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PROVIDER CREDENTIALING
PROVIDER ENROLLMENT
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SERVICES
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GET STARTED
ABOUT
OUR MISSION
OUR TEAM
RESOURCES
DOCUMENTS
EVENTS
FAQ
BLOG
CLIENT PORTAL
REQUEST TO SEND APPLICATION
SERVICES
PROVIDER CREDENTIALING
PROVIDER ENROLLMENT
GET STARTED
ABOUT
OUR MISSION
OUR TEAM
RESOURCES
DOCUMENTS
EVENTS
FAQ
BLOG
CLIENT PORTAL
REQUEST TO SEND APPLICATION
REQUEST TO SEND APPLICATION PAGE
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2020-12-30T14:57:46-06:00
Request To Send Application
Request To Submit Application
Applicant Legal Name
*
First
Middle
Last
Date Of Birth
*
Date Format: MM slash DD slash YYYY
Professional Suffix (e.g. MD, PA, DDS, RN)
*
Requesting Clinical Privileges In Speciality(ies) (separate with commas)
*
Group/Practice Info
Primary Employer/Group/Practice
*
Group/Practice Address
*
Street Address
Address Line 2
City
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Armed Forces Americas
Armed Forces Europe
Armed Forces Pacific
State
ZIP Code
Group/Practice Phone
Group/Practice Fax
Group/Practice Email
*
Credentialing Contact Info
Credentialing Contact/Office Manager
*
Credentialing Contact Address
*
Street Address
Address Line 2
City
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Armed Forces Americas
Armed Forces Europe
Armed Forces Pacific
State
ZIP Code
Credentialing Contact Phone
Credentialing Contact Fax
Credentialing Contact Email
*
Provider Information
Provider Home Address
*
Street Address
Address Line 2
City
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Armed Forces Americas
Armed Forces Europe
Armed Forces Pacific
State
ZIP Code
Provider Phone
Provider Fax
Provider Email
*
Please Send Application To:
*
Group/Practice
Credentialing Contact
Home
Do you want this file expedited?
*
Expedited
Non-expedited
Additional fee of $615 is required prior to expedited processing. Please submit expedited fee to Katie Degenhardt, Expedited File Specialist, at katiedegenhardt@mprcred.com.
Anticipated date to begin practice.
*
Date Format: MM slash DD slash YYYY
Does the applicant have, or plan to establish, an office and live within a reasonable distance of the hospital(s)/health care entity to which you are applying to allow for continuous care for hospitalized patients?
*
Yes
No
N/A
Physician Applicant: Is the applicant board certified?
*
Yes
No
N/A
If no, is provider currently practicing as a locum tenens or telemedicine practitioner?
*
Yes
No
N/A
Non-Physician Practitioner Applicant: Have and maintain professional liability insurance?
*
Yes
No
N/A
Sponsoring Physician
Medical Societies:
Medical Society of Sedgwick County * NPP CREDENTIALING NOT APPLICABLE
Health Care Facilities:
*
Andover Ambulatory Surgery Center
Ascension Via Christi Hospital Manhattan, Inc.
Ascension Via Christi Hospitals Wichita, Inc.
Ascension Via Christi Hospital St. Teresa
Ascension Via Christi Rehabilitation Hospital, Inc
Ashland Hospital District #3
Aspen Mountain Medical Center
Center for Same Day Surgery
Cheyenne County Hospital
Citizens Medical Center Inc.
Clay County Medical Center
Cloud County Health Center
Coffey County Hospital
Coronado Surgical Recovery Suites
Cypress Surgery Center
Edwards County Medical Center
Ellinwood District Hospital
Ellsworth County Medical Center
Endoscopic Services, PA
Fredonia Regional Hospital
Goodland Regional Medical Center
Greeley County Hospital
Greenwood County Hospital
HealthCore Clinic
Hunter Health Clinic
Jewell County Hospital
Kansas Heart Hospital
Kansas Medical Center
Kansas Spine & Specialty Hospital
Kansas Surgery and Recovery Center
Kansas Surgical Arts
Kearny County Hospital
Kiowa County Memorial Hospital
KVC Hospitals Inc.
Lane County Hospital
Larksfield Place Retirement Community * NPP CREDENTIALING NOT APPLICABLE
Lincoln County Hospital
MAO Leawood Surgery Center
Medicine Lodge Memorial Hospital
Midwest Surgery Center * NPP CREDENTIALING NOT APPLICABLE
Minneola District Hospital
Mitchell County Hospital
Neosho Memorial Regional Medical Center
Newton Medical Center * NPP CREDENTIALING NOT APPLICABLE
Ottawa County Health Center
Phillips County Hospital
Plastic Surgery Center-Wichita
PrairieStar Health Center
Precision Surgery Center
Rawlins County Hospital
Ridgewood Surgery and Endoscopy Center
Rock Regional Hospital
Satanta District Hospital
Sheridan County Health Complex
Smith County Hospital
St. Anthony’s Senior Care Hospital - Olathe
St. Anthony’s Senior Care Hospital - Wichita
St. Luke’s South Ambulatory Surgery Center (ASC)
Summit Medical Center
Surgery Center at Lone Tree
Surgery Center of Kansas
Susan B Allen Memorial Hospital
Trego County Lemke Memorial Hospital
Wamego Health Center
Wesley Medical Center
Wichita County Health Center
*NON-PHYSICIAN PRACTITIONER CREDENTIALING NOT APPLICABLE
Additional Comments
Name of Requesting Individual
*
Requesting Individual's Email Address
*
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