Register to become a contracted medical provider with MAI

To register to become a contracted medical provider with MAI, please fill out the following form :

Provider Name *
  
Address 1
  
Address 2
  
Address 3
  
Zip code
  
Country
  
City
  
Direct Tel
  
Direct Fax
  
Currency of payment
  
Contact name
  
E-mail address
  
Payment method
  
Bank details
  
Account owner
  
IBAN
  
Code
  
Name of Bank
  
Address 1
  
Address 2
  
Address 3
  
Zip code
  
Country
  
City
  
Swift
  
     
   

 

Medical Administrators International
37 rue Anatole France, F-92300 Levallois- Perret FRANCE
Tel +33 1 77 68 01 60 - Fax +33 1 77 68 01 68 - contact@medical-administrators.com