Contact Provider ServicesHelp * Required field Provider Information: * Provider Name: * Address Line 1: * Medicaid ID: Address Line 2: * Telephone: * City: * Email Address: * State: AK AL AR AZ CA CO CT DC DE FL GA HI IA ID IL IN KS KY LA MA MD ME MI MN MO MS MT NC ND NE NH NJ NM NV NY OH OK OR PA PR RI SC SD TN TX UT VA VT WA WI WV WY Fax: * Zip Code: Your Information: Name: Telephone: Choose a subject from the list below: * Subject: Other Directory of Individual Medicaid Provider Numbers LTC Form Request Medicaid Claims Inquiry/Response Form Medicaid Forms Order Provider Manual Request