Doctor Add Form

"*" indicates required fields

Click here for Instructions to learn how to fill out Doctor Add Form below.

Doctor Name*

First Last

Practice Name*

NPI Number*

Don't have the NPI number? Call the doctor's office or look it up on the NPI registry website:
https://npiregistry.cms.hhs.gov

Choose Option*

New Doctor Add

Add New Address

Delete Address - No longer at location

Delete Doctor

Update Phone/Fax Only

Is this the Doctor's new main address?*

Yes - This is their new primary location

No - This is an additional location

If you aren't sure, choose "No".

Reason*

Moved Out of Region

Retired

Deceased

AMD Office Key (Optional)

Degree Type*

Phone 1*

Fax*

Email

Address*

Street Address Address Line 2 City State ZIP Code

Additional Info

Requested By*

Clinic*

Department