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Click ‘Get Form’ to open the CAQH Provider Data Form in the editor.
Begin by entering your personal information, including your last name, first name, middle initial, and date of birth. Ensure accuracy as this data is crucial for credentialing.
Fill in your primary telephone number and office address details, including street address, city, state, county, and zip code.
Provide your Practice Tax ID and attach a W-9 form. This is essential for tax identification purposes.
Indicate your provider type (e.g., MD, DO) and specify if you are applying as a PCP or Specialist. Include your specialty if applicable.
Answer questions regarding board certification and CAQH registration. If registered, include your CAQH Provider ID.
Complete the remaining fields such as primary fax number, email address, social security number, DEA certificate number, state license number, licensed state, and NPI number.

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