Registration

Provider information entered here will be submitted to CAQH to collect the information needed by TennCare for assigning a Medicaid ID.
Make sure to click SUBMIT once all information has been entered. CAQH ProView: https://proview.caqh.org/Login

PROVIDERS: Please review the Electronic Registration

Fields marked with * are required.

Personal Information

* First Name

Middle Name

* Last Name

Suffix

* Birth Date

* SSN

Professional Identification

* Provider Type

* Primary Practice State

* Provider NPI

* License Number

* License State

DEA

UPIN

Credentialing Contact Information

* Address

Address 2

* City

* State

* Zip (First 5)

Ext Zip (Last 4)

* Phone No

Phone Extension

* E-mail

* Confirm E-mail