Provider Registration


* = Required
Date Entered
5/22/2017 7:59:50 PM
* Program
* Name
(Must fill in the Provider's First and Last Name and/or the Facility/Group Name)
Provider First Name
Provider Last Name
Degree
Facility/Group Name
* Number of Providers in Group
* States Served
(Hold the 'Ctrl' key down to select multiple)
* Specialty
Federal Healthcare Clinic
 (Select if you are an FQHC, CHC, or RHC)
* NPI
(Must enter an Individual NPI, Organizational NPI or both)
Individual
Organizational
* Tax ID
* Address
 
* City
* State
* Zip Code
Provider Point of Contact
* Name
* Email
 
* Phone
Fax
State License Number
DEA License Number
Remit Address
Medicare Certification Number
Comment

 
Please fill out the provider registry form found here and send it with a copy of your W-9 via fax to #866-269-5891 or email to choiceprovider@triwest.com.