Group Provider Enrollment (Demographic) Page

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You use the Demographic page to add or edit group provider's identifying information to the enrollment application.

The Demographic page for Group Provider Enrollment contains the following panels:

Field	Description
Group Organization Name	Identifies the full name under which the provider group is doing business.
Years Doing Business Under This Name	The number of years you have done business under the name in the Group Organization Name field.
Have you ever used a different Doing Business As (DBA) name?	Select Yes or No to indicate if your group has ever operated under another business name. If Yes, enter the name in the Former DBA Name field.
Former Doing Business As (DBA) Name	Identifies the former name in which the business was operating under.

Field	Description
Legal Name	Official name of the provider group for tax reporting purposes.
Federal Employer Identification # (EIN)	Identifies the Employer Identification Number of the provider group for tax reporting purposes.
Begin Date	The beginning date the provider group first reported taxes under this name.
End Date	The ending date the provider group reported taxes under this name.

Field	Description
If the group was previously enrolled as a Medicaid provider in North Dakota, to enter the current and/or previous ND provider #(s), click Add Previous ND Provider ID and complete the field for each number. To edit, in the ND Previous ID # table, click the appropriate row.
ND Provider #	Current or previous ND Medicaid provider number for the service location you are now applying for.

Field	Description
Is the business listed under tax-exempt status?	Select Yes or No if the group is listed as tax-exempt. If Yes, please send a copy of your IRS issued exemption. The exemption form is also known as the IRS CP575 Form.

Version as of 5/16/14.