Join Our Network

Thank you for your interest in participating with Ambetter from Louisiana Healthcare Connections! If you would like to receive more information on becoming a provider within our network, please complete the form below.

Required fields are marked with an asterisk (*)

First Name *

Last Name *

Contact Phone Number *

Contact Email Number *

Provider Information

Provider Type *

Legal Entity Name *

ATTN: *

Street_Address *

Address Line 2

City *

State *

Zip Code *

Provider Identification Numbers

Tax ID *

Group NPI *

Will you function as a Primary Care Physician (PCP)? Yes No

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

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

Become An Ambetter Provider in Louisiana | Ambetter from Louisiana Healthcare Connections

Join Our Network

Provider Information

Provider Identification Numbers