Provider Inquiry - Enrollment Credentialing Status

Provider Name (Group) *

TIN (Group) *

NPI (Group) *

Practitioner/Clinician Name *

Practitioner/Clinician NPI *

Primary Contact Name *

Primary Contact Phone *

Primary Contact Email Address *

Date the enrollment request was submitted *

Reference number you were provided from Home State Health *

Network (Select all that apply) * Medicaid/Home State Health Ambetter Allwell