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NATIONAL PROVIDER IDENTIFIER (NPI) SUBMISSION FORM

 

 

What is an NPI number and what is it's use?

The NPI (National Provider Identifier) is a 10-position, intelligence-free, numeric identifier (10-digit number).  These numbers are randomly selected, and are not based on any information pertaining to the healthcare provider, such as the state they live in or their medical specialty.

Effective May 23, 2007, all HIPAA covered entities such as Health Care Professionals, and Health Care Facilities, are required to submit claims with their NPI number.  The intent of the NPI is to eliminate the need for payers and providers to keep numerous identifiers, and in turn simplify transaction processing between these entities.

Click here to apply for your personal NPI:
https://nppes.cms.hhs.gov/NPPES/Welcome.do

Instructions for submitting your NPI:

Each field that is marked with an asterisk (*) is a required field, and needs to be completed by the registrant.

If you have difficulty filling out this form please contact:
Ruth De Jesus - Provider Relations
William C. Earhart Co., Inc.
503.331.8226

[email protected]

We will keep your submitted information confidential and use it only for business purposes.
SECTION 1 - BASIC INFORMATION
Entity Type (Check the appropriate box) * An individual who renders health care.
An organization that renders health care.
NPI Number *          
SECTION 2 - IDENTIFYING INFORMATION

A. Individuals 		     
First Name *        
Middle Name        
Last Name*        
Suffix       (e.g., Jr., Sr.)
Credential *       (e.g., M.D., D.O.)
Tax Identification Number (TIN, EIN or SSN)*

B. Organizations and Groups 		         
Name *          
DBA Name      
Tax Identification Number (TIN or EIN) *          
SECTION 3 - ADDRESSES AND OTHER INFORMATION

A. Registrant Data 		         

Registrant is the person filling out this form.
Registrant Name *      
Registrant Phone Number * - -
Registrant Email Address*

B. Practice Location Information 		         
Address *      
Suite Number      
City *
State *
Zip Code *
Phone * - -
     




 
 

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