Form Cms-10114 - National Provider Identifier (Npi) Application/update Form
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DEPARTMENT OF HEALTH AND HUMAN SERVICES
OMB No. 0938-0931
CENTERS FOR MEDICARE & MEDICAID SERVICES
Expires: 03/18
NATIONAL PROVIDER IDENTIFIER (NPI) APPLICATION/UPDATE FORM
Please PRINT or TYPE all information so it is legible. Use only blue or black ink. Do not use pencil. Failure to provide pages 1,
2 and 3 with complete and accurate information may cause your application to be returned and delay processing. In addition,
you may experience problems being recognized by insurers if the records in their systems do not match the information you
have furnished on this form. Information submitted on this application (except for Social Security Number, IRS Individual
Taxpayer Identification Number, and Date of Birth) may be made available on the internet.
SECTION 1: BASIC INFORMATION
A. Reason for Submittal of this Form
(Required) (Only provide one Reason for Submittal and/or NPI per form.
Use additional forms if necessary.)
1.
Initial Application*
3.
Deactivation (See Instructions)
(*Denotes required field for initial application only.)
NPI: (Required)
Change of Information (See instructions)
2.
Reason: (Check only one box) (Required)
NPI: (Required)
Death
Business Dissolved
Other, Specify: (See Instructions)
Only complete the appropriate sections with the
information that is changing. If removing information,
Reactivation (See Instructions)
4.
please indicate within the appropriate field(s) by
NPI: (Required)
writing ‘Remove’.
Reason: (Required)
B. Entity Type
(Check only one box) (Required for initial applications only) (See Instructions)
An individual who renders health care. (Complete Sections 2A, 3, 4A and 5 only)
1.
• Is the individual a sole proprietor? (See Instructions)
Yes
No
2.
An organization that renders health care. (Complete Sections 2B, 3, 4B and 5 only)
• Is the organization a subpart? (See Instructions)
Yes
No
• If yes, enter the Legal Business Name (LBN) and Taxpayer Identification Number (TIN) of the “parent”
organization health care provider:
Parent Organization LBN:
Parent Organization TIN:
SECTION 2: IDENTIFYING INFORMATION
A. Individuals (includes Sole Proprietorships and Incorporated Individuals)
1. Prefix (e.g., Mr., Mrs.)
2. First*
3. Middle
4. Last*
5. Suffix (e.g., Jr., Sr.)
6. Credential (e.g., M.D., D.O.)
Other Name Information (If applicable. Use additional sheets of paper if necessary)
1. Prefix (e.g., Mr., Mrs.)
2. First
3. Middle
4. Last
5. Suffix (e.g., Jr., Sr.)
6. Credential (e.g., M.D., D.O.)
13. Type of Other Name
Former Name
Professional Name
Other
14. Date of Birth* (mm/dd/yyyy)
15. State of Birth* (U.S. only)
16. Country of Birth* (If other than U.S.)
17. Gender*
Male
Female
18. Social Security Number (SSN) (See Instructions)
19. IRS Individual Taxpayer Identification Number (ITIN) (See Instructions)
B. Organizations (includes Groups, Corporations and Partnerships) (Do not report an SSN in the EIN field.)
1. Name* (Legal Business Name)
2. Employer Identification Number* (EIN)
3. Other Name (if applicable see instructions)
4. Type of Other Name
Former Legal Business Name
D/B/A Name
Other
Subpart (See Instructions)
CMS-10114 (10/16)
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