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Practice information

Practice name:

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Specialty:

Tax ID:

NPI Type 1:

NPI Type 2:

CAQH #

List all practice locations (primary and secondary offices) or service areas by county, state (if applicable) and CAQH#:

Is/are the physician(s) board certified or board eligible working towards certification?

Is/are the physician(s) currently enrolled in the PA Medical Assistance program with an active PROMISe ID?

Do you have admitting privileges? If yes, at which facilities?

Counties you service:

Do you provide any ancillary services in your practice - Lab, radiology, DME, etc.?

List all ancillary services:

Additional comments:

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