Physician Information Form

 If you are an FMC physician and would like to be included in the online directory, please fill out this form. For more information, call Physician Relations at 928 773-2197.

PHYSICIAN NAME:

EMAIL ADDRESS:

ADDRESS OF PRACTICE:

CITY: STATE: ZIP:

PHONE: TOLL FREE: FAX:

SPECIALTY:

MEDICAL SCHOOL: CITY/STATE:

INTERNSHIP: CITY/STATE:

RESIDENCY: CITY/STATE:

BOARD CERTIFICATION:

SPECIAL PROCEDURES/MEDICAL INTERESTS:

PROFESSIONAL ORGANIZATIONS:

NAH WEB SITE ONLINE DIRECTORY YES  NO

Please check spelling before pressing submit. The information above will be placed in the appropriate places as it was received. Thank you.

If you have questions or problems with this form please call 928 773-2197. For information about getting your photograph taken you can make an appointment with James Harris Photography, 928 779-3813. There is no charge for this service.

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Northern Arizona Healthcare - 1200 N. Beaver St., Flagstaff, Ariz. 86001 - 928 779-3366
Flagstaff Medical Center - 1200 N. Beaver St., Flagstaff, Ariz. 86001 - 928 779-3366
Verde Valley Medical Center - 269 S. Candy Lane, Cottonwood, Ariz. 86326 - 928 639-6000
VVMC - Sedona Campus - 3700 W. Highway 89A, Sedona, Ariz., 86336 - 928 204-3000