What information will I need to provide when I enroll?

You will need to provide the following information during the enrollment process:

  • First name, last name, gender, date of birth, social security number, and place of birth
  • Taxonomy and Primary Taxonomy – list one or more specialties that you practice
  • Provider name, address, and ZIP code of the mailing, billing, primary service location, as well as secondary service location address if applicable.
  • Owners and/or Key Personnel must have first name, last name, gender, date of birth, social security number, and place of birth
  • National provider identifier (NPI) and tax ID (FEIN)
  • License, CLIA, DEA or any license or certification information
  • If a pay-to provider, financial information and a filled out W-9 will need prepared
  • Pharmacy providers will be required to fill out a Trading Partner Agreement

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