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Provider Site Registration Request

Step 1

Step 1. Identify your provider site

Provider Site Name* Site Type*
Enter DBA (Doing Business As) optional
Site Street Address 1* Site Street Address 2
Site City* Site State* Site Zip Code* Site County*
click to find county
Phone #* Fax #
Provider Site NPI* Tax ID*
Is the practice part of a Medical Group? Medical Group
Yes No
*Please select the type of vaccines that are administered at your site.
 Pediatric   Adult   Practice does not administer immunizations  
Is this provider site currently registered with the MDPH Immunization Program to receive state-supplied vaccine? Site PIN#
Yes No
Enter the Estimated Monthly Volume of Immunization Records*:
 * Required