CMS-10114 (updated National Provider Identifier (NPI) Application/Update Fo

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

Form Approved
OMB No. 0938-0931

NATIONAL PROVIDER IDENTIFIER (NPI) APPLICATION/UPDATE FORM
Please PRINT or TYPE all information so it is legible. Use only blue or black ink. Do not use pencil. Failure to provide complete and accurate information may cause your application to be returned and delay processing of your application. In addition, you may experience problems being recognized
by insurers if the records in their systems do not match the information you have furnished on this form. Information submitted on this application
(except for Social Security Number, IRS Individual Taxpayer Identification Number, and Date of Birth) may be made available on the internet.

SECTION 1 – BASIC INFORMATION
A. Reason For Submittal Of This Form

(Check the appropriate box)

1. o Initial Application
2. o Change of Information (See instructions)
NPI: ___________________________________
o Add Information
o Replace Information

3. o Deactivation (See Instructions)
NPI: ________________________________________
Reason (Check one of the following)
o Death o Business Dissolved
o Other, Specify: (See Instructions) __________________

4. o Reactivation (See Instructions)
NPI: ________________________________________
Reason: ____________________________________

B. Entity Type

(Check only one box)

1. o An individual who renders health care. (Complete Sections 2A, 3, 4A and 5 only)
• Is the individual a sole proprietor? (See Instructions) o Yes o No
2. o An organization that renders health care. (Complete Sections 2B, 3, 4B and 5 only)
o Yes
o No
• Is the organization a subpart? (See Instructions)
If
yes,
enter
the
Legal
Business
Name
(LBN)
and
Taxpayer
Identification
Number (TIN) of the “parent”
•
organization health care provider:
Parent Organization LBN:
Parent Organization TIN:

SECTION 2 – IDENTIFYING INFORMATION
A. Individuals
1. Prefix

(e.g.,Major, Mrs.)

5. Suffix

(e.g., Jr., Sr.)

2. First

3. Middle

4. Last

6. Credential

(e.g., M.D., D.O.)

Other Name Information (If applicable. Use additional sheets of paper if necessary)
7. Prefix
11. Suffix

8. First

(e.g.,Major, Mrs.)

9. Middle
12. Credential

(e.g., Jr., Sr.)

13. Type of other Name

o Former Name

o Professional Name

14. Date of Birth (mm/dd/yyyy)
17. Gender

o Male

10. Last

o Other, specify:

15. State of Birth

(e.g., M.D., D.O.)

_______________________________________________________

(U.S. only)

16. Country of Birth (If other than U.S.)

o Female

18. Social Security Number (SSN)

19. IRS Individual Taxpayer Identification Number (ITIN) (See Instructions)

B. Organizations (includes Groups)
1. Name

(Legal Business Name)

3. Other Name

(Use additional sheets of paper if necessary)

4. Type of Other Name

o Former Legal Business Name o D/B/A Name

Form CMS-10114

2. Employer Identification Number (EIN)

o Other

(Describe)

______________________________________
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SECTION 3 – BUSINESS ADDRESSES AND OTHER INFORMATION
A. Business Mailing Address Information
1. Business Mailing Address Line 1

(Street Number and Name or P.O. Box)

2. Business Mailing Address Line 2

(Address Information; e.g., Suite Number)

3. Business City
6. Business Country Name

4. Business State

5. ZIP+4 or Foreign Postal Code

8. Business Fax Number

(Include Area Code)

(if outside U.S.)

7. Business Telephone Number

(Include Area Code & Extension)

B. Business Practice Location Information
1. Business Primary Practice Location Address Line 1 (Street Number and Name – P.O. Boxes Not Acceptable)
2. Business Primary Practice Location Address Line 2 (Address Information; e.g., Suite Number)
3. Business City
6. Business Country Name

4. Business State

5. ZIP+4 or Foreign Postal Code

8. Business Fax Number

(Include Area Code)

(if outside U.S.)

7. Business Telephone Number

(Include Area Code & Extension) (Required)

C. Other Provider Identification Numbers (Use additional sheets of paper if necessary) Do not include SSN or ITIN in this section.
Issuer
Medicare UPIN
Medicare OSCAR/Certification
Medicare PIN
Medicare NSC
Medicaid
Other, Specify:

Issuer For Other Number Type Only)

Number

State (If applicable)

_____________________
_____________________
_____________________
_____________________
_____________________

_____________________
_____________________
_____________________
_____________________
_____________________

___________________
___________________

___________________
___________________

(State is required if Medicaid number is furnished.)

