Ganta, MD, PA","Omni PPO","Participating","Enrollment Complete","2019-09-01","1750794749","","2020-07-27","IMS completed"]
["Tiffany B Hansen, APRN-FNP-BC","1750794749","20-8658501","TX","PE - Shylesh Ganta, MD, PA","CAQH","Participating","CAQH Reattested","2024-08-16","12740460","","2024-06-10","06/10/2024 CAQH Reattested all locations current. Updated and uploaded COI wthompson"]
["Tiffany B Hansen, APRN-FNP-BC","1750794749","20-8658501","TX","PE - Shylesh Ganta, MD, PA","First Health Coventry","Participating","Enrollment Complete","2020-08-01","3524170","","2022-04-05","4/5/2022  Per First Health online provider directory provider is PAR and linked to group/locations  effective 8/1/2020.  DCannon"]
["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","2020-05-15","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","2024-08-29","11714128","","2024-08-29","08/29/2024 CAQH Reattested updated and uploaded COI wthompson"]
["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","Wellmed","Participating","Enrollment Complete","2022-01-01","","","2023-03-23","3/23/2023 Rcvd roster from UHC w/ all Wellmed participating providers.  Provider is PAR effective 1/1/2022.  DCannon"]
["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",42628,"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","4216518","","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",44348,"","","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","Enrollment Stopped","","","","2022-10-17","10/17/2022 - Received roster from Scarlett of TriWest VA; provider status: \"No Action.  Pediatrics specialty.\""]
["Irina Remsburg, MD","1639439185","83-0358685","TX","PE - Midland Community Healthcare Services","Superior","Participating","Enrollment Complete",44409,"","","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","Wellmed","Participating","Enrollment Complete","2022-01-01","","","2023-03-23","3/23/2023 Rcvd roster from UHC w/ all Wellmed participating providers.  Provider is PAR effective 1/1/2022.  DCannon"]
["Irina Remsburg, MD","1639439185","83-0358685","TX","PE - Midland Community Healthcare Services","Wellmed","Participating","Enrollment Complete","2022-01-01","","","2023-03-23","3/23/2023 Rcvd roster from UHC w/ all Wellmed participating providers.  Provider is PAR effective 1/1/2022.  DCannon"]
["Irina Remsburg, MD","1639439185","83-0358685","TX","PE - Midland Community Healthcare Services","Wellmed","Participating","Enrollment Complete","2022-01-01","","","2023-03-23","3/23/2023 Rcvd roster from UHC w/ all Wellmed participating providers.  Provider is PAR effective 1/1/2022.  DCannon"]
["Irina Remsburg, MD","1639439185","83-0358685","TX","PE - Midland Community Healthcare Services","Wellmed","Participating","Enrollment Complete","2022-01-01","","","2023-03-23","3/23/2023 Rcvd roster from UHC w/ all Wellmed participating providers.  Provider is PAR effective 1/1/2022.  DCannon"]
["Irina Remsburg, MD","1639439185","83-0358685","TX","PE - Midland Community Healthcare Services","Wellmed","Participating","Enrollment Complete","2022-01-01","","","2023-03-23","3/23/2023 Rcvd roster from UHC w/ all Wellmed participating providers.  Provider is PAR effective 1/1/2022.  DCannon"]
["Irina Remsburg, MD","1639439185","83-0358685","TX","PE - Midland Community Healthcare Services","Wellmed","Participating","Enrollment Complete","2022-01-01","","","2023-03-23","3/23/2023 Rcvd roster from UHC w/ all Wellmed participating providers.  Provider is PAR effective 1/1/2022.  DCannon"]
["Irina Remsburg, MD","1639439185","83-0358685","TX","PE - Midland Community Healthcare Services","Wellmed","Participating","Enrollment Complete","2022-01-01","","","2023-03-23","3/23/2023 Rcvd roster from UHC w/ all Wellmed participating providers.  Provider is PAR effective 1/1/2022.  DCannon"]
["Irina Remsburg, MD","1639439185","83-0358685","TX","PE - Midland Community Healthcare Services","Wellmed","Participating","Enrollment Complete","2022-01-01","","","2023-03-23","3/23/2023 Rcvd roster from UHC w/ all Wellmed participating providers.  Provider is PAR effective 1/1/2022.  DCannon"]
["Irina Remsburg, MD","1639439185","83-0358685","TX","PE - Midland Community Healthcare Services","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",44348,"","","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",44621,"","","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",43843,"","","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",44348,"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",43873,"","","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",44150,"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",44075,"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",44012,"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",44348,"","","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",44102,"","","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",44348,"","","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","Aetna","Participating","Enrollment Complete",44150,"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","TriCare Standard","Participating","Enrollment Complete",44544,"","","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","Omni PPO","Participating","Enrollment Complete",44348,"","","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",44348,"","","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",44044,"","","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",44075,"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",44348,"","","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",44044,"","","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",44240,"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",44075,"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",44652,"","","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",44652,"","","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",44652,"","","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",44652,"","","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",44652,"","","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",44652,"","","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",44652,"","","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",44501,"","","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",44501,"","","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",44501,"","","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",44501,"","","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",44501,"","","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",44501,"","","2022-12-01","12/1/2022 Per roster received from Wellcare provider is PAR and linked to group TIN/location effective 11/1/2021.  DCannon"]
["Irina Remsburg, MD","1639439185","83-0358685","TX","PE - Midland Community Healthcare Services","Triwest VA","Enrollment Stopped","Enrollment Stopped","","","","2022-10-17","10/17/2022 - Received roster from Scarlett of TriWest VA; provider status: \"No Action.  Pediatrics specialty.\""]
["Irina Remsburg, MD","1639439185","83-0358685","TX","PE - Midland Community Healthcare Services","HealthSmart PPO","Participating","Enrollment Complete",43664,"","","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",44103,"","","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",44348,"","","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",44544,"","","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",44440,"","","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",44440,"","","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",42629,"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",44348,"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",44440,"","","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",43709,"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",44075,"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",44348,"","","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"]
["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",42925,"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",44203,"","","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",44440,"","","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",44203,"","","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",44203,"","","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","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","Participating","Enrollment Complete","2022-12-01","","","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",44652,"","","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","Wellmed","Participating","Enrollment Complete","2022-01-01","","","2023-03-23","3/23/2023 Rcvd roster from UHC w/ all Wellmed participating providers.  Provider is PAR effective 1/1/2022.  DCannon"]
["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, Inc","Triwest VA","Facility Enrollment","Facility Enrollment","","","","2022-10-17","10/17/2022 - Received roster from Scarlett of TriWest VA; provider status: \"No Action.  TIN is CCN participating under own DCN.\""]
["Saranya Rajasekar, MD","1871028365","75-2656723","TX","","Triwest VA","Facility Enrollment","Facility Enrollment","","","","2022-10-17","10/17/2022 - Received roster from Scarlett of TriWest VA; provider status: \"No Action.  TIN is CCN participating under own DCN.\""]
["Saranya Rajasekar, MD","1871028365","75-2656723","TX","","Triwest VA","Facility Enrollment","Facility Enrollment","","","","2022-10-17","10/17/2022 - Received roster from Scarlett of TriWest VA; provider status: \"No Action.  TIN is CCN participating under own DCN.\""]
["Saranya Rajasekar, MD","1871028365","75-2656723","TX","PE - Premier Family Care, Inc","TriCare Standard","Participating","Enrollment Complete","2024-01-03","","","2024-01-19","Received confirmation of approval. MS"]
["Saranya Rajasekar, MD","1871028365","75-2656723","TX","","TriCare Standard","Participating","Enrollment Complete","2024-01-03","","","2024-01-19","Received confirmation of approval. MS"]
["Saranya Rajasekar, MD","1871028365","75-2656723","TX","","TriCare Standard","Participating","Enrollment Complete","2024-01-03","","","2024-01-19","Received confirmation of approval. MS"]
["Saranya Rajasekar, MD","1871028365","75-2656723","TX","PE - Premier Family Care, Inc","TriCare Standard","Participating","Enrollment Complete","2024-01-03","","","2024-02-13","Re-Cred has been completed. MS"]
["Saranya Rajasekar, MD","1871028365","75-2656723","TX","","TriCare Standard","Participating","Enrollment Complete","2024-01-03","","","2024-02-13","Re-Cred has been completed. MS"]
["Saranya Rajasekar, MD","1871028365","75-2656723","TX","","TriCare Standard","Participating","Enrollment Complete","2024-01-03","","","2024-02-13","Re-Cred has been completed. MS"]
["Saranya Rajasekar, MD","1871028365","75-2656723","TX","PE - Premier Family Care, Inc","Boon Chapman","Participating","Enrollment Complete",44662,"","","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",44662,"","","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",44662,"","","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, Inc","IMS","Participating","Enrollment Complete",44662,"","","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",44662,"","","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",44662,"","","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, Inc","HealthSmart PPO","Participating","Enrollment Complete",44662,"","","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",44662,"","","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",44662,"","","2022-06-10","6/10/2022 Per Healthsmart website provider is PAR and loaded under TIN/location effective 4/11/2022.  DCannon"]
