Member Network-Providers - Berkshire Health Partners and Medicus Resource Management

> Provider Resources
> Provider Links
> Join our Provider
Network
> NPI Submission

> Quote Request
> Frequently Asked
Questions
> Health and Wellness
Information/Discounts

Please list the name and TIN of your facility.

Name

TIN

Is your facility accredited by JCAHO or Medicare and have a state license and/or certification?

Yes No Please name the accrediting body.

Where is your facility located?

Address Line 1:

Address Line 2:

City:

State:

Zip Code:

County:

What services do you offer?

5. Who may we contact regarding this request for network participation?

Name:

Title:

Company:

Address:

City:

State:

Zip Code:

Phone:

- - Extension:

Fax:

- -

Email: