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Practicing Providers with Prescribing Authority tab |
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Purpose |
This section captures the practicing provider's information. During a renewal, this information will be prepopulated with the information that was filled in earlier for this organization.
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Required Fields |
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Field Name |
Description |
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First Name |
Required. The provider's first name. |
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Middle Name |
The provider's middle name. |
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Last Name |
Required. The provider's last name. |
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Job Title |
Required. The provider's job title. |
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Specialty |
Required. The provider's area of specialization. |
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License Type |
Required. The license type the provider holds. |
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License Number |
Required. The license number associated to the license type selected. |
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NPI Number |
Required. The provider's National Provider Index number. |
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Provider Medicaid ID |
The provider's Medicaid ID. |
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Employee ID Number |
The provider's employee number. |
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Required. The provider's email address. |
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+ Add Additional Entry |
Select this to add more providers associated with this organization. |