["Saranya Rajasekar, MD","1871028365","75-2656723","TX","PE - Premier Family Care, Inc","Medicaid","Participating","Enrollment Complete",45373,"","","2024-04-08","The taxonomy code for Dr. Rajasekar has been updated. However, I was given an effective date of 03/22/2024 instead of 06/11/2022 as requested. Upon calling TMHP, I was not given a clear answer on if this will be an issue, so I am having it escalated (Ticket# 48490724000). It can take up to 30 days for a response. In the meantime, MQA if you could ask the office to rebill the claims that they were originally having problems and let us know the outcome (accepted or denied). Jen Videan"]
["Saranya Rajasekar, MD","1871028365","75-2656723","TX","","Medicaid","Participating","Enrollment Complete",45373,"","","2024-04-08","The taxonomy code for Dr. Rajasekar has been updated. However, I was given an effective date of 03/22/2024 instead of 06/11/2022 as requested. Upon calling TMHP, I was not given a clear answer on if this will be an issue, so I am having it escalated (Ticket# 48490724000). It can take up to 30 days for a response. In the meantime, MQA if you could ask the office to rebill the claims that they were originally having problems and let us know the outcome (accepted or denied). Jen Videan"]
["Saranya Rajasekar, MD","1871028365","75-2656723","TX","","Medicaid","Participating","Enrollment Complete",45373,"","","2024-04-08","The taxonomy code for Dr. Rajasekar has been updated. However, I was given an effective date of 03/22/2024 instead of 06/11/2022 as requested. Upon calling TMHP, I was not given a clear answer on if this will be an issue, so I am having it escalated (Ticket# 48490724000). It can take up to 30 days for a response. In the meantime, MQA if you could ask the office to rebill the claims that they were originally having problems and let us know the outcome (accepted or denied). Jen Videan"]
["Saranya Rajasekar, MD","1871028365","75-2656723","TX","PE - Premier Family Care, Inc","Medicaid","Participating","Payor Follow Up",45373,"","","2024-08-21","Application in PE Review status. Jen Videan"]
["Saranya Rajasekar, MD","1871028365","75-2656723","TX","","Medicaid","Participating","Payor Follow Up",45373,"","","2024-08-21","Application in PE Review status. Jen Videan"]
["Saranya Rajasekar, MD","1871028365","75-2656723","TX","","Medicaid","Participating","Payor Follow Up",45373,"","","2024-08-21","Application in PE Review status. Jen Videan"]
["Saranya Rajasekar, MD","1871028365","75-2656723","TX","PE - Premier Family Care, Inc","CAQH","Participating","Pending Info/Document",45394,"","","2024-04-12","current username and password is invalid wthompson"]
["Saranya Rajasekar, MD","1871028365","75-2656723","TX","","CAQH","Participating","Pending Info/Document",45394,"","","2024-04-12","current username and password is invalid wthompson"]
["Saranya Rajasekar, MD","1871028365","75-2656723","TX","","CAQH","Participating","Pending Info/Document","2024-04-12","","","2024-04-12","current username and password is invalid wthompson"]
["Saranya Rajasekar, MD","1871028365","75-2656723","TX","PE - Premier Family Care, Inc","Medicaid","Participating","Enrollment Complete","2022-06-01","1871028365","1275522864","2022-08-17","8/17/2022 Rcvd TX Medicaid approval letter.  TPI # 1871028365 - effective 6/1/2022 - 8/15/2027.  DCannon"]
["Saranya Rajasekar, MD","1871028365","75-2656723","TX","","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, 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, Inc","First Health Coventry","Participating","Enrollment Complete","2023-05-01","","","2022-11-04","11.04.2022: S/W Kourtney of First Health @ 800-226-5116. Provider NPI# is on file for the provider and contracted under the TIN effective 05/01/2022. Provider ID# 3556714. Physical location is on file. Payer# 73159. Ref# 458389. - Mary Rose Acebedo"]
["Saranya Rajasekar, MD","1871028365","75-2656723","TX","","First Health Coventry","Participating","Enrollment Complete",45047,"","","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","Participating","Enrollment Complete",45047,"","","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, Inc","Wellcare","Participating","Enrollment Complete",44682,"","","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",44682,"","","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",44682,"","","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, Inc","United Health Care","Participating","Enrollment Complete",44662,"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",44662,"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",44662,"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, 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, Inc","Wellmed","Participating","Enrollment Complete","2022-11-20","","","2023-03-23","3/23/2023 Rcvd roster from UHC w/ all Wellmed participating providers.  Provider is PAR effective 11/20/2022.  DCannon"]
["Saranya Rajasekar, MD","1871028365","75-2656723","TX","","Wellmed","Participating","Enrollment Complete","2022-11-20","","","2023-03-23","3/23/2023 Rcvd roster from UHC w/ all Wellmed participating providers.  Provider is PAR effective 11/20/2022.  DCannon"]
["Saranya Rajasekar, MD","1871028365","75-2656723","TX","","Wellmed","Participating","Enrollment Complete","2022-11-20","","","2023-03-23","3/23/2023 Rcvd roster from UHC w/ all Wellmed participating providers.  Provider is PAR effective 11/20/2022.  DCannon"]
["Saranya Rajasekar, MD","1871028365","75-2656723","TX","PE - Premier Family Care, Inc","Humana","Participating","Enrollment Complete","2022-04-11","","","2022-07-14","7/14/2022 Per email received from Humana provider is PAR and linked to group TIN/location effective 4/11/2022.  DCannon"]
["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, 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",44662,"","","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",44662,"","","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, Inc","Ambetter","Participating","Enrollment Complete",44682,"","","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",44682,"","","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",44682,"","","2022-06-13","6/13/2022 Per roster received from Superior provider is PAR w/ Ambetter and linked to group delegation roster effective 5/1/2022.  DCannon"]
["Saranya Rajasekar, MD","1871028365","75-2656723","TX","PE - Premier Family Care, Inc","Multiplan","Participating","Enrollment Complete",44662,"","","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",44662,"","","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",44662,"","","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, Inc","Rail Road Medicare","Participating","Enrollment Complete",44713,"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, 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, Inc","Tricare Prime","Participating","Enrollment Complete","2024-01-03","","","2024-01-26","Confirmed provider is credentialed and in network with Tricare. MS"]
["Saranya Rajasekar, MD","1871028365","75-2656723","TX","","Tricare Prime","Participating","Enrollment Complete","2024-01-03","","","2024-01-26","Confirmed provider is credentialed and in network with Tricare. MS"]
["Saranya Rajasekar, MD","1871028365","75-2656723","TX","","Tricare Prime","Participating","Enrollment Complete","2024-01-03","","","2024-01-26","Confirmed provider is credentialed and in network with Tricare. MS"]
["Saranya Rajasekar, MD","1871028365","75-2656723","TX","PE - Premier Family Care, Inc","Aetna","Participating","Enrollment Complete",44866,"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",44866,"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",44866,"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, Inc","Galaxy Health","Participating","Enrollment Complete",44662,"","","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, 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, 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, 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",44691,"","","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",44691,"","","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, Inc","Medicare","Participating","Enrollment Complete",44713,"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",44713,"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",44713,"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",44562,"","","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",44562,"","","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",44562,"","","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",44562,"","","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",44652,"","","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","Participating","Enrollment Complete",45237,"6G9855","1S4719","2024-01-17","Received welcome letter eff 11/7/23. MS"]
["Deepika Devalla, MD","1265872592","86-3825791","TX","PE - West Texas Ob/Gyn","Medicare","Participating","Enrollment Complete",45237,"6G9855","1S4719","2024-01-17","Received welcome letter eff 11/7/23. MS"]
["Deepika Devalla, MD","1265872592","86-3825791","TX","PE - West Texas Ob/Gyn","Medicare","Participating","Enrollment Complete",45237,"6G9855","1S4719","2024-01-17","Received welcome letter eff 11/7/23. MS"]
["Deepika Devalla, MD","1265872592","86-3825791","TX","PE - West Texas Ob/Gyn","Medicare","Participating","Enrollment Complete",45237,"6G9855","1S4719","2024-01-17","Received welcome letter eff 11/7/23. MS"]
["Deepika Devalla, MD","1265872592","86-3825791","TX","PE - West Texas Ob/Gyn","Caprock (CapStar)","Participating","Enrollment Complete",43831,"","","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",43831,"","","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",43831,"","","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",43831,"","","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",44694,"","","2022-07-20","7/20/2022 Per email received from  from UHC monthly delegated roster submission has been completed and provider is PAR and in linked to group TIN effective 5/13/2022.   MPIN# 006290221.   DCannon"]
["Deepika Devalla, MD","1265872592","86-3825791","TX","PE - West Texas Ob/Gyn","United Health Care","Participating","Enrollment Complete","2022-05-13","","","2022-07-20","7/20/2022 Per email received from  from UHC monthly delegated roster submission has been completed and provider is PAR and in linked to group TIN effective 5/13/2022.   MPIN# 006290221.   DCannon"]
["Deepika Devalla, MD","1265872592","86-3825791","TX","PE - West Texas Ob/Gyn","United Health Care","Participating","Enrollment Complete","2022-05-13","","","2022-07-20","7/20/2022 Per email received from  from UHC monthly delegated roster submission has been completed and provider is PAR and in linked to group TIN effective 5/13/2022.   MPIN# 006290221.   DCannon"]
["Deepika Devalla, MD","1265872592","86-3825791","TX","PE - West Texas Ob/Gyn","United Health Care","Participating","Enrollment Complete","2022-05-13","","","2022-07-20","7/20/2022 Per email received from  from UHC monthly delegated roster submission has been completed and provider is PAR and in linked to group TIN effective 5/13/2022.   MPIN# 006290221.   DCannon"]