D. Provider Taxonomy Code

(Provider Type/Specialty. Enter one or more codes) and

___________________
___________________

License Number Information

Information on provider taxonomy codes is available at www.wpc-edi.com/taxonomy. Please see instructions if you plan
to submit more than one taxonomy code for a Type 2 (organization) entity.
1. Primary Provider Taxonomy Code or describe your specialty or provider type (e.g., chiropractor, pediatric hospital)
2. License Number (See Instructions)

3. State where issued

4. Provider Taxonomy Code or describe your specialty or provider type (e.g., chiropractor, pediatric hospital)
5. License Number (See Instructions)

6. State where issued

7. Provider Taxonomy Code or describe your specialty or provider type

(e.g., chiropractor, pediatric hospital)

8. License Number (See Instructions)

9. State where issued

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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
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.

A. Individual Practitioner’s Signature
1. Applicant’s Signature (First, Middle, Last, Jr., Sr., M.D., D.O., etc.)

2. Date (mm/dd/yyyy)

B. Authorized Official’s Information and Signature for the Organization
1. Prefix

(e.g.,Major, Mrs.)

2. First

3. Middle
6. Credential

5. Suffix (e.g., Jr., Sr.)

4. Last
(e.g., M.D., D.O.)

7. Title/Position

8. Telephone Number

9. Authorized Official’s Signature

(Area Code & Extension)

10. Date (mm/dd/yyyy)

(First, Middle, Last, Jr., Sr., M.D., D.O., etc.)

SECTION 5 – CONTACT PERSON
A. Contact Person's Information
o Check here if you are the same person identified in 2A or 4B.
If you checked the box, complete only items 8 and 9 in this section (Section 5).
1. Prefix

(e.g.,Major, Mrs.)

5. Suffix

(e.g., Jr., Sr.)

7. Title/Position

2. First

3. Middle
6. Credential
8. E-Mail Address

4. Last
(e.g., M.D., D.O.)

9. Telephone Number

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
P.O. Box 6059
Fargo, ND 58108-6059
According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control number. The valid OMB control number for this
information collection is 0938-0931. The time required to complete this information collection is estimated to average 20 minutes per response for new applications and 10 minutes for changes, including the
time to review instructions, search existing data resources, gather the data needed, and complete and review the information collection. If you have any comments concerning the accuracy of the time estimate
or suggestions for improving this form, please write to: CMS, Attn: Reports Clearance Officer, 7500 Security Boulevard, Baltimore, Maryland 21244-1850. Do not send the applications to this address.

Form CMS-10114

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PRIVACY ACT STATEMENT
Section 1173 of the Social Security Act authorizes the adoption of a standard unique health identifier for all health care providers
who conduct electronically any standard transaction adopted under 45 CFR 162. The purpose of collecting this information is to
assign a standard unique health identifier, the National Provider Identifier (NPI), to each health care provider for use on standard
transactions. The NPI will simplify the administrative processing of certain health information. Further, it will improve the efficiency
and effectiveness of standard transactions in the Medicare and Medicaid programs and other Federal health programs and private
health programs. The information collected will be entered into a new system of records called the National Provider System (NPS),
HHS/HCFA/OIS No. 09-70-0008. Institutional providers’ data are protected by section 1106 of the Social Security Act and the
Freedom of Information Act, while individually identifiable providers’ data are protected by the Privacy Act of 1974.
Failure to provide complete and accurate information may cause the application to be returned and delay processing. In addition, you
may experience problems being recognized by insurers if the records in their systems do not match the information you furnished on
the form. (See the instructions for completing the NPI application/update form to find the information that is voluntary or mandatory.)
Information may be disclosed under specific circumstances to:
1. The entity that contracts with HHS to perform the enumeration functions, and its agents, and the NPS for the purpose of
uniquely identifying and assigning NPIs to providers.
2. Entities implementing or maintaining systems and data files necessary for compliance with standards promulgated to comply
with title XI, part C, of the Social Security Act.
3. A congressional office, from the record of an individual, in response to an inquiry from the congressional office made at the
request of that individual.
4. Another Federal agency for use in processing research and statistical data directly related to the administration of its programs.
5. The Department of Justice, to a court or other tribunal, or to another party before such tribunal, when
(a) HHS, or any component thereof, or
(b) Any HHS employee in his or her official capacity; or
(c) Any HHS employee in his or her individual capacity, where the Department of Justice (or HHS, where it is authorized to
do so) has agreed to represent the employee; or
(d) The United States or any agency thereof where HHS determines that the litigation is likely to affect HHS or any of
its components
is party to litigation or has an interest in such litigation, and HHS determines that the use of such records by the Department of
Justice, the tribunal, or the other party is relevant and necessary to the litigation and would help in the effective representation
of the governmental party or interest, provided, however, that in each case HHS determines that such disclosure is compatible
with the purpose for which the records were collected.
6. An individual or organization for a research, demonstration, evaluation, or epidemiological project related to the prevention of
disease or disability, the restoration or maintenance of health, or for the purposes of determining, evaluating and/or assessing
cost, effectiveness, and/or the quality of health care services provided.
7. An Agency contractor for the purpose of collating, analyzing, aggregating or otherwise refining or processing records in this
system, or for developing, modifying and/or manipulating automated data processing (ADP) software. Data would also be disclosed to contractors incidental to consultation, programming, operation, user assistance, or maintenance for ADP or telecommunications systems containing or supporting records in the system.
8. An agency of a State Government, or established by State law, for purposes of determining, evaluating and/or assessing cost,
effectiveness, and/or quality of health care services provided in the State.
9. Another Federal or State agency
(a) As necessary to enable such agency to fulfill a requirement of a Federal statute or regulation, or a State statute or regulation
that implements a program funded in whole or in part with Federal funds.
(b) For the purpose of identifying health care providers for debt collection under the provisions of the Debt Collection
Information Act of 1996 and the Balanced Budget Act.

