HealthCare Facility / Provider Registration
HealthCare Facility Details
Facility Name
*
Doctor First Name
*
Doctor Last Name
*
NPI Number
Tax ID
Phone Number
*
Fax Number
Email / Username
*
Street Address
*
Apartment, Unit, Suite, or Floor #
City
*
State
*
ZIP / Postal Code
*
Specialization
*
Required
Login Credentials
Password
*
Confirm Password
*
Enable 2-factor authentication
Everytime
Only when system changes
Submit
Close
MyPhysicianPlan
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