Npi Provider Data Fax Form Unitedn Healthcare
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1
2
3Please use this to update your NPI information.
Please ensure that ALL pertinent information is completed as
we will be unable to process incomplete forms. Complete all
information pertaining to your practice.
NPI Provider Data Fax Form
All States Fax To: 1-866-455-4068 or 1-414-721-9006
Section I
Group Demographics
Practice/Organization Name___________________________________________ Current Tax ID (TIN) _______________________
National Provider Identifier _____________________
Date issued
____/____/_____
*Please list your NUCC Taxonomy Code(s) 1) ___________ 2) ___________ 3) ___________4) __________, 5) ___________
Basis for NPI (applies to organizations only, circle or highlight only 1 per NPI): Provider Name, Tax ID only (entity whose name is in the
W-9 form), License Number, NUCC Taxonomy Code, Place of Service Address, Department, Other (please explain)
Please check here if you have multiple NPIs representing your Practice or Organization. Refer to Section II of this fax form.
Name of individual completing this form___________________________ Telephone (
)_________(ext)_______Email____________
Section II
National Provider Identification- Requested Information
For organization providers we would like to capture the “basis” or reason for each NPI, if the organization has
more than one or has sub-parts who will have NPIs. Please use the grid below as a reference when filling in the
“Basis for NPI” and Level Information columns in the data collection grid further below.
If the Basis for your NPI is:
Then supply this information into
Instructional Information
the Level Information column
C = Entity whose name is on the W-9
Tax ID and Name Filed on W-9
If the organization or sub-part was
enumerated strictly on the basis of the name
associated with the Tax ID on the W-9 form,
then use a “C” in the “Basis for NPI” column.
(You will need to indicate whether the Tax
ID is a social security number or if it is an
employer identification number.) Place the
Tax ID in the “Level Information” column.
If the organization or sub-part was
D = Department
Department Name
enumerated on the basis of a particular
department, provide the Department Name
that the NPI was based on, and designate
this with a “D” in the “Basis for NPI” column.
Insert the Department Name in the “Level
Info
If the organization or sub-part was
L = License
License Number and State or (state
enumerated by License, provide the State or
code)
(State Code) and License Number that the
NPI was based on, and designate this with
an “L” in the “Basis for NPI” column. Insert
the License Number and State or State
Code) in “Level Information” column.
P = Place of Service Address
Place of Service Address (Street,
If the organization was enumerated by place
of service address level, provide the street
City, State, Zip +4)
address that the NPI was based on and
designate this with a “P” in the “Basis for
NPI” column. Insert the Place of Service
address in the “Level Information” column.
T= Tax ID number and provider name
Tax ID and Provider Name, where
If the organization or sub-part was
enumerated by Tax ID Level and Provider
provider is not the name on the W-
Name, where the provider is not the name
9, but bills using this TIN
listed on the W-9, but uses this TIN, then
Pg. 1
7/24/2008
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