Checklist for Sole Proprietor or Solely Owned Organizations (eg. LLC, PC)
Below is a checklist of information that will be needed to complete enrollments via Internet-based PECOS:
-
An active National Provider Identifier (NPI).
- Sole Proprietors only need a type 1 (individual) NPI
- Solely Owned Organizations need both a type 1 (Individual) NPI and type 2 (Organization) NPI
-
National Plan and Provider Enumeration System (NPPES) User ID and password. Internet-based
PECOS can be accessed with the same User ID and password that a physician or non-physician
practitioner uses for NPPES.- For help in establishing an NPPES User ID and password or assistance in changing
an NPPES password, contact the NPI Enumerator at 1-800-465-3203 or send an e-mail
to customerservice@npienumerator.com.
- For help in establishing an NPPES User ID and password or assistance in changing
-
Personal identifying information. This includes:
- Legal name on file with the Social Security Administration
- Date of birth
- Social Security Number
-
Schooling information. This includes:
- Name of School
- Graduation year
-
Professional license information. This includes:
- Medical license number
- Original effective date
- Renewal date
- State where issued
-
Certification information. This includes:
- Certification number
- Original effective date
- Renewal Date
- State where issued
- Specialty/secondary specialty information
- Drug Enforcement Agency (DEA) number
-
If applicable, information regarding any final adverse actions. A final adverse action includes:
- a Medicare-imposed revocation of any Medicare billing privileges;
- suspension or revocation of a license to provide health care by any State licensing authority;
- revocation or suspension by an accreditation organization;
- a conviction of a Federal or State felony offense (as defined
in 42 CFR 424.535(a)(3)(A)(i)) within the last ten years preceding
enrollment or revalidation; - or an exclusion or debarment from participation in a Federal or State health care program.
-
Practice location information. This information includes:
- Practitioner’s medical practice location
- Legal business name of a solely-owned Professional Association,
Professional Corporation, or Limited Liability Company (LLC) on file
with the Internal Revenue Service and appearing on the IRS CP575 - Special Payment Information
- Medical Record Storage Information
- Billing Agency Information (if applicable)
- Any Federal, State, and/or local (city/county) business licenses,
certifications and/or registrations specifically required to operate as
a health care facility.
-
Electronic Funds Transfer documentation – mechanism by which providers and suppliers receive
Medicare Part A and Part B payments directly into a designated bank account.