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Select Your Practice Type
Select Your Practice Type
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Provider Information
First Name
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Last Name
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Date of Birth
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Social Security Number
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Gender
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Other
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Phone Number
Email Address
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Professional Licenses
License Type
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MD – Doctor of Medicine
DO – Doctor of Osteopathy
NP – Nurse Practitioner
PA – Physician Assistant
RN – Registered Nurse
License Number
Issuing State
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Issue Date
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Expiration Date
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Upload License Copy
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Organization Information
Organization / Group Name
Tax ID Number
Do not enter spaces (e.g., 123456789)
Type 2 NPI (Group NPI)
10-digit National Provider Identifier
CAQH Organization ID
Primary Contact Person
First Name
Last Name
Email Address
Phone Number
Practitioners
First Name
Last Name
Type 1 NPI
10-digit National Provider Identifier
CAQH ProView ID
Ensure CAQH application is complete
License Type
MD – Doctor of Medicine
DO – Doctor of Osteopathy
NP – Nurse Practitioner
PA – Physician Assistant
RN – Registered Nurse
LCSW – Licensed Clinical Social Worker
PhD – Psychologist
DDS – Doctor of Dental Surgery
License Number
License State
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Health Plans
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