Maryland Uniform Credentialing Form

Tennessee Uniform Credentialing Form

Section 1 of 8: Personal Information and Professional IDs
Provider Type:*
Auto Field for Provider Type:
Provider Type Code:
YesNo

Tennessee Uniform Credentialing Form

Section 1 of 8: Personal Information and Professional IDs
Name:

Do not use nicknames or initials, unless they are part of your legal name.
Full Name:*

First NameMiddle NameLast NameSuffix
YesNo
Other Name:

First NameMiddle NameLast NameSuffix
Date started using other name?

MonthDayYear
Date
Date stopped using other name?

MonthDayYear
Date

Tennessee Uniform Credentialing Form

Section 1 of 8: Personal Information and Professional IDs
Home Address:
Street Number:*
Street Name:*
APT/Unit Number:
City:*
State:*
Zip Code:*
Telephone Number:*
Format: (000) 000-0000.

Tennessee Uniform Credentialing Form

Section 1 of 8: Personal Information and Professional IDs
Application Follow-Up:

This information used for application follow-up.
Email:*
example@example.com
Fax Number:
Please enter a valid phone number.Format: (000) 000-0000.
EmailFax

Tennessee Uniform Credentialing Form

Section 1 of 8: Personal Information and Professional IDs
Professional ID's:

Include all state licenses, DEA Registration and State Controlled Dangerous Substance (CDS) certification numbers. Provide all current and previous licenses/ certifications.
Federal DEA Number:
DEA State of Registration:
DEA Issue Date:

MonthDayYear
Date
DEA Expiration Date:

MonthDayYear
Date
Please upload DEA Certificate:

Cancelof
YesNo
CDS Certificate Number:
CDS State of Registration:
CDS Issue Date:

MonthDayYear
Date
CDS Expiration Date:

MonthDayYear
Date
Please upload CDS Certificate:

Cancelof
State Licenses:

Non-licensed professionals should enter certification/registration number in the space provided for license number.
State License Number:
License Issuing State:
License Issue Date:

MonthDayYear
Date
License Expiration Date:

MonthDayYear
Date
YesNo
License Status:
Auto Field for License Status Code:
License Status Code 1:
License Type:
Auto Field for License Type Code:
License Type Code 1:
YesNo
State License Number:
License Issuing State:
License Issue Date:

MonthDayYear
Date
License Expiration Date:

MonthDayYear
Date
YesNo
License Status:
Auto Field for License Status Code:
License Status Code 2:
License Type:
Auto Field for License Type Code:
License Type Code 2:

Tennessee Uniform Credentialing Form

Section 1 of 8: Personal Information and Professional IDs
Other ID Numbers:
YesNo
Medicare Number:
UPIN:
YesNo
Medicaid Number
Medicaid State:
National Provider Identification (NPI) Number:
USMLE Number (Without Hyphens)
Workers Compensation Number:
YesNo
ECFMG Number:
Non-U.S. / Canadian Graduate Only
ECFMG Certificate Issue Date:

MonthDayYear
Date
Should be Empty:

Tennessee Uniform Credentialing Form