PPO Application Request

Fill in all of the fields below and then click the Submit button.

An asterisk (*) indicates a required field.

Provider Name:*
National Provider Identifier (Type 1)
- if applicable:
Group Name:
National Provider Identifier (Type 2)
- if applicable:
Contact Name:*
Contact E-mail Address:*
Practice Address:*
City:*
County:*
State:*
Note: You must practice in IL or Lake County, IN in order to apply.
Zip Code:*
Type of Degree:
Phone Number:* - -
Specialty:*
Tax ID:*
Professional License Number:*
State of Issue:*
Additional Comments:
*Indicates a required field.