Provider Enrollment - Vertos

Enrolling As

Are you employed by the:

Physician’s Office to submit Prior Authorizations, Appeals or Physician Claim Appeals

Facility to submit only Post-service Claim Appeals for the Service

Both

User Information

User Contact Name

First

Last

User Contact Email *

User Contact Phone *

Add Remove

Practice Information

Physicians Office Name *

Phone Number *

Fax Number *

Physician’s Address *

Physician's Address

City

State/Province

Zip/Postal

Physicians Office Tax ID *

Physicians Office NPI *

Physicians Office PTAN

Physician Information

Physician Name *

Physician NPI *

Physician Tax ID *

Individual Physician PTAN *

Add Remove

Facility Information (where cases will be performed)

Facility Name (where cases will be performed) *

Facility Address *

Facility Address

City

State/Province

Zip/Postal

Phone Number *

Fax Number *

Facility Tax ID *

Facility NPI *

Facility PTAN

Add Remove

Facility Physician Information

Facility Physician Name

Facility Physician NPI

Facility Physician Tax ID

Facility Physician PTAN

Add Remove

Vertos Sales Representative Name