N.P.I. Submission Form
For verification purposes, please provide the following information:
  • For Facility / Group:
    • Facility / Group Name
    • Primary Address
    • Telephone Number
    • At least one of the following:
      • Permanent Facility Identifier Number
      • Operating Certificate Number
  • For Individual Provider:
    • Practitioner Name
    • Primary Address
    • Telephone Number
    • At least one of the following:
      • License Number
      • Medicaid / MMIS Number
      • Fidelis/CenterCare ID Number
  • Provide the individual / group NPI numbers issued to you.
  • Provide your primary and secondary specialties, as well as the associated taxonomy codes you will use for billing.
  • Click on the "Submit Your Information" button near the bottom when you have completed the form.
Facility/Group Name:
ex. Smith Hospital
P.F.I. #:  
P.F.I.: Permanent Facility Identifier
Op. Cert. #:
Op. Cert.: Operating Certificate
Practitioner Name:  
ex. John Smith
Degree
License #:
Medicaid / MMIS #:  
MMIS: Medicaid Provider Identification Number
Fidelis/CenterCare ID #:  
Primary Address (1):  
ex. 123 Anywhere St.
Primary Address (2):  
ex. Anywhere, NY 12345
Primary Address (3):
ex. Suite 123
Telephone #:
ex. 888-555-1212
Group NPI #:
Billing \ Pay To NPI #
Individual Practitioner NPI #:
Rendering \ Servicing NPI #
Primary Specialty:
Secondary Specialty:
Primary Taxonomy Code:  
Taxonomy code associated with primary specialty.
Secondary Taxonomy Code:  
Taxonomy code associated with secondary specialty.
Taxonomy Code is not required - however, please note that if you have more than one specialty per NPI, then the taxonomy code will be required for billing. Individual providers are assigned only one NPI while larger groups and facilities can get NPI's for their sub-parts.
Email Address:    
E-Signature:  
Please type your full name.
Privacy: Check this box in the case you do not wish to share this information with any other parties.
By clicking on the following "Submit Your Information" button you are verifying and stating that you are the person identified in the E-Signature field above. Further, you attest that the NPI number(s) supplied are correct to the best of your knowledge.
To to view a printer or fax friendly version of this form, please click the appropriate link below.
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