Physician First Name
Physician Last Name
Phone Number
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Email Address
Primary Office
Primary Office Address
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Degree of Provider
Specialty Acupuncturist Aerospace Medicine Air Ambulance Allergy and Immunology Ambulance Service Anesthesiology Aquatic Therapy Audiology Brain Injury Rehab Cardiac Electrophysiology Cardiology Cardiovascular Disease Cardiovascular Surgery CAT Scan Chemical Dependency Chiropractic Clinical Neurophysiology Colon and Rectal Surgery Critical Care Medicine Dentistry Dermatology Dermatopathology Dialysis Center Durable Medical Equipment Electrophysiology Emergency Medicine Endocrinology Family Practice Forensic Psychiatry Gastroenterology General Practice General Preventive Medicine General Surgery General Vascular Surgery Hand Surgery Hand Surgery - Plastic Mechanotherapy Nephrology Neurological Surgery Neurology Neuropsychology Neuroradiology Nuclear Medicine Nuclear Radiology Occupational Medicine Occupational Therapy Oncology Ophthalmology Optometry Oral and Maxillofacial Surgery Oral Surgery Orthopedic Surgery Orthopedic Surgery: Foot & Lower Limb Orthopedic Surgery: Joints Orthopedic Surgery: Spine Orthopedic Surgery: Trauma Orthotics Osteopathic Physician Otolaryngology Outpatient Surgery Center Pain Management Pathology Pathology-Lab Pharmacy
Is the provider a member of a group practice? YesNo
Tax ID
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CAQH ID Number (if applicable)
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