Provider Credentials - Salud Healthcare

New Provider Form

First name(Required)

Last name

Job title

Hours of Operation

Email

Phone number

Fax number

NPI #

Group NPI

ME License #

Medical License

Max. file size: 1 MB.

No file chosen

DEA #

DEA Certificate

Max. file size: 1 MB.

No file chosen

CAQH #

Medicare #

Group Medicare #

Medicaid #

Group Medicaid #

Street address

City

State/Region

Postal code

Practice Tax ID

W9

Max. file size: 1 MB.

No file chosen

Please provide proof of malpractice insurance. If you do not have insurance please upload the Financial Responsibility Form

Malpractice Insurance

Max. file size: 1 MB.

No file chosen