Provider Application
Name
First Name
Last Name
Please Upload a Profile Picture (Headshot)
Browse Files
Drag and drop files here
Choose a file
Cancel
of
Credentials
NPI
DEA
Please Upload an Image of Your Government ID (DL, Passport)
Browse Files
Drag and drop files here
Choose a file
Cancel
of
Degree
Please Select
MD
DO
NP
PA
Your Interest
I am an independent Provider
I want to join GenieMD Medical Group
Practice Name (Independet Provider)
Please specify your practice name
Licenses (State, License Number, Expiration)
Browse Files
Drag and drop files here
Choose a file
State, License Number, Expiration
Cancel
of
E-mail
example@example.com
Cell Phone Number
-
Area Code
Phone Number
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Additional Information (Optional)
Submit
Should be Empty: