Healthcare Professional Credentialing Application Completed Form Examples and Samples

CONFIDENTIAL – PHYSICIAN ONBOARDING MEMO
Prepared by: Riverstone Medical Group, Human Resources
Date: March 12, 2026
Re: Credentialing File – Dr. Priya S. Nair, MD

This memo summarizes the information collected from Dr. Nair's onboarding interview and submitted documents for use in completing her credentialing application. Please verify all items with primary source documents before submission.

Personal Information:
Dr. Priya Sunita Nair (no suffix) was born on July 14, 1983 in Mumbai, India. She is a U.S. citizen and currently resides at 47 Ridgewood Terrace, Apt 3B, Hoboken, NJ 07030. Her home phone is (201) 555-0194 and her Social Security Number is 523-88-4712. Prior to marriage she went by the surname Krishnamurti (used 2001–2009), and briefly used the name Priya Iyer during a research appointment (2009–2011). For correspondence, please use her practice address at 180 Park Avenue, Suite 640, New York, NY 10017; phone (212) 555-0388; fax (212) 555-0399; email [email protected].

Education:
Dr. Nair completed her MD at Weill Cornell Medicine, 1300 York Avenue, New York, NY 10065, attending from August 2007 through May 2011. She subsequently completed a three-year Internal Medicine Residency at NewYork-Presbyterian Hospital/Weill Cornell Medical Center, 525 East 68th Street, New York, NY 10065, from July 2011 to June 2014 (completed successfully; program director was Dr. Alan Forrest; current director is Dr. Linda Chu). Following residency she completed a two-year Cardiovascular Disease Fellowship at NYU Langone Medical Center, 550 First Avenue, New York, NY 10016, from July 2014 through June 2016 (completed; program director Dr. Harold Patel; current director Dr. Sandra Kim). She also holds a Master of Public Health (MPH) from Columbia University Mailman School of Public Health, 722 West 168th Street, New York, NY 10032, attended September 2005 to May 2007.

Licensure and Certifications:
Dr. Nair holds an active New York State medical license (MD License No. 254881, originally issued April 10, 2014, expires March 31, 2028; she does currently practice in NY) and a New Jersey medical license (MD License No. NJ-98234, originally issued January 15, 2015, expires January 31, 2027; she does currently practice in NJ). She has a DEA registration number BN4782901, originally issued June 1, 2014, expiring May 31, 2027. Her NPI is 1234567890. ECFMG is not applicable to her (she is a US medical school graduate). She is a participating Medicare provider (Provider No. 1234567890-M) and a participating Medicaid provider (Provider No. NJ-MCD-88821).

Board Certification:
Dr. Nair is board certified in Internal Medicine by the American Board of Internal Medicine (ABIM). Initial certification was October 2014; recertification October 2020; current certification expires September 2030. Her secondary specialty is Cardiovascular Disease, also certified by ABIM; initial certification June 2017, recertification not yet applicable, expiration June 2027.

Work History:
Dr. Nair's current position begins April 1, 2026 with Riverstone Medical Group, 180 Park Avenue Suite 640, New York, NY 10017. Previously she was employed at Manhattan Internal Medicine Associates, 250 West 57th Street, Suite 920, New York, NY 10107 from July 2016 to March 2026 (reason for leaving: joined Riverstone Medical Group for expanded cardiology integration). Before that she had a brief locum tenens role with Atlantic Health Hospitalist Services, 475 South Street, Morristown, NJ 07960, March 2016 to June 2016 (reason: temporary position pending permanent placement).

Hospital Affiliations:
Primary hospital: NYU Langone Medical Center, 550 First Avenue, New York, NY 10016; phone (212) 263-7300; fax (212) 263-8426; email [email protected]. Privileges began July 2016. She holds full unrestricted privileges, privileges are not temporary, and approximately 70% of her admissions are to this hospital. She also holds privileges at Mount Sinai West, 1000 Tenth Avenue, New York, NY 10019; phone (212) 523-4000; fax (212) 523-3100; email [email protected], since January 2018; full unrestricted, not temporary, approximately 30% of admissions.

