End Date and Time:

Would you be interested in seeing patients outside your traditional office hours via telehealth?

Would you like for GPT to publish your information on GPT website?

Contact Person for scheduling telehealth appointments:

Contact 1

First

Last

Physical Address 1:

Street Address

Address Line2

City

State
AlabamAlabama Alaska American Samoa Arizona Arkansas California Colorado Connecticut Delaware District of Columbia Florida Georgia Guam Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Northern Mariana Islands Ohio Oklahoma Oregon Pennsylvania Puerto Rico Rhode Island South Carolina South Dakota Tennessee Texas Utah U.S. Virgin Islands Vermont Virginia Washington West Virginia Wisconsin Wyoming Armed Forces Americas Armed Forces Europe Armed Forces Pacific

ZIP Code

Phone

Contact2

First

Last

Physical Address 2:

Street Address

Address Line2

City

State
AlabamAlabama Alaska American Samoa Arizona Arkansas California Colorado Connecticut Delaware District of Columbia Florida Georgia Guam Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Northern Mariana Islands Ohio Oklahoma Oregon Pennsylvania Puerto Rico Rhode Island South Carolina South Dakota Tennessee Texas Utah U.S. Virgin Islands Vermont Virginia Washington West Virginia Wisconsin Wyoming Armed Forces Americas Armed Forces Europe Armed Forces Pacific

ZIP Code

Phone

TELEHEALTH PROVIDER INFORMATION

Name

First

Last

Provider Credentials:

Scope of Service(s)

State(s) Licensed In:

Hold CTRL key to select multiple Scopes of Service and States.

NPI Number