NATIONAL PROVIDER IDENTIFIER (NPI) APPLICATION/UPDATE FORM

DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES

Form Approved OMB No. 0938-0931 Expires: 08/2024
NATIONAL PROVIDER IDENTIFIER (NPI) APPLICATION/UPDATE FORM
SECTION 1: BASIC INFORMATION
A. Reason for Submittal of this Form (Required) (Only provide one Reason for Submittal and/or NPI per form.
Reason for submittal of this form
NPI If Applicable
Entity Type
SECTION 2: IDENTIFYING INFORMATION
FIRST MIDDLE LAST NAME

First NameLast Name
5 Suffix eg Jr Sr
14 Date of Birth mmddyyyy

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
15 State of Birth US only
18 Social Security Number SSN LAST 4 ONLY
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
B. Business Practice Location Information This address can include a post office box only for Individual Providers that do not have a physical location other than their home address (e.g., a provider that exclusively provides telehealth services
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Penalties for Falsifying Information on the National Provider Identifier (NPI) Application/Update Form

18 U.S.C. 1001 authorizes criminal penalties against an individual who in any matter within the jurisdiction of any department or agency of the United States knowingly and willfully falsifies, conceals or covers up by any trick, scheme or device a material fact, or makes any false, fictitious or fraudulent statements or representations, or makes any false writing or document knowing the same to contain any false, fictitious or fraudulent statement or entry. Individual offenders are subject to fines of up to $250,000 and imprisonment for up to 5 years. Offenders that are organizations are subject to fines of up to $500,000. 18 U.S.C. 3571(d) also authorizes fines of up to twice the gross gain derived by the offender if it is greater than the amount specifically authorized by the sentencing statute.

SECTION 4: CERTIFICATION STATEMENT (See Instructions)

I, the undersigned, certify to the following: This form is being completed by, or on behalf of, a health care provider as defined at 45 CFR 160.103. I have read the contents of the application and the information contained herein is true, correct and complete. If I become aware that any information in this application is not true, correct, or complete, I agree to notify the NPI Enumerator of this fact immediately. I authorize the NPI Enumerator to verify the information contained herein. I agree to notify the NPI Enumerator of any changes in this form within 30 days of the effective date of the change. I have read and understand the Penalties for Falsifying Information on the NPI Application/Update Form as printed in this application. I am aware that falsifying information will result in fines and/or imprisonment. I have read and understand the Privacy Act Statement. **All signatures must be original and signed in ink. Applications with signatures deemed not original will not be processed. Stamped, faxed or copied signatures will not be accepted.**

A. Individual Practitioner's Signature (Required for Type 1 Individuals ONLY
1 Practitioners Signature Required for Type 1 Individuals ONLY First Middle Last Jr Sr MD DO etc
2 Date mmddyyyy

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
For the most efficient and fast receipt of your NPI, please use the web-based NPI process at the following address: https://nppes.cms.hhs.gov. NPI web is a quick and easy way for you to get your NPI. Or send the completed signed application to:

NPI Enumerator 7125 Ambassador Rd. Ste 100 Windsor Mill, MD 21244
Should be Empty:

NATIONAL PROVIDER IDENTIFIER (NPI) APPLICATION/UPDATE FORM

SECTION 1: BASIC INFORMATION

SECTION 2: IDENTIFYING INFORMATION