["Deepika Devalla, MD","1265872592","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","Participating","Enrollment Complete","","1265872592","","2024-04-15","421 N TOM GREEN AVE, ODESSA, TX, 79761 has been added effective 11/07/2023. Jen Videan"]
["Deepika Devalla, MD","1265872592","86-3825791","TX","PE - West Texas Ob/Gyn","Medicaid","Participating","Enrollment Complete","","1265872592","","2024-04-15","421 N TOM GREEN AVE, ODESSA, TX, 79761 has been added effective 11/07/2023. Jen Videan"]
["Deepika Devalla, MD","1265872592","86-3825791","TX","PE - West Texas Ob/Gyn","Medicaid","Participating","Enrollment Complete","","1265872592","","2024-06-13","4911 Andrews Hwy Midland TX effective 11/07/2023. Jen Videan"]
["Deepika Devalla, MD","1265872592","86-3825791","TX","PE - West Texas Ob/Gyn","Medicaid","Participating","Enrollment Complete","","1265872592","","2024-06-13","4911 Andrews Hwy Midland TX effective 11/07/2023. Jen Videan"]
["Deepika Devalla, MD","1265872592","86-3825791","TX","PE - West Texas Ob/Gyn","Medicaid","Participating","Enrollment Complete","","1265872592","","2024-04-15","421 N TOM GREEN AVE, ODESSA, TX, 79761 has been added effective 11/07/2023. Jen Videan"]
["Deepika Devalla, MD","1265872592","86-3825791","TX","PE - West Texas Ob/Gyn","Medicaid","Participating","Enrollment Complete","","1265872592","","2024-04-15","421 N TOM GREEN AVE, ODESSA, TX, 79761 has been added effective 11/07/2023. Jen Videan"]
["Deepika Devalla, MD","1265872592","86-3825791","TX","PE - West Texas Ob/Gyn","Medicaid","Participating","Enrollment Complete","","1265872592","","2024-06-13","4911 Andrews Hwy Midland TX effective 11/07/2023. Jen Videan"]
["Deepika Devalla, MD","1265872592","86-3825791","TX","PE - West Texas Ob/Gyn","Medicaid","Participating","Enrollment Complete","","1265872592","","2024-06-13","4911 Andrews Hwy Midland TX effective 11/07/2023. Jen Videan"]
["Deepika Devalla, MD","1265872592","47-5554737","TX","PE - Midland Inpatient Medical Association","Galaxy Health","Participating","Enrollment Complete",43910,"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",43370,"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",43709,"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",43709,"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",44562,"","","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",44562,"","","2004-07-24","7/24/2022 Per email from Marcie Eckhart-Havens Multiplan July delegated roster has been completed  and provider is PAR and linked to group TIN effective 1/1/2022.  DCannon"]
["Deepika Devalla, MD","1265872592","86-3825791","TX","PE - West Texas Ob/Gyn","Boon Chapman","Participating","Enrollment Complete","2022-01-01","","","2004-07-24","7/24/2022 Per email from Marcie Eckhart-Havens Multiplan July delegated roster has been completed  and provider is PAR and linked to group TIN effective 1/1/2022.  DCannon"]
["Deepika Devalla, MD","1265872592","86-3825791","TX","PE - West Texas Ob/Gyn","Boon Chapman","Participating","Enrollment Complete","2022-01-01","","","2004-07-24","7/24/2022 Per email from Marcie Eckhart-Havens Multiplan July delegated roster has been completed  and provider is PAR and linked to group TIN effective 1/1/2022.  DCannon"]
["Deepika Devalla, MD","1265872592","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","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","47-5554737","TX","PE - Midland Inpatient Medical Association","CAQH","Participating","CAQH Reattested","2024-08-29","13885700","","2024-08-29","08/29/2024 CAQH Reattested updated and uploaded COI wthompson"]
["Deepika Devalla, MD","1265872592","86-3825791","TX","PE - West Texas Ob/Gyn","Ambetter","Participating","Enrollment Complete","2022-05-01","","","2022-06-13","6/13/2022 Per roster received from Superior provider is PAR w/ Ambetter and linked to group delegation roster effective 5/1/2022.  DCannon"]
["Deepika Devalla, MD","1265872592","86-3825791","TX","PE - West Texas Ob/Gyn","Triwest VA","In House Enrollment","In House Enrollment","","","","2022-04-13",""]
["Deepika Devalla, MD","1265872592","86-3825791","TX","PE - West Texas Ob/Gyn","Triwest VA","In House Enrollment","In House Enrollment","","","","2022-04-13",""]
["Deepika Devalla, MD","1265872592","86-3825791","TX","PE - West Texas Ob/Gyn","Triwest VA","In House Enrollment","In House Enrollment","","","","2022-04-13",""]
["Deepika Devalla, MD","1265872592","86-3825791","TX","PE - West Texas Ob/Gyn","Triwest VA","In House Enrollment","In House Enrollment","","","","2022-04-13",""]
["Deepika Devalla, MD","1265872592","86-3825791","TX","PE - West Texas Ob/Gyn","HealthSmart PPO","Participating","Enrollment Complete","2022-01-01","","","2022-06-10","6/10/2022 Per Healthsmart website provider is PAR and loaded under TIN/location effective 1/1/2022.  DCannon"]
["Deepika Devalla, MD","1265872592","86-3825791","TX","PE - West Texas Ob/Gyn","HealthSmart PPO","Participating","Enrollment Complete","2022-01-01","","","2022-06-10","6/10/2022 Per Healthsmart website provider is PAR and loaded under TIN/location effective 1/1/2022.  DCannon"]
["Deepika Devalla, MD","1265872592","86-3825791","TX","PE - West Texas Ob/Gyn","HealthSmart PPO","Participating","Enrollment Complete","2022-01-01","","","2022-06-10","6/10/2022 Per Healthsmart website provider is PAR and loaded under TIN/location effective 1/1/2022.  DCannon"]
["Deepika Devalla, MD","1265872592","86-3825791","TX","PE - West Texas Ob/Gyn","HealthSmart PPO","Participating","Enrollment Complete","2022-01-01","","","2022-06-10","6/10/2022 Per Healthsmart website provider is PAR and loaded under TIN/location effective 1/1/2022.  DCannon"]
["Deepika Devalla, MD","1265872592","86-3825791","TX","PE - West Texas Ob/Gyn","Omni PPO","Participating","Enrollment Complete","2022-01-01","","","2022-05-26","5/26/2022 Rcvd email from G. Aviles at IMS/OMNI stating that the monthly delegated roster provider loads for April has been completed.  Provider is PAR and linked to location/TIN effective 1/1/2022. DCannon"]
["Deepika Devalla, MD","1265872592","86-3825791","TX","PE - West Texas Ob/Gyn","Omni PPO","Participating","Enrollment Complete","2022-01-01","","","2022-05-26","5/26/2022 Rcvd email from G. Aviles at IMS/OMNI stating that the monthly delegated roster provider loads for April has been completed.  Provider is PAR and linked to location/TIN effective 1/1/2022. DCannon"]
["Deepika Devalla, MD","1265872592","86-3825791","TX","PE - West Texas Ob/Gyn","Omni PPO","Participating","Enrollment Complete","2022-01-01","","","2022-05-26","5/26/2022 Rcvd email from G. Aviles at IMS/OMNI stating that the monthly delegated roster provider loads for April has been completed.  Provider is PAR and linked to location/TIN effective 1/1/2022. DCannon"]
["Deepika Devalla, MD","1265872592","86-3825791","TX","PE - West Texas Ob/Gyn","Omni PPO","Participating","Enrollment Complete","2022-01-01","","","2022-05-26","5/26/2022 Rcvd email from G. Aviles at IMS/OMNI stating that the monthly delegated roster provider loads for April has been completed.  Provider is PAR and linked to location/TIN effective 1/1/2022. DCannon"]
["Deepika Devalla, MD","1265872592","86-3825791","TX","PE - West Texas Ob/Gyn","Humana","Participating","Enrollment Complete","2022-01-01","","","2022-07-14","7/14/2022 Per email received from Humana provider is PAR and linked to group TIN/location effective 1/1/2022.  DCannon"]
["Deepika Devalla, MD","1265872592","86-3825791","TX","PE - West Texas Ob/Gyn","Humana","Participating","Enrollment Complete","2022-01-01","","","2022-07-14","7/14/2022 Per email received from Humana provider is PAR and linked to group TIN/location effective 1/1/2022.  DCannon"]
["Deepika Devalla, MD","1265872592","86-3825791","TX","PE - West Texas Ob/Gyn","Humana","Participating","Enrollment Complete","2022-01-01","","","2022-07-14","7/14/2022 Per email received from Humana provider is PAR and linked to group TIN/location effective 1/1/2022.  DCannon"]
["Deepika Devalla, MD","1265872592","86-3825791","TX","PE - West Texas Ob/Gyn","Humana","Participating","Enrollment Complete","2022-01-01","","","2022-07-14","7/14/2022 Per email received from Humana provider is PAR and linked to group TIN/location effective 1/1/2022.  DCannon"]
["Deepika Devalla, MD","1265872592","86-3825791","TX","PE - West Texas Ob/Gyn","First Health Coventry","In Process","Application Resubmitted","","","","2023-10-20","10/20/2023 Per action needed note 2nd app resubmitted online via Aetna web portal.  DCannon"]
["Deepika Devalla, MD","1265872592","86-3825791","TX","PE - West Texas Ob/Gyn","First Health Coventry","In Process","Application Resubmitted","","","","2023-10-20","10/20/2023 Per action needed note 2nd app resubmitted online via Aetna web portal.  DCannon"]
["Deepika Devalla, MD","1265872592","86-3825791","TX","PE - West Texas Ob/Gyn","First Health Coventry","In Process","Payor Follow Up","","","","2024-06-26","6/26/2024 Submitted letter of intent to pdsdallas@aetna.com to add Dr. Devalla to the network. FC"]
["Deepika Devalla, MD","1265872592","86-3825791","TX","PE - West Texas Ob/Gyn","First Health Coventry","In Process","Payor Follow Up","","","","2024-06-26","6/26/2024 Submitted letter of intent to pdsdallas@aetna.com to add Dr. Devalla to the network. FC"]
["Deepika Devalla, MD","1265872592","86-3825791","TX","PE - West Texas Ob/Gyn","First Health Coventry","In Process","Application Resubmitted","","","","2023-10-20","10/20/2023 Per action needed note 2nd app resubmitted online via Aetna web portal.  DCannon"]
["Deepika Devalla, MD","1265872592","86-3825791","TX","PE - West Texas Ob/Gyn","First Health Coventry","In Process","Application Resubmitted","","","","2023-10-20","10/20/2023 Per action needed note 2nd app resubmitted online via Aetna web portal.  DCannon"]
["Deepika Devalla, MD","1265872592","86-3825791","TX","PE - West Texas Ob/Gyn","First Health Coventry","In Process","Payor Follow Up","","","","2024-06-26","6/26/2024 Submitted letter of intent to pdsdallas@aetna.com to add Dr. Devalla to the network. FC"]
["Deepika Devalla, MD","1265872592","86-3825791","TX","PE - West Texas Ob/Gyn","First Health Coventry","In Process","Payor Follow Up","","","","2024-06-26","6/26/2024 Submitted letter of intent to pdsdallas@aetna.com to add Dr. Devalla to the network. FC"]
["Deepika Devalla, MD","1265872592","47-5554737","TX","PE - Midland Inpatient Medical Association","Rail Road Medicare","Participating","Enrollment Complete",43123,"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","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","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","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","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","Participating","Enrollment Complete","2023-11-07","P02729129","ED2193","2024-03-06","Provider is linked. MS"]
["Deepika Devalla, MD","1265872592","86-3825791","TX","PE - West Texas Ob/Gyn","Rail Road Medicare","Participating","Enrollment Complete","2023-11-07","P02729129","ED2193","2024-03-06","Provider is linked. MS"]
["Deepika Devalla, MD","1265872592","86-3825791","TX","PE - West Texas Ob/Gyn","Rail Road Medicare","Participating","Enrollment Complete","2023-11-07","P02729129","ED2193","2024-03-06","Provider is linked. MS"]
