Practitioner Data Sheet - Blue Cross Blue Shield Of Washington
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1Premera Blue Cross
P.O. Box 327, MS 453
Seattle, WA 98111-0327
Practitioner Data Sheet
The following information is required for OIC and internal reporting.
Practitioner Name: _______________________________________________________,____________
(Last Name)
(First Name)
(MI )
(Credential based on licensure)
Social Security #: _____________________ DOB: ______________
Male
Female
State License #: ______________________________ State:_________
Additional State License #: __________________________ State:_________
DSHS #: _________
UPIN #:_____________ DEA #:______________ Medicare #: __________
(if applicable)
Individual NPI #: ________________________________
Foreign Languages Spoken: ____________________________________________________________
Specialty(s):
1)_____________________________________ Board Status:
N/A
Board Certified
Board Eligible
(Primary Specialty)
(check one. If other, please explain)
2)_____________________________________ Board Status:
N/A
Board Certified
Board Eligible
(Secondary Specialty)
(check one. If other, please explain)
Clinic/Group Name: _____________________________________________________________________
Group NPI #: ________________________________
Start Date at Clinic/Group: ______________________________
Primary practice address: ________________________________________________________________
(Street Address - City – State – Zip Code)
Services available:
Wheelchair Accessible?
Interpretive Services?
Tax ID#:__________________________ Office Hours:__________________________________
Phone (_____)______________________ Phone - Fax (_____)_______________________
Pay to Address: __________________________________________________________________________
Mailing Address:
__________________________________________________________
(ie., correspondence)
E-mail address (clinic): ____________________ E-mail address (practitioner): _____________________
If more than one practice location, please attach list and provide the same information for each location.
Form completed by:__________________________________________________ Date:______________
014664 (12-2005)
An Independent Licensee of the Blue Cross Blue Shield Association
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