Credentialing

To submit credentialing information, please use the form below.

Main Contact

Contact name*

Contact phone*

Contact email*

Contact fax

Practice/Facility Info

Practice name*

Street address

Street address*

City*

State*

Zip*

Different mailing address?

Mailing address

City

State

Zip

Tax ID*

Group NPI*

New provider information

New provider name*

New provider date of birth*

New provider specialty*

New provider NPI*

CAQH ID*

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.

Supervising MD NPI

Supervising MD Name

Check box if new provider will file claims under their own name.

Credentialing contact

Credentialing contact name*

Credentialing contact address

Street address*

City*

State*

Zip*

Credentialing contact phone*

Credentialing contact email*

Credentialing contact fax

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Credentialing

Main Contact

Practice/Facility Info

Street address

Mailing address

New provider information

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

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Looking For a Doctor or Facility?

COVID-19 Updates

For MedCost Administered Plans

For All Plans

Credentialing

Main Contact

Practice/Facility Info

Street address

Mailing address

New provider information

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

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