Physician Information

Please select the state that this physician will be making referrals to.

Please provide your unique National Provider Identifier provided by the NPPES.

Please enter the full name of the registering physician.

Please enter the name of the Hospital, Clinic, or Practice that the physician is affiliated with.

Please enter the best phone number to reach the physician's office.

Please enter the fax number where secure faxes will be sent. This number will be verified in the next step.

Instructions


To ensure successful registration and delivery of important information, please make sure that all data is accurate. In the next step, you will be asked to verify some information, to protect the privacy of any potential participants.

Any information entered into Compass is encrypted and kept on highly secure servers. We will not share any information without prior consent.

Need Help?


Contact us by phone: 877-496-2780
Or by e-mail: compass@qtacny.org