Please fill out the following fields in order to sign-up a PROVIDER(S) at your location working under the same Tax Identification Number. You will be able to add as many Providers as you have during your session.


 

  
 

If you have any questions, please contact William DeGasperis at 973-451-8232

 
 

* indicates a required field

     STEP 1:   TREATING PROVIDER CORPORATE INFORMATION
* Treating Provider Corporate or Office Name:

 
*Treating Provider Tax ID:

 
Group NPI:

 
*Treating Provider Address 1:
 
Treating Provider Address 2:

 
*Treating Provider City:

 
*Treating Provider County:

 
*Treating Provider State and Zip:

 
     STEP 2:   CONTACT INFORMATION
     Please provide primary contact information for claims and/or facility operations questions.
* Contact Last Name:
 
* Contact First Name:
 
* Contact Phone:
 
* Fax:
 
* Contact Email Address:
 
     STEP 3:   BILLING ADDRESS INFORMATION
* Billing Address 1:
 
Billing Address 2:

 
* Billing City:

 
* Billing County:

 
* Billing State and Zip:

 
 
     STEP 4.   ADD TREATING PROVIDERS
To add treating providers, enter the information in the text boxes below, then click "Add Provider". You should see the provider's name appear in the box directly below these instructions. Please add all providers that work for your facility.
* Associated Providers:
 
Provider Information:
* Provider Last Name:  
* Provider First Name:  
Provider Middle Initial:  
* Provider Sex:    
Provider Date Of Birth:  
* Provider Specialty
WCB Classification:		  
* Provider NPI #:  
* Provider License #:  
* License State:  

* Workers Compensation Authorization Number: