This form is used by credentialed providers to add a new Tax ID to their record, change an existing Tax ID or inactivate a Tax ID from their record.
If you are a TennCare only Provider, please use the paper form at providerexpress.com
For all other Providers, please enter the following Information to Proceed.
IMPORTANT NOTE:
This Information is used to retrieve your submission if you are disconnected during the process or wish to wait to complete the form at a later time.
The combination of the Provider Name and Individual NPI (Type 1) uniquely identifies you and your requests in the system.
Please use the same information each time so you can view all of your requests together.
REMINDER:
If you are only making DEMOGRAPHIC CHANGES to an existing practice, you can add, modify and/or delete a practice, remit, mailing, credentialing or 1099 address on providerexpress.com under Transactions --> My Practice Info.
Pending Additional Information requests will be automatically deleted after 180 days of inactivity.
