Attention: Practice information MUST MATCH THE NPI REGISTRY or we cannot send you an activation notification to allow you to activate and use the DMERX website.  If your current Practice address is different than the NPI Registry, you will need to use the NPI registered address.  If your practice address is not current, please log into your NPI registry account and update it.  Once the NPI registered address has been updated, you can then update your account profile in DMERX and change the practice address there to match the NPI registered address.

The information you provide will remain confidential.  DMERX does not share your information with outside sources.

For security and compliance purposes, DO NOT give your user name and password to ANYONE.

Items marked with (*) are required.

First Name:	*
Middle Name:
Last Name:	*
Title:	*	(MD, DO, etc)
NPI:	*
DEA:		(Prescribers only)
DOB:	*
Gender:	*	Male Female
Clinician Role:	*	Prescribing Clinician Therapist
Exam Encounters:	*	Home    Clinic    Telemed Select all exam encounters accepted
Email:	*
Confirm Email:	*
Clinician Home Address is required for verification and credentialing.  Not required for non-prescribing clinicians.
Home Address 1:
Home Address 2:
Home City:
Home State:		Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Puerto Rico Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming Philippines
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