Please enable JavaScript in your browser to complete this form.Please enable JavaScript in your browser to complete this form.Group/Clinic Name (DBA) *Name of EIN/TIN Registeredwith the IRS *Name of Owner(s)* *Percentage of Ownership * Office Hours Monday *Tuesday *Wednesday *Thursday *Friday *Saturday *Sunday *Practice LimitationsMinimum AgeMax AgeGender LimitationsADA Accessibility requirements met? *YesNoHandicapped Acessible *YesNoLanguage spoken officePhysical Address *City *State *Zip Code *Phone *FaxOffice Contact Name *Office Contact Email *Billing Address City *State *Zip Code *Phone *FaxBilling Contact Name *Billing Contact Email *Correspondence AddressCityStateZip CodePhoneFaxCorrespondence Contact NameCorrespondence Contact EmailMedical Record AddressCityStateZip Code * to Correspondence & PhoneFaxMedical Record Contact NameMedical Record Contact Email Credentialing Information TID *Group NPI *Group Medicaid ID (If applicable)Group Medcare PTAN (If applicable) Railroad Medicare PTAN (If applicable)CLIN (If applicable)NPPES/PECOS User IDNPPES/PECOS PasswordSpecialtyTaxonomy CodeHospital Affiliations(List Facility: Name, Address, Types of Privileges, Effective dat of Privileges) Authroized Offical Name *SSN *Cell Phone *Home AddressNPPES Login IDNPPES Password I authroize Med Credential Pro to use my signature below for credentialing purpose Initials *Date / Time *DateTime Ownership & Control Interests (42 CFR 455.104) Full Legal NameAddress% of OwnerInterestSSN OR FEINRelationshipFull Legal NameAddress% of OwnerInterestSSN OR FEINRelationshipFull Name of Business or OrgamizationName of OtherAddressSSN or FEIN% of Ownership Interest Significant Business Transactions (42 CFR 455.402) Full Legal Name AddressSSN or FEINReasonName of Wholly Owneed SupplierAddressSSN or FEINNature of Bussiness TransactionSubmit
