Initial Application Request Application Access Request for Application Thank you for your interest in joining Tri-City Medical Center's Medical Staff. Please fill out the form below to receive a user name and password to our site. We look forward to working with you on the credentialing process.Name* First Last Degree*ex: MD, DO, etc.Phone*Provider E-mail* National Provider Identifier (NPI)*Group Practice Name (if applicable)Specialty*Board Certified in Speciality Area?* Yes No Are you board eligible or qualified? Yes No If you are board certified, please provide the name of the board you are certified though.Authorized User (optional) If you wish to designate office staff to assist with completion of the application, please provide the following. First and Last Name, Email Address
