For all other Providers, please enter the following Information to Proceed.
This Information is used to retrieve your submission if you are disconnected during the process or wish to wait to complete the form at a later time.
The combination of your name, NPI or SSN, and email address uniquely identifies you and your requests in the system.
Please use the same information each time, so that when on the Summary Page, you can view all of your requests
Contact email address will be used for all correspondence for filling out the form.
If you are only making DEMOGRAPHIC CHANGES to an existing practice, you can add, modify and/or delete a practice, remit, mailing, credentialing or 1099 address on providerexpress.com under Transactions --> My Practice Info.
Incomplete requests will be automatically deleted after 30 days of inactivity.