If the provider is an individual, this is the legal name. Provider Credential Text M. Many types of health care providers could be sole proprietorships for example, group practices, pharmacies, home health agencies. Provider First Name The first name of the provider, if the provider is an individual. Provider Business Mailing Address Telephone Number The telephone number associated with mailing address of the provider being identified.
Provider Business Practice Location Address Telephone Number The telephone number associated with the location address of the provider being identified. Provider Middle Name The middle name of the provider, if the provider is an individual. In a sole proprietorship, the sole proprietor owns all of the assets of the business and is solely liable for all of the debts of the business. Provider Gender The provider's gender if the provider is a person.
Is Sole Proprietor N Indicate whether provider is a sole proprietor. Last Update Date The date that a record was last updated or changed.
First and last names are required for initial applications. The abbreviations for professional degrees or credentials used or held by the provider, if the provider is an individual.
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