Registration Information

Practice Name: __________________________________________________________ Address: _______________________________________________________________ City: _______________________    State: ___________    Zip: ____________________ Phone: ______________________________    Fax: _____________________________ Tax I.D. #: _____________________    Type of Practice:  (  ) Group     (  ) Individual Practice Provider Numbers Medicare: __________________________   Medicaid: __________________________ Physician 1: Full Name: _______________________________________________ License #: __________________________  S.S. #: ____________________________ Individual Medicaid Provider #: _____________________________________________ Individual Medicare Provider #: _____________________________________________ Individual Blue Shield Provider #: ___________________________________________ Medicare UPIN #: ________________________    (  ) PAR        (  ) NON PAR Physician 2: Full Name: _______________________________________________ License #: __________________________  S.S. #: _____________________________ Individual Medicaid Provider #: ______________________________________________ Individual Medicare Provider #: ______________________________________________ Individual Blue Shield Provider #: ____________________________________________ Medicare UPIN #: ________________________    (  ) PAR         (  ) NON PAR

(For additional physicians, please copy this form)

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