NPI Submissions

*Entity type

Individual (entity type 1)

Organization (entity type 2)

*Tax Identification Number (Tax ID) format code

Please select Social Security Number ONLY if you do not have an Employer ID Number.

*Primary specialty

*The billing address and the primary service location's address above are

*Does this NPI apply to all providers using this Tax ID?

Yes

No

*Does this NPI apply to all Tax IDs for this provider only?

Yes

No

*Does this NPI apply to all service locations and billing addresses for this Tax ID?

Yes

No

*Does this NPI apply to all service locations and billing addresses for this provider only?

Yes

No

Contact Information