Provider Type * RequiredPlease SelectPrimary Care PhysicianSpecialistPrimary Care Physician & SpecialistLegal Name of Practice You Want to be Added to * RequiredProvider Tax ID Number * RequiredPractice/Group NPI * RequiredPractice Website (URL) - enter a valid website URL for example https://www.google.com * Required Teleservices Offered * RequiredPlease SelectTelemedicineTelehealthTelemonitoringNoneName of Provider to be Added * Required First Last Provider NPI Number * RequiredDell Children’s Health Plan is currently on CAQH and is able to pull credentialing information from the CAQH database. Please ensure that you authorize Seton Insurance Services PO ID #1097 to access their information.Please ensure that the following documents are loaded in CAQH and attested to within the past 6 months:Texas Standardized Credentialing ApplicationProof of Malpractice InsuranceCopies of all LicensureDEA/DPS if applicableCAQH Number * RequiredIf you are currently not enrolled with CAQH, please register here: https://proview.caqh.org/Login?Type=PMPractice Location Full Address * Required Street Address Address Line 2 City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Credentialing Contact Name * Required First Last Credentialing Contact Email * Required Credentialing Contact Phone Number * RequiredPhoneThis field is for validation purposes and should be left unchanged.
