Staff Type: * |
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Credentials/Title: *
(Resident/Fellow: please choose credentials)
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If Credentials/Title is 'Other', enter it here: * |
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NPI Number: * |
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DEA Number:
**Trainees who hold a full physician license in the state of Colorado, must have their own DEA number to prescribe controlled substances.**
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DEA Expiration Date: * |
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Medicaid Number: |
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Do you have a medical license? * |
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Worked/Rotated at CHCO previously? * |
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Date of Birth: * |
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Social Security Number: * |
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Passport Number: |
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Section 2. Personal Contact Information |