LAND, SEA AND AIR MEDICAL REVIEW SPECIALISTS
|
Arnold D. Panzer, MD |
Phone: (631) 225-3060 |
Date _________________
To set-up a Company Account:
Please complete the information below and fax to Land, Sea
& Air Medical Review at (631) 225-3064.
We will contact you to set-up
your account.
| Company Name | _______________________________________________________ |
| Street Address | _______________________________________________________ |
| City, State Zip | _______________________________________________________ |
| E-Mail Address | _______________________________@______________________ |
| DER of Company | _______________________________________________________ |
| Phone | _(________)______________________________________________ |
| Designated Secure Fax | _(________)______________________________________________ |
| Billing Contact | _______________________________________________________ |
| Billing Phone Number | _(________)______________________________________________ |
910 Route 109 ° North Lindenhurst, New York 11757