["Deepika Devalla, MD","1265872592","86-3825791","TX","PE - West Texas Ob/Gyn","Rail Road Medicare","Participating","Enrollment Complete","2023-11-07","P02729129","ED2193","2024-03-06","Provider is linked. MS"]
["Deepika Devalla, MD","1265872592","86-3825791","TX","PE - West Texas Ob/Gyn","Amerigroup","Participating","Enrollment Complete","2022-01-10","","","2022-09-23","9/23/2022 Per roster received from Joe Rodriguez at Amerigroup provider is PAR and linked to group TIN effective 1/10/2022.  DCannon"]
["Deepika Devalla, MD","1265872592","86-3825791","TX","PE - West Texas Ob/Gyn","Amerigroup","Participating","Enrollment Complete","2022-01-10","","","2022-09-23","9/23/2022 Per roster received from Joe Rodriguez at Amerigroup provider is PAR and linked to group TIN effective 1/10/2022.  DCannon"]
["Deepika Devalla, MD","1265872592","86-3825791","TX","PE - West Texas Ob/Gyn","Amerigroup","Participating","Enrollment Complete","2022-01-10","","","2022-09-23","9/23/2022 Per roster received from Joe Rodriguez at Amerigroup provider is PAR and linked to group TIN effective 1/10/2022.  DCannon"]
["Deepika Devalla, MD","1265872592","86-3825791","TX","PE - West Texas Ob/Gyn","Amerigroup","Participating","Enrollment Complete","2022-01-10","","","2022-09-23","9/23/2022 Per roster received from Joe Rodriguez at Amerigroup provider is PAR and linked to group TIN effective 1/10/2022.  DCannon"]
["Deepika Devalla, MD","1265872592","86-3825791","TX","PE - West Texas Ob/Gyn","Multiplan","Participating","Enrollment Complete","2022-01-01","","","2022-07-24","7/24/2022 Per email from Marcie Eckhart-Havens Multiplan July delegated roster has been completed  and provider is PAR and linked to group TIN effective 1/1/2022.  DCannon"]
["Deepika Devalla, MD","1265872592","86-3825791","TX","PE - West Texas Ob/Gyn","Multiplan","Participating","Enrollment Complete","2022-01-01","","","2022-07-24","7/24/2022 Per email from Marcie Eckhart-Havens Multiplan July delegated roster has been completed  and provider is PAR and linked to group TIN effective 1/1/2022.  DCannon"]
["Deepika Devalla, MD","1265872592","86-3825791","TX","PE - West Texas Ob/Gyn","Multiplan","Participating","Enrollment Complete",44562,"","","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",44562,"","","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",44562,"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",44562,"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",44562,"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",44562,"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",43709,"1265872592","","2020-07-27","IMS complete"]
["Deepika Devalla, MD","1265872592","86-3825791","TX","PE - West Texas Ob/Gyn","Wellmed","Participating","Enrollment Complete",44694,"","","2023-03-23","3/23/2023 Rcvd roster from UHC w/ all Wellmed participating providers.  Provider is PAR effective 5/13/2022.  DCannon"]
["Deepika Devalla, MD","1265872592","86-3825791","TX","PE - West Texas Ob/Gyn","Wellmed","Participating","Enrollment Complete",44694,"","","2023-03-23","3/23/2023 Rcvd roster from UHC w/ all Wellmed participating providers.  Provider is PAR effective 5/13/2022.  DCannon"]
["Deepika Devalla, MD","1265872592","86-3825791","TX","PE - West Texas Ob/Gyn","Wellmed","Participating","Enrollment Complete",44694,"","","2023-03-23","3/23/2023 Rcvd roster from UHC w/ all Wellmed participating providers.  Provider is PAR effective 5/13/2022.  DCannon"]
["Deepika Devalla, MD","1265872592","86-3825791","TX","PE - West Texas Ob/Gyn","Wellmed","Participating","Enrollment Complete",44694,"","","2023-03-23","3/23/2023 Rcvd roster from UHC w/ all Wellmed participating providers.  Provider is PAR effective 5/13/2022.  DCannon"]
["Deepika Devalla, MD","1265872592","47-5554737","TX","PE - Midland Inpatient Medical Association","USA PPO","Participating","Enrollment Complete",44222,"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",44682,"","","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","Wellmed","Participating","Enrollment Complete",44562,"","","2023-03-23","3/23/2023 Rcvd roster from UHC w/ all Wellmed participating providers.  Provider is PAR effective 1/1/2022.  DCannon"]
["Deepika Devalla, MD","1265872592","47-5554737","TX","PE - Midland Inpatient Medical Association","Boon Chapman","Participating","Enrollment Complete",43910,"","","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",44682,"","","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",44682,"","","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",44682,"","","2022-05-03","5/3/2022 Rcvd email from Superior that April delegation roster has been completed and provider is PAR and linked to group TIN/location effective 5/1/2022.  DCannon"]
["Deepika Devalla, MD","1265872592","86-3825791","TX","PE - West Texas Ob/Gyn","Superior","Participating","Enrollment Complete","2022-05-01","","","2022-05-03","5/3/2022 Rcvd email from Superior that April delegation roster has been completed and provider is PAR and linked to group TIN/location effective 5/1/2022.  DCannon"]
["Deepika Devalla, MD","1265872592","86-3825791","TX","PE - West Texas Ob/Gyn","USA PPO","Participating","Enrollment Complete","2022-01-01","","","2024-01-11","1/11/2024 Per email from USA MCO - LaNetricia Myart provider is PAR and linked to group TIN/location effective 1/1/2022.  Provider is also listed on the online provider directory.  DCannon"]
["Deepika Devalla, MD","1265872592","86-3825791","TX","PE - West Texas Ob/Gyn","USA PPO","Participating","Enrollment Complete","2022-01-01","","","2024-01-11","1/11/2024 Per email from USA MCO - LaNetricia Myart provider is PAR and linked to group TIN/location effective 1/1/2022.  Provider is also listed on the online provider directory.  DCannon"]
["Deepika Devalla, MD","1265872592","86-3825791","TX","PE - West Texas Ob/Gyn","USA PPO","Participating","Enrollment Complete","2022-01-01","","","2024-01-11","1/11/2024 Per email from USA MCO - LaNetricia Myart provider is PAR and linked to group TIN/location effective 1/1/2022.  Provider is also listed on the online provider directory.  DCannon"]
["Deepika Devalla, MD","1265872592","86-3825791","TX","PE - West Texas Ob/Gyn","USA PPO","Participating","Enrollment Complete","2022-01-01","","","2024-01-11","1/11/2024 Per email from USA MCO - LaNetricia Myart provider is PAR and linked to group TIN/location effective 1/1/2022.  Provider is also listed on the online provider directory.  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",43123,"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",44562,"","","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",44562,"","","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",44562,"","","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",44562,"","","2022-05-26","5/26/2022 Rcvd email from G. Aviles at IMS/OMNI stating that the monthly delegated roster provider loads for April has been completed.  Provider is PAR and linked to location/TIN effective 1/1/2022. DCannon"]
["Deepika Devalla, MD","1265872592","86-3825791","TX","PE - West Texas Ob/Gyn","Scott&White (First Care)","Participating","Enrollment Complete",45187,"","","2023-10-02","10/2/2023 Rcvd email confirmation from Scott & White that provider is PAR and linked to group/locations effective 9/18/2023.  DCannon"]
["Deepika Devalla, MD","1265872592","86-3825791","TX","PE - West Texas Ob/Gyn","Scott&White (First Care)","Participating","Enrollment Complete",45187,"","","2023-10-02","10/2/2023 Rcvd email confirmation from Scott & White that provider is PAR and linked to group/locations effective 9/18/2023.  DCannon"]
["Deepika Devalla, MD","1265872592","86-3825791","TX","PE - West Texas Ob/Gyn","Scott&White (First Care)","Participating","Enrollment Complete","2023-09-18","","","2023-10-02","10/2/2023 Rcvd email confirmation from Scott & White that provider is PAR and linked to group/locations effective 9/18/2023.  DCannon"]
["Deepika Devalla, MD","1265872592","86-3825791","TX","PE - West Texas Ob/Gyn","Scott&White (First Care)","Participating","Enrollment Complete","2023-09-18","","","2023-10-02","10/2/2023 Rcvd email confirmation from Scott & White that provider is PAR and linked to group/locations effective 9/18/2023.  DCannon"]
["Deepika Devalla, MD","1265872592","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, APRN-FNP-BC","1649713595","47-5554737","TX","PE - Midland Inpatient Medical Association","CAQH","Provider Load","CAQH Reattested","2024-08-30","","","2024-08-30","08/30/2024 CAQH Reattested updated and uploaded COI wthompson"]
["Jeremiah L Stewart, APRN-FNP-BC","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, APRN-FNP-BC","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, APRN-FNP-BC","1649713595","47-5554737","TX","PE - Midland Inpatient Medical Association","HealthSmart PPO","Participating","Re-Credentialing","2016-12-15","1649713595","","2024-02-20","2/20/2024- Submitted recred status via delegated monthly roster on 2/15/2024. FC."]
["Jeremiah L Stewart, APRN-FNP-BC","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, APRN-FNP-BC","1649713595","47-5554737","TX","PE - Midland Inpatient Medical Association","Cigna","Participating","Enrollment Complete",43249,"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, APRN-FNP-BC","1649713595","47-5554737","TX","PE - Midland Inpatient Medical Association","Galaxy Health","Participating","Enrollment Complete",43831,"1649713595","","2020-10-05","10/5/2020 - Rec'd email back from the payer stating this enrollment has been completed - Stacey"]
["Jeremiah L Stewart, APRN-FNP-BC","1649713595","47-5554737","TX","PE - Midland Inpatient Medical Association","First Health Coventry","Participating","Re-Credentialing",44075,"1649713595","","2024-02-20","2/20/2024- Submitted recred status via delegated monthly roster on 2/15/2024. FC."]
["Jeremiah L Stewart, APRN-FNP-BC","1649713595","47-5554737","TX","PE - Midland Inpatient Medical Association","TriCare Standard","Participating","Enrollment Complete",42719,"1649713595","","2020-04-30","04/30/2020 - confirmed this provider/service location are linked to TIN through payer portal - Stacey Hudak"]
["Jeremiah L Stewart, APRN-FNP-BC","1649713595","47-5554737","TX","PE - Midland Inpatient Medical Association","Humana","Participating","Enrollment Complete",43831,"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, APRN-FNP-BC","1649713595","47-5554737","TX","PE - Midland Inpatient Medical Association","USA PPO","Participating","Enrollment Complete",44222,"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, APRN-FNP-BC","1649713595","47-5554737","TX","PE - Midland Inpatient Medical Association","Scott&White (First Care)","Participating","Enrollment Complete",42691,"1649713595","","2020-02-13","02/13/2020 - Rec'd emailed confirmation from the payer that this provider is EFF and DIRECT CONTRACTED under this TIN - Stacey Hudak"]
["Jeremiah L Stewart, APRN-FNP-BC","1649713595","47-5554737","TX","PE - Midland Inpatient Medical Association","Medicaid","Participating","Enrollment Complete",44256,"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, APRN-FNP-BC","1649713595","47-5554737","TX","PE - Midland Inpatient Medical Association","IMS","Participating","Re-Credentialing",43709,"1649713595","","2024-02-20","2/20/2024- Submitted recred status via delegated monthly roster on 2/15/2024. FC."]
