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PROVIDER INFORMATION FORM
IDENTIFICATION INFORMATION
PROVIDER LAST NAMEPROVIDER FIRST NAME NPI NUMBERPROVIDER TYPE (PCP, SPECIALIST, ETC)ACCEPTING NEW PATIENTS
(Y or N)TAXONOMY CODETITLECAQH NUMBERDOBPRIMARY
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How to fill out provider information form
How to fill out provider information form
01
Start by gathering all the necessary information about the provider, including their name, contact details, address, and any unique identifiers they may have.
02
Begin filling out the form by entering the provider's full name in the designated field.
03
Next, include their phone number, email address, and any other relevant contact information.
04
Move on to the address section, where you will need to provide the provider's complete mailing address.
05
If the provider has any specific identification numbers or codes, make sure to input them accurately.
06
Double-check all the entered information for accuracy and completeness.
07
Finally, submit the completed provider information form either online or by following the specified submission method.
Who needs provider information form?
01
The provider information form is needed by organizations or individuals who require accurate and up-to-date information about a particular service provider. This can include healthcare institutions, insurance companies, government agencies, and other entities that need to maintain a comprehensive database of providers.
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