Form Cms-855a - Medicare Enrollment Application - Institutional Providers Page 21

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SECTION 4: PRACTICE LOCATION INFORMATION
(Continued)
A. Practice Location Information
Report all practice locations where services will be furnished. If there is more than one location, copy and
complete this section for each. Please list your primary practice location first.
To ensure that CMS establishes the correct associations between your Medicare legacy number (if issued)
and your NPI, you must list a Medicare legacy number—NPI combination for each practice location. If
you have multiple NPIs associated with both a single legacy number and a single practice location, please
list below all NPIs and associated legacy numbers for that practice location.
If you are changing, adding, or deleting information, check the applicable box, furnish the effective date,
and complete the appropriate fields in this section.
CHECk ONE
CHANGE
ADD
DELETE
DATE
(mm/dd/yyyy)
Practice Location Name (“Doing Business As” name if different from Legal Business Name)
Practice Location Street Address Line 1 (Street Name and Number – NOT a P.O. Box)
Practice Location Street Address Line 2 (Suite, Room, etc.)
City/Town
State
ZIP Code + 4
Telephone Number
Fax Number (if applicable)
E-mail Address (if applicable)
Medicare Identification Number (if issued)
NPI
Medicare Identification Number (if issued)
NPI
Medicare Identification Number (if issued)
NPI
Medicare Identification Number (if issued)
NPI
CLIA Number for this location (if applicable)
FDA/Radiology (Mammography) Certification Number for
this location (if issued)
Hospitals and HHAs only (Identify type of practice location):
HHA Branch
Main/Primary Hospital Location
Hospital Psychiatric Unit
OPT Extension Site
Hospital Rehabilitation Unit
Other Hospital Practice Location:_________________________________
Hospital Swing-Bed Unit
CMS-855A (07/11)
20

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