D. SPECIALTY INFORMATION
Please specify specialties practised or services provided.
Allergy and Immunology
Gastroenterology
Pathology
Alternative Medicine
General Surgery
Pediatrics (please specify) ___________________________________
________________________________________________________
Andrology
Internal Medicine
Anesthesiology
Long Term Care
Physiotherapy
Cardiology
Neonatology
Podiatry
Chiropractic
Neurology
Proctology
Cosmetic/Reconstructive Surgery
Neurosurgery
Psychiatry
Counseling and Social Work
Obstetrics and Gynecology
Pulmonology
Dentistry
Oncology and Hematology
Radiology
Dermatology
Ophthalmology
Surgery (please specify type) _________________________________
_________________________________________________________
Emergency Medicine
Orthopedics
Family/General Practice
Otolaryngology (ENT)
Urology
Other _______________________________________________________________________________________________________________________
____________________________________________________________________________________________________________________________
E. OTHER SPECIALTY INFORMATION
Please specify other specialties practiced or services provided.
24/7/365 Emergency Room
Maternity
Surgery - Ophthalmology
Burn Centre
MRI
Surgery - Oral
Bariatric Surgery
Neonatal
Surgery - Orthopedic
CT
On Site Lab
Surgery - Pediatric
Durable Medical Equipment
Plasmapheresis
Surgery - Plastic
Endocrinology
Rehabilitation
Surgery - Thoracic
Executive Health and Wellness
Surgery - Cardiothoracic
Surgery - Vascular
Gamma Knife Surgery
Surgery - Colon And Rectal
Surgery - Others ___________________________________________
_________________________________________________________
Geriatrics
Surgery - Cosmetic/Reconstructive
Immunology
Surgery - Hand
Transplant (particular types to be included) ______________________
IMRT
Surgery - Head and Neck
_________________________________________________________
_________________________________________________________
Infectious diseases
Surgery - Maxillofacial
International Services
Surgery - Neurological
Trauma
Other _______________________________________________________________________________________________________________________
____________________________________________________________________________________________________________________________
Provider-Enrollment-Form
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2013- 05-13