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Change Healthcare Provider Complete Enrollment & Deactivation
Select one of the following options to begin:
Enroll a Practice or Provider
Deactivate a Provider
Enroll Practice or Provider
Deactivate Provider
Enroll Practice or Provider
Provider Complete - Enroll a Practice or Provider
Are you a Billing Service?
*
Yes
No
Phone
This field is for validation purposes and should be left unchanged.
Deactivate Provider
Provider Complete - Deactivate a Provider
Billing Service (if applicable)
Contact Name
*
First
Last
Suffix
Contact Phone
*
Contact Email
*
Practice Name
*
Provider Name
*
First
Last
Credentials
Provider Tax ID
*
Provider NPI
*
Do you wish to deactivate another provider?
*
Yes
No
2nd Provider Name
*
First
Last
Credentials
Provider Tax ID
*
Provider NPI
*
Do you wish to deactivate another provider?
*
Yes
No
3rd Provider Name
*
First
Last
Credentials
Provider Tax ID
*
Provider NPI
*
Do you wish to add another provider?
*
Yes
No
4th Provider Name
*
First
Last
Credentials
Provider Tax ID
*
Provider NPI
*
Do you wish to deactivate another provider?
*
Yes
No
5th Provider Name
*
First
Last
Credentials
Provider Tax ID
*
Provider NPI
*
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