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Start Enrollment
Tuesday 12/03/2024 11:48 AM CST
Provider Enrollment: Start Enrollment
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Select Enrollment Type, Provider Type, and Specialty then enter your assigned NPI and Tax ID (Employee Identification Number or Social Security Number)
The
*
indicates a required field.
*
Enrollment Type
Atypical
Group
Individual
Individual Within Group
Enrollment Type is a required field.
*
Provider Type
Provider Type is a required field.
*
Specialty
Specialty is a required field.
NPI
NPI is not valid or in the correct format. Enter a valid value in the format '9999999999'.
*
Tax ID
Tax ID is a required field.
Tax ID is not valid or in the correct format. Enter a valid value in the format '999999999'.
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