How to enroll in PECOS, Check list you need

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 to customerservice@npienumerator.com.
• 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.