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	Registration Step 1 of 2 - Personal Information * Indicates a required field. This section is not required for Billing Agents. NPI must be entered for all healthcare providers (taxonomy is optional). If you do not qualify for an NPI, please provide your Medicaid Provider Number. Please provide the following information to get started. Trading Partner ID Trading Partner ID is a required field. The text field contains invalid characters. Acceptable characters include [a-z], [A-Z], [0-9], spaces and characters [.?!,()-_+';:"]. Trading Partner Full Name Trading Partner Full Name is a required field. The text field contains invalid characters. Acceptable characters include [a-z], [A-Z], [0-9], spaces and characters [.?!,()-_+';:"]. FEIN (Tax ID) FEIN (Tax ID) is a required field. ID Type ID Type is a required field. *Provider ID Provider ID is a required field. The text field contains invalid characters. Acceptable characters include [a-z], [A-Z], [0-9], spaces and characters [.?!,()-_+';:"]. Taxonomy The text field contains invalid characters. Acceptable characters include [a-z], [A-Z], [0-9], spaces and characters [.?!,()-_+';:"].

R4.4.02