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Application for Provider Enrollment and Certification (MEDCO-13)
Please complete each box and click
next.
Practice type
--Select--
Business (Corp, LLC, S-Corp, Single Member LLC, Partnership, Non-profit, and etc. per W9)
Individual (Not a business - no W9)
Sole Proprietor (Person is business - per W9)
Please select a dropdown value
Provider type
--Select--
Please select a dropdown value
NPI
Please provide a valid NPI
NPI issue date
Please provide a valid NPI Issue Date
Federal tax ID
Please provide a valid federal tax ID
SSN
Please provide a valid SSN
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