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Company
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First Name
*
Last Name
*
Email
*
Phone
*
Address
*
City
*
State
*
Zip Code
*
Service Needed
*
Consulting
Hospital Privileging
Provider Enrollment Services (Insurance Credentialing)
Medicaid Provider Enrollment
Medicare Provider Enrollment
Medical Licensing
What is your Organization Type?
*
Facility
Group (more than 1 provider billing with a Type 2 NPI Number)
Individual Provider (Billing with a Type 1 NPI Number)
Other
What is your Practice Specialty?
*
- Acupuncture
- Allergy
- Anesthesiology
- Cardiology
- Chiropractic
- Dentist
- Dermatology
- Emergency Medicine
- Family Medicine
- Hematology/Oncology
- Hospitalist
- Immunology
- Internal Medicine
- License Clinical Social Worker (LCSW)
- Licensed Professional Counselor (LPC)
- LMFT
- LMHC
- Massage Therapy
- Nephrology
- Neurology
- Neurosurgery
- Nurse – Midwifery
- Nurse Practitioner
- OB/GYN
- Occupational Medicine
- Occupational Therapy
- Ophthalmology
- Optometry
- Orthopedics
- Other
- Otolaryngology
- Pain Management
- Pathology
- Pediatrics
- Physical Medicine
- Physician Assistant
- Podiatry
- Psychiatry
- Psychology
- Pulmonary
- Radiation Oncology
- Radiology
- Rheumatologist
- Speech Therapy
- Surgery: Cardiothoracic
- Surgery: General
- Surgery: Oral and Maxillofacial
- Orthopedic
- Vascular
- Urology
- Vascular Disease
Number of Providers
*
- Individual Practioner
- 2 to 5
- 6 to 10
- 11 to 20
- 21 to 50
- 51 to 100
- 101 to 500
- 501 to 1000
- 1001 to 2000
- 2000 plus
Tell us which Insurance Networks you would like to enroll with (and include any additional Comments and/or services needed):
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