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Provider Registration

Required fields are marked with ** in red.
Provider Name:  **   [?] 
EIN\TIN:  **   [?] 
Zip:  **  (5 numbers, no punctuation) 
Phone #:   [?] 
Fax #:   [?] 
UserID:  ** Same as EIN\TIN   [?] 
Password:  **   [?]
Re-enter Password:  **    
Email Address:  **   [?]   
Re-enter Email:  **