Texas Cancer Registry (TCR)
Cancer Reporting Registration

Reporting Entity Information

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* 1. Type of Reporting Entity

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

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.

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* 3. Identification Numbers

Individual NPI number:

Organizational NPI number:

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

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* 4. Primary Contact

First Name:

Last Name:

Title/Position:

Phone Number:

Email Address:

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* 5. Mailing Address

Address:

City:

State:

Zip:

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20% of survey complete.