Learn more about Geisinger Health Plan

We look forward to helping you learn more about Geisinger Health Plan and the benefits of becoming a participating provider. Complete the form below and a representative will contact you by telephone or email.

This form is for non-participating providers only.

Requestor name:

Phone:

Email:

Fax:

I would prefer to receive information by:

Practice information

Practice name:

Street:

City

State:

ZIP code:

Practice phone:

Practice fax:

County:

Specialty:

Tax ID:

NPI Type 1:

NPI Type 2:

List all practice locations (primary and secondary offices) or service areas by county, state (if applicable) and CAQH#:

Is/are the physician(s) board certified or board eligible working towards certification?

Is/are the physician(s) currently enrolled in the PA Medical Assistance program with an active PROMISe ID?

Do you have admitting privileges? If yes, at which facilities?

Counties you service:

Do you provide any ancillary services in your practice - Lab, radiology, DME, etc.?

List all ancillary services:

Additional comments:

Related information

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