Join Our Network

Thank you for your interest in participating in the Ambetter of Alabama network! If you would like to receive more information on becoming a provider within our network or would like to receive a contract, please contact us at 1-800-442-1623.

Required fields are marked with an asterisk (*)

Are you currently contracted with an Independent Practice Association (IPA) or a Physician Hospital Organization (PHO)? * Yes No

Enter IPA or PHO Name *

Select Your Primary Specialty *

Sub-Specialty

Enter Provider Name *

Enter Group Practice Name *

Enter Provider Tax ID Number (e.g. 999999999) *

Enter Provider NPI Number *

Enter Group NPI Number

Primary Practice Address *

City *

State *

Zip Code *

County

Contact Name *

Contact Number *

Contact Email *

Agreement * I understand this inquiry does not guarantee my participation in the Ambetter of Alabama network.

Agreement * I understand that failure to complete this inquiry accurately and completely will result in the delay of evaluating my request.