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Medical Staff Application

* Practitioner Full Name and Credentials:
* Clinic/Group:
Expected Clinic Start Date:
Requested Hospital Start Date:
* Address:
* E-mail:
* Home Phone:
* Cell Phone:
Office Phone:
Preferred Communication Method




Fax:
NPI #:
Arkansas License # :
Arkansas License Expiration Date:
Arkansas License Pending?


Practice Specialty:
Board Certified?


Board Certification Expiration Date:
Requested Hospital Practice Started Date:
Credentialing Contact Name and Title:
Credentialing Contact Email:
Credentialing Contact Phone: