Online Provider Enrollment

GENERAL INFORMATION
Last Name (include Jr.,Sr., as applicable):			First Name:		MI:
Birth Date (mmddyy):	Professional Degree:	Social Security Number:
Specialty:		2nd Specialty:
Clinical Name or D.B.A. Name:		Tax ID Number:
OFFICE LOCATIONS
Office Location #1:			Phone:
Street Address for Directory:			Fax:
City:		State:	County:		Zip
Office Location #2			Phone:
Street Address for Directory:			Fax:
City:		State:	County:		Zip:
BILLING LOCATION
Billing address if different from above:			Phone:
Address:			Fax:
City:		State:	County:		Zip:
LICENSURE
State Licensed:	License Number:	Effective Date:		Expiration Date:
State Licensed:	License Number:	Effective Date:		Expiration Date:
Federal DEA Certificate:	Registration Number:	Date Issued:		Expiration Date:
State CDS Certificate:	Registration Number:	Date Issued:		Expiration Date:
INSURANCE MINIMUM 200/600 THOUSAND
Malpractice/Prof. Liability Insurance Company:		Policy Number:		Expiration Date:
Name:			Address:
City:			State:	Zip:

Phone: 800.213.1009

Fax: 210.828.1800

Revised: 04/03/07