National Provider Identification Number (NPI) Submission Form

Effective May 23, 2007 the Health Insurance Portability and Accountability Act (HIPAA) will require all health care providers, defined as "covered entities", to begin using a unique 10-digit identification number when submitting all HIPAA standard transactions,

This number will replace your existing Virginia Premier Provider ID, which is the also the Medicaid Provider ID Number. If you have not yet applied for and received your individual and group (if applicable) NPI Number, you may do so by choosing one of the following options;

Apply for an NPI number via the Web at https://nppes.cms.hhs.gov
Download the application from the Website above and mail it to:
NPI Enumerator
PO Box 6059
Fargo, ND 58108-6059

If you have obtained your individual and/or NPI group number and are ready to provide it to Virginia Premier, please complete the form below. An asterisk (*) denotes a required field for a completed section. We are working very diligently to ensure that your claim payments and demographic information is accurate in our systems. Please provide as much information as possible. If you have multiple NPI Numbers, please complete a separate form for each NPI Number.

Fields with a * beside them are mandatory (Please note that all information provided is confidential).

Organizational or Group Information
Group Name: *
DBA Name:
Tax ID Number: *
Group NPI Number: * (10-digit Number)
Group Mailing Address Line 1: * (Payment Address)
Group Mailing Address Line 2:

City: *		State: *
Zip: (5 digits) *		Phone: * (10 digits, no dashes)

Individual Provider Information
Prefix: (Mr., Mrs.,etc)
First Name: *		Last Name: *
Suffix: (Jr. Sr., etc)		Credentials: * (M.D.,PhD, etc)

Social Security Number: * (no dashes)
Individual NPI Number: * (10 digits)
Taxonomy Code: *
Practice Location Address Line 1: *
Practice Location Address Line 2:

City: *		State: *
Zip: (5 digits) *		Phone: * (10 digits, no dashes)

Is your Practice Location Address also your Claim Payment Address?

Yes No

If you answered No to the previous question, please complete below:
Payment Address Line 1:
Payment Address Line 2:

City:		State:
Zip: (5 digits)		Phone: (10 digits, no dashes)

Provider Legacy Identifiers
Medicaid Provider Numbers 1: *		State: *
Medicaid Provider Numbers 2:		State:
Medicaid Provider Numbers 3:		State:
Medicaid Provider Numbers 4:		State:
Medicaid Provider Numbers 5:		State:

Other Provider Identifiers
License Numbers 1:		State:
License Numbers 2:		State:
License Numbers 3:		State:

National Provider Identification Number (NPI) Submission Form

Organizational or Group Information

Individual Provider Information

Provider Legacy Identifiers

Other Provider Identifiers