Texas Cancer Registry
Department of State Health Services
Cancer Reporting Registration for Ambulatory Providers (Non-Hospital)
Step 1: Create Reporting Entity Profile

1. 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 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.
      • Pathology laboratory, enter your CLIA 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.
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6. Primary Contact | First Name
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7. Primary Contact | Last Name
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8. Primary Contact | Title
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9. Primary Contact | Phone Number
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10. Primary Contact | Email Address
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11. Primary Contact | Mailing Address
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