["Jeremiah L Stewart, APRN-FNP-BC","1649713595","47-5554737","TX","PE - Midland Inpatient Medical Association","Superior","Participating","Enrollment Complete",44105,"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, APRN-FNP-BC","1649713595","47-5554737","TX","PE - Midland Inpatient Medical Association","Caprock (CapStar)","Participating","Re-Credentialing",43891,"1649713595","","2024-02-20","2/20/2024- Submitted recred status via delegated monthly roster on 2/15/2024. FC."]
["Jeremiah L Stewart, APRN-FNP-BC","1649713595","47-5554737","TX","PE - Midland Inpatient Medical Association","Multiplan","Participating","Re-Credentialing",43924,"","","2024-02-20","2/20/2024- Submitted recred status via delegated monthly roster on 2/15/2024. FC."]
["Jeremiah L Stewart, APRN-FNP-BC","1649713595","47-5554737","TX","PE - Midland Inpatient Medical Association","United Health Care","Participating","Enrollment Complete",43902,"1649713595","","2020-08-31","08/31/2020 - moved to completed status after reviewing follow up completed status - Stacey Hudak"]
["Jeremiah L Stewart, APRN-FNP-BC","1649713595","47-5554737","TX","PE - Midland Inpatient Medical Association","Boon Chapman","Participating","Enrollment Complete",43924,"","","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, APRN-FNP-BC","1649713595","47-5554737","TX","PE - Midland Inpatient Medical Association","Amerigroup","Participating","Re-Credentialing",42789,"1649713595","","2024-02-20","2/20/2024- Submitted recred status via delegated monthly roster on 2/15/2024. FC."]
["Jeremiah L Stewart, APRN-FNP-BC","1649713595","47-5554737","TX","PE - Midland Inpatient Medical Association","Aetna","Participating","Re-Credentialing",44044,"1649713595","","2024-02-20","2/20/2024- Submitted recred status via delegated monthly roster on 2/15/2024. FC."]
["Jeremiah L Stewart, APRN-FNP-BC","1649713595","47-5554737","TX","PE - Midland Inpatient Medical Association","Wellmed","Participating","Enrollment Complete","2022-01-01","","","2023-03-23","3/23/2023 Rcvd roster from UHC w/ all Wellmed participating providers.  Provider is PAR effective 1/1/2022.  DCannon"]
["Jeremiah L Stewart, APRN-FNP-BC","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","2020-04-03","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","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","","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","HealthSmart PPO","Participating","Application Resubmitted",42892,"1013456649","","2024-07-22","Submitted reapplication via delegated roster on 7/15/2024. FC"]
["Gypsy J Jasso, APRN, FNP-C","1013456649","47-5554737","TX","","HealthSmart PPO","Participating","Application Resubmitted",42892,"1013456649","","2024-07-22","Submitted reapplication via delegated roster on 7/15/2024. FC"]
["Gypsy J Jasso, APRN, FNP-C","1013456649","47-5554737","TX","PE - Midland Inpatient Medical Association","First Health Coventry","Participating","Enrollment Complete",44910,"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","","First Health Coventry","Participating","Enrollment Complete",44910,"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","First Health Coventry","Participating","Application Resubmitted",44910,"3546231","","2024-07-22","Submitted reapplication via delegated roster on 7/15/2024. FC"]
["Gypsy J Jasso, APRN, FNP-C","1013456649","47-5554737","TX","","First Health Coventry","Participating","Application Resubmitted",44910,"3546231","","2024-07-22","Submitted reapplication via delegated roster on 7/15/2024. FC"]
["Gypsy J Jasso, APRN, FNP-C","1013456649","47-5554737","TX","PE - Midland Inpatient Medical Association","Multiplan","Participating","Enrollment Complete",43924,"","","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","","Multiplan","Participating","Enrollment Complete",43924,"","","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","Multiplan","Participating","Application Resubmitted",43924,"","","2024-07-22","Submitted reapplication via delegated roster on 7/15/2024. FC"]
["Gypsy J Jasso, APRN, FNP-C","1013456649","47-5554737","TX","","Multiplan","Participating","Application Resubmitted",43924,"","","2024-07-22","Submitted reapplication via delegated roster on 7/15/2024. FC"]
["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","2024-05-08","Rcvd approval ltr. Jen Videan"]
["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","Aetna","Participating","Enrollment Complete","2020-08-01","","","2024-07-22","As per January roster provider participating as of 8.1.2020 listed as a SPEC. FC"]
["Gypsy J Jasso, APRN, FNP-C","1013456649","47-5554737","TX","PE - Midland Inpatient Medical Association","Wellmed","Participating","Enrollment Complete","2022-01-01","","","2023-03-23","3/23/2023 Rcvd roster from UHC w/ all Wellmed participating providers.  Provider is PAR effective 1/1/2022.  DCannon"]
["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","","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","IMS","Participating","Application Resubmitted","2019-09-01","1013456649","","2024-07-22","Submitted reapplication via delegated roster on 7/15/2024. FC"]
["Gypsy J Jasso, APRN, FNP-C","1013456649","47-5554737","TX","","IMS","Participating","Application Resubmitted","2019-09-01","1013456649","","2024-07-22","Submitted reapplication via delegated roster on 7/15/2024. FC"]
["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","","Caprock (CapStar)","Participating","Enrollment Complete","2020-03-01","1013456649","","",""]
["Gypsy J Jasso, APRN, FNP-C","1013456649","47-5554737","TX","PE - Midland Inpatient Medical Association","Caprock (CapStar)","Participating","Application Resubmitted","2020-03-01","1013456649","","2024-07-22","Submitted reapplication via delegated roster on 7/15/2024. FC"]
["Gypsy J Jasso, APRN, FNP-C","1013456649","47-5554737","TX","","Caprock (CapStar)","Participating","Application Resubmitted",43891,"1013456649","","2024-07-22","Submitted reapplication via delegated roster on 7/15/2024. FC"]
["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","","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","Amerigroup","Participating","Application Resubmitted","2018-04-20","1013456649","","2024-07-22","Submitted reapplication via delegated roster on 7/15/2024. FC"]
["Gypsy J Jasso, APRN, FNP-C","1013456649","47-5554737","TX","","Amerigroup","Participating","Application Resubmitted",43210,"1013456649","","2024-07-22","Submitted reapplication via delegated roster on 7/15/2024. FC"]
["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"]
["Gypsy J Jasso, APRN, FNP-C","1013456649","47-5554737","TX","","Omni PPO","Participating","Enrollment Complete","2019-09-01","1013456649","","2020-07-27","IMS complete"]
["Gypsy J Jasso, APRN, FNP-C","1013456649","47-5554737","TX","PE - Midland Inpatient Medical Association","Omni PPO","Participating","Application Resubmitted","2019-09-01","1013456649","","2024-07-22","Submitted reapplication via delegated roster on 7/15/2024. FC"]
["Gypsy J Jasso, APRN, FNP-C","1013456649","47-5554737","TX","","Omni PPO","Participating","Application Resubmitted","2019-09-01","1013456649","","2024-07-22","Submitted reapplication via delegated roster on 7/15/2024. FC"]
["Tzu-Ching Wu, MD","1396930426","75-2656723","TX","PE - Premier Family Care, 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","","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, Inc","Caprock (CapStar)","Participating","Application Resubmitted","2019-05-21","1396930426","","2024-07-18","Submitted reapplication via delegated roster on 7/15/2024. FC"]
["Tzu-Ching Wu, MD","1396930426","75-2656723","TX","","Caprock (CapStar)","Participating","Application Resubmitted",43606,"1396930426","","2024-07-18","Submitted reapplication via delegated roster on 7/15/2024. FC"]
["Tzu-Ching Wu, MD","1396930426","75-2656723","TX","PE - Premier Family Care, Inc","Triwest VA","Facility Enrollment","Facility Enrollment","","","","2022-10-17","10/17/2022 - Received roster from Scarlett of TriWest VA; provider status: \"No Action.  TIN is CCN participating under own DCN.\""]
["Tzu-Ching Wu, MD","1396930426","75-2656723","TX","PE - Premier Family Care, Inc","Multiplan","Participating","Enrollment Complete","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","","Multiplan","Participating","Enrollment Complete","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, Inc","Multiplan","Participating","Application Resubmitted",43560,"1396930426","West Texas Physicians Alliance","2024-07-18","Submitted reapplication via delegated roster on 7/15/2024. FC"]
["Tzu-Ching Wu, MD","1396930426","75-2656723","TX","","Multiplan","Participating","Application Resubmitted",43560,"1396930426","West Texas Physicians Alliance","2024-07-18","Submitted reapplication via delegated roster on 7/15/2024. FC"]
["Tzu-Ching Wu, MD","1396930426","75-2656723","TX","PE - Premier Family Care, Inc","United Health Care","Participating","Enrollment Complete","2019-01-01","3382000","","2020-06-08","06/8/2020 - Rec'd email from the payer stating this provider/address is EFF - Stacey Hudak"]
["Tzu-Ching Wu, MD","1396930426","75-2656723","TX","PE - Premier Family Care, Inc","Medicare","Participating","Enrollment Complete",43472,"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, 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, Inc","Boon Chapman","Participating","Enrollment Complete",43560,"","","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, Inc","Omni PPO","Participating","Enrollment Complete","2019-05-21","1396930426","","2020-06-26",""]
["Tzu-Ching Wu, MD","1396930426","75-2656723","TX","","Omni PPO","Participating","Enrollment Complete",43606,"1396930426","","2020-06-26",""]
["Tzu-Ching Wu, MD","1396930426","75-2656723","TX","PE - Premier Family Care, Inc","Omni PPO","Participating","Application Resubmitted",43606,"1396930426","","2024-07-18","Submitted reapplication via delegated roster on 7/15/2024. FC"]
["Tzu-Ching Wu, MD","1396930426","75-2656723","TX","","Omni PPO","Participating","Application Resubmitted","2019-05-21","1396930426","","2024-07-18","Submitted reapplication via delegated roster on 7/15/2024. FC"]
["Tzu-Ching Wu, MD","1396930426","75-2656723","TX","PE - Premier Family Care, Inc","Galaxy Health","Participating","Enrollment Complete",43606,"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, Inc","IMS","Participating","Enrollment Complete",43606,"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","","IMS","Participating","Enrollment Complete",43606,"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, Inc","IMS","Participating","Application Resubmitted","2019-05-21","1396930426","","2024-07-18","Submitted reapplication via delegated roster on 7/15/2024. FC"]
