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PROVIDER INFORMATION: Last Name

First Name

MI

Suffix (e.g. Jr., Sr.)

Alias (also known as)

Office Address (including Suite #)

City

Zip Code

E-mail address

Gender Female

Male

Ethnicity

CHDP Certified Yes

No

CPSP Provider

Yes

No

AB 373 Provider

Yes

No

Social Security Number

Date of Birth

Federal Tax ID Number

Medi-Cal ID Number

UPIN/NPI Number

License Number

License Number Exp. Date

Supervisory License Number

DEA Number

DEA Expiration Date

Language(s) Spoken by Provider:

Language(s) Spoken by Provider Staff:

1.

2.

3.

4.

________________________

________________________

________________________

Fluent

Intermediate

Fluent

Intermediate

Fluent

Intermediate

Fluent

Intermediate

1.

2.

3.

4

.

________________________

________________________

________________________

Fluent

Fluent

Fluent

Fluent

Intermediate

Intermediate

Intermediate

Intermediate

________________________

________________________

PRACTICE INFORMATION: Appt. Telephone No. (include ext.)

After Hours Telephone No.

Member Svcs. Telephone No.

FAX Number

Pager Number

Provider Last Credentialing Date:

Practice Limitation: (if applicable)

Other Practice Limits:

Provider Education: Medical School Internship Residency

Start Date & Completion Date

_____ Minimum Age Office Site Hours:

_____

Maximum Age

M o n d a y _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _

Tuesday _____________________

W e d n e s d a y _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _

Thursday ____________________

CHP Hospital Affiliation: ______________________________ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ Address: _ _ _ _ _ _

F r i d a y _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _

Saturday_____________________

Phone:

__________________________________________ __________________________________________

Sunday_________________________

Form Revised 12/30/03

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