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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
Subspecialty
Subspecialty
Premedical Education
College or University
Start Date
Stop Date
Graduation Date
Address
City
State
Zip Code
Degree
Medical Education
Is your practice limited to a speciality or subspecialty? If so, please indicate:
Limited Specialty
Other interests in practice, research, etc:
Total years in practice.
Medical School
Start Date
Stop Date
Graduation Date
Address
City
State
Zip Code
Degree
Medical School
Start Date
Stop Date
Graduation Date
College or University
Start Date
Stop Date
Graduation Date
Address
City
State
Zip Code
Degree
Medical Education - continued
Internship
Institution
Address
Post graduate education
List name and type (Internship, Residency, Fellowship, Preceptorship) of all postgraduate educational programs in chronological order with dates, location, chiefs of staff, and speciality. List first postgraduate program first. If there is a time gap, please explain on a separate sheet of paper and make reference to this section.
Residency
Start Date
Stop Date
Chief of Staff
City
State
Zip Code
Training Program
If currently in residency, expected date of completion:
City
State
Zip Code
Institution
Start Date
Stop Date
Chief of Staff
Address
Institution
Start Date
Stop Date
Chief of Staff
Address
City
State
Zip Code
Training Program
Address
City
State
Zip Code
Degree
Residency - continued
Fellowship
Training Program
Institution
Start Date
Stop Date
Chief of Staff
Address
City
State
Zip Code
Preceptorship
City
State
Zip Code
Training Program
Address
Start Date
Stop Date
Chief of Staff
Institution
Institution
Start Date
Stop Date
Chief of Staff
Institution
Start Date
Stop Date
Chief of Staff
Address
City
State
Zip Code
Training Program
Training Program
Preceptorship - continued
Additional Postgraduate Education (Both hospital & non-hospital based)(Attach copies of ALL postgradual certificates)
Armed Services / Public Health List all medical and surgical dates and locations. Attach copy of your DD214
Address
City
State
Zip Code
Training Program
Institution
Start Date
Stop Date
Chief of Staff
Address
City
State
Zip Code
Training Program
Institution
Start Date
Stop Date
Chief of Staff
Address
City
State
Zip Code
Training Program
Military Branch
Type of Discharge
Start Date
End Date
Reserve Status
Rank at time of discharge
Public Health Institution
Start Date
Stop Date
Address
City
State
Zip Code
Public Health Institution
Start Date
Stop Date
Address
City
State
Zip Code
Armed Services / Public Health - continued
PROFESSIONAL PRACTICE
Chronological listing of medical practice since medical training, including office and clinic. Include nature of and principal associates (solo, partnership, group) including office address and inclusive dates. If additional space is required, attach sheet of paper and make reference to this section.
Practice Type
Address
City
State
Zip Code
Start Date
End Date
Country
Practice Type
Address
City
State
Zip Code
Start Date
End Date
Country
Practice Type
Address
City
State
Zip Code
Start Date
End Date
Country
Practice Type
Address
City
State
Zip Code
PROFESSIONAL PRACTICE - continued
Practice Type
Address
City
State
Zip Code
Start Date
End Date
Country
Practice Type
Address
City
State
Zip Code
Start Date
End Date
Country
Practice Type
Address
City
State
Zip Code
Start Date
End Date
Country
Practice Type
Address
City
State
Zip Code
Start Date
End Date
Country
ACADEMIC APPOINTMENTS
Start Date
End Date
Country
Institution
Address
ACADEMIC APPOINTMENTS - continued
City
State
Zip Code
Start Date
End Date
Country
Phone Number
Fax Number
Title
Rank
City
State
Zip Code
Institution
Address
Start Date
End Date
Country
Phone Number
Fax Number
Title
Rank
Institution
Address
City
State
Zip Code
Start Date
End Date
Country
Phone Number
Fax Number
Title
Rank
Institution
Address
City
State
Zip Code
Start Date
End Date
Country
ACADEMIC APPOINTMENTS - continued
INSTITUTIONAL APPOINTMENTS
Institution
Address
City
State
Zip Code
Start Date
End Date
Country
Phone Number
Fax Number
Institution
Address
City
State
Zip Code
Start Date
End Date
Country
Phone Number