Form CMS-10114

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INSTRUCTIONS FOR COMPLETING THE NATIONAL PROVIDER IDENTIFIER (NPI) APPLICATION/UPDATE FORM
Please PRINT or TYPE all information so it is legible. Use only blue or black ink. Do not use pencil. Failure to provide complete and accurate information
may cause your application to be returned and delay processing of your application. In addition, you may experience problems being recognized by insurers
if the records in their systems do not match the information you have furnished on this form. Please note: Social Security Number (SSN) or IRS
Individual Taxpayer Identification Number (ITIN) information should only be listed in block 18 or block 19 of this form. DO NOT report SSN or
ITIN information in any other section of this application form.
This application is to be completed by, or on behalf of, a health care provider or a subpart seeking to obtain an NPI. (See 45 CFR 162.408 and 162.410 (a) (1).
SECTION 1 – BASIC INFORMATION
This section is to identify the reason for submittal of this form and the type of entity seeking to obtain an NPI.
A. Reason for Submittal of this Form
This section identifies the reason the health care provider is submitting this form. (Required)
1. Initial Application
If applying for a NPI for the first time check box #1, and complete appropriate sections as indicated in Section 1B for
your entity type.
2. Change of Information
If changing information, check box #2, write your NPI in the space provided, and provide the add/replace information within the appropriate section.
If you are adding information, please check the ‘Add Information’ box and fill out the appropriate section(s) with the information you are adding. If
you are replacing information, please check the ‘Replace Information’ box and fill out the appropriate section(s) with the replaced information. See
the instructions in Section 4, then sign and date the certification statement in Section 4A or 4B. All changes must be reported to the NPI Enumerator
within 30 days of the change. It is not necessary to complete sections that are not being changed; however, please ensure that your NPI is legible and
correct. Complete Section 5 so that we may contact you in the event of problems processing this form.
3. Deactivation
If you are deactivating the NPI, check box #3. Record the NPI you want to deactivate, indicate the reason for deactivation, and complete Section 2.
Sign and date the certification statement in Section 4A or 4B, as appropriate. See instructions for Section 4. Use additional sheets of paper if necessary.
4. Reactivation
If you are reactivating the NPI, check box #4. Record the NPI you want to reactivate, provide the reason for reactivation, and complete Section 2.
Sign and date the certification statement in Section 4A or 4B, as appropriate. See instructions for Section 4. Use additional sheets of paper if necessary.
B. Entity Type
Check only one box (Required for initial applications)
Entity Type 1: Individuals who render health care or furnish health care to patients; e.g., physicians, dentists, nurses, chiropractors, pharmacists,
physical therapists. Note that incorporated individuals may obtain NPIs for themselves if they are health care providers and may obtain NPIs for their
corporations (EntityType 2 Organizations). A sole proprietor is an Entity Type 1. (A sole proprietorship is a form of business in which one person owns
all the assets of the business and is solely liable for all the debts of the business in an individual capacity. Therefore, sole proprietorships are not
organization health care providers.) Note that sole proprietors may obtain only one NPI. Sole proprietors must report their SSNs (not EINs even if they
have EINs).
Entity Type 2: Organizations that render health care or furnish health care supplies to patients; e.g., hospitals, home health agencies, ambulance
companies, group practices, health maintenance organizations, durable medical equipment suppliers, pharmacies. If the organization is a subpart, check
yes and furnish the Legal Business Name (LBN) and Taxpayer Identification Number (TIN) of the “parent” organization health care provider. (A
subpart is a component of an organization health care provider. A subpart may be a different location or may furnish a different type of health care than
the organization health care provider.For ease of reference, we refer to that organization health care provider as the “parent”.)
SECTION 2 – IDENTIFYING INFORMATION
A. Individual
NOTE: An individual may obtain only one NPI, regardless of the number of taxonomies (specialties), licenses, or business practice
locations he/she may possess. SSN or ITIN information should only be listed in block 18 or block 19 of this form. DO NOT report
SSN and ITIN information in any other section of this application form.
A sole proprietor is an individual.
Name Information
1–6. Provide your full legal name. (Required first and last name) Do not use initials or abbreviations. If you furnish your social security number in
block 18, this name must match the name on file with the Social Security Administration (SSA). In addition, the date of birth must match that on
file with SSA. You may include multiple credentials. Use additional sheets of paper for multiple credentials if necessary.
Other name information (Use additional sheets of paper if necessary)