["Tzu-Ching Wu, MD","1396930426","75-2656723","TX","","IMS","Participating","Application Resubmitted",43606,"1396930426","","2024-07-18","Submitted reapplication via delegated roster on 7/15/2024. FC"]
["Tzu-Ching Wu, MD","1396930426","75-2656723","TX","PE - Premier Family Care, 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, Inc","TriCare Standard","Participating","Enrollment Complete",43952,"","","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, Inc","First Health Coventry","Participating","Enrollment Complete",43586,"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, Inc","HealthSmart PPO","Participating","Enrollment Complete",43616,"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","","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, Inc","HealthSmart PPO","Participating","Application Resubmitted",43616,"1396930426","","2024-07-18","Submitted reapplication via delegated roster on 7/15/2024. FC"]
["Tzu-Ching Wu, MD","1396930426","75-2656723","TX","","HealthSmart PPO","Participating","Application Resubmitted",43616,"1396930426","","2024-07-18","Submitted reapplication via delegated roster on 7/15/2024. FC"]
["Tzu-Ching Wu, MD","1396930426","75-2656723","TX","PE - Premier Family Care, Inc","Wellmed","Participating","Enrollment Complete",44562,"","","2023-03-23","3/23/2023 Rcvd roster from UHC w/ all Wellmed participating providers.  Provider is PAR effective 1/1/2022.  DCannon"]
["Tzu-Ching Wu, MD","1396930426","75-2656723","TX","PE - Premier Family Care, Inc","Amerigroup","Participating","Enrollment Complete","2019-05-31","1396930426","","2020-03-20","03/20/2020 - Rec'd email from the payer (multiplan/true texas choice) stating this provider/service location is EFF with amerigroup - Stacey Hudak"]
["Tzu-Ching Wu, MD","1396930426","75-2656723","TX","","Amerigroup","Participating","Enrollment Complete",43616,"1396930426","","2020-03-20","03/20/2020 - Rec'd email from the payer (multiplan/true texas choice) stating this provider/service location is EFF with amerigroup - Stacey Hudak"]
["Tzu-Ching Wu, MD","1396930426","75-2656723","TX","PE - Premier Family Care, Inc","Amerigroup","Participating","Application Resubmitted",43616,"1396930426","","2024-07-18","Submitted reapplication via delegated roster on 7/15/2024. FC"]
["Tzu-Ching Wu, MD","1396930426","75-2656723","TX","","Amerigroup","Participating","Application Resubmitted",43616,"1396930426","","2024-07-18","Submitted reapplication via delegated roster on 7/15/2024. FC"]
["Tzu-Ching Wu, MD","1396930426","75-2656723","TX","PE - Premier Family Care, Inc","USA PPO","Participating","Enrollment Complete","2019-05-31","","","2020-09-09","Confirmed provider is participating with PPO and H&W networks (list of networks attached). Kimberly Frazier"]
["Tzu-Ching Wu, MD","1396930426","75-2656723","TX","PE - Premier Family Care, 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, Inc","Tricare Prime","Participating","Enrollment Complete",43952,"","","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, Inc","Superior","Participating","Enrollment Complete",44136,"","","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, 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, 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",43398,"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"]

{"sheet":"TaxIDSearch","index":2,"n_rows":83,"n_cols":11,"rows_kept":83,"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"]
["Coby R Robins, MD","PE - Midland Pediatric Associates, PLLC","HealthSmart PPO","Participating","Enrollment Complete","2018-07-27",1104237015,null,"2020-06-05","06/05/2020 -Rec'd email from the payer stating provider is EFF - Stacey Hudak"]
["Coby R Robins, MD","PE - Midland Pediatric Associates, PLLC","First Health Coventry","Participating","Enrollment Complete","2017-09-01",3094146,null,"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","PE - Midland Pediatric Associates, PLLC","IMS","Participating","Enrollment Complete","2018-07-01",1790767119,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"]
["Coby R Robins, MD","PE - Midland Pediatric Associates, PLLC","Caprock (CapStar)","Participating","Enrollment Complete","2018-06-19",1104237015,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"]
["Coby R Robins, MD","PE - Midland Pediatric Associates, PLLC","Tricare Prime","Participating","Enrollment Complete","2018-07-11",null,null,"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","PE - Midland Pediatric Associates, PLLC","Scott&White (First Care)","Participating","Enrollment Complete","2018-04-16",1104237015,null,"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","PE - Midland Pediatric Associates, PLLC","CAQH","Participating","CAQH Reattested","2024-08-22",14218808,null,"2024-08-22","08/22/2024 CAQH Reattested updated and uploaded license wthompson"]
["Coby R Robins, MD","PE - Midland Pediatric Associates, PLLC","Galaxy Health","Participating","Enrollment Complete","2018-06-19",null,null,"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","PE - Midland Pediatric Associates, PLLC","Multiplan","Participating","Enrollment Complete","2018-08-13",1104237015,null,"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","PE - Midland Pediatric Associates, PLLC","TriCare Standard","Participating","Enrollment Complete","2018-07-11",null,null,"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","PE - Midland Pediatric Associates, PLLC","Boon Chapman","Participating","Enrollment Complete","2018-08-13",1104237015,null,"2020-10-05","Enrollment thru PHCS"]
["Coby R Robins, MD","PE - Midland Pediatric Associates, PLLC","Humana","Participating","Enrollment Complete","2018-07-18",1104237015,null,"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","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","PE - Midland Pediatric Associates, PLLC","Cigna","Participating","Enrollment Complete","2018-10-11",1104237015,null,"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","PE - Midland Pediatric Associates, PLLC","United Health Care","Participating","Enrollment Complete","2017-09-17",1104237015,null,"2020-07-30","7/30/2020 - moved to completed status after reviewing follow up complete note - Stacey Hudak"]
["Tokkie Orogbemi, CPNP","PE - Midland Pediatric Associates, PLLC","Omni PPO","Participating","Enrollment Complete","2023-06-01",null,null,"2023-07-18","7/18/2023 Per email received from IMS/OMNI June delegated roster has been processed and provider is PAR and linked to group effective 6/1/2023.  DCannon"]
["Tokkie Orogbemi, CPNP","PE - Midland Pediatric Associates, PLLC","HealthSmart PPO","Participating","Enrollment Complete","2023-06-01",null,null,"2023-12-15","12/15/2023 Per email rcvd from Aleece Moerbe at Healthsmart provider is PAR and linked to group TIN/location effective 6/1/2023.  DCannon"]
["Tokkie Orogbemi, CPNP","PE - Midland Pediatric Associates, PLLC","Multiplan","Participating","Enrollment Complete","2023-06-01",null,null,"2023-07-25","7/25/2023 Rcvd email confirmation from Jessica Bess at Multiplan that June roster has been processed and provider is PAR w/ group effective 6/1/2023.  DCannon"]
["Tokkie Orogbemi, CPNP","PE - Midland Pediatric Associates, PLLC","Scott&White (First Care)","Participating","Enrollment Complete","2023-07-20",null,null,"2023-08-17","8/17/2023 Received email from Scott & White HPDELEGATION@BSWHealth.org that provider load from June has been completed and provider is PAR effective 7/20/2023.  DCannon"]
["Tokkie Orogbemi, CPNP","PE - Midland Pediatric Associates, PLLC","Cigna","Participating","Enrollment Complete","2023-09-28",7682322,null,"2023-10-19","10.16.2023 S/W LynP of Cigna @ 1-800-882-4462. Per rep, Provider is in network with Cigna and linked to the group and TIN# effective on 09/28/2023. No next recredentialing date available. PIN: 7682322. Servicing location is on file. No payer# available. Call ref# LynP10162023. - Willie Ravas"]
["Tokkie Orogbemi, CPNP","PE - Midland Pediatric Associates, PLLC","Aetna","Participating","Enrollment Complete","2023-06-01",null,null,"2023-08-17","8/17/2023 Per email from Priscilla Albertine at MQA she received confirmation that provider is PAR and linked to group TIN/location effective 6/1/2023.  DCannon"]
["Tokkie Orogbemi, CPNP","PE - Midland Pediatric Associates, PLLC","Tricare Prime","Participating","Enrollment Complete","2019-11-27",null,null,"2024-01-26","Confirmed provider is credentialed and in network with Tricare. MS"]
["Tokkie Orogbemi, CPNP",null,"Tricare Prime","Participating","Enrollment Complete","2019-11-27",null,null,"2024-01-26","Confirmed provider is credentialed and in network with Tricare. MS"]
["Tokkie Orogbemi, CPNP","PE - Midland Pediatric Associates, PLLC","Tricare Prime","Participating","Enrollment Complete","2019-11-27",null,null,"2024-02-28","Re-Cred has been completed. eff 11/27/2023. MS"]
["Tokkie Orogbemi, CPNP",null,"Tricare Prime","Participating","Enrollment Complete","2019-11-27",null,null,"2024-02-28","Re-Cred has been completed. eff 11/27/2023. MS"]
["Tokkie Orogbemi, CPNP","PE - Midland Pediatric Associates, PLLC","Galaxy Health","Participating","Enrollment Complete","2023-06-01",null,null,"2023-07-20","7/20/2023 Per email received from Galaxy June delegated roster has been processed and provider is PAR and linked to group effective 6/1/2023.  DCannon"]
["Tokkie Orogbemi, CPNP","PE - Midland Pediatric Associates, PLLC","Caprock (CapStar)","Participating","Enrollment Complete","2023-06-01",null,null,"2023-07-26","7/26/2023 Rcvd email  confirmation from Caprock that provider is PAR and linked to group TIN/locations effective 6/1/2023.  DCannon"]
["Tokkie Orogbemi, CPNP","PE - Midland Pediatric Associates, PLLC","Boon Chapman","Participating","Enrollment Complete","2023-06-01",null,null,"2023-07-25","7/25/2023 Rcvd email confirmation from Jessica Bess at Multiplan that June roster has been processed and provider is PAR w/ group effective 6/1/2023.  DCannon"]
["Tokkie Orogbemi, CPNP","PE - Midland Pediatric Associates, PLLC","United Health Care","Participating","Enrollment Complete","2023-06-01",8736952,null,"2023-10-13","10/13/2023 Per email received from  from UHC monthly delegated roster submission has been completed and provider is PAR and in linked to group TIN effective 6/1/2023.   MPIN# 00008736952.   DCannon"]
["Tokkie Orogbemi, CPNP","PE - Midland Pediatric Associates, PLLC","Humana","Participating","Enrollment Complete","2023-06-01",null,null,"2024-06-21","Received email confirmation from Marcus Wester, provider is par and linked to TIN/location, eff. 06/01/2023. PA."]
