NET HEALTHCLAIM SERVICES
PROVIDER IDENTIFICATION SHEET
Provider Name
NHS ClientID
Clinic/Group Name
Address
City, State Zip
Phone
Fax
Email
Address where checks are to be sent, (if different from above):
Address
City, State Zip
Contact Name
Provider Specialty
Software Used
Provider Licensing Information
(if multiple States use additional information box below):
State of Business
Taxonomy Code
TAX ID/EIN
State License Number
NPI Ind #
Grp #
CLIA #
UPIN
Medicare Ind #
Grp #
Medicare Ind #
Grp #
BC/BS Ind #
Grp #
Champus/Tricare (SS#)
Railroad Medicare Ind #
Grp #
Other #
Additional Information
