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Provider Account Registration

To register as a Provider, please enter the following information. Please note that registration designates you as your organization's Master Administrator and you will be required to perform user maintenance duties. If you are not a registered Medicaid Provider, you can find out how to ENROLL HERE.

 
Please choose your type of organization and create your "Login ID", please note that your Login ID is case-sensitive and should consist of 6-14 alpha-numeric characters; example Login ID:"example123"
Individual Group Login ID  
 
       
Please enter your Medicaid Provider ID or NPI information.
Provider ID NPI Taxonomy
   OR   
       
To use the EDI Exchange feature, you must supply your EDI Submitter information below. If you are not registered as an EDI Submitter but wish to do so, please contact Conduent EDI Gateway Services by phone at (866) 407-2005 or online at http://acs-gcro.com.
EDI Submitter ID EDI Password    
   
       
Please enter your Last Name, First Name, and Middle Initial. If you are registering as an individual the Last 4 digits of your Social Security Number (SSN) or your EIN are required.
Last Name First Name Middle Initial  
 
       
Please enter your Organization Name and EIN if you are registering as a group.
Organization Name      
     
       
Tax Information.
SSN (Last Four Digits) EIN    
  OR    
     
Please enter your Email Address and select your hint question/answer.
What is your Email Address? Verify your Email Address Hint Question Hint Answer