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Participating Professional Provider Registration Form

Please complete this form with as much information as possible. The receipt of accurate, up-to-date information is vital to ensuring successful registration with Independence Blue Cross.

*Denotes a required field. Please review the required fields before filling out the form.

Provider Information

« Required

If you have additional NPI Numbers, please complete a separate form.

« Required
Type 1 (individual)
Type 2 (organization) « Required
« Required

« Required

« Required

« Required



Physical Location Information

« Required

« Required
« Required
« Required


Contact Information