Telephone Number ( ) PRIMARY HOSPITAL AFFILIATION Name of Organization, Hospital, or Office Practice Address, City, State, Zip From: To: Position LICENSES AND REGISTRATION License Number Date Granted Expiration Date State License Number Date Granted Expiration Date Federal DEA Number Date Granted Expiration Date SPECIALTY IN WHICH VOLUNTEER DISASTER PRIVILEGES ARE DESIRED Anesthesiology Radiology Pediatrics Ophthalmology Family Medicine Surgery Psychiatry Pathology Neurosciences Dentistry/Oral Surgery Reproductive Medicine Podiatry Orthopedics Medicine Other
Telephone Number ( ) PRIMARY HOSPITAL AFFILIATION Name of Organization, Hospital, or Office Practice Address, City, State, Zip From: To: Position LICENSES AND REGISTRATION License Number Date Granted Expiration Date State License Number Date Granted Expiration Date Federal DEA Number Date Granted Expiration Date SPECIALTY IN WHICH VOLUNTEER DISASTER PRIVILEGES ARE DESIRED Anesthesiology Ophthalmology Psychiatry Dentistry/Oral Surgery Orthopedics Radiology Family Medicine Pathology Reproductive Medicine Medicine Pediatrics Surgery Neurosciences Podiatry Other
TJC_Medical_Staff_Standards_Resources.docx