Texas Cancer Registry (TCR)
Cancer Reporting Registration

Reporting Entity Information

Question Title

1. Type of Reporting Entity (Required.)

Question Title

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

Please enter the applicable 10-digit identification number(s) below.
• Individual health care provider (e.g., a physician), enter your individual NPI number.
• Organizational health care provider (e.g., a physician group), enter your organizational NPI number.

Question Title

3. Identification Numbers

Individual NPI number:

Organizational NPI number:

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

Question Title

4. Primary Contact (Required.)

First Name:

Last Name:

Title/Position:

Phone Number:

Email Address:

Question Title

5. Mailing Address (Required.)

Address:

City:

State:

Zip:

Page1 / 5

20% of survey complete.

Question Title

* 1. Type of Reporting Entity (Required.)

Question Title

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

Question Title

* 3. Identification Numbers

Question Title

* 4. Primary Contact (Required.)

Question Title

* 5. Mailing Address (Required.)

1. Type of Reporting Entity (Required.)

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

3. Identification Numbers

4. Primary Contact (Required.)

5. Mailing Address (Required.)