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Hospital medical staff application · Interventional Radiologist, Fort Myers, FL · sent by Northstar Locums

40 of 48 filled 3 need a look 2 for you to enter 6 questions only you can answer

Hospital Medical Staff Application

Initial appointment · Department of Radiology · demo form A

1. Applicant

Full legal nameVinayak Thakur

DegreeMD

Date of birth••/••/••••

Social Security numberEnter this yourself

NPI1999000141

Primary specialtyDiagnostic and Interventional Radiology

Emailvinayak.thakur.demo@example.com

Cell phone(954) 555-0141

2. Licensure and DEA

Florida license no. · expires••••1207 · 01/31/2027

Texas license no. · expires••••8412 · 08/31/2027

Georgia license no. · expires••••7731 · 11/30/2026

New York license no. · expires••••2114 · 03/31/2028

DEA no. · state · expires••••4567 · FL · 05/31/2027

3. Education and training

Medical school · yearsAtlantic Coast School of Medicine · 2008-2012

Internship · yearsBayside General Hospital · 2012-2013

Residency, Diagnostic RadiologyMeridian University Medical Center · 2013-2017

Fellowship, Vascular and InterventionalMeridian University Medical Center · 2017-2018

4. Board certification

ABR, Diagnostic RadiologyCertified 2017 · through 2027

ABR, Interventional RadiologyCertified 2019 · through 2029

5. Practice history

Years in practice since training8

Gaps in practice longer than 6 monthsNone

Current hospital affiliationsBroward Shores Medical Center; Palm Harbor Regional Hospital

6. Professional liability

CarrierSentinel Physicians Mutual

Policy no.••••5120

Limits$1M / $3M

Expires01/01/2027

7. References

Reference 1Dr. Alan Reyes, Chief of Radiology

Reference 2Dr. Priya Nand, IR Section Lead

Reference 3Dr. Mark Ellison, Vascular Surgery

Reference 3 phone or emailNot in your documents

Attestation and disclosure. Only you can answer these. We left them blank.

Has any license to practice in any jurisdiction ever been limited, suspended or revoked?YesNo

Have clinical privileges ever been denied, reduced or not renewed?YesNo

Have you been named in a professional liability claim in the last 10 years?YesNo

Have you ever been convicted of a felony?YesNo

Do you have any condition that could affect your ability to practice safely?YesNo

I attest that the information in this application is accurate and complete.I agree

Applicant signature

Date

Fields

37 of 40 confirmed

Confirm 3 fields to continue.

We never submit without you.

Needs a look · 3

Current hospital affiliations

Broward Shores Medical Center; Palm Harbor Regional Hospital

Confirmed

Medium · 72%

Your CV lists these as of 2023. Still current?

Gaps longer than 6 months

None

Confirmed

Medium · 80%

We found no gaps from 2012 to today. Please confirm.

Years in practice since training

Confirmed

Calculated

Fellowship ended 2018, so 8 years as of 2026.

For you to enter · 2

Social Security number

Enter this yourself

Never stored

We never store SSNs, so we can't fill this. Type it on the form when you sign.

Reference 3 phone or email

Not in your documents

Only you can answer · 6

Attestation and disclosure questions

Left blank on purpose

Untouched

We never answer attestation or disclosure questions for you.

Filled from your profile · 37

Full legal name

Vinayak Thakur

99%

Date of birth

••/••/••••

99%

Florida license no.

••••1207

99%

Pre-checked against public source

DEA no.

••••4567

98%