Providers Add Provider

Add Provider

Create, validate, and onboard a provider across clinical, operational, billing, access, and compliance workflows.

Auto-saved

Provider Readiness

Real-time

Onboarding Completeness

Items to Complete:

All requirements met

Basics

Required

Add Photo

Change

Provider Type

First Name

Last Name

Middle Name

Preferred Display Name

Suffix

Primary Specialty

Secondary Specialties

Credentials

Department

Employment Type

Start Date

Professional Bio

Female English Spanish

Identity & External IDs

NPI Type 1

Verified with NPPES

CAQH ID

DEA Registration

PECOS Status

SSN (Last 4)

Date of Birth

Professional Email

Mobile Phone

Home Address

Mailing Address (if different)

Credentials & Licenses

Credential Type	Number / State	Issue Date	Expiration	Status	Documents	Actions
			Expiring

Malpractice Insurance

Carrier

Medical Protective

Policy Number

MP-7849201

Coverage

$1M / $3M

Expiration

Dec 31, 2026

365 days remaining

Scope of Practice

Clinical Authority

Prescriptive Authority Controlled Substance Authority Diagnostic Ordering Referral Authority

Supervision Required

Select supervising physician

Service Capabilities

Age Groups Served

Visit Types

Procedure Codes Authorized

Practice Locations

Location	Department	Room	Schedule	Status	Actions
			Mon-Fri

Floating Provider (cross-site coverage)

Scheduling Configuration

Scheduling Status

Patient Self-Booking Allow online appointment requests

New Patient Acceptance Accept new patient appointments

Overbooking Allowed Enable double-booking slots

Daily Appointment Cap

Default Visit Duration

Weekly Availability Preview

Jul 15-21, 2026

Available

Blocked

Unavailable

Billing & Enrollment

Individual NPI

Group NPI

Tax ID (TIN)

Taxonomy Code Family Medicine

CMS Enrollment Status

Fee Schedule

Payer Enrollment Status

Payer	Plan Types	Effective Date	Status	Credentialing	Actions

Telehealth Configuration

Enable Telehealth

Virtual Visit Settings

Video Platform

Patient Self-Check-in Interpreter Integration

Cross-State Eligibility

Virtual Room Preview

Virtual Waiting Room

Telehealth Attestation Required

Provider must complete telehealth training before activation.

Telehealth is disabled for this provider

Access Control & Security

Account Status

Role Template

Permission Level

Multi-Factor Authentication Required for login

Session Timeout (minutes)

IP Restriction

Account Expiration Date Leave blank for no expiration

Remote Access Allowed Access from outside network

Recent Access Activity

Last Login

Never (New Account)

—

Password Status

Temporary (Setup Required)

2FA Status

Not Configured

Location Access Rights

All Locations

Access to every facility

Review & Submit

Please verify all information

Validation Summary

I attest that all information provided is accurate and complete