|
Address Line 1
|
Displays the street address of the requested provider.
| |
|
Cancel
|
Click on Cancel to cancel the information that you entered.
| |
|
City
|
Displays the city of the requested provider.
| |
|
Financial Payer
|
From the drop down list, select the Financial Payer from the choices of Medicaid, WCDP, or W3P.
| |
|
NPI Number
|
Enter your National Provider Identification (NPI) number.
| |
|
Name
|
Displays the provider name of the requested provider.
| |
|
Provider ID
|
Enter the provider ID of the requested provider if you don't have a NPI.
| |
|
Provider Number
|
Enter your Medicaid Provider Number.
| |
|
SSN or TIN
|
Enter either your Social Security Number (SSN) or Tax Identification Number (TIN).
| |
|
Submit
|
Click on Submit to have the information that you entered transmitted to the system.
| |
|
Taxonomy
|
Enter the Taxonomy code that applies to your specialty.
| |
|
ZIP
|
Enter your ZIP Code of record.
| |
|
Zip Code Extension
|
Enter the ZIP Code +4 digit Extension for your location of record.
| |