110 physician leaders to know - 2019 nomination form

Thank you for your submission to the "110 physician leaders to know" list. Nominations will close July 15 and we anticipate the list will be published in October. However, publication dates are subject to change.

This nomination form indicates word count for questions where appropriate. No section should exceed 500 words.

Please only submit one nomination per individual. Multiple nominations does not increase the chances of being recognized on this list.

Please contact Laura Dyrda at ldyrda@beckershealthcare.com with any questions you have about the nomination process.

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