Perspectum Coverage Support

Provider Enrollment - Perspectum

Practice Name *

Practice Phone Number *

Practice Fax Number *

Practice Address *

Practice Address

City

State/Province

Zip/Postal

Practice Tax ID *

Practice NPI *

Primary Admin Contact Name (First and Last) *

Primary Admin Contact Email *

Primary Admin Contact Phone *

Perspectum Sales Representative Name *

Physician Name (1)

Physician NPI (1)

Physician Tax ID (1)

Facility Name *

Facility Address *

Facility Address

City

State/Province

Zip/Postal

Country

Facility Phone *

Facility Tax ID *

Facility NPI *

Date: Onboarding Call Availability (Option 1)

Time (EST)

Date: Onboarding Call Availability (Option 2)

Time (EST)

PROGRAM SUPPORT:

MONDAY–FRIDAY 8:30AM–5:00PM EST
PHONE: (860) 900-0731 FAX: (860) 261-0640
EMAIL: PCS@PRIAHEALTHCARE.COM