National Provider Identifier (Npi) Registration Form (Page 2 of 2) in pdf

National Provider Identifier (Npi) Registration Form Page 2

Louisiana Medicaid

National Provider Identifier (NPI) Registration Form

Registration Type:

New

Updated

Provider /Organization Name:

Contact Information (please print)

First and Last

Name:

Title:

Email Address:

(If Available)

Phone Number with

Ext:

Area Code:

Please complete the section below with your specific information:

Louisiana Medicaid Provider #

NPI Number

If the one to many option is applicable, please complete the section below with your specific information:

LA Medicaid ID

NPI Number

Taxonomy OR Zip Code + 4

Once you have completed all the appropriate entry(s), please fax the signed form to (225) 216-6495 or mail it to: Unisys

NPI, PO Box 80159, Baton Rouge, LA, 70898-0159. Confirmations will not be sent, but you will be contacted if there are

any questions or issues.

Your signature below authorizes Unisys to update the above information as part of your NPI registration information and

also signifies that you have authorization to update this information on behalf of the provider indicated above.

___________________________________________

______________

Signature

Date

___________________________________________

Printed Name and Title

Rev: 2/08

UNINPIREG

National Provider Identifier (Npi) Registration Form Page 2