NeuensDiagnostics Inc.
(205)385-8851
(205)997-2455
2683 Pelham Pkwy Pelham, AL 35124
NEW ACCOUNT FORM
Clinic / Facility Name:
Clinic NPI:
Type of Account:
Address:
City:
State / Zip:
Office Email:
example@example.com
Phone:
Format: (000) 000-0000.
Fax:
Main Contact / Position:
Email:
example@example.com
Phone:
Format: (000) 000-0000.
Critical Value Call Name:
Critical Value Call #:
Critical Value Call Name:
Critical Value Call #:
STAT Hospital:
Phone #:
Format: (000) 000-0000.
Medical Director::
NPI#:
Email:
example@example.com
MD Cell #
Format: (000) 000-0000.
MD Fax #
Provider Name:
NPI#:
Email:
example@example.com
NP Cell #
Format: (000) 000-0000.
NP Fax #
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Provider Name:
NPI #
Email:
example@example.com
NP Cell #
Provider Name:
NPI #
Email:
example@example.com
NP Cell #
Provider Name:
NPI#
Email:
example@example.com
NP Cell #
Provider Name:
NPI#
Email:
example@example.com
Email:
example@example.com
NP Cell #
Portal user email address:
example@example.com
Portal user email address:
example@example.com
Portal user email address:
example@example.com
Provider Visit Days & Hours:
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Tuesday
Wednesday
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Friday
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