Note: Provider includes Physician, Physician Group, Professional Provider and Facility Provider.
* All fields are required.
* Provider / Office / Group Name:
* Tax ID:
* NPI Number:
* Primary Specialty:
* Assigned Administrator’s First and Last Name:
* Address (Location where services were rendered):
* City / State / Zip Code:
* Contact Phone Number:
* Assigned Administrator’s Email Address:
Note: The iEXCHANGE Help Desk will email your iEXCHANGE ID, User ID and temporary password. Please allow five business days for processing.
Updated April 2018