Provider Scheduling Parameters

Practice Name*

ACO Name*

Practice Address*

Practice City*

Practice State*

Practice Zip*

Practice Phone*
(Phone # patients will be transferred to for scheduling with the practice directly)

Tax ID Number*

9-digit Tax Identification Number

NPI Numbers*

10-digit National Provider Identifier

Parameters are Applicable to All NPIs Belonging to this TIN

Provider Names*

Additional Provider Names

Provider Consultant Name*

ACO Provider Scheduling Parameters