To complete an application you will need to know or be able to obtain about the provider applicant all or some of the following information, depending on the type of enrollment you are completing:
National Provider Identifier
Basic Business Office Data (i.e., address, phone, fax, email address, etc.)
Specific Office Data (i.e., CLIA Certification, Name and SSN of employees/personnel, etc.)
Specific Provider Data (i.e., CLIA Certification, SSN, Licensure Information, etc.)
IRS Tax Identification Data
Group Identification Data (i.e., Name, NPI, Medicaid ID).