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Print Form NPI Submission Form Individual Practitioner Provider Name: Provider Number: SECTION 1 BASIC INFORMATION A. Reason for Submittal of This Form (Check the appropriate box) Initial Submission
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How to fill out the NPI submission form individual:

01
Start by gathering all the required information, including your personal details such as your full name, address, social security number, and contact information.
02
Identify your taxonomy code, which represents your specific healthcare provider category. This code helps classify your practice or profession.
03
Fill out the sections related to your practice location(s), including the address, phone number, and type of healthcare services provided.
04
Provide information about your practice's billing arrangements, such as whether you bill directly or through a billing service, and any associated payers or insurance plans.
05
Answer the questions regarding your practice's ownership and financial relationships with other healthcare providers or organizations.
06
Review all the information you have entered for accuracy and completeness before submitting the form.

Who needs the NPI submission form individual:

01
Any healthcare providers who perform services independently and are not associated with a larger organization or group practice may need to complete the NPI submission form individual.
02
This includes professionals such as doctors, dentists, psychologists, therapists, and other individual healthcare providers.
03
The NPI submission form individual is required by the Centers for Medicare and Medicaid Services (CMS) for identification and tracking purposes in the healthcare system.
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Taxonomy NPI yy Submittal UPIN SSN wpc edi Suffix Credential Deactivation applicable IRS Prefix Medicare Medicaid MD Practitioner Submission Dissolved Mailing Provider IDENTIFYING Postal

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