* What's the legal business name associated with this Tax ID Number?
* How many geographic locations(sites) that perform primary care are covered by this Tax ID?
* How many patient encounters per year? (Estimate)
* How many unique patients per year? (Estimate)
* Patient insurance mix (Estimate)
Patient Insurance Mix must add to 100%.
* Number of Support Staff at the Practice?
* Business address associated with this Tax ID?
* City
* State
* ZIP
* Phone
* Fax
* Practice Name
* Practice Address
* County
* FAX
* Email
* First Name
* Last Name
Title
Address
City
State
ZIP
FAX
How many prescribing providers are in your practice?
* Does your practice see Medicare patients?
* Does your practice see Medicaid patients?
What is your specialty?
If other, please specify
Are you owned by a hospital or health system?
If yes, name of hospital or health system
