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Apr 26, 2024
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Application Type Information
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Application Type
Individual
Group
Canadian Application
Trading Partner Application
If you are applying with a Federal Employer Identification Number (FEIN), please request and submit the Group Provider Enrollment Application.
Address Information
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If the application type being requested is Individual, do NOT enter the Organization name, but instead enter the name fields.
If the application type being requested is Group, do NOT enter the name fields, but instead enter the Organization name.
Organization
Last Name
First Name
Middle Initial
Title
Adult Nurse Practitioner
Certificat Clinical Competence-Audiology
Cert Clinical Competence-Spch/Lang Path
Certified Health Education Specialist
Certified Medical Illustrator
Certified Nurse Midwife
Certified Orthotist
Certified Occupational Therapy Assistant
Certified Prosthetist
Certified Prosthetist-Orthotist
Certified Registered Nurse Anesthetist
Certified Respiratory Therapist
Doctor of Chiropractic
Doctor of Dentistry
Doctor of Dental Surgery
Doctor of Dental Medicine
Doctor of Osteopathic Medicine
Doctor of Podiatric Medicine
Licensed Clinical Social Worker
Licensed Dispensing Optician
Licensed Midwife.
Licensed Nutritionist
Licensed Professional Counselor
Licensed Practical Nurse
Doctor of Medicine
Master of Nursing, Nurse Practitioner
Master of Nursing
Master of Social Work
Nurse Practitioner
Doctor of Optometry
Occupational Therapist, Registered
Physician's Assistant
Physician Assistant-Certified
Doctor of Pharmacy
Doctor of Philosophy (Doctorate Degree)
Doctor of Psychology
Physical Therapist
Physical Therapist Assistant
Registered Dietician
Registered Dietitian and Nutritionist.
Registered Nurse
Registered Pharmacist
Registered Respiratory Therapist
Reg Tech; Radiation Therapy
Doctorate in Speech-Language Pathology
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