Louisiana Premier Physicians Program

• 1. A. GENERAL INFORMATION SECTION
  2. Todays Date
  3. Physician’s Name
  4. Practice Entity Name
  5. Office Address (street, city, state, zip)
  6. Billing Address (street or P.O. Box, city, state, zip)
  7. Home Address (street, city, state, zip)
  8. Other Locations To Be Covered (include addresses)
  9. Other location #1:
  10. Other location #2:
  11. Other location #3:
  12. Office Phone Number
  13. Fax Number
  14. E-mail
  15. Social Security No.
  16. Federal Tax I.D. No.