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Business Information
*
Indicates required field
Legal Business Name
*
Full Legal Business Name
Primary Practice Address
*
Line 1
Line 2
City
State
Zip Code
Country
Doing Business as
*
Enter Full DBA
Clinic Email Address
*
Email for General Correspondence
Clinic Phone Number
*
Phone for General Correspondence
Clinic Fax Number
*
Fax for General Correspondence
Group NPI
*
Enter Group's National Provider Identifier
Group Tax ID
*
Enter Group's Tax Identification Number
CLIA Certification Number (if available)
*
Enter Clinical Laboratory Improvement Amendments Certification Number
CLIA Expiration Date
*
CLIA Effective Date
*
List all Owners
*
Enter full name of all Owner(s)
Business Establishment Date
*
Enter the full mm/dd/yyyy.
Office Manager/POC Name
*
Enter full name of POC/Manager
POC's Email Address
*
POC's Email address for correspondence
Group's Specialty (Taxonomy)
*
Enter Group's Taxonomy Specifying Specialty
Billing Software (Currently in use)
*
Enter the name of Billing software currently in use (if any)
EMR (Currently in use)
*
Enter the name of EMR which is in use of the Clinic (if any)
Group's PTAN
*
Enter Group's Medicare Number
Group TPI
*
Enter Group's TPI Number
Additional Information
*
Enter all additional information/request/instructions here
Please provide copies of all following documents:
Completed & Signed W-9 Form
CLIA Certification (if available)
Certification of Filing
CP-575 (IRS Form)
Voided Check
Submit Group Info
Individual Provider Information
*
Indicates required field
Provider Full Name
*
Enter Full Name as (First, Middle, Last Name + Degree)
Primary Specialty
*
Enter Provider's Primary Specialty With Taxonomy Code
NPI Number
*
Enter Provider's National Provider Identifier (if available)
Provider's DOB
*
Enter Provider's Date of Birth
Provider's SSN
*
Enter Provider's Social Security Number
Phone Number
*
Enter Phone Number which can be used for General Correspondence
Email Address
*
Enter Email Address which can be used for General Correspondence
Driving License
*
Enter State's Driving License Number
State License Number
*
Enter Provider's Active State License Number
DEA Certification Number
*
Enter Provider's Active DEA Certification Number
Medicare Number
*
Enter Individual Provider's Medicare Number
Medicaid Number
*
Enter Individual Provider's Medicaid Number
CAQH ID
*
Enter CAQH ID (if available)
Issued Date
*
Enter Issue Date of Driving License
Effective Date
*
Enter State License's Effective Date
Effective Date
*
Enter DEA Certification Effective Date
Expiration Date
*
Enter Expiration Date of Driving License
Expiration Date
*
Enter State License's Expiration Date
Expiration Date
*
Enter DEA's Expiration Date
Effective Date
*
Enter Medicare's Effective Date
Effective Date
*
Enter Medicaid's Effective Date
CAQH Username
*
Enter CAQH Username
CAQH Password
*
Enter CAQH Password
Place of Birth
*
Enter Provider's Place of Birth
State of Birth
*
Enter Provider's State of Birth
Citizenship
*
Enter Provider's Citizenship
Hospital Privileges
*
Enter Provider's Hospital Privileges (if available) along with the address and type of Privileges
Practice Location(s)
*
Enter all Locations Where Provider is (currently/going to) Provider Services
Will this provider only be acting as a Supervising Physician?
*
Yes
No
Please provide copies of all following documents:
State License
Driving License
DEA
Updated Resume
Professional Liability Sheet
All additional License/Certificates (if Any)
Submit Individual Provider's Info
Home
About Us
Resources
Services
Provider Enrollment and Credentialing Services
Denial Management Services
Medical Billing Services
Sign Up
Request a Quote
Blog
Contact Us
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