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Provider First Name

Provider Last Name

Degree Type

Check to add provider to existing agreement

Check to join as a group

Check if you service more than one state

If you service more than one state, please list your states:

Group Name

Tax Identification Number

Specialty

Line of Business

Street Address

City

State

ZIP Code

County

Please explain if you picked "Not Applicable" as your "Specialty"

Facility

NPI

CAQH Number

Medicare Number

Medicaid Number

License Number

Your Contact Information

Primary Contact Name

Phone Number

Please provide any additional information

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Thank you for your interest in joining WellCare's provider network. If you are submitting this form on behalf of a group, please note that your group only needs to complete and submit this information once. Please note: This form is an inquiry for consideration and not an official registration. We will review your request and if we are in need of your specialty, a representative will contact you to help guide you through our formal application process. Thank you again for your interest in WellCare!

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Y0020_WCM_134133E_M Last Updated On: 10/1/2023

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