Contact Us
|
Login
Logout Confirmation
Are you sure you want to logout?
Logout Confirmation
If you navigate away from this page, you will lose unsaved data. Are you sure you want to logout?
Timeout Notification
As of
, your session will expire in
5 minutes
.
To remain logged in and avoid losing any data that you may have entered, please click Extend.
Otherwise, you will be logged off and your current session will end. Any unsaved data will be lost.
Timeout Notification - Session Ended
Your session has ended for security reasons due to inactivity.
If you were logged on, you will have to log on again to start a new session.
Home
Home
>
Provider Enrollment
>
Start Enrollment
Thursday 04/25/2024 06:37 AM CST
Provider Enrollment: Start Enrollment
Back to Home
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'.
Data load in progress...
Privacy Notice