Provider Enrollment – Xtant Medical Coflex® Provider Enrollment – Xtant Medical Provider Enrollment – Xtant Medical Portal User Information User Contact Name * User Contact Name First First Last Last User Contact Email * User Contact Phone * Add Remove Practice Name * Practice Address * Practice Address Practice Address Practice Address City City State/Province AlabamaAlaskaArkansasArizonaCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyoming State/Province Zip/Postal Zip/Postal Practice Phone Number * Practice Fax Number * Practice Tax ID * Practice NPI * Physician Information Physician Name * Physician Specialty * Physician PTAN (Medicare Provider Number) Physician NPI * Physician Tax ID * Add Remove Facility Information Facility Name * Facility Address * Facility Address Facility Address Facility Address City City State/Province AlabamaAlaskaArkansasArizonaCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyoming State/Province Zip/Postal Zip/Postal Facility Phone * Facility Tax ID * Facility NPI * Add Remove Xtant Sales Representative Name * Date: Onboarding Call Availability (Option 1) Date: Onboarding Call Availability (Option 2) Time (EST) 121234567891011 : 0030 AMPM Time (EST) 121234567891011 : 0030 AMPM If you are human, leave this field blank. Submit
