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Residence Address
City
State
Zip Code
UPIN
Place of Birth
Secondary Office Address
Date of Birth
Residence Phone Number
Street Address & Suite #
City
State
Zip Code
Phone Number
Fax Number
Answering Service Number
Pager Number
Street Address & Suite #
City
State
Zip Code
Phone Number
Answering Service Number
Fax Number
Pager Number
Additional Office Address
Street Address & Suite #
Sex
Marital Status
Name of Spouse
Last Name
First Name
Middle Name
Maiden Name/Other Name by Which You Have Been Known
Social Security Number
Office Address (If maintaining more than one office , list each office and address)
If not currently at this address - expected starting date.
Primary Office Address
Preferred Mailing Address:
Start Date
Universal Physician Credentialing Application
Copyright 1998-2001 Stephen Scott & Associates, Inc.
IDENTIFYING INFORMATION
Additional Office Address - continued

Practice Information
Identifying Information Physicians Who Share Call If Outside Your Group
On Call Physician Name #1
Address
City
State
Zip Code
Daytime Phone Number
After Hours Number
On Call Physician Name #2
Address
City
State
Zip Code
Daytime Phone Number
After Hours Number
Group Name
Clinic Manager
Billing Address & Suite #
City
State
Zip Code
Phone Number
Fax Number
City
State
Zip Code
Phone Number
Fax Number
Answering Service Number
Pager Number
Primary Specialty