Get Organizational Provider Credentialing Application 2011-2024
Ment (Level I, II, III, IV, V) PT, OT, Speech Therapy Imaging Department Laboratory/Pathology Department Skilled Nursing Outpatient Surgery Hospice Infusion Therapy Home Health Other _________________________ ____________________________ ____________________________ II. CERTIFICATION AND ACCREDITATION A. Certification 1. Is this provider participating in the Medicare program? Yes No Pending If Yes, please provide the following: 2. Date of in.
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