Become a Provider

Organization Name*

County*

Organization Address*

Organization City*

Organization State*

Organization ZIP*

TIN*

NPI Number*

Medicare Number*

CAQH*

Provider Service Area*

Include Fee/Rate Schedule*

Contact Name*

Contact Number*

Contact Name Email*

Provider Specialty*
000 Other001 General Practice002 Family Practice003 Internal Medicine004 Geriatrics005 Primary Care - Physician Assistants006 Primary Care - Nurse Practitioners007 Allergy and Immunology008 Cardiology010 Chiropractor011 Dermatology012 Endocrinology013 ENT/Otolaryngology014 Gastroenterology015 General Surgery016 Gynecology, OB/GYN017 Infectious Diseases018 Nephrology019 Neurology020 Neurosurgery021 Oncology - Medical, Surgical022 Oncology - Radiation/Radiation Oncology023 Ophthalmology025 Orthopedic Surgery026 Physiatry, Rehabilitative Medicine027 Plastic Surgery028 Podiatry029 Psychiatry030 Pulmonology031 Rheumatology033 Urology034 Vascular Surgery035 Cardiothoracic Surgery036 Clinical Psychology037 Clinical Social Work048 Mammography049 Physical Therapy050 Occupational Therapy051 Speech Therapy052 Inpatient Psychiatric Facility Services057 Outpatient Infusion/ChemotherapyS03 Primary Care

Other Specialties Not Listed:

Note: For more information, please reach out to providerservices@VerdaHealthcare.com

Δ