Provider Credentialing

What is your full legal name?

What is your date of birth?

What is your gender?

What is your Social Security Number?

Please upload a picture of the FRONT of Social Security card

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Please upload a picture of the BACK of Social Security card

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What is your National Provider Identifier (NPI)?

What is your CAQH ID number?

What is your taxonomy/specialty code?

What is your provider type (MD, DO, NP, PA, etc.)?

What languages do you speak fluently?

What is your professional email address?

What is your preferred phone number?

Where did you complete your undergraduate education (school name, city, state, dates)?

Where did you complete your graduate or medical school training?

What degree did you earn?

Please upload a pictures of your Certificate or Diploma of Program Completion

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What is your current professional license number and issuing state?

When does your license expire?

Do you hold additional state licenses? If yes, please list them.

Please upload a copy of ACTIVE State License

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What is your DEA registration number and expiration date?

Please upload a copy of DEA Registration Certificate

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Are you board certified? If yes, list board(s) and expiration date(s).

Please upload a copy of your Board Certificate

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Who is your current malpractice insurance carrier?

What are your coverage limits?

What is the policy number and expiration date?

Have you ever had a malpractice claim filed against you? If yes, provide details.

Please upload a copy of your Malpractice Insurance Certificate

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Please upload a copy Government-issued ID (driver's license, passport, or state ID)

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Please upload a picture (professional headshot)

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Current CV/Resume (signed and dated)

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Do you have a PECOS account?

Yes

We can create one for you.

PECOS Account Details

Username

Password

Signature

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Provider Credentialing

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