OEIS NR Participating Physician Sign-Up

Please complete one form for each participating physician.

Site Name*

Enter the name of your Registry Participating Site

City*

State (or Territory)*

Select or enter value

First Name*

Enter physician first name

Last Name*

Enter physician last name

Middle Initial

Enter physician middle initial

Suffix

Select suffix (if applicable)

Select or enter value

Title

Select title (if applicable)

Select or enter value

Physician Specialty*

Select physician specialty from dropdown.

Select or enter value

Physician Specialty: Other specify

Enter physician specialty here if not listed in the dropdown above.

Physician NPI Number*

Enter PHYSICIAN-SPECIFIC NPI number.

Do you bill Medicare Part B?*

Select or enter value

OEIS Membership*

Please enter physician's OEIS membership status

Select or enter value

Work Email Address*

Please enter the work email address to be used for all communication and correspondence regarding this Registry.

Phone Number*

Send me a copy of my responses