Credentialing &
Re-Credentialing

HIPPAA Compliant credentialing application

Provider NameRequired

Individual NPI Number Required

Date Of BirthRequired

Providers Home AddressRequired

Practioner Speciality

Providers Email AddressRequired

Providers Cell NumberRequired

Providers Hours of OperationsRequired

Group/Practice NameRequired

NPI NumerRequired

TIN NumberRequired

Servicing AddressRequired

Mailing AddressRequired

Billing AddressRequired

Phone NumberRequired

Fax numberRequired

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