Get startedInterested in becoming a certified BLACKDOC provider? Just fill out the form below to get started. Name * First Name Last Name Email * Phone (###) ### #### Address Address 1 Address 2 City State/Province Zip/Postal Code Country What is the state of your primary residence? * Please Select AK AL AR AZ CA CO CT DE DC FL GA HI IA ID IL IN KS KY LA MA MD ME MI MN MO MS MT NC ND NE NH NJ NM NV NY OH OK OR PA RI SC SD TN TX UT VA VT WA WV WI WY GU MP PR VI We only accept Board Certification from ABMS or AOA in Internal Medicine, Family Medicine, Emergency Medicine, or Pediatrics. Do you hold active board certification in one of these specialties by ABMS or AOA? * Yes No Do you have an active state medical license? Please include license number * Do you have an active Federal DEA certificate/number? please include * Do you have at least three years of clinical experience (education + experience)? * Yes No Can you commit to a minimum of 20 hours per month as a remote Physician? * Yes No Where do you currently hold state licenses? Check all that apply. * TX GA CA VA NJ NY OH NC TN FI IL MI PA Please provide your 10-digit NPI (National Provider Identifier) number * Are you currently a Medicaid or Medicare Provider? * Yes No Have you previously worked as a Physician with TheBlackdoc Health? * Yes No Please list any additional languages you are proficient in? If your middle name or middle initial appears on your state medical license and/or NPI number, please include it here. If a suffix appears as part of your name on your state medical license and/or NPI number (ex. Jr., III), please include it here. What is your availability to start at TheBlackdoc ? * Thank you!
