 Information you will be asked
- Practice Location Information
- Individual practice name and individual NPI
number
- Corporate practice name and corporate NPI
number (if applicable)
- Address and contact information
- Billing, office manager and credentialing contact
- Services, certifications, limitations and hours of operation
- Partners and covering colleagues
- Education and Training
- Medical /Professional school
- Graduate school
- Internships and residencies
- Fellowships and preceptorships
- Teaching appointments
- Specialties and Board Certification
- Hospital Affiliation Information
- Malpractice Insurance Information
- Work History and References
- Disclosure and Malpractice History
- Basic Personal Information
- A clear copy of all license and certificates are required
- IRS Form W-9(s)
- Drug Enforcement Administration (DEA) Certificate
- Controlled and Dangerous Substances (CDS) Certificate
- State medical license(s)
- Various identification numbers (UPIN, Medicare, Medicaid etc)
- Malpractice insurance policy(ies)
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