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Name:
Practice Name:
Specialty:
Gross Billing: An Estimated Gross Monthly Amount Billed
# of Physicians:
# of Locations:

My Practice Employs:

Nurse Practioner(s)
Physician Assistant(s)

My Patient Demographic Contains:

Medicare Patients
Medicaid Patients
Managed Care Patients
Blue Shield Patients
Capitization Insurance Patients
Workers Compensation Patients
Commercial Insurance Patients
Other
Phone #: EG: 555-555-5555
Email Address:
Comment:
Custom Data Services, Inc.


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Custom Data Service, Inc.
55 East 86th Avenue
Merrillville, IN 46410

Phone (219) 769-1670

Fax (219) 738-6716

Toll Free 1-800-589-4924