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Practice Type

Individual Practice (Single physician)

Group Practice (Physicians added separately)

Name

First Last

Credentials

NPI Number

Medical License State

License Number

Medical Practice Name(Required)

Address(Required)

Street Address Street Address Line 2 City State ZIP Code

Email(Required)

Practice Email(Required)

We suggest you use a general office contact email for this account. Staff and physicians will be set up as separate accounts, and must have their own unique email addresses.

Phone(Required)

Fax(Required)

Business Hours(Required)

Your regular office business hours.

After Hours

Any information your patients might need for contacting your office outside of business hours.

Opt In to Physician Search

If selected, your practice information will appear in the public physician search. Existing patients will always have access to your office contact information whether this is checked or not.

By registering you agree to our Privacy Policy and our Terms and Conditions.(Required)

By registering you agree to our Privacy Policy and our Terms and Conditions. (Required)

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Read our Privacy Policy

By registering you accept our Business Associate Agreement.(Required)

By registering you accept our Business Associate Agreement. (Required)

Read our Business Associate Agreement