1. Reporting Entity Information

* 2. Name of Reporting Entity (Legal Business Name or Physician Name, if registering as individual physician)

Please enter the applicable 10-digit identification number below.

      • Individual health care provider (e.g., a physician), enter your individual NPI number.
      • Organizational health care provider (e.g., a physician group, ASC), enter your organizational NPI number.
      

3. Individual NPI Number

4. Organizational NPI Number

5. CLIA Number

Please enter the contact information of the person responsible for reporting duties below.

* 6. Primary Contact | First Name

* 7. Primary Contact | Last Name

* 8. Primary Contact | Title

* 9. Primary Contact | Phone Number

* 10. Primary Contact | Email Address

* 11. Primary Contact | Mailing Address

 
25% of survey complete.

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