TGH Provider Information Form

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	Country

Phone Number *

Area Code Phone Number

Practice Physical address *

Street Address
Street Address Line 2
City	State / Province
Postal / Zip Code	Country

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):
Should be Empty: