ENROLLMENT FORM

Category(s) of Service:
0046 - Group is comprised of Physicians Only, OR Physicians and/or Nurse Practitioners and/or Physician Assistants , OR
0090 - Group is comprised of various Licensed Professionals
(e.g., physicians, nurse practitioners, registered physician assistants, clinical psychologists, podiatrists, chiropractors, clinical social workers, optometrists, therapists (physical, occupational, speech), Midwives)


If you are ALREADY ENROLLED and need to change your address, click here.

  Application Fee is NOT Required  


Print Instructions

Provider Index > Practitioner Groups

Provider Enrollment & Maintenance



Multi Professional Group Providers: Group is comprised of various Licensed Professionals, e.g., physicians, nurse practitioners, registered physician assistants, clinical psychologists, podiatrists, chiropractors, clinical social workers, optometrists, therapists (physical, occupational, speech)

Physician Group Providers: Group is comprised of Physicians Only, OR Physicians and/or Nurse Practitioners and/or Physician Assistants




Complete this Enrollment Form if you are:
  1. Applying for initial ENROLLMENT or ALREADY ENROLLED and enrolling another NPI, or
  2. Responding to a letter instructing you to REVALIDATE your enrollment, or
  3. Seeking REINSTATEMENT or REACTIVATION of your previous enrollment, or
  4. Reporting an OWNERSHIP CHANGE

GROUP Enrollment Form

Last Updated: 9/2017


Supplemental Information

If you have any questions or concerns, please contact the eMedNY Call Center at 1-800-343-9000 or click here to send us an email.