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Use of the NPI is required for most electronic HIPAA-compliant transactions beginning May 23 2008. Please print or type. 19418 W0312 DD YYYY To report a facility/group/practice NPI please use the Facility/Group/Practice NPI Form.. Individual Practitioner/Physician Please complete the following information regarding your individual National Provider Identifier. Fax completed forms and CMS NPI Notifications to 1-973-274-4416. Name Last First MI This NPI corresponds with TIN Suffix if...

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