Nominate a Provider

Don’t see your provider in our network?

Fill out the form below and we will consider adding them! Please provide as much info as you can.

Your Name

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Company Name

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Your Title

Your Email

Provider First Name

Provider Last Name

Facility Name

Tax ID

Please enter the provider's Tax ID

NPI

Address

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City

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State

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Zip Code

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Provider Email

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Provider Phone

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Provider Fax

Please enter the provider's fax number

Additional Notes

To Make Requests For Further Information,
Contact Us!

Call Us Or Email For Any inquiry

Phone: (866) 348-3887
Email: info@primehealthservices.com

866-348-3887