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 Phone
 
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
39 rue Anatole France
92300 Levallois- Perret
FRANCE

Phone +33 184 790 880
Fax +33 184 790 881
contact@medical-administrators.com