7-12. If you have used another name, including a maiden name, supply that “Other Name” in this area. (Optional) You may include multiple credentials.
Use additional sheets of paper for multiple credentials if necessary.
13. Mark the check box to indicate the type of “Other Name” you used. (Required if 7-12 are completed)
14-16. Provide the date (Required), State (Required), and country (Required, if other than U.S.) of your birth. Do not use abbreviations other than
United States (U.S.).
17. Indicate your gender. (Required)
18. Furnish your Social Security Number (SSN) for purposes of unique identification. (Optional) If you furnish your SSN, this name must match the
name and date of birth on file with the Social Security Administration (SSA). If you do not furnish your SSN, processing of your application may
be delayed because of the difficulty of verifying your identity via other means; you may also have difficulty establishing your proper identity
with insurers from which you receive payments. If you are not eligible for an SSN, see item #19. If you do not furnish your SSN, you must
furnish 2 proofs of identity with this application form: passport, birth certificate, a photocopy of your driver’s license, State issued
identification, or information requested in item #19.
19. If you do not qualify for an SSN, furnish your IRS Individual Taxpayer Identification Number (ITIN) along with a photocopy of your driver’s
license, State issued ID, birth certificate or passport. You may not use an ITIN if you have an SSN. Do not enter an Employer Identification
Number (EIN) in the ITIN field. Note: Your passport, birth certificate, photocopy of the driver’s license or State issued identification
must accompany your ITIN. If you do not furnish the information requested in blocks 18 or 19, you must furnish 2 proofs of identity
with this application form: passport, birth certificate, a photocopy of your driver’s license or State issued identification. Examples of
individuals who need ITINs include:
• Non-resident alien filing a U.S. tax return and not eligible for an SSN;
• U.S. resident alien (based on days present in the United States) filing a U.S. tax return and not eligible for an SSN;
• Dependent or spouse of a U.S. citizen/resident alien; and
• Dependent or spouse of a non-resident alien visa holder.
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B. Organizations and Groups
1-2. Provide your organization’s or group’s name (legal business name used to file tax returns with the IRS) and Employer Identification Number
(assigned by the IRS) (Required)
3. If your organization or group uses or previously used another name, supply that “Other Name” in this area. (Optional) Use additional sheets of paper
if necessary.
4. Mark the check box to indicate the type of “Other Name” used by your organization. (D/B/A Name=Doing Business As Name.) (Required if 3 is completed.)
SECTION 3 – ADDRESSES AND OTHER INFORMATION
A. Business Mailing Address Information (Required)
This information will assist us in contacting you with any questions we may have regarding your application for an NPI or with other information regarding
NPI. You must provide an address and telephone number where we can contact you directly to resolve any issues that may arise during our review of your
application.
B. Business Practice Location Information (Required)
Provide information on the address of your primary practice location. If you have more than one practice location, select one as the “primary” location.
Do not furnish information about additional locations on additional sheets of paper.
C. Other Provider Identification Numbers (Situational, Required if known)
Please list the provider identification number(s) you currently use. This would include Medicare-issued numbers (UPIN, NSC, OSCAR, and PIN
numbers), Medicaid-issued number (the name of the State is required if Medicaid Number is furnished), and numbers issued by other health plans or
organizations, such as the DEA number (give a brief description of issuer). If you do not have such numbers, you are not required to obtain them in order
to be assigned an NPI. Organizations should only furnish other provider identification numbers that belong to the organization; do not list identification
numbers that belong to health care providers who are individuals who work for the Organizations. NOTE: Information provided may be disclosed under specific
circumstances (See PrivacyStatement on Page 4). DO NOT report SSN or ITIN information in this section of the application form.
D. Provider Taxonomy Code (Provider Type/Specialty) (Required)
Provide your 10-digit taxonomy code. You must select a primary taxonomy code in order to facilitate aggregate reporting of providers byclassification/specialization. If you
need additional taxonomy codes to describe your type/classification/specialization, you may select additional codes. Information on taxonomy codes is available at
www.wpc-edi.com/taxonomy.
Furnish the provider’s health care license, registration, or certificate number(s) (if applicable). If issued by a State, show the State that issued the license/certificate. The
following individual practitioners are required to submit a license number (If you are one of the following and do not have a license or certificate, you must enclose a letter to
the Enumerator explaining why not):
Certified Registered Nurse
Anesthetist
Chiropractor
Clinical Nurse Specialist

