Do you have a preferred Sales Rep? YesNo
Preferred Sales Rep Name:
Legal Practice Name:
Practice NPI:
Practice Name / DBA:
Practice PTAN:
Practice TAX ID:
Street Address:
City:
State:
Zip:
+ Add Another Location
Adds Location 3, 4, 5 (one at a time).
First Name
Last Name
Phone
Fax
Email
Practice Owner
Insurance Eligibility Contact
Orders & Logistics Contact
Accounts Payable / Invoices Contact
First Name:
Last Name:
Provider Credentials:DPMMDDONPPA
Individual NPI:
Medicare PTAN:
+ Add Another Provider
Adds Provider 6–10 (one at a time).
Medicare
URL: Username: Password:
State Medicaid
EMR
Other
