Network Data Access Services (NDAS) Online Enrollment


To be eligible for NDAS Online you must have a valid National Provider Identifier (NPI). Please complete one form for each site (separate facility) utilizing a different organizational (Type 2) NPI. Processing time is 2 - 3 weeks. Your enrollment document will be sent via email.

Site Information
* indicates a required field

*Provider/Site Name  
*Street Address


Address Line 2  
*City/*State/*Zip: / /  
*Contact Name:
*Contact Phone  /  /  
*Contact Fax  /  /   
*Contact Email   
*Site NPI Number (Type 2)
NPI must be 10 digits.
Example: 1234567890
*Number of User IDs Requested

If you wish to access information for multiple providers, enter each provider's name, individual (Type 1) NPI, and Tax ID Number below:

(Type 1)
Tax ID