UKHC Physician Information Submission Form

This information is used by UKMDs to build and maintain their physician database and to develop the UK HealthCare Provider directory, an important reference for internal and referring physicians. Collecting this information electronically will assist in the creation of a new centralized database for UK physicians and administrators.

Your help in collecting and entering the fullest and most complete information possible for physicians in your department or division is greatly appreciated. If for any reason this form does not meet your needs, feel free to contact Peggy Foster at 859-257-2630.

Click here if you would like to request REMOVAL of a physician from the directory.

Physician Name:	*Required
Degree:
Rank:
Title:

Primary Specialty:	*Required
Sub-specialty #1:
Sub-specialty #2:
Sub-specialty #3:

Department:
Division:

Part Time:
Full Time:

Clinical Interests: *Please enter all clincial interests, separated by a comma.

Certificates: *Please enter all certificates, separated by a comma.

Medical or Dental Degree:
School Name:
City:
State:

Residency:
School Name:
City:
State:

Fellowship:
School Name:
City:
State:

Clinic:
Office Address:
Office Phone:
Office Fax:
Pager number:
E-mail:
Appointment phone: *Will be displayed on the UKHC web site

Submitted by:	*Required
Verification phone: No submissions will be posted until they are verified by calling the number you provide here.	*Required

call us at (859) 231-9922 or (800) 888-5533

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To make an appointment or find a physician, please call UK HealthCare at 859-257-1000 or toll free 1-800-333-8874.
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Page last updated Thursday, August 23, 2007 11:06 AM

UKHC Physician Information Submission Form

Medical or Dental Degree:

Residency:

Fellowship: