National Provider Identifier (Npi) Registration Page 2
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2SFN 43 (7-2006)
Page 2 of 2
Instructions for completing National Provider Identification (NPI) Registration:
These instructions will assist in completing the National Provider Identification (NPI) Registration form (SFN 43). The
information provided will be used to update legacy billing provider/clinic numbers and facility information for electronic and
paper transactions. All sections must be filled out. Print legibly and complete every section as accurately as possible.
PROVIDER INFORMATION
1. Fill in all of the blanks with the requested information for the provider/facility.
NPI INFORMATION
1.
NPI Number - Fill in the blank with the assigned 10-digit NPI number. If additional NPI numbers need to be submitted
please complete on a separate application.
2.
Medicaid Number - Fill in the blank with the North Dakota Medicaid Number. If additional space is needed please
complete on a separate application.
3.
Code - Fill in the blank with the Taxonomy Code associated with the NPI Number.
4.
Taxonomy Start/End Date - Fill in the blank with the Taxonomy Code Start/End date.
CONTACT INFORMATION
6. Fill in all of the blanks with the requested information for the contact person.
ORIGINAL SIGNATURE
7.
The signature section needs to be filled out completely and signed by the provider's authorized signer. If the
provider's signature is not available, a signature of someone from the facility holding a management position or higher
will be accepted.
The completed form with the appropriate signature can be mailed to the following address. Or, if you prefer,
it can be emailed to the following address.
Mailing Address:
North Dakota Department of Human Services
Medical Services/NPI Help Desk
600 East Boulevard Avenue - Dept. 325
Bismarck, ND 58505
E-mail Address:
dhsnpihelpdesk@nd.gov
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