Request Credentialing

If you are a participating practice in the MedCost Network and would like to provide your CAQH ID to request credentialing, please complete the form below.

Provider name*

Provider NPI*

Provider date of birth*

Provider specialty*

Provider degree*

CAQH ID*

Practice/facility information

Practice or facility name*

Street address

Street address*

City*

State*

Zip*

Different Mailing address?

Mailing address

City/Town

State

Zip

TaxID*

Group NPI*

Credentialing contact

Credentialing contact name*

Credentialing contact address

Address*

City*

State*

Zip*

Credentialing contact phone*

Credentialing contact email*

Credentialing contact fax

Comments

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