Send Information about a New Provider

Use the form below to submit information about a new provider who is not currently in the Brown University Health system. Form results will be sent to the Brown University Health Medical Staff Office.

Your Information

Provider Information

Degree
Find a license number at the RI DOH website
Find an NPI number

Primary Practice Address

Type of EHR Used
Would you like to add a second address?

Second Location Information

Type of EHR Used at Second Location

Additional Comments

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