Request Pre-Application

Thank you for your interest in becoming a member of Touro's Medical Staff. Please complete this form to receive a pre-application packet.
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First Name
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Last Name
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Email
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Telephone
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Address1
Address2
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City
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State
select
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Zip
  
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Cell Phone
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Office Address
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Office City
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Office State
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Office Zip
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Office Phone
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Office Email
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Office Fax Number
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Office Contact Person
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Office Contact Phone
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Office Contact Email
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Date of Birth
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National Practitioner Identification (NPI) number:
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Are you board-certified?
If yes, please specify:
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Are you with a medical group?
If yes, please specify:
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Are you with a university?
If yes, please specify:
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Type of privileges you are requesting:
If you selected other, please explain:
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Your specialty/specialties:
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Cross Covering Physician? Provide complete name, address, phone and fax number.
Cross Covering Physicians must be a current member of Touro’s Medical Staff with the same type of privileges you are requesting.
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Why would you like to become a member of Touro's medical staff?
For example, to provide coverage for a physician on Touro’s active staff, to join a group associated with Touro Infirmary, or relocating to the New Orleans/Uptown area.
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How would you like to receive your application?
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Touro Infirmary, 1401 Foucher Street, New Orleans, Louisiana 70115
Phone: 504-897-7011 Pencil
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