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Office Registration

Please enter the Group iInformation below. Select a Main Banner Health facility for Sponsoring physicians with BH admitting privileges.  

Office Group Information
Group Name* |    
Address* |    
Suite/P.O. Box |   
City* |    
State* |    
Zip Code* |      
Phone Number* |   ex: 999/999-9999   
Phone Extension |   
Main Banner Health Facility* |