Become a Provider

Thank you for your interest in joining WellCare of North Carolina's provider network. If you are submitting this form on behalf of a group, please note that your group only needs to complete and submit this information once. This form is an inquiry for consideration and not an official registration. We will review your request and if we are in need of your specialty, a representative will contact you to help guide you through our formal application process.

Thank you again for your interest!

Please complete the form:

Provider First Name *

Provider Last Name *

Check to add provider to existing agreement Check to join as a group Check if you service more than one state

If you service more than one state, please list your states:

Group Name

Tax Identification Number

Specialty

Street Address *

City *

State *

ZIP Code *

County *

Please explain if you picked "Not Applicable" as your "Specialty"

NPI

CAQH Number

Medicare Number

Medicaid Number

License Number

Your Contact Information

Primary Contact Name *

Email *

Phone Number *

Please provide any additional information