Meeting Registration
4/25/2023 at 6:30 PM ET
Brick and Brine
100 W Michigan Ave, Kalamazoo, MI 49007
Registration
How would you like to attend?
Live
(if you are undecided, please choose Virtual, you can change your preference later pending space is available at the venue)
Virtual
(Zoom)
Who are you?
*
Attendee
Speaker
First Name
*
Last Name
*
Address
*
City
*
State
*
Zip
*
Sunshine Reporting Name/Address (if different from above)
Phone
Mobile
Email
*
Degree
*
Select Degree
MD
DO
PA
NP
LNP
APRN
RN
PhD
MA
DPM
Office
Staff
Other
Other
*
Title
Affiliation
Administrative Assistant Name
Administrative Assistant Phone Number
NPI #
Medical License #
*
Any food allergies/restrictions (e.g., vegetarian)
Please ensure all required information (
*
) is completed.
Please select a meal option below:
I would like to OPT-IN for the meal.
I would like to OPT-OUT for the meal.
Register
Americans with Disabilities Act: Event staff will be happy to assist you with any special needs (e.g., physical, dietary, etc.). Please contact Cindy Miller at 203-604-1856 or
cindy@cmeroundtable.com
prior to the event.
NPI Lookup
Please verify that the npi number entered belongs to you.
The npi number entered was not found.
NPI Number:
First Name:
Last Name:
Address:
City:
State:
Zip:
NPI Lookup
First Name
Last Name
Practice City
Practice State
Results
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