User Account Information

Fields marked with * are required

* First Name
* Last Name
* Email Address
* Practice / Organization Name
* Street Address
* City
* State/Territory
* Zipcode
* Practice / Organization Phone
(xxx-xxx-xxxx)
* Practice / Organization Fax
(xxx-xxx-xxxx)
* Practice / Organization Specialties
(Press Ctlr on your keyboard to
choose multiple specialties)
* Approximate Number of Providers
* Submission Type
Individual Provider or Group Practice
Large GPRO (100 or greater NPIs)
Medium GPRO (25-99 NPIs)
Small GPRO (2-24 NPIs)
 
* Choose a username:
(minimum of 3 characters)
* Choose a good password:
(minimum of 8 characters)
* Re-enter password for verification:
 
Please create only one account per group
By clicking 'Continue' you are indicating that you have read and agree to the terms
and conditions of our "User License Agreement" and "Business Associates Agreement".
Once an account is created with our registry, MDinteractive should send you a confirmation email.
If an email is not received, contact MDinteractive at 800-634-4731.

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