Provider Information

Thank you for your interest in becoming a participating provider with Maryland Physicians Care, Inc.
Please complete the online intake form below. The information provided will be used to determine contract eligibility.

* required fields

Your Name *

Your Email Address *

Your Phone Number *

Your Fax Number

What is the main type of services the practice would provide to MPC members? *

Name of Group Practice *

County/counties the practice serves *

Languages other than English practice's providers speak

Provider's Tax Identification Number (TIN) *

What is the group National Provider Identifier (NPI)? *

Additional Information

If you have any questions regarding your online intake form, please contact our Provider Contracting team at MPCProviderContracts@mpcmedicaid.com.

Provider Participation Request Intake Form

Provider Information

Additional Information