Physician Profile Form

Provider Profile Submission Form

New Provider or Update to Existing? New Provider Update to Existing

Provider Name

Suffix

Primary Specialty

Secondary Specialty

Gender Female Male

Primary Location

Secondary Location(s)

Are you a member of INTEGRIS Health Partners? Yes No

At which INTEGRIS hospitals does this provider have ACTIVE privileges? INTEGRIS Health Baptist Medical Center INTEGRIS Bass Baptist Health Center INTEGRIS Health Canadian Valley Hospital INTEGRIS Health Grove Hospital INTEGRIS Health Edmond Hospital INTEGRIS Health Miami Hospital INTEGRIS Southwest Medical Center Lakeside Women's Hospital INTEGRIS Health Woodward Hospital INTEGRIS Health Ponca City Hospital

Phone

Fax

Please List Board Certification(s)/Accreditation(s)

Language

Education

Bachelors Degree

Medical School

Fellowship(s)

Residency

NPI

Brandfolder Link for Provider Photo

Brandfolder Image Number

Biography

Areas of Interest

Practice Philosophy (Quote from provider)

Does this provider need to be submitted to Reputation.com? Yes No

A provider is added to the Reputation.com platform for review requesting if they have their own patient panel.

Do you use an electronic medical record (EMR)? If yes, please list:

The items below are for INTEGRIS Health records only and will not be published.

Name of Person Submitting Form

Submitter Email

Provider Primary Email Address

Office Manager

Office Manager Email

Office Manager Phone Number

Physician Profile Form