Allegiance Provider Direct Credentialing Documents ...
Allegiance Provider Direct Credentialing Documents Requirements ? Type I
For Represented Providers with the following degrees: MD, DO, DPM, DDS, DMD, DC, and OD, nurse practitioners, certified midwives, certified nurse midwives, physician assistants, certified registered nurse anesthetists:
Signed Credentialing Application Signed Allegiance participation agreement on file DEA Certificate if applicable ECFMG (Education Commission on Foreign Medical Graduates) if applicable Copy of Professional Liability Insurance Copy of Board of other Specialty Certificates if applicable Up to date Curriculum Vitae or Resume (not to substitute for completing the application)
Please return these documents to:
Allegiance Provider Direct P.O. Box 3018 Missoula, MT 59806
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