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
  • 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.