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MedCost

Add a Provider to a Participating Practice

Add a Provider to a Participating Practice

If you are a participating practice in the MedCost Network and would like to add a new provider, please complete the form below.

Main Contact

Practice/Facility Info

Street address
Street address
List this address in provider directory
Mailing address
Mailing address
(enter one Tax ID per form submission)

New provider information

New provider degree*
New provider specialty*
Supervising MD

Information message

If the new provider is a mid-level provider (Nurse Practitioner, Physician Assistant), we require information about their Supervising MD to process the request. Without that information, the process will be delayed.

Credentialing contact

Credentialing contact address
Credentialing contact address