Please include phone number where you can be reach in the event additional information is needed by Physician Svcs in processing your request.
Please add your extension number. (If applicable)
Enter 6 digit provider ID. For example: 136705 = Pediatric Associates
Please enter providers name and or group practice name.
For GROUP PRACTICE only enter NA in this field.
Please enter professional suffix.
Please enter provider's medical specialty. For example: Pediatrics, Internal Medicine, etc...
lease enter 10 digit National Provider Identification number.
Please enter provider medical license # here.
Please enter additional office location/phone and fax # in this section.
Please enter any hospital practices provider is affiliated with.
Please enter any comments or special instructions that will help in processing your request. For example: Patient Name, etc...