AMA Physician Profile

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AMA Physician Profile AMA Files Checked 05/01/2009 12:55:04 AMA Physician Profle for John Q. Public MD Page 1 of 4 ©2009 by the American Medical Association Name and Mailing Address: Primary Office Address: JOHN Q. PUBLIC MD HOMETOWN MEDICAL CENTER SPECIALTY MEDICAL CENTER 123 MAIN ST 123 MAIN ST ANYCITY, IL 12345-9876 ANYCITY, IL 12345-9876 Birthdate : 01/01/1960 Phone : 1-234-555-1212 Birthplace : ANYTOWN, IL UNITED STATES OF AMERICA Physician 9s Major Professional Activity : OFFICE BASED PRACTICE Practice Specialties Self Designated by the Physician* : Primary Specialty : FAMILY PRACTICE Secondary Specialty : UNSPECIFIED *Self-Designated Practice Specialties/Areas of Practice (SDPS) listed on the AMA Physician Profile do not imply crecognition d o r cendorsement d of any field of medical practice by the Association, nor does it imply, certification by a Member Medical Special ty Board of the American Board of Medical Specialties, or that the physician has been trained or has special competence to practice the SDP S.

AMA membership : MEMBER ____________________ All Information from this Point Forward is Provided by the Primary Source ___________________ Current and/or Historical Medical School: UNIV OF IL MED SCH AT CHICAGO, CHICAGO IL 12345 Degree Awarded: YES Degree Year: 1998 UNIV OF ... more. less.

