Individual Practitioners
(Physicians, Adjuncts, Mid-levels)
- Practitioner Name and Degree
- Social Security Number or IRS Individual Taxpayer ID
- Practitioner Date of Birth
- Country of Birth
- State of Birth (if Country of Birth is U.S.)
- Mailing Address
- Practice Location (No PO Boxes)
- MVP Provider ID numbers (UPIN, Medicare, Medicaid)
- Taxonomy Code
- State License Number
- Application Contact Person
|
|
Organizations
(Hospitals, Vendors, Agencies)
- Legal Organization Name
- Other Name (former DBA)
- Employer Identification Number
- Mailing Address
- Practice Location (No PO Boxes)
- MVP Provider ID numbers (UPIN, Medicare, Medicaid)
- Taxonomy Code
- State Operating Certificate (if applicable)
- Application Contact Person
|
