New Physician Survey Question Title * 1. What is your full name? (Please include middle initial) (Required.) Question Title * 2. Degree? (M.D. or D.O.) Question Title * 3. Gender Female Male Question Title * 4. What is your E-Mail address? Question Title * 5. What is the name and street address of your current practice? Question Title * 6. What is the city, state and zip code of your current practice? Question Title * 7. What is the telephone number of your current practice? Question Title * 8. What was your start date at this practice? Date / Time Date Time AM/PM - AM PM Question Title * 9. What is your current home address? Question Title * 10. What is the city, state and zip code for your home address? Question Title * 11. What is your current personal phone number? Question Title * 12. At which address do you prefer to received mailings from the Montana Medical Legal Panel? Home Practice Question Title * 13. What is your medical specialty? Question Title * 14. Do you have a second specialty? if so, what is it? Question Title * 15. Are you board certified in your first specialty? Question Title * 16. Are you board certified in your second specialty? Question Title * 17. What is your Montana Medical License Number? Question Title * 18. What is your NPI number? Question Title * 19. What medical school did you graduate from? Question Title * 20. What year did you graduate medical school? Please type "Other" if you did not graduate from a medical school. Question Title * 21. Where was your residency program? Question Title * 22. When did you complete your residency? Date / Time Date Question Title * 23. What is your practice environment? Solo Practice Partnership Multi-Specialty Clinic Single Specialty Clinic Hospital VA or IHS Hospital Local Health Department Volunteer Free Clinic Work as a Locum Tenens Other Question Title * 24. Would you like information about the Montana Medical Association and possible membership in that Association? Yes No Done