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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