["Tokkie Orogbemi, CPNP","PE - Midland Pediatric Associates, PLLC","First Health Coventry","Participating","Enrollment Complete","2023-06-01",null,null,"2023-08-23","08.23.2023 S/W Bridgette of First Health @ 800-226-5116, per rep provider is showing participating and link under the Group and TIN with an Effective date 06/01/2023. Provider ID 3694262. Physical location is on file. Call ref#:734006. - Danico Gabriel Melendres"]
["Tokkie Orogbemi, CPNP","PE - Midland Pediatric Associates, PLLC","TriCare Standard","Participating","Enrollment Complete","2023-11-27",null,null,"2023-12-07","Provider is linked to this location. MS"]
["Willie Clyde Watson, III, MD","PE - Midland Pediatric Associates, PLLC","IMS","Participating","Enrollment Complete","1999-04-01",1659366433,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"]
["Willie Clyde Watson, III, MD","PE - Midland Pediatric Associates, PLLC","Aetna","Participating","Enrollment Complete","2014-09-29",1659366433,null,"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","PE - Midland Pediatric Associates, PLLC","HealthSmart PPO","Participating","Enrollment Complete","2011-02-01",1659366433,null,"2020-06-05","06/05/2020 - Rec'd email from the payer stating this provider is EFF -Stacey Hudak"]
["Willie Clyde Watson, III, MD","PE - Midland Pediatric Associates, PLLC","Tricare Prime","Participating","Enrollment Complete","1996-01-26",null,null,"2024-01-26","Confirmed provider is credentialed and in network with Tricare. MS"]
["Willie Clyde Watson, III, MD","PE - Midland Pediatric Associates, PLLC","USA PPO","Participating","Enrollment Complete","2002-11-15",1659366433,752133441,"2020-08-19","Confirmed provider is participating with PPO and H&W networks (list of networks attached). Kimberly Frazier"]
["Willie Clyde Watson, III, MD","PE - Midland Pediatric Associates, PLLC","CAQH","Active","CAQH Reattested","2024-08-14",null,null,"2024-08-14","08/14/2024 CAQH REattested all locations current and all expirables up to date wthompson"]
["Willie Clyde Watson, III, MD","PE - Midland Pediatric Associates, PLLC","Caprock (CapStar)","Participating","Enrollment Complete","2012-04-01",1659366433,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"]
["Willie Clyde Watson, III, MD","PE - Midland Pediatric Associates, PLLC","Scott&White (First Care)","Participating","Enrollment Complete","2018-01-01",1659366433,null,"2020-04-16","04/16/2020 - Rec'd confirmation from the payer stating this provider is EFF under the DELEGATED PRIMED agreement with HMO/PPO only products with this TIN/Service Location- Stacey Hudak"]
["Willie Clyde Watson, III, MD","PE - Midland Pediatric Associates, PLLC","Galaxy Health","Participating","Enrollment Complete","2014-09-26",1659366433,null,"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","PE - Midland Pediatric Associates, PLLC","TriCare Standard","Participating","Enrollment Complete","2019-05-01",1659366433,null,"2020-09-24","09/24/2020 - moved to completed status after reviewing follow up complete note - Stacey Hudak"]
["Willie Clyde Watson, III, MD","PE - Midland Pediatric Associates, PLLC","Multiplan","Participating","Enrollment Complete","2017-04-15",1659366433,null,"2020-08-27","08/27/2020 - Rec'd email from the payer stating this provider is :  \"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: - Willie Watson-Effective 04/15/2017\" - Stacey Hudak"]
["Willie Clyde Watson, III, MD","PE - Midland Pediatric Associates, PLLC","Humana","Participating","Enrollment Complete","2011-03-01",1659366433,null,"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"]
["Willie Clyde Watson, III, MD","PE - Midland Pediatric Associates, PLLC","Cigna","Participating","Enrollment Complete","2012-07-01",1659366433,null,"2020-04-22","04/22/2020--SW Monic of Cigna @ 8008824462, Provider NPI# is on file and participating under the group and TIN# effective 7/1/2012. Location is on file. Call ref# Monic4202020.\n-copied note from spreadsheet-tisha rader"]
["Willie Clyde Watson, III, MD","PE - Midland Pediatric Associates, PLLC","First Health Coventry","Participating","Enrollment Complete","2008-09-01",1902473,null,"2020-03-24","3/24/2020-received email with roster from payor stating provider PAR 9/1/2008 PID # 1902473\ntisha rader"]
["Willie Clyde Watson, III, MD","PE - Midland Pediatric Associates, PLLC","United Health Care","Participating","Enrollment Complete","2017-12-01",1659366433,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"]
["Willie Clyde Watson, III, MD","PE - Midland Pediatric Associates, PLLC","Boon Chapman","Participating","Enrollment Complete","2017-04-15",1659366433,null,"2020-10-05","enrolled thru PHCS"]
["Debbie P Reese, MD","PE - Midland Pediatric Associates, PLLC","HealthSmart PPO","Participating","Re-Credentialing","2011-02-01",10120298,null,"2024-05-16","5/16/2024- Submitted recred status via delegated monthly roster on 5/15/2024. FC."]
["Debbie P Reese, MD","PE - Midland Pediatric Associates, PLLC","Galaxy Health","Participating","Enrollment Complete","2014-11-04",1629074984,null,"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","PE - Midland Pediatric Associates, PLLC","Scott&White (First Care)","Participating","Enrollment Complete","2015-01-01",1629074984,null,"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"]
["Debbie P Reese, MD","PE - Midland Pediatric Associates, PLLC","Cigna","Participating","Enrollment Complete","2020-09-01",1629074984,null,"2020-07-20","07/20/2020 - moved to completed status after reviewing follow up complete note - Stacey Hudak"]
["Debbie P Reese, MD","PE - Midland Pediatric Associates, PLLC","USA PPO","Participating","Enrollment Complete","2002-11-15",1629074984,752133441,"2020-08-19","Confirmed provider is participating with PPO and H&W networks (list of networks attached). Kimberly Frazier"]
["Debbie P Reese, MD","PE - Midland Pediatric Associates, PLLC","IMS","Participating","Re-Credentialing","1999-04-01",1629074984,null,"2024-05-16","5/16/2024- Submitted recred status via delegated monthly roster on 5/15/2024. FC."]
["Debbie P Reese, MD","PE - Midland Pediatric Associates, PLLC","Medicaid","Participating","Enrollment Complete",null,132863503,212775501,"2020-09-25","09/25/2020 - Rec'd email from the clinic with TPI (provider and group only) typed in. No actual letter from the payer naming the group - Stacey Hudak"]
["Debbie P Reese, MD","PE - Midland Pediatric Associates, PLLC","United Health Care","Participating","Enrollment Complete","2017-10-31",466023,null,"2020-07-30","7/30/2020 - moved to completed status after reviewing follow up complete note - Stacey Hudak"]
["Debbie P Reese, MD","PE - Midland Pediatric Associates, PLLC","Multiplan","Participating","Re-Credentialing","2020-09-09",null,null,"2024-05-16","5/16/2024- Submitted recred status via delegated monthly roster on 5/15/2024. FC."]
["Debbie P Reese, MD","PE - Midland Pediatric Associates, PLLC","Aetna","Participating","Re-Credentialing","2019-01-01",1629074984,null,"2024-05-16","5/16/2024- Submitted recred status via delegated monthly roster on 5/15/2024. FC."]
["Debbie P Reese, MD","PE - Midland Pediatric Associates, PLLC","CAQH","Participating","CAQH Reattested","2024-08-14",null,null,"2024-08-14","08/14/2024 CAQH REattested all locations current and all expirables up to date wthompson"]
["Debbie P Reese, MD","PE - Debbie P. Reese, MD PA","CAQH","Participating","CAQH Reattested","2024-08-14",null,null,"2024-08-14","08/14/2024 CAQH REattested all locations current and all expirables up to date wthompson"]
["Debbie P Reese, MD","PE - Midland Pediatric Associates, PLLC","Humana","Participating","Enrollment Complete","2011-03-01",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 3/1/2011.  DCannon"]
["Debbie P Reese, MD","PE - Midland Pediatric Associates, PLLC","Superior","Participating","Enrollment Complete","2020-08-01",1629074984,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"]
["Debbie P Reese, MD","PE - Midland Pediatric Associates, PLLC","TriCare Standard","Participating","Enrollment Complete","2020-08-09",null,null,"2021-10-29","10/29/21 Received email from Walker47@humana.com she confirmed practitioner is associated with group at the practice location as of 08/09/2020. Cbankston"]
["Debbie P Reese, MD","PE - Midland Pediatric Associates, PLLC","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"]
["Debbie P Reese, MD","PE - Midland Pediatric Associates, PLLC","First Health Coventry","Participating","Re-Credentialing","2008-09-01",1094380,null,"2024-05-16","5/16/2024- Submitted recred status via delegated monthly roster on 5/15/2024. FC."]
["Debbie P Reese, MD","PE - Midland Pediatric Associates, PLLC","Tricare Prime","Participating","Enrollment Complete","1996-09-23",null,null,"2021-09-14","9/14/2021 Per Tricare portal, provider is participating under the Tax ID as of 9/23/96. Cbankston"]
["Debbie P Reese, MD","PE - Midland Pediatric Associates, PLLC","Boon Chapman","Participating","Re-Credentialing","2020-09-09",null,null,"2024-05-16","5/16/2024- Submitted recred status via delegated monthly roster on 5/15/2024. FC."]
