AVLS UMD - LIVE Provider Application

LIVE Provider Application

Provider Information

Practice Information

Additional NPI Information

Provider Information

NPI Number:

First Name:

Last Name:

Referral Code:

Year Began Treating Veins:

ABVLM Certification:

Yes

Primary Specialty:

Phlebology Emergency Medicine
Vascular Medicine Internal Medicine
Vascular Surgery General Surgery
Dermatology Interventional Radiology
Other

Vascular Lab Accreditation:

Yes

IAC Vein Treatment Facility Accreditation:

Yes

Practice Information

Practice Name:

Street Address:

City:

State:

Zip:

Practice Contact First Name:

Practice Contact Last Name:

E-Mail:

Phone:

Fax:

Does your practice currently use an EHR/EMR:

Yes

If Yes, please specify the name of your EHR/EMR :

Additional NPI Information

If additional physicians within the practice will be contributing data, please add them here

NPI Number:

First Name:

Last Name:

Year Began Treating Veins:

ABVLM Certification:

Yes

Primary Specialty:

Phlebology Emergency Medicine
Vascular Medicine Internal Medicine
Vascular Surgery General Surgery
Dermatology Interventional Radiology
Other

Vascular Lab Accreditation:

Yes

IAC Vein Treatment Facility Accreditation:

Yes

NPI Number:

First Name:

Last Name:

Year Began Treating Veins:

ABVLM Certification:

Yes

Primary Specialty:

Phlebology Emergency Medicine
Vascular Medicine Internal Medicine
Vascular Surgery General Surgery
Dermatology Interventional Radiology
Other

Vascular Lab Accreditation:

Yes

IAC Vein Treatment Facility Accreditation:

Yes