Independent Medical Systems - Online

PROVIDER UPDATE
Please use this form to update the information we have on file. All information submitted is verified by our provider relations department before being added to our system. If you have any questions please contact the provider relations department at (800) 853-7003.
Provider Information
Practice/Facility Name:
Provider First Name:
Provider Last Name:
Tax Id: NPI:
Address:
City: State Zip Code:
Contact:
Phone: Fax:
Email:
Select Provider type and specialties. (you can use the CTRL key to select multiple specialties)
Physician:
Ancillary:  
Hospital:  
Enter a message or comments for the provider relations department.
Comments:
Note: You will receive an email confirmation of your submission.


NOTE: All fields are required.

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