a. In addition to other information required by the State Board of Medical Examiners on the biennial license renewal form, a physician or podiatrist, hereinafter referred to as “practitioner,” shall list: the address of all practice locations and the name of any other licensee directly associated with the practice; the name and address of each licensed health care facility and health maintenance organization with which the licensee has an affiliation and the nature of the affiliation; and the name and address of the practitioner’s medical malpractice insurer.

b. A practitioner shall notify the board in writing, within 21 days, of any changes, additions or deletions to the information provided pursuant to subsection a. of this section.

c. In the case of a practitioner who receives his license on or after the effective date of P.L.1989, c.300 (C. 45:9-19.4 et al.), the practitioner shall provide the board with the information required pursuant to subsection a. of this section as soon as practicable, but in no case later than 90 days after the practitioner receives his license from the board.

d. The board shall promptly provide the information obtained pursuant to this section to the Medical Practitioner Review Panel established pursuant to section 8 of P.L.1989, c.300 (C. 45:9-19.8).

L.1989, c.300, s.7.