Previous hospital: Dr. Nair held privileges at Weill Cornell Medical Center (as a resident, not staff privileges) — not applicable for prior staff privileges disclosure.

Malpractice Insurance:
Dr. Nair is not self-insured. Current carrier: ProAssurance Specialty Insurance Company, 100 Brookwood Place, Birmingham, AL 35209; phone (800) 282-6242. Policy number: PS-2024-NJ-99214; effective date January 1, 2024; expiration December 31, 2026. Coverage: $1,000,000 per occurrence / $3,000,000 aggregate. Individual policy. She has been with ProAssurance for approximately 3 years. Prior carrier: The Doctors Company, 185 Greenwood Road, Napa, CA 94558; phone (800) 421-2368; policy number TDC-IM-20181102; effective July 1, 2016 to December 31, 2023; coverage $1,000,000/$3,000,000; individual policy; 7 years with prior carrier. No malpractice claims in the past 5 years.

References:
1. Dr. Alan Forrest, MD – Program Director (former), NewYork-Presbyterian Hospital, 525 East 68th Street, New York, NY 10065; phone (212) 746-1000.
2. Dr. Sandra Kim, MD – Fellowship Director, NYU Langone, 550 First Avenue, New York, NY 10016; phone (212) 263-7300.
3. Dr. Robert Cho, MD – Chief of Medicine, Manhattan Internal Medicine Associates, 250 West 57th Street, New York, NY 10107; phone (212) 555-0210.

Practice Location:
Primary practice: Riverstone Medical Group, 180 Park Avenue Suite 640, New York, NY 10017. Group primary care and specialty. Phone (212) 555-0388, fax (212) 555-0399, email [email protected]. Tax ID (EIN): 83-4521097. NPI group: Group 1234567890-G. Office manager: Maria Delgado, (212) 555-0300. Credentialing contact: Jennifer Wu, 180 Park Avenue Suite 640, New York, NY 10017; phone (212) 555-0301; fax (212) 555-0302; email [email protected]. Currently practicing: yes (as of April 1, 2026). Listed in directory: yes.

Office hours: Monday 8:00 AM–12:00 PM / 1:00 PM–5:00 PM; Tuesday 8:00 AM–12:00 PM / 1:00 PM–5:00 PM; Wednesday closed; Thursday 8:00 AM–12:00 PM / 1:00 PM–5:00 PM; Friday 8:00 AM–12:00 PM; Saturday and Sunday closed. After-hours coverage via answering service. Accepts all new patients, new Medicare and Medicaid patients. No practice limitations by gender or age. Non-physician providers: Nurse Practitioner Rebecca Torres, NP, NY NP License #NP-44821. Interpreters available (Spanish, Hindi). ADA accessible: yes (building, parking, restrooms). Public transportation: bus and regional train. No childcare. Not a minority business enterprise. CPR and ACLS certified (staff and provider). Laboratory services on site (CLIA certificate #31D1234567). Drawing blood, EKG, age-appropriate immunizations, and routine office gynecology offered. Billing through Riverstone Medical Group billing dept.; Tax ID 83-4521097; checks payable to Riverstone Medical Group; electronic billing: yes.

Call Coverage Colleagues:
1. Dr. James Park, MD – Internal Medicine
2. Dr. Angela Torres, MD – Cardiovascular Disease

Disclosure Questions: Dr. Nair answers No to all disclosure questions (1–23). No malpractice claims in the past 5 years. No prior licensure actions, hospital privilege issues, Medicare/Medicaid exclusions, felony convictions, or substance use issues.

Applying to: Empire BlueCross BlueShield, United Healthcare New York, NYU Langone Health Network.

Applicant initials and date: P.S.N. 03/12/2026