Licensed Provider Application
First Name *
Last Name *
Email *
Phone Number *
Address *
What position are you applying for? *
Part-time or Full-time? *
Professional Title/Credentials *
What days and hours can you see patients? *
Insurance Credentialing (if any) *
NPI Number *
CAQH Number/Login *
Medicare Number(s) / States *
Social Security # *
List all states you hold licenses in *
Upload License Certificates
Collaborating Physicians / States *
Upload Collaborating Physician Agreements
License Restrictions / Insurance Bans *
DEA Numbers / States
Upload DEA Certificates
Available Start Date *
Current Employment Status *
Employed
Unemployed
Self-Employed
Student
1099 Contractor
Upload Resume *
Are you legally authorized to work in the U.S? *
Yes
No
Upload Driver's License / State ID *
Upload Current Malpractice Insurance *
Malpractice Expiration Date *
Upload Headshot (for marketing)
Submit Application