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Health Professionals NPI
Use this form if you are submitting NPIs for five or fewer providers.
OR
Request the NPI submission spreadsheet if you are submitting NPIs for six or more providers.

Choices for submitting NPIs
Submit NPIs for five or fewer providers
Request the NPI submission spreadsheet to submit NPIs

All fields marked with a RED asterisk(*) are required in order to proceed.
Contact information
- - (please leave today's date in this field)
*
*
*  (example@sample.com)
*  (example@sample.com)
* Phone number: - -  (000-123-4567)
NPI Information
Please select the number of NPIs and enter the required information for each below.

Number of provider NPIs being submitted *
1 2 3 4 5
Provider 1
* Individual (Entity Type 1) Organization (Entity Type 2)
* Tax ID format code:
* Tax ID number: (please do not use hyphens, i.e. 123456789)
* Social Security Number: - -  (000-12-3456)
* Degree:
* Primary specialty:

Provider 1 name (individual / organization)
* First name:
Middle Initial:
* Last name/organization name:

Provider 1 primary service location information
* Address line 1:
* City:
* State:
* Zip code:
Billing address same as service address:

Provider 1 primary billing location information
* Address line 1:
* City:
* State:
* Zip code:

Provider 1 NPI information
* NPI: (first number cannot be a zero.)

Provider 1 NPI usage
(How you are using this NPI)
1. Does this NPI apply to all providers using this Tax ID? *
2. Does this NPI apply to all Tax IDs for this provider only? *
3. Does this NPI apply to all Service Locations and Billing Addresses for this Tax ID? *
4. Does this NPI apply to all Service Locations and Billing Addresses for this provider only? *
 

Provider 2
* Individual (Entity Type 1) Organization (Entity Type 2)
* Tax ID format code:
* Tax ID number: (please do not use hyphens, i.e. 123456789)
* Social Security Number: - -  (000-12-3456)
* Degree:
* Primary specialty:

Provider 2 name (individual / organization)
* First name:
Middle initial:
* Last name/organization name:

Provider 2 primary service location information
* Address line 1:
* City:
* State:
* Zip code:
Billing address same as service address:

Provider 2 primary billing location information
* Address line 1:
* City:
* State:
* Zip code:

Provider 2 NPI information
* NPI: (first number cannot be a zero.)

Provider 2 NPI usage
(How you are using this NPI)
1. Does this NPI apply to all providers using this Tax ID? *
2. Does this NPI apply to all Tax IDs for this provider only? *
3. Does this NPI apply to all Service Locations and Billing Addresses for this Tax ID? *
4. Does this NPI apply to all Service Locations and Billing Addresses for this provider only? *
 

Provider 3
* Individual (Entity Type 1) Organization (Entity Type 2)
* Tax ID format code:
* Tax ID number: (please do not use hyphens, i.e. 123456789)
* Social Security Number: - -  (000-12-3456)
* Degree:
* Primary specialty:

Provider 3 name (individual / organization)
* First name:
Middle initial:
* Last name/organization name:

Provider 3 primary service location information
* Address line 1:
* City:
* State:
* Zip code:
Billing address same as service address:

Provider 3 primary billing location information
* Address line 1:
* City:
* State:
* Zip code:

Provider 3 NPI information
* NPI: (first number cannot be a zero.)

Provider 3 NPI usage
(How you are using this NPI)
1. Does this NPI apply to all providers using this Tax ID? *
2. Does this NPI apply to all Tax IDs for this provider only? *
3. Does this NPI apply to all Service Locations and Billing Addresses for this Tax ID? *
4. Does this NPI apply to all Service Locations and Billing Addresses for this provider only? *
 

Provider 4
* Individual (Entity Type 1) Organization (Entity Type 2)
* Tax ID format code:
* Tax ID number: (please do not use hyphens, i.e. 123456789)
* Social Security Number: - -  (000-12-3456)
* Degree:
* Primary specialty:

Provider 4 name (individual / organization)
* First name:
Middle initial:
* Last name/organization name:

Provider 4 primary service location information
* Address line 1:
* City:
* State:
* Zip code:
Billing address same as service address:

Provider 4 primary billing location information
* Address line 1:
* City:
* State:
* Zip code:

Provider 4 NPI information
* NPI: (first number cannot be a zero.)

Provider 4 NPI usage
(How you are using this NPI)
1. Does this NPI apply to all providers using this Tax ID? *
2. Does this NPI apply to all Tax IDs for this provider only? *
3. Does this NPI apply to all Service Locations and Billing Addresses for this Tax ID? *
4. Does this NPI apply to all Service Locations and Billing Addresses for this provider only? *

Provider 5
* Individual (Entity Type 1) Organization (Entity Type 2)
* Tax ID format code:
* Tax ID number: (please do not use hyphens, i.e. 123456789)
* Social Security Number: - -  (000-12-3456)
* Degree:
* Primary specialty:

Provider 5 name (individual / organization)
* First name:
Middle initial:
* Last name/organization name:

Provider 5 primary service location information
* Address line 1:
* City:
* State:
* Zip code:
Billing address same as service address:

Provider 5 primary billing location information
* Address line 1:
* City:
* State:
* Zip code:

Provider 5 NPI information
* NPI: (first number cannot be a zero.)

Provider 5 NPI usage
(How you are using this NPI)
1. Does this NPI apply to all providers using this Tax ID? *
2. Does this NPI apply to all Tax IDs for this provider only? *
3. Does this NPI apply to all Service Locations and Billing Addresses for this Tax ID? *
4. Does this NPI apply to all Service Locations and Billing Addresses for this provider only? *
 



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