Npi Submission Form - Individual Practitioner
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NPI Submission Form – Individual Practitioner
Provider Name: _________________________
Provider Number: _________________
SECTION 1 – BASIC INFORMATION
A. Reason for Submittal of This Form (Check the appropriate box)
1.
Initial Submission
3. Deactivation of NPI No. ____________________
2.
Change of Information (See instructions)
REASON (check one of the following)
NPI No. ___________________________
Death
Business Dissolved
Other _____________
SECTION 2 – IDENTIFYING INFORMATION
1. Prefix
2. First
3. Middle
4. Last
(e.g., Major, Mrs.)
5. Suffix
6. Credential
(e.g., Jr., Sr.)
(e.g., MD, DO)
7. Date of Birth (mm/dd/yy)
8. State (U.S. only)
9. Country (if other than US)
10. Social Security Number (SSN)
11. IRS Individual Tax Identification No.
12. NPI #
SECTION 3 – ADDRESS AND OTHER INFORMATION
1. Mailing Address Line 1
(Street Number and Name or P.O. Box)
2. Mailing Address Line 2
(Address Information; e.g., Suite Number)
3. City
4. State
5. Zip + 4 or Foreign Postal Code
6. Country Name
7. Telephone Number
(if outside US)
(Include Area Code & Extension)
8. Fax Number
9. Email
(Include Area Code)
B. Other Provider Identification Numbers
Number Type
Number
State (if applicable)
Update
UPIN/Medicare
___________________
_________________
______________________
Medicaid
___________________
_________________
______________________
Other ______________
___________________
_________________
______________________
Other ______________
___________________
_________________
______________________
C. Provider Taxonomy Code (
and License Number Information
Provider Type/Specialty. Enter one or more codes)
Information on provider taxonomy codes is available at
1. Primary Provider Taxonomy Code or describe your specialty or provider type (e.g., psychologist, social worker)
2. License Number:
3. State where issued:
4. Provider Taxonomy Code or describe your specialty or provider type (e.g., psychologist, social worker)
5. License Number:
6. State where issued:
7. Provider Taxonomy Code or describe your specialty or provider type (e.g., psychologist, social worker)
8. License Number:
9. State where issued:
SECTION 4 – INDIVIDUAL PRACTITIONER’S SIGNATURE
1. Signature
2. Date
)
(First, Middle, Last, Jr., Sr., MD, DO, etc.)
(mm/dd/yy
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Parent category: Medical