"*" indicates required fields Step 1 of 4 25% Personal & Account InformationMembership Level*SelectSubscriberSMA Alliance ($40)Medical Student (Free)Resident Physician ($100)Healthcare Management ($150)Allied Health Professional ($150)Physician MD/DO ($320)Select your desired membership to proceed, payment information will be requested before submission.HiddenUsername* (Temporarily visible for testing only)HiddenRedirect Name* First Last Spouse Name* First Last Gender*SelectMaleFemaleProfession*Select Best FitAdministratorDiagnostic Medical PhysicsEducation SponsorExecutiveFellowHealthcare ProfessionalManagementMedical StudentNurseNurse PractitionerPatientPhDPhysicianPhysician AssistantPractice ManagerResidentSMA StaffSocial WorkerSpouseOtherDate of Birth* MM slash DD slash YYYY NPI Number* e.g. 1619967726Email* Existing accounts, please login for upgrade or renewal options.Password* Enter Password Confirm Password Strength indicator Professional Information LicenseState*SelectAlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict Of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMontanaNebraskaMississippiMississippiNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingLicense Number* Board(s)* Add AnotherRemove* If you are board certified please indicate which board.HiddenLicense DataSpecialty*SelectAllergy/ImmunologyAnesthesiologyCardiologyDermatologyEndocrinology/Diabetes/MetabolismEmergency MedicineFamily Practice/General PracticeFamily MedicineGeriatricsInternal MedicineMedical GeneticsNeurological SurgeryNeurologyObstetrics/GynecologyOncologyOphthalmologyOrthopedicsOtolaryngologyPathologyPediatricsPhysical Medicine & RehabPlastic SurgeryPreventive MedicinePsychiatryRadiologySurgeryUrologyOtherArea of Interest*SelectBioethics & Medical EducationEmergency & Disaster MedicineMedicine & Medical SubspecialtiesMental HealthPublic Health & Environment MedicineQuality Health Care, Patient Safety, & Best PracticesSurgery & Surgical SubspecialtiesName of the Practice/Group in which you work?* Practice/Office Manager's Full Name* Practice Type*SelectSoloGroupAcademicUniversityHospitalHMOACOMilitaryOtherPractice Setting*SelectAffluent suburbsMetropolitan urbanMiddle income suburbsMinority inner cityRuralNAPatient Population*SelectAcutely ill but mostly curableChronic with adequate functionHealthyIntermittent exacerbations and sudden death mostly heart and lung failureLong dwindling course mostly frailty and dementiaMaternal and infant healthShort period of decline near death mostly cancerStable with significant disability often not elderlyNAPatient Demographic*SelectAdult all genderAdult maleAdult femaleChildrenGeneral all age and genderGeriatricYoung adults and adolescentNAEducation InformationDegrees and Certifications* Insert commas between each to separate. Entered exactly as you would like it shown. Enter NA if not applicable. Medical School* Name of Residency Program* Residency Director's Name* Graduation Date* MM slash DD slash YYYY End of Residency Date* MM slash DD slash YYYY Contact InfoPrimary Address 1* Primary Address 2 Primary City* State*Select StateAlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces PacificPostal Code* Country*United StatesCanadaAfghanistanÅland IslandsAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua/BarbudaArgentinaArmeniaArubaAustriaAustraliaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBosnia/HerzegovinaBotswanaBouvet IslandBrazilBrunei DarussalamBulgariaBurkina FasoBurundiCambodiaCameroonCape VerdeCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos (Keeling) IslandsColombiaComorosCongoCook IslandsCosta RicaCôte D'IvoireCroatiaCubaCyprusCzech RepublicDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEthiopiaalkland Islands(Malvinas)Faroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island/Mcdonald IslandsHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle Of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKuwaitKyrgyzstanLaoLatviaLebanonLesothoLiberiaLibyan Arab JamahiriyaLiechtensteinLithuaniaLuxembourgMacaoMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNetherlands AntillesNew CaledoniaNew ZealandNicaraguaNigerNiueNorfolk IslandNorth KoreaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestinePanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRéunionRomaniaRussian FederationRwandaSt. BarthélemySt. HelenaSt. Kitts/NevisSt. LuciaSt. MartinSt. Pierre/MiquelonSt. Vincent/The GrenadinesSamoaSan MarinoSao Tome/PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia/Sandwich IslandsSouth KoreaSpainSri LankaSudanSurinameSvalbard/Jan MayenSwazilandSwedenSwitzerlandSyrian Arab RepublicTaiwanTajikistanTanzaniaThailandTimor-LesteTogoTokelauTongaTrinidad And TobagoTunisiaTurkeyTurkmenistanTurks/Caicos IslandsTuvaluUgandaUkraineUnited Arab EmiratesUnited KingdomUnited States Minor IslandsUruguayUzbekistanVanuatuVatican City StateVenezuelaVietnamVirgin Islands, BritishVirgin Islands, U.S.Wallis/FutunaWestern SaharaYemenZambiaZimbabwePrimary Phone*Mobile PhoneSeparate Billing Address* Yes No Billing Address 1* Billing Address 2* Billing City* Billing State*Select StateAlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces PacificBilling Zip* Billing Email* Billing Phone*SocialFacebook LinkedIn Twitter Instagram Contact PreferenceCan we contact you by the following methods?Email Yes No Text Yes No Mail Yes No Fax Yes No Phone Yes No How did you hear about us?*SelectAttended a live/virtual eventEmail CampaignInternet SearchSocial MediaOtherTotal Coupon Credit Card*Card Details Cardholder Name Privacy & Terms of Use* I have read and agree to the Terms of Use and Privacy and Confidentiality Policy
