Group Practice Information
Company Name (as Reported to IRS)
Group/Practice NPI
123456789
Full Name of Company Owner
First Name
Last Name
Tax-ID Number
xxx-xx-xxxx
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
Hours of Operation
Rows
Open
Close
Monday
Tuesday
Wednesday
Thursday
Friday
Saturday
Sunday
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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