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Please answer the following questions
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1
Step 1
Enrollment Type:
Individual
Group Practice
Facility/Agency/Organization
Provider Type (ex: md, Rn, medical clinic, home health) :
Individual Information: If Using SS# For Enrollment
First Name
your full name
Last Name
MI
SS#
Driver License Number
Driver License Exp
State
Provider Type
License Number
License State
Issue Date
Initial Issue Date
Expiration Date
Licensing Board
NPI
Taxonomy
Taxonomy
Organization Information: If Using FEIN# For Enrollment
Provider Type
Legal Name of Business:
Doing Business As Name
FEINs Name
Business License Number
Issuing State
License Expiration
Business Address
City
State
Zip
Mailing Address
City
State
Zip
Email
a valid email
email
Phone
Fax
Contact Person
Title
NPI
Medicare Number
Medicaid Number
Medical Professional Type
License Number
Issuing State
License Expiration
Initial Licensure Date
Address
City
State
Zip
NPI
Taxonomy
Taxonomy
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