The Provider Name must be the current name on tax, corporation, or other legal documents. The legal name and Provider Federal Tax Identification Number (TIN) must match the information on the W-9 for businesses and Internal Revenue Service records for individuals.
If this application is for enrollment into the Fee-for-Service (FFS) program only. It will not be shared with the other state Managed Care Organizations. You will need to apply directly to each MCO program once your FFS application is approved. Your answer to the question below is strictly for informational purposes. Please select the appropriate option
General Credential Information
Please list the other names under which you have been known.
Please select your place of birth.