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https://www.grmedcenter.com/credentialing-payments/
https://www.grmedcenter.com/credentialing-payments/
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Credentialing Payments
Credentialing Payments
Provider Information
Provider First Name (Required)
*
Provider Last Name (Required)
Credentials (Required)
*
Credentials (Required)
MD
DO
DDS
DPM
NP
PA
Other
Phone Number
*
Email Address
*
Office Street Address
*
Office Street Address
City
Street Address (Required)
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State
Zip Code
Select Fee(s) Payment (select all that apply)
*
Initial Appointment ($200)
Temporary Privileges ($200)
Reappointment ($200)
Late Fee ($100)
Total:
Price:
$0.00
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Date
MM slash DD slash YYYY