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.

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* 3. Individual NPI Number

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* 4. Organizational NPI Number

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* 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

Address Line 1: *

Address Line 2:

City: *

State: *

ZIP: *

25% of survey complete.