Reset Form
National Provider Identifier (NPI) Collection Form
You may complete the required fields below online and then save or print a copy for submission. To save a
completed copy to your computer, choose File > Save As to rename the file and save the form with your information
to your computer.
You may complete the required fields below online and then save or print a copy for submission. To save a completed copy
to your computer, choose File > Save As to rename the file and save the form with your information to your computer.
Facility/Group/Practice
Please complete the following information regarding your organization’s National Provider Identifier(s).*
Use of the NPI is required for most electronic HIPAA-compliant transactions beginning May 23, 2008.
Please print or type. Fax completed forms and CMS NPI Notifications to 1-973-274-4416.
Organization Name: _________________________________________________________________________
Organization NPI 1: _________________________________________________________________________
Address 1: ________________________________________________________________________________
City: __________________________________________________ State: ________ ZIP: __________________
TIN 1: __________________________________ Suffix 1 (if applicable): ________________________________
Medicare Number/UPIN: _____________________ Specialty: ________________________________________
Organization NPI 2*: _________________________________________________________________________
Address 2: ________________________________________________________________________________
City: __________________________________________________ State: ________ ZIP: __________________
TIN 2: __________________________________ Suffix 2 (if applicable): ________________________________
Medicare Number/UPIN: _____________________ Specialty: ________________________________________
Taxonomy Codes: __________________________ ________________________ _______________________
Type
(check one)
Hospital
Ambulatory Surgery Center
Physician/Professional Organization
Other (please explain): _______________________________________________________
This section must be completed for verification purposes.
Contact Name: _____________________________________________________________________________
Telephone Number: _______ – _______ – _____________
E-mail: _________________________________________
An independent licensee of the Blue Cross and Blue Shield Association.
19419 (W0312)
* To report additional facility/group/practice
NPIs, please photocopy this form. To report
individual practitioner NPIs, please use the
Individual Practitioner/Physician NPI form.