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* 1. Practice Name

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* 2. Mailing Address

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* 3. Phone Number

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* 4. Name of Practice Administrator / Office Manager

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* 5. Specialty

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* 6. Number of physicians

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* 7. Number of mid-level providers

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* 8. Annual Collections in...

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* 9. Total number of patients in...

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* 10. Total square footage of practice

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* 11. Do you lease or own your building?

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