Physician Providers Candidate Profile · Physician Providers

Providing Healthcare Professionals Nationwide Since 1995

Contact Us: (800) 581-3627 - info@physicianproviders.com

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Candidate profile

Overview of physician information

Step 1 of 4

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Name*
First Last
Email*
Address*
Street Address City State ZIP Code
Primary phone*
Home phone
Office phone
About you
I am a ...*
- Physician
- Physician Assistant
- Nurse Practitioner
If you have a specialty, list it here.
Indicate which applies:*
- Board certified
- Board eligible
- Neither
Specialties I would also consider include:
Please indicate which, if any, of the following areas of practice you are considering at this point in your career
- Select All
- Emergency room
- Hospitalist
- Nocturnist
- ObGYN
- Other
- Pediatrician
- Primary Care/General Practice
- Urgent care
- N/A
If the Area of Practice is not listed above, please list below
Where did you earn your medical degree and what year did you graduate?*
List the states where your license is active.

Will you consider relocating?*
- Yes
- No
Would you be relocating alone?
- Yes
- No
Relocating with minors where schools are a consideration?
- Yes
- No
Best times/days to call?

USA citizenship status:*
- Naturalized or born in USA
- Work visa or green card holder
- Other
Foreign languages spoken:
Why are you seeking new employment?
Date you are available for a new position?
Type of placement you desire: (choose any you want)
- Permanent
- Locum Tenens
- Locum to permanent
What type of practice peaks your interest?
- Solo
- S/S Group
- M/S Group
- Employed Position
- Partnership
- Traditional IP/OP
- IP Practice
- OP Practice
- Any
List states and cities that you would prefer. (list in preference order)

Desired hourly compensation (locums) rate:
Desired permanent placement salary (annual):
What EMR software programs do you have experience with?
Exceptions*
- Do you have problems with licensing or privileges?
- Any malpractice suits?
- Any past treatment for alcohol/drug abuse?
- Is there anything on your National Practitioner Database Report that would affect your placement?
If any of the following apply to you, please send details in a separate document emailed to appexceptions@physicianproviders.com
If Available, Please List the Reference ID below
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We are located in Suwanee, GA

4485 Tench Road, Suite 2320
Suwanee, GA 30024-6745
(800) 581-3627
Fax (678) 714-3907

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