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Individual Credentialing Intake Form
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After submitting this form, you will be redirected to our Credentialing Dashboard.
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Email *
  Portal Password   *
Create a password for future portal access.
Group Name *
First Name *
Middle Name *
Last Name *
NPI Number *
DOB *
MM
/
DD
/
YYYY
Professional School *
Degree *
Graduation Date *
MM
/
DD
/
YYYY
License Type *
License Number *
License Issue Date *
MM
/
DD
/
YYYY
License Expiration Date *
MM
/
DD
/
YYYY
DEA Number
DEA Issue Date
MM
/
DD
/
YYYY
DEA Expiration Date
MM
/
DD
/
YYYY
Certifying Board
Board Specialty
Board Number
Board Initial Date
MM
/
DD
/
YYYY
Board Expiration Date
MM
/
DD
/
YYYY
Taxonomy 1
Taxonomy 2
Taxonomy 3
Taxonomy 4
SS# *
Birth City *
Birth State *
Email *
Home Address 1 *
Home Address 2
City *
State *
Zip *
Cell Phone *
CAQH ID Number *
CAQH User Name *
CAQH Password *
CAQH Attestation Date
MM
/
DD
/
YYYY
Medicare ID/PTAN
Medicare Effective Date
MM
/
DD
/
YYYY
PECOS/NPI Username
PECOS/NPI Password
State Medicaid ID
Medicaid Effective Date
MM
/
DD
/
YYYY
State Medicaid User Name
State Medicaid Password
State Medicaid PIN
One Healthcare ID User
One Healthcare Password
Date of Employment
MM
/
DD
/
YYYY
Supervising/Collaborating Physician
Supervising/Collaborating Physician NPI
Are you covered under the group malpractice policy? *
Criminal History? *
A copy of your responses will be emailed to the address you provided.
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