Add Individual Provider Form

Clinic/Facility Information


* indicates a required field

Requestor Name: *

Phone/Ext.: *

Requestor Email: 

Clinic/Facility Name: *

Tax ID: *

Provider Information

Provider Name: *

SSN/Tax ID: *

  State: *      License #: *  

Effective Date: *


  Credentials

Title/Degree: *

DEA #:

Specialty #1: *

Board Certified: *

 Yes    No

Specialty #2: 

Board Certified:

 Yes    No

  (To list additional specialties, please use the comment box at the end of this form.)


  Address Information

Address #1: *

Billing
Physical

  Billing Phone:  
  Appt. Phone:   

City:
 

County:
 

State:
  

Zip:

Address #2:

Billing
Physical

  Billing Phone:  
  Appt. Phone:   

City:
 

County:
 

State:
  

Zip:

Address #3:

Billing
Physical

  Billing Phone:  
  Appt. Phone:   

City:
 

County:
 

State:
  

Zip:

Comments:

Completion of this form does not guarantee inclusion in the WPS Networks.


   
| WPS Home | About WPS | News | Careers | Site Map | Privacy Policy | Disclaimer | Contact Webmaster |
©2010 Wisconsin Physicians Service Insurance Corporation. All Rights Reserved.