Sandbox

Legal Provider Name:*

DBA (If Applicable):

Tax ID:

Additional Tax ID (If Applicable):

NPI(s):

Additional NPI (If Applicable):

License #:

Organization Website:

Service Location Information

Please provide information about your service location(s).

Primary Service Address:

Street Address Address Line 2 City State ZIP Code

Phone:

Fax:

Email :

NPI:

Tax ID:

Do you have a secondary location?

Secondary Service Address:

Street Address Address Line 2 City State ZIP Code

Phone:

Fax:

Email :

NPI:

Tax ID:

If you have more than two service locations, please send a list of your locations, with address, contact info, and NPI/TaxID to frostj@southerntierconnect.org

Organizational Contacts

Provider Contact:

Prefix First Last Suffix

Phone:

Fax:

Email:

Credentialing Contact:

Prefix First Last Suffix

Phone:

Fax:

Email:

Service Area

Are you licensed to provide service in all NY counties?*

Please choose the NY counties where you are licensed to provide service:

Services Provided

Please check all services your organization provides:

Free Standing Clinic
I/DD Service Provider
Inpatient Hospital
Medical Care Providers
Outpatient Hospital

Free Standing Clinic Services Provided:

Please select all services your free standing clinic provides

I/DD Services Provided:

Please select all I/DD services your organization provides

Inpatient Hospital Services Provided:

Behavioral Health
Dental
General
Psychiatric
Residential Treatment Facility
Substance Abuse Services

Please select all services your inpatient hospital provides

Medical Care Services Provided:

Please select all medical care services you provide

Additional Specialist Services Provided:

Outpatient Hospital Services Provided:

Please select all services your outpatient hospital provides