IOWA, IOWA SCH OF MED, IOWA CITY IA 52242 Degree Awarded: NO Degree Year: 1996 Current and/or Historical Post Graduate Medical Training Programs Accredited by the Accreditation Council for Graduate Medical Education (ACGME): Future training dates, as reported by the program, should be interpreted as cin progress d or ccurrent d with the projected date of completion. If the training program indicates that training for a physician in a particular specialty was not completed at their institution, the training segment will be identified as cINCOMPLETE TRAINING d. AMA Physician Profile AMA Files Checked 05/01/2009 12:55:04 AMA Physician Profle for John Q. Public MD Page 2 of 4 ©2009 by the American Medical Association Institution : LA STATE UNIV HP-SHREVEPORT State : LOUISIANA Specialty : INTERNAL MEDICINE 07/1999 3 06/2001 (VERIFIED) Institution : EARL K LONG MED CTR State : LOUISIANA Specialty : INTERNAL MEDICINE 07/1998 3 06/1999** (VERIFIED) **INCOMPLETE TRAINING: Program reports specialty training as cIncomplete. d Institution : LA STATE UNIV HP-SHREVEPORT State : LOUISIANA Specialty : CARDIOVASCULAR DISEASE 07/2001 3 06/2004 (VERIFIED) Note: If you have discrepant information, please submit a Request for Investigation to the AMA so that we may verify the information with the primary source(s). See the last page of this Profile for instructions on how to report a data discrepancy. Current and/or Historical Medical Licensure: Jurisdiction: MD/ Date Expiration License Last DO Granted Date Status Type Reported LOUISIANA MD 07/01/1999 05/31/2010 ACTIVE UNLIMITED 04/21/2009 Note: When the specific month and day are unknown, the date will display the default value of c01. d Not all licensing boards m aintain or provide full date values. Please contact the appropriate licensing board directly for this information. ECFMG Certification: Applicant Number : Note: The Education Commission for Foreign Medical Graduates (ECFMG) applicant identification number does not imply curre nt ECFMG certification status. To verify ECFMG status, contact the ECFMG Certification Verification Service in writing at P.O. Box 13679, Philadelphia , PA 19101. Federal Drug Enforcement Administration: * Only the last three characters of active DEA number(s) are displayed. DEA Number * Schedule Expiration Date Last Reported XXXXXX389 22N 33N 4 5 11/01/2010 04/30/2009 Address: 123 Main Street, Anycity, IL 12345-9876 XXXXXX174 2N 33N 4 5 11/01/2010 04/30/2009 Address: 5678 Central Ave., Anotherville, IL 12654-3210 Note: Many states require their own controlled substances registration/license. Please check with your state licensing authori ty for requirement information as the AMA does not maintain this information. AMA Physician Profile AMA Files Checked 05/01/2009 12:55:04 AMA Physician Profle for John Q. Public MD Page 3 of 4 ©2009 by the American Medical Association Specialty Board Certification(s)*: Specialty Board Certification(s) by one or more of the 24 boards recognized by the American Board of Medical Specialties (ABMS) and the American Medical Association (AMA) through the Liaison Committee on Specialty Boards, as reported by the ABMS: The AMA Physician Profile has been designated by the ABMS as an official cdisplay agent d of the ABMS Specialty Board Certification data. Therefore, the ABMS Board Certification information on the AMA Physician Profile is considered a designated equivalent source in regard to credentialing standards set forth by accrediting bodies such as the Joint Commission and National Committee for Quality Assurance (NCQA). Certifying Board: AMERICAN BOARD OF FAMILY PRACTICE Certificate: FAMILY PRACTICE Certificate Type: GENERAL Duration Effective Expiration Occurrence Last Reported TIME LIMITED 01/01/2001 12/31/2010 RE-CERT 04/14/2009 TIME LIMITED 01/01/1994 12/31/2002 RE-CERT 04/14/2009 TIME LIMITED 01/01/1987 NONE REPORTED TO DATE INITIAL 04/14/2009 Note: For certification dates, a default value of c01 d appears in the month field if data was not provided to AMA. Please cont act the appropriate specialty board directly for this information. **Indicates an expired certificate. *This information is proprietary data maintained in a copyrighted database compilation owned by the American Board of Medical S pecialties. Copyright 2009 American Board of Medical Specialties. All rights reserved. Physician 9s Recognition Award: THIS PHYSICIAN HOLDS AMA PHYSICIAN 9S RECOGNITION AWARD CERTIFICATE (AMA PRA), VALID THROUGH 01/01/2010. THE AMA PRA CERTIFICATE RECOGNIZES PHYSICIANS WHO COMPLETE AT LEAST FIFTY HOURS OF CONTINUING MEDICAL EDUCATION ANNUALLY. Medicare/Medicaid Sanction(s) : TO DATE, THERE HAVE BEEN NO SUCH SANCTIONS REPORTED TO THE AMA BY THE DEPARTMENT OF HEALTH AND HUMAN SERVICES. Other Federal Sanctions(s) : TO DATE, THERE HAVE BEEN NO FEDERAL SANCTIONS REPORTED TO THE AMA BY ANY BRANCH OF THE US MILITARY, THE VETERAN 9S ADMINISTRATION OR THE US PUBLIC HEALTH SERVICE. Additional Information : TO DATE, THERE IS NO ADDITIONAL INFORMATION FOR THIS PHYSICIAN ON FILE. The content of the Physician Profile is intended to assist with credentialing. Appropriate use of the data contained in the AM A Physician Masterfile by an organization meets selected primary source verification requirements of the Joint Commission, National Committ ee for AMA Physician Profile AMA Files Checked 05/01/2009 12:55:04 AMA Physician Profle for John Q. Public MD Page 4 of 4 ©2009 by the American Medical Association Quality Assurance (NCQA), the Accreditation Association for Ambulatory Health Care (AAAHC), and the American Accreditation Heal th Care Commission (AAHCC)/Utilization Review Accreditation Commission (URAC). If you note any discrepancies, please log onto our web site (www.ama-assn.org/go/amaprofiles) and go to the order detail page, select the D following the physician 9s name and enter the data in question. Or you can mark the issues on a copy of the profile and mail or fax to: Division of Database Products and Licensing Attn: Credentialing Products 515 N. State Street Chicago, IL 60610 800-665-2882 312 464-5900(fax) If you have any questions or need additional information about the AMA Profile Service, please call 1-800-665-2882.

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