Add a Practice Location to an Existing Contract

Contracted providers can use this form to add a location to an existing contract. Please note, if you are affiliated with a third party Delegate Manager, all changes must be made at the request of the Delegate. Contact your Delegate Manager for additional information.

NOTE:  Medical Providers and Groups (MD, DO, DC, DPM and Physician Extenders) who want to add a new practice location and are currently credentialed by Superior; or ancillary providers who want to add a new practice location that will operate under the same state license and TIN/NPI combination should contact your Account Management Representative.

Click here to find your Account Management Representative.

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Will this new practice location be operating under the same state license as the existing location? *


Will the new practice location be operating under the same TIN/NPI combination? *


Please enter the name that appears on the W9


9 digits, no dashes


10 digits, no dashes




Street Address or P.O. Box