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GENERAL INFORMATION
Physicians name
First
Last
Practice name
Practice managers name
First
Last
Mailing address
Street Address
Address Line 2
City
State / Province
Zip / Postal Code
United States
Canada
United Kingdom
Ireland
Australia
New Zealand
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antarctica
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bosnia and Herzegovina
Botswana
Bouvet Island
Brazil
British Indian Ocean Territory
Brunei Darussalam
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos (Keeling) Islands
Colombia
Comoros
Congo
Congo, The Democratic Republic of The
Cook Islands
Costa Rica
Cote D'ivoire
Croatia
Cuba
Cyprus
Czech Republic
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Falkland Islands (Malvinas)
Faroe Islands
Fiji
Finland
France
French Guiana
French Polynesia
French Southern Territories
Gabon
Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guinea
Guinea-bissau
Guyana
Haiti
Heard Island and Mcdonald Islands
Holy See (Vatican City State)
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran, Islamic Republic of
Iraq
Ireland
Israel
Italy
Jamaica
Japan
Jordan
Kazakhstan
Kenya
Kiribati
Korea, Democratic People's Republic of
Korea, Republic of
Kuwait
Kyrgyzstan
Lao People's Democratic Republic
Latvia
Lebanon
Lesotho
Liberia
Libyan Arab Jamahiriya
Liechtenstein
Lithuania
Luxembourg
Macao
Macedonia, The Former Yugoslav Republic of
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia, Federated States of
Moldova, Republic of
Monaco
Mongolia
Montserrat
Morocco
Mozambique
Myanmar
Namibia
Nauru
Nepal
Netherlands
Netherlands Antilles
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
Northern Mariana Islands
Norway
Oman
Pakistan
Palau
Palestinian Territory, Occupied
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn
Poland
Portugal
Puerto Rico
Qatar
Reunion
Romania
Russian Federation
Rwanda
Saint Helena
Saint Kitts and Nevis
Saint Lucia
Saint Pierre and Miquelon
Saint Vincent and The Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia and Montenegro
Seychelles
Sierra Leone
Singapore
Slovakia
Slovenia
Solomon Islands
Somalia
South Africa
South Georgia and The South Sandwich Islands
Spain
Sri Lanka
Sudan
Suriname
Svalbard and Jan Mayen
Swaziland
Sweden
Switzerland
Syrian Arab Republic
Taiwan, Province of China
Tajikistan
Tanzania, United Republic of
Thailand
Timor-leste
Togo
Tokelau
Tonga
Trinidad and Tobago
Tunisia
Turkey
Turkmenistan
Turks and Caicos Islands
Tuvalu
Uganda
Ukraine
United Arab Emirates
United Kingdom
United States
United States Minor Outlying Islands
Uruguay
Uzbekistan
Vanuatu
Venezuela
Viet Nam
Virgin Islands, British
Virgin Islands, U.S.
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Country
Phone
-
(###)
-
###
####
Fax
-
(###)
-
###
####
Cell
-
(###)
-
###
####
E-Mail
Web page address
OFFICE INFORMATION
Specialty
Practice type
Private Practice
Medical Group
Healthcare System
# Full-Time Physicians at this Office
-
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
33
34
35
36
37
38
39
40
41
42
43
44
45
46
47
48
49
50
50+
# Part-Time Physicians at this Office
-
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
20+
# Physicians Assistants/other
-
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
20+
How many offices/locations are affiliated with your practice
-
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
20+
Total patients seen during a typical month (entire practice)
-
1
500
1000
1500
2000
2500
3000
3500
4000
4500
5000
5500
6000
6500
7000
7500
8000
8500
9000
9500
10000
10500
11000
11500
12000
12500
13000
13500
14000
14500
15000
15500
16000
16500
17000
17500
18000
18500
19500
20000
20500
21000
21500
22000
22500
23000
23500
24000
24500
25000
25500
26000
26500
27000
27500
28000
28500
29000
29500
30000
30500
31000
31500
32000
32500
33000
33500
34000
34500
35000
35500
36000
36500
37000
37500
38000
38500
39000
39500
40000
40500
41000
41500
42000
42500
43000
43500
44000
44500
45000
45500
46000
46500
47000
47500
48000
48500
49000
49500
50000
Estimated average patient wait time (Minutes)
-
5
10
15
20
25
30
35
40
45
50
55
60+
RECEPTION AREA INFORMATION
Number of patient waiting areas at this address
-
1
2
3
4
5
6
7
8
9
10
10+
Total patients seen during a typical month (this location)
-
1
500
1000
1500
2000
2500
3000
3500
4000
4500
5000
5500
6000
6500
7000
7500
8000
8500
9000
9500
10000
10500
11000
11500
12000
12500
13000
13500
14000
14500
15000
15500
16000
16500
17000
17500
18000
18500
19500
20000
20500
21000
21500
22000
22500
23000
23500
24000
24500
25000
25500
26000
26500
27000
27500
28000
28500
29000
29500
30000
30500
31000
31500
32000
32500
33000
33500
34000
34500
35000
35500
36000
36500
37000
37500
38000
38500
39000
39500
40000
40500
41000
41500
42000
42500
43000
43500
44000
44500
45000
45500
46000
46500
47000
47500
48000
48500
49000
49500
50000
What types of T.V. or video programs do you curently provide in your waiting areas
What kind of internet access do you currently have, if any?
-
None
Cable
DSL
T1
Dial Up
Dont know
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