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Provider Center 2021
Join Our Network Form - Hospital
Please complete the questionnaire for our Provider Relations team.
Provider Information
Group Name:
Required
Business Name (DBA):
Required
Main Practice Address:
Required
City:
Required
State:
Required
AK
AL
AZ
AR
CA
CO
CT
DE
FL
GA
HI
ID
IL
IN
IA
KS
KY
LA
ME
MD
MA
MI
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NM
NY
NC
ND
OH
OK
OR
PA
RI
SC
SD
TN
TX
UT
VT
VA
WA
WV
WI
WY
Zip:
Required
Main Practice Location Phone:
Required
Example: (555) 555-5555 or 555-555-5555
Main Practice Email:
Required
TIN:
Required
NPI:
Required
Number of Practice Locations:
Required
Number of Providers In Group:
Required
I am interested in delegation:
Credentialing Information
Contact Name:
Required
Contact Phone:
Required
Example: (555) 555-5555 or 555-555-5555
Extension:
Contact Email:
Required
Form Completed By
Completed By Name:
Required
Completed By Email:
Required
Completed By Phone:
Required
Example: (555) 555-5555 or 555-555-5555
Extension:
Comments: