1Physician Information

2Corporate Information

3Power of Attorney

4General Questions

5Insurance Information

6Hospital Information

7Bank Deposit Information

8Insurance Information

9Attachments

10Submit

Physician Information

First Name:*

Middle Initial:*

Last Name:*

Suffix:

Mailing Address Line 1(Street Name and Number):

Mailing Address Line 2:

City:

State:

Zip:

County:

Telephone #:*

Fax #:*

Email Address:*

Date of Birth:*

SSN:*

CLIA #:

Please enter a valid CLIA number (12A3456789).

UPIN #:

State of Birth:*

Country of Birth:*

Year of Graduation:*

Medical School Name:*

NPI Type 1 (Individual):

NPI Registry – Username:

Password:

DEA #:

Please enter a valid DEA number (AB12345678).

Physician License # & Effective Date:

Driver’s License #:*

Weight (lbs):*

Please enter a number from 30 to 400.

Height (ft):*

Please enter a number from 4 to 12.

Is your rendering provider outside the State?

Yes

State:

Corporate Information

Provider Legal Business Name:*

Doing Business As (if different):

Address of Service Location - Clinic or Practice Location (Street Name and Number):*

City:*

State:*

Zip:*

County

Physician’s Specialty(s):*

Category of Service:

Tax ID (FEIN):*

Corporate File Number:

NPI Type 2 (Entity/group):*

NPI Registry – Username:

Password:

Corporation

Partnership

LLC

Date Started:

Incorporation Date (if applicable):

State of Incorporation:

Solutions

Company

Providers Form

Physician Information

Corporate Information

Power of Attorney

General Questions

Insurance Information

Hospital Information

Bank Deposit Information

Additional Information

Attachments

Solutions

Company

Contact Us

Solutions

Company

Resources

Solutions

Company

Providers Form

Physician Information

Corporate Information

Power of Attorney

General Questions

Insurance Information

Hospital Information

Bank Deposit Information

Additional Information

Attachments

Solutions

Company

Contact Us

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