St. Luke's - Home
St. Luke’s Health System
PROVIDER DATABASE MAINTENANCE FORM
For accuracy of data input ** PLEASE TYPE **
Complete and e-mail or fax to CVO at cvo@ or 381-8786.
We will add the provider and return this form within 2 days.
Date: _________ Each data field in the text boxes below must be completed.
|Name of Provider |
| | | | |
|(Last) |(First) |(Middle Initial) |(Title [MD/DO/NP/PA/etc.]) |
|Office Address |
| |
|(Clinic) |
| |
|(Street Address) |
| | | |
|(City) |(State) | (Zip) |
| | |
|(Office Phone) |(Office Fax) |
|State of License and License # |NPI# (10-digits) |
| | | |
|(State) (License Number) |If provider does not have an NPI number provider can obtain one from |
| |. |
|** Verification of License is required ** |Takes about 24 hours. |
| | |
|Specialty e.g. Internal Medicine, Family Medicine, General Surgery, Nurse Practitioner, Physician Assistant, etc. |
|Please return form to: |
| | |
|(Requester’s Name) |(E-mail/Fax) |
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