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	A: Provider Personal & Professional Information TEST 2/17/2012			B: Physical Data Information
	C: Professional Schools			D: Medical Schools
	E: Professional / Medical Specialty			F: Military Medical Training
	G: Office Addresses			H: Group Practice Employment
	J: Hospital Affiliations			K: Board Certification
	M: Medical License Registration			N: Professional Liability Insuracne Carrier
	O: Professional Associations			P: Professional Medical Refferences
	Q: Disclosure Questions If you answer YES to any of the following questions, please provide full details in the space provided.

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