National Provider Identifier (Npi) Registration
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2NATIONAL PROVIDER IDENTIFIER (NPI) REGISTRATION
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NORTH DAKOTA DEPARTMENT OF HUMAN SERVICES
MEDICAL SERVICES DIVISION
SFN 43 (7-2006)
Name
Telephone Number
EIN/TIN/SSN
Billing Address
City
State
Zip Code
Physical Address
City
State
Zip Code
Taxonomy Code
Taxonomy Start Date
Taxonomy End Date
NPI Number
Medicaid Numbers for above NPI
Medicaid Number
Medicaid Number
Medicaid Number
Medicaid Number
Taxonomy Code
Taxonomy Start Date
Taxonomy End Date
NPI Number
Medicaid Numbers for above NPI
Medicaid Number
Medicaid Number
Medicaid Number
Medicaid Number
Contact Person
Telephone Number
Contact E-mail Address
As a member of the organization, I am authorized to sign this document on behalf of the provider/facility. And I authorize the
NPI setup noted above all claim transactions.
Signature
Date
Printed Name
Title
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Parent category: Life