Demographic Change

Home 9 Provider Updates 9 Demographic Change

What do you want to do?

Change Phone Number

Change Practitioner Name

Update Practitioner Office Hours

Update Service Location Office Hours

Update Specialty

Group/Facility Name

Tax ID #

Group NPI #

Service Location Address

Street Address

Address Line 2

City

State

Zip Code

Old Phone Number

New Phone Number

Comments

Practitioner NPI #

Practitioner Current Name

Prefix

First Name

Last Name

Suffix

Practitioner New Name

Prefix

First Name

Last Name

Suffix

Comments

Practitioner NPI #

Group NPI #

Tax ID #

Practitioner Name

First Name

Last Name

Group Name

Service Location Address

Street Address

Address Line 2

City

State

Zip Code

New Provider Office Hours

Sunday

Monday

Tuesday

Wednesday

Thursday

Friday

Saturday

Comments

Group/Facility Name

Group NPI #

Service Location Address

Street Address

Address Line 2

City

State

Zip Code

Service Location Office Hours

Sunday

Monday

Tuesday

Wednesday

Thursday

Friday

Saturday

Comments

Practitioner NPI #

Practitioner Current Specialty

Prefix

First Name

Last Name

Suffix

Current Specialty

Practitioner New Specialty

Prefix

First Name

Last Name

Suffix

New Specialty

Comment

Type of change

Change from Specialist to PCP

Change from PCP to Specialist

Follow the instructions for updating the specialty

If multiple practitioners' provider updates are needed, please download the EHP Roster Template and attach it in the upload field. All roster fields are required.

EHP Roster Template (Excel)
(Roster template revised 02/04/2022)

File Upload

Choose File

Update Requested By

First Name

Last Name

Contact Email

Contact Phone Number

Date Requested

This form will send your message to EHP Contracting as an email. The email is not encrypted and is not transmitted in a secured format. By communicating with EHP Contracting through email, you accept associated risks. EHP Contracting does not accept responsibility or liability for any loss or damage arising from the use of email. To ensure the safety of your protected health information (PHI), please send us a message through the Secure Member or Provider portal.