TGH Provider Information Form
* Indicates a required field
Provider Name and Credentials:
*
Provider Specialty:
*
Practice Mailing Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code / + 4
Phone Number
*
-
Area Code
Phone Number
Practice Physical address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code / + 4
Fax:
-
Area Code
Phone Number
Email:
example@example.com
Federal I.D. #:
*
Social Security #:
*
NPI Number:
*
Group NPI:
*
State License Number:
*
Blue Shield Provider #:
Medicare Provider #:
Medicaid Provider # (if applicable):
Submit
Should be Empty: