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: _________________________________________

19419 (W0312)

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 copyto your computer, choose File > Save As to rename the file and save the form with your information to your computer.

* To report additional facility/group/practiceNPIs, please photocopy this form. To reportindividual practitioner NPIs, please use theIndividual Practitioner/Physician NPI form.

An independent licensee of the Blue Cross and Blue Shield Association.

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.