Efficiency App | Adm.

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Provider Demographic

Email

Status

ProviderType

PrimarySpecialty

LastName

FirstName

MiddleName

TitleName

DateOfBirth

SocialSecurityNumber

Drivers License

TaxIDNumber

Cellphone

HomePhone

Personal Email

EmergencyContactName

EmergencyContactPhone

EmergencyContactEmail

Home Address Line 1

Home Address Line 2

Home Address City

Home Address State

Home Address ZipCode

Provider Office

Office Contact Name

Office Phone

Fax

Office Email

Office Address Line 1

Office Address Line 2

OfficeCity

OfficeState

OfficeZipCode

Website

Provider Numbers

IndividualNPI

IndividualPTAN

Rendering Provider Entity

Rendering Provider Last Name

Rendering Provider First Name

GroupNPI

GroupPTAN

Billing Provider Entity

Billing Provider Name

Billing Provider Email

Billing Provider Phone Number

Billing Provider Tax ID Number

Billing Provider Address Line 1

Billing Provider Address Line 2

Billing Provider Address City

Billing Provider Address State

Billing Provider Address Zip Code

TaxonomyCode

Provider License

StateLicenseNumber

StateLicenseExpirationDate

DEANumber

DEAExpirationDate

ControlledSubstancesLicenseNumber

ControlledSubstancesLicenseExpirationDate

CAQHID

CAQHExpirationDate

MedicaidID

MedicareID

Medicare Jurisdiction

Provider Malpractice

MalpracticeInsuranceCarrier

MalpracticeInsuranceCarrierAddress

MalpracticeInsurancePolicyNumber

MalpracticeEffectiveDate

MalpracticeInsuranceExpirationDate

MalpracticePerOccurenceLiability

MalpracticeAggregateLiability

Others

Picture

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Signature

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Suffix

Drivers LicenseFile

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StateLicenseNumberFile

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DEANumberFile

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ControlledSubstancesLicenseNumberFile

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MalpracticeInsuranceCarrierFile

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Pay To

Bank Name

Bank Address

Bank Zip Code

Bank Account

Bank Route Number

Swift Code

Percentage

Contract Url

Hipaa Url

CreatedDate

wallet address

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