Let's work together — Specialized Physicians Specialized Physicians Let's work together. Complete the form below to start your provider application. Name First Name * Last Name * Basic Info Profession / Occupation * Select an option Physician (MD/DO) Nurse (RN, BSN) Physician Assistant (PA) CRNA (Nurse Anesthetist) Nurse Practitioner Anesthesiologist Assistant Medical Physicist (PhD) Dosimetrist Radiation Therapist Imaging Technologist (CT, MRI, Nuclear, X-Ray, Ultrasound) Email * Sign up for news and updates Your Message Subject * Message * Phone Mobile Phone * SMS Opt-in By checking this box, I agree to receive text messages from Specialized Physicians related to appointments / meeting reminders at the phone number provided above. The SMS frequency may vary. Data rates may apply. For assistance reply HELP. Reply STOP to opt out of receiving text messages. Credentialing NPI# * Required for all billing providers: MD/DO, NP/PA. Enter "N/A" if not applicable for your role. Specialty (list all) * Address Country * Address Line 1 * Address Line 2 City * State * ZIP Code * Licensure State Licenses * Start typing a state name or abbreviation, select it from the list, then enter your license number for that state. Add as many as you need. Are you enrolled with the IMLC (Interstate Medical Licensure Compact) and have a Valid LOQ (Letter of Qualification)? * Select an option YES NO If you are not enrolled in IMLC, enter "N/A". Medical License number of the SPL (State of Principal License) * IMLC LOQ holders only. Enter "N/A" if you do not have IMLC. NPDB Date of last NPDB Self-Query * Please provide the date of your last NPDB self-query. If you do not have this information, please request one: npdb.hrsa.gov Summary of NPDB self-query * Please provide a succinct summary of your last NPDB self-query (if applicable), and identify if there were any lawsuits, sanctions, or malpractice settlements within the last 10 years. If yes, please provide as much context and detail as possible. Availability & Systems Your Availability * Please provide exact dates of availability. EMRs you have experience with * Please list all EMRs you have experience with. Professional Reference 1 Please provide a peer reference that has worked with you within the last 3 years. Full Legal Name * Specialty * Email * Phone * Professional Reference 2 Please provide a peer reference that has worked with you within the last 3 years. Full Legal Name * Specialty * Email * Phone * Professional Reference 3 Please provide a peer reference that has worked with you within the last 3 years. Full Legal Name * Specialty * Email * Phone * CV Upload Your CV * Click to choose a file (PDF or Word) Submit Application