["Wayne L Sager, MD","PE - Midland Pediatric Associates, PLLC","Caprock (CapStar)","Participating","Enrollment Complete","2012-04-01",1225182314,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"]
["Wayne L Sager, MD","PE - Midland Pediatric Associates, PLLC","TriCare Standard","Participating","Enrollment Complete","2020-10-27",null,null,"2020-12-01","12/1/2020 - Per f/u report Provider is on file and Par under the group and TIN# effective 10/27/2020.  DCannon"]
["Wayne L Sager, MD","PE - Midland Pediatric Associates, PLLC","Scott&White (First Care)","Participating","Enrollment Complete","2016-02-01",1225182314,null,"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"]
["Wayne L Sager, MD","PE - Midland Pediatric Associates, PLLC","Tricare Prime","Participating","Enrollment Complete","2009-04-30",null,null,"2020-10-08","10/8/2020 Confirmed via Self-Service Portal provider is participating under Tax ID and location. Kimberly Frazier"]
["Wayne L Sager, MD","PE - Midland Pediatric Associates, PLLC","HealthSmart PPO","Participating","Enrollment Complete","2011-02-01",1225182314,null,"2020-06-05","06/05/2020 - Rec'd email from the payer stating this provider is EFF - Stacey Hudak"]
["Wayne L Sager, MD","PE - Midland Pediatric Associates, PLLC","CAQH","Participating","CAQH Reattested","2024-08-15",11035862,null,"2024-08-15","08/15/2024 CAQH Reattested all locations current and all expirables up to date wthompson"]
["Wayne L Sager, MD","PE - Midland Pediatric Associates, PLLC","Cigna","Participating","Enrollment Complete","2012-07-01",1225182314,null,"2020-04-22","04/22/2020--SW Monic of Cigna @ 8008824462, Provider NPI# is on file and participating under the group and TIN# effective 7/1/2012. Location is on file. Call ref# Monic4202020.\n-copied note from spreadsheet-tisha rader"]
["Wayne L Sager, MD","PE - Midland Pediatric Associates, PLLC","United Health Care","Participating","Enrollment Complete","2019-12-01",1225182314,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"]
["Wayne L Sager, MD","PE - Midland Pediatric Associates, PLLC","IMS","Participating","Enrollment Complete","2009-08-28",1225182314,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"]
["Wayne L Sager, MD","PE - Midland Pediatric Associates, PLLC","First Health Coventry","Participating","Enrollment Complete","2011-02-01",2271235,null,"2020-03-24","3/24/2020-received email with roster from payor stating provider PAR 2/1/2011 PID # 2271235\ntisha rader"]
["Wayne L Sager, MD","PE - Midland Pediatric Associates, PLLC","Galaxy Health","Participating","Enrollment Complete","2014-11-04",1225182314,null,"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","PE - Midland Pediatric Associates, PLLC","Multiplan","Participating","Enrollment Complete","2017-04-15",1225182314,null,"2020-08-27","08/27/2020 -Rec'd email from the payer stating \"\nThank you for contacting our Customer Service Department with Multiplan/PHCS. We received your request have confirmed that the following providers are participating with Multiplan and PHCS through Midland Pediatric Associates: - Wayne Sager-Effective 04/15/2017\" - Stacey Hudak"]
["Wayne L Sager, MD","PE - Midland Pediatric Associates, PLLC","USA PPO","Participating","Enrollment Complete","2009-08-28",350398,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"]
["Wayne L Sager, MD","PE - Midland Pediatric Associates, PLLC","Humana","Participating","Enrollment Complete","2011-03-01",1225182314,null,"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"]
["Wayne L Sager, MD","PE - Midland Pediatric Associates, PLLC","Boon Chapman","Participating","Enrollment Complete","2017-04-15",1225182314,null,"2020-10-05","Enrolled thru PHCS"]

{"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, Inc","TriCare Standard","Participating","Enrollment Complete","2023-10-17",null,null,"2023-10-27","Ste. 102 and 103 effective 10/17/2023 has been approved. MD"]
["Douglas J Colson, MD",null,"TriCare Standard","Participating","Enrollment Complete","2023-10-17",null,null,"2023-10-27","Ste. 102 and 103 effective 10/17/2023 has been approved. MD"]
["Douglas J Colson, MD","PE - Premier Family Care, Inc","TriCare Standard","Participating","Enrollment Stopped","2023-10-17",null,null,"2023-11-06","Ste. 240, 205, and 107 have been confirmed as non current service addresses. Provider should only be linked to Ste. 103. MS"]
["Douglas J Colson, MD",null,"TriCare Standard","Participating","Enrollment Stopped","2023-10-17",null,null,"2023-11-06","Ste. 240, 205, and 107 have been confirmed as non current service addresses. Provider should only be linked to Ste. 103. MS"]
["Douglas J Colson, MD","PE - Premier Family Care, Inc","Amerigroup","Participating","Enrollment Complete","2023-07-19",null,null,"2023-11-09","11/9/2023 Per email received from Jessica Bess at  Multiplan provider is PAR with Amerigroup and linked to group TIN/locations thru Multiplan enrollment effective 7/19/2023.  DCannon"]
["Douglas J Colson, MD","PE - Premier Family Care, Inc","USA PPO","Participating","Enrollment Complete","2018-08-29",null,null,"2023-11-22","11/22/2023 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 8/29/2018.  DCannon"]
["Douglas J Colson, MD","PE - Premier Family Care, Inc","Humana","Participating","Enrollment Complete","2023-07-19",null,null,"2023-12-21","12/21/2023 Per Humana online directory provider is PAR and linked to group TIN and  all locations effective 7/19/2023.  DCannon"]
["Douglas J Colson, MD","PE - Premier Family Care, Inc","Galaxy Health","Participating","Enrollment Complete","2023-07-19",null,null,"2023-11-07","11/7/2023 Per email received from Galaxy October delegated roster has been processed and provider is PAR and linked to group/location effective 7/19/2023.  DCannon"]
["Douglas J Colson, MD","PE - Premier Family Care, Inc","Cigna","Participating","Enrollment Complete","2023-07-19",6670877,null,"2023-11-08","Received confirmation of update. MS"]
["Douglas J Colson, MD","PE - Premier Family Care, Inc","Scott&White (First Care)","Participating","Enrollment Complete","2023-07-19",null,null,"2024-01-29","1/29/2024 Rcvd confirmation from S&W that provider is PAR and linked to group TIN/location effective 7/19/2023.  DCannon"]
["Douglas J Colson, MD","PE - Premier Family Care, Inc","IMS","Participating","Enrollment Complete","2023-07-19",null,null,"2024-01-02","1/2/2024 Rcvd email from German Avilies at IMS/OMNI that October delegation roster is complete.  Provider is PAR and linked to group TIN/location effective 7/19/2023.  DCannon"]
["Douglas J Colson, MD","PE - Premier Family Care, Inc","Aetna","Participating","Enrollment Complete","2023-07-19",5117734,null,"2023-11-19","11.29.2023 S/W PhilC of Aetna @ 1-800-353-1232. Per rep, Provider is in network with Aetna and linked to the group and TIN# effective 07/19/2023. Next recredentialing date is on 07/19/2026. PIN: 5117734. Servicing location is on file. Payer# 60054. Call ref# 6172179371. - Willie Ravas"]
["Douglas J Colson, MD","PE - Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","2023-10-17",null,null,"2024-01-25","Confirmed provider is credentialed and in network with Tricare. MS"]
["Douglas J Colson, MD","PE - Premier Family Care, Inc","Superior","Participating","Enrollment Complete","2023-11-01",null,null,"2023-11-06","11/6/2023 Rcvd email from Superior that provider is PAR and linked to group TIN/location effective 11/1/2023.  DCannon"]
["Douglas J Colson, MD","PE - Premier Family Care, Inc","Wellmed","Participating","Enrollment Complete","2022-01-01",null,null,"2023-11-03","11/3/2023 Rcvd confirmation email from UHC/Wellmed that provider is PAR and linked to group TIN/location effective 1/1/2022.  DCannon"]
["Douglas J Colson, MD","PE - Premier Family Care, Inc","Boon Chapman","Participating","Enrollment Complete","2023-07-19",null,null,"2023-11-09","11/9/2023 Rcvd email confirmation from Jessica Bess at Multiplan that October roster has been processed and provider is PAR w/ group effective 7/19/2023.  DCannon"]
["Douglas J Colson, MD","PE - Premier Family Care, Inc","Omni PPO","Participating","Enrollment Complete","2023-07-19",null,null,"2024-01-02","1/2/2024 Rcvd email from German Avilies at IMS/OMNI that October delegation roster is complete.  Provider is PAR and linked to group TIN/location effective 7/19/2023.  DCannon"]
["Douglas J Colson, MD","PE - Premier Family Care, Inc","Medicare","Participating","Enrollment Complete","2023-10-01",679507,"0008AH","2024-02-07","Location was added to group record eff 10/1/2023. MS"]
["Douglas J Colson, MD","PE - Premier Family Care, Inc","HealthSmart PPO","Participating","Enrollment Complete","2023-07-19",null,null,"2023-12-15","12/15/2023 Per email rcvd from Aleece Moerbe at Healthsmart provider is PAR and linked to group TIN/location effective 7/19/2023.  DCannon"]
["Douglas J Colson, MD","PE - Premier Family Care, Inc","First Health Coventry","Participating","Enrollment Complete","2023-07-19",1046218,null,"2023-12-06","12/6/2023 S/W Kim of First Health @ 800-226-5116 and transferred me over to Courtney. Per rep, Provider is in network with First Health and linked to the group and TIN# effective 7/19/2023.  PIN: 1046218. Servicing location is on file. No payer# available. DCannon"]
["Douglas J Colson, MD","PE - Premier Family Care, Inc","Caprock (CapStar)","Participating","Enrollment Complete","2023-07-19",null,null,"2023-10-19","10/19/2023 Rcvd email  confirmation from Caprock that provider is PAR and linked to group TIN/locations effective 7/19/2023.  DCannon"]
["Douglas J Colson, MD","PE - Premier Family Care, Inc","Wellcare","Participating","Enrollment Complete","2023-11-01",null,null,"2023-11-06","11/6/2023 Rcvd email from Superior that provider is PAR and linked to group TIN/location effective 11/1/2023.  DCannon"]
["Douglas J Colson, MD","PE - Premier Family Care, Inc","Medicaid","Participating","Enrollment Complete","2023-02-22",null,null,"2024-03-20","Welcome ltr rcvd. Provider effective at this location 02/22/2023. Jen Videan"]
["Douglas J Colson, MD","PE - Premier Family Care, Inc","Multiplan","Participating","Enrollment Complete","2023-07-19",null,null,"2023-11-09","11/9/2023 Rcvd email confirmation from Jessica Bess at Multiplan that October roster has been processed and provider is PAR w/ group effective 7/19/2023.  DCannon"]
["Douglas J Colson, MD","PE - Premier Family Care, Inc","Ambetter","Participating","Enrollment Complete","2023-11-01",null,null,"2023-11-06","11/6/2023 Rcvd email from Superior that provider is PAR and linked to group TIN/location effective 11/1/2023.  DCannon"]
["Douglas J Colson, MD","PE - Premier Family Care, Inc","Triwest VA","In House Enrollment","In House Enrollment",null,null,null,"2023-10-13"]
["Douglas J Colson, MD","PE - Premier Family Care, Inc","CAQH","Participating","CAQH Reattested","2024-07-05",11483093,null,"2024-07-05","07/05/2024 CAQH Reattested all locations current and all expirables up to date wthompson"]
["Douglas J Colson, MD","PE - Premier Family Care, Inc","United Health Care","Participating","Enrollment Complete","2018-07-10",2539407,null,"2023-11-03","11/3/2023 Rcvd confirmation email from UHC that provider is PAR and linked to group TIN/location effective 7/10/2018.  MPIN # 002539407.  DCannon"]