Individual Provider Information
Provider Name
First Name
Last Name
Individual NPI
123456789
Date of Birth
Social Security Number
xxx-xx-xxxx
CAQH Provider ID Number
License Number
DEA Number (if applicable)
Medicare PTAN
Medicaid ID Number
Primary Office Location
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Claims Billing Address (if Different than Above)
Same as above
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Office Phone Number
-
Area Code
Phone Number
Office Fax Number
-
Area Code
Phone Number
Email
example@example.com
Medical Plans
*
Rows
Already Credentialed
Interested in Credentialing
Aetna
Affinity
Cigna
Elderplan
Empire BCBS
Fidelis
GHI
Health First
Health Plus (Amergroup)
HIP
Integra
Magnacare
Medicare
Medicaid
Medicaid DME
MetroPlus
Oxford
United Healthcare
WellCare
Vision Plans
Rows
Already Credentialed
Interested in Credentialing
Davis Vision
March Vision
EyeMed
GVS
Superior Vision
VSP
Spectera
Vision Screening
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