Clinical Psychologist
Dentist
Licensed Nurse
Nurse Practitioner

Optometrist
Pharmacist
Physician/Osteopath

Podiatrist
Registered Nurse

You may use the same license, registration, or certification number for multiple taxonomies; e.g., if you are a physician with several different specialties.
NOTE: A health care provider that is an organization, such as a hospital, may obtain an NPI for itself and for any subparts that it determines need to be assigned NPIs. In
some cases, the subparts have Provider Taxonomy Codes that may be different from that of the hospital and of each other, and each subpart may require separate licensing by
the State (e.g., General Acute Care Hospital and Psychiatric Unit). If the organization provider chooses to include these multiple Provider Taxonomy Codes in a request for a
single NPI, and later determines that the subparts should have been assigned their own NPIs with their associated Provider Taxonomy Codes, the organization provider must
delete from its NPPES record any Provider Taxonomy Codes that belong to the subparts who will be obtaining their own NPIs. The organization provider must do this by
initiating the Change of Information option on this form.
SECTION 4 – CERTIFICATION STATEMENT (Required)
This section is intended for the applicant to attest that he/she is aware of the requirements that must be met and maintained in order to obtain and retain an NPI. This section also
requires the signature and date of signature of the “Individual” who is the type 1 provider, or the “Authorized Official” of the type 2 organization who can legally bind the provider
to the laws and regulations relating to the NPI. See below to determine who within the provider qualifies as an Authorized Official. Review these requirements carefully.
Authorized Official’s Information and Signature for the Organization
By his/her signature, the authorized official binds the provider/supplier to all of the requirements listed in the Certification Statement and acknowledges that the
provider may be denied a National Provider Identifier if any requirements are not met. This section is intended for organizations; not health care providers who
are individuals. All signatures must be original. Stamps, faxed or photocopied signatures are unacceptable. You may include multiple credentials. Use additional
sheets of paper for multiple credentials if necessary.
An authorized official is an appointed official with the legal authority to make changes and/or updates to the provider’s status (e.g., change of address, etc.) and
to commit the provider to fully abide by the laws and regulations relating to the National Provider Identifier. The authorized official must be a general partner,
chairman of the board, chief financial officer, chief executive officer, direct owner of 5 percent or more of the provider being enumerated, or must hold a
position of similar status and authority within the provider.
Only the authorized official(s) has the authority to sign the application on behalf of the provider.
By signing this application for the National Provider Identifier, the authorized official agrees to immediately notify the NPI Enumerator if any information in the
application is not true, correct, or complete. In addition, the authorized official, by his/her signature, agrees to notify the NPI Enumerator of any changes to the
information contained in this form within 30 days of the effective date of the change.
SECTION 5 – CONTACT PERSON (If the contact person is the same person identified in 2A or 4B, complete items 8 & 9 in this section.) (Required)
To assist in the timely processing of the NPI application, provide the name and telephone number of an individual who can be reached to answer questions
regarding the information furnished in this application. The contact person can be the health care provider. The contact person will recieve the NPI notification
once the health care provider has been assigned an NPI. Please note that if a contact person is not provided, all questions about this application will be directed to
the health care provider named in Section 2 or the authorized official named in Section 4, as appropriate. You may include multiple credentials. Use additional
sheets of paper for multiple credentials if necessary.
Form CMS-10114

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