Department of Neonatology
Beth Israel Deaconess Medical Center
Policy and Procedure
Title: Credentialing for Clinical Care
Policy #: CL-9
Purpose: To outline the licensure, certification and registration requirements for neonatologists and
advanced practice nurses responsible for providing on-site NICU coverage at BIDMC.
Policy Statement: It is the policy of the Department of Neonatology that all neonatologists and nidlevel providers providing on-site coverage for newborns at BIDMC have the required licenses, credentials
and certification to provide care within the scope of practice of their specialty.
Guideline for Implementation:
It is the physician’s or employee’s responsibility to keep his/her license, accreditation, certification and/or
registration current and to provide the Department with a copy of this documentation.
The following licenses, certifications and/or registrations will be a requirement of employment for
neonatologists:
 Current Massachusetts medical license
 Current Federal Controlled Substance Registration Certificate
 Current Massachusetts Controlled Substance Registration Certificate
 American Academy of Pediatrics Neonatal Resuscitation Program Certification
 Board certification in neonatal-perinatal medicine (per BIDMC professional staff bylaws)
The following licenses, certifications and/or registrations will be a requirement of employment for midlevel providers:
 Current Massachusetts nursing or physician assistant license
 Current Federal Controlled Substance Registration Certificate
 Current Massachusetts Controlled Substance Registration Certificate
 American Academy of Pediatrics Neonatal Resuscitation Program Certification
 Certification as a neonatal nurse practitioner from the National Certification Corporation for the
Obstetric, Gynecologic and Neonatal Nursing Specialties or certification as a physician assistant
from the National Commission on Certification of Physician Assistants
Copies of the above documents will be maintained in the Department of Neonatology files. Failure of an
employee to provide current documentation will be grounds for suspension of privileges and/or dismissal.
Appendices:
BIDMC Policy PM-12 Employee Licensure/Accreditation, Certification and/or Registration Content
Management System
Version: 10/1101; revised 11/04/04, revised 4/13/09
Policy #CL-9: Page 1 of 1