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