Twitter
Facebook
Linkedin
817-332-8847 |
Physician Login
About NTSP
Core Values
Leadership
News
Careers
Join NTSP
NTSP Membership Inquiry
Find a Physician
Physician Search
Physician Spotlight
Contact
Search
Menu
You are here:
Home
/
Join NTSP
Membership Inquiry
Thank you for inquiring about becoming a member of NTSP Holding Company, LLC. Please provide the information requested below. The submitted form will be reviewed by the NTSP Contracting Department.
Physician Name
*
First
Last
Gender
*
Male
Female
Primary Care Physician
*
Yes
No
Physician's Degree
*
M.D.
D.O.
D.P.M.
Physician's Primary Specialty:
*
Physician's Primary Specialty: - Board Certified
*
Yes
No
Physician's Sub-specialties:
Physician's Sub-specialties - Board Certified
*
Yes
No
Invidivual NPI:
*
Tax ID:
*
Physician's Medicare #:
*
CAQH #:
*
Accepting new Medicare Advantage Patients?
*
Yes
No
Physican's Practice Legal Name:
*
Is Physician Part of a Group?
*
Yes
No
Group Name:
*
Are other physicians in your group members of NTSP?
*
Yes
No
Please provide the names of the physicians who are members of NTSP:
*
Practice Address
*
Street Address
Address Line 2
City
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Armed Forces Americas
Armed Forces Europe
Armed Forces Pacific
State
ZIP Code
Practice Phone #:
*
Practice Fax #:
*
Email address
*
Do you have hospital admission privileges?
*
Yes
No
If you do not have hospital admission privileges, please list the hospitalist group used:
*
List all hospital privileges in North Texas:
*
Are you currently contracted and credentialed with the following Medicare Advantage Plans (check all that apply)?
*
Care N' Care HMO & PPO
Humana Gold HMO
UnitedHealthcare AARP MedicareComplete Secure Horizons
How did you hear about NTSP?
*
Please tell us why you are interested in joining NTSP?
*
Physician Office Contact Information
Contact person name and title:
*
Email address
*
Phone #
*
Fax #
*
Person completing this form:
*
Date
*
Scroll to top