Effective Date: Effective / opening date of facility

List in Provider Directory:  Should the facility be listed in electronic and paper directories? Select Yes or No

Location Name: The complete legal name of institution, corporate entity, practice or individual provider

Physical Address: The number and street name associated with the new location

City: City associated with physical address

State: State associated with physical address

Zip: Zip code associated with physical address

County: County in which the new facility is located

Accepts mail at this address? Is mail delivered by the USPS at this address? Select Yes or No

Clinic Phone Number: Business telephone number to be published in electronic and paper directories

Clinic Fax Number: Business fax number for referrals or prior authorizations

Clinic Manager Name: Complete name of the clinic manager

Clinic Manager Phone: Business telephone number associated with the clinic manager

Business Fax: Business fax number associated with the clinic manager

Clinic Manager Email: Business email associated with the clinic manager

Billing Tax ID: The nine-digit identification number used by the Internal Revenue Service in the administration of tax laws for this location

Billing Contact Name: Complete name of the individual responsible for billing within the organization or corporate entity

Billing Name (Check Payable To): Complete legal name of the organization or corporate entity

Billing Address: Billing address where payments should be mailed

City: City associated with billing address

State: State associated with billing address

Zip: Zip associated with billing address

Phone: Telephone number associated with billing organization or contact

Fax: Fax associated with billing organization or contact

Email: Email associated with billing organization or contact


Facility NPI s / Taxonomy codes:

Facility NPI: The unique 10-digit identification number for covered health care facility

Service Type: Type of services performed at this location (for example: clinic, hospital, emergency care, urgent care, surgery center, nursing home, etc.)

Taxonomy Code: The hierarchical code categorizing the type, classification, and / or specialization of health care providers at this facility

Billing NPI: The unique 10-digit identification number for covered health care providers


Practitioners at this Location: (If practitioner is new to our organization, please complete the New Practitioner Form)

Practitioner: First and last name of the each individual practitioner as listed on state license where care is being rendered. If practitioner is new to our organization a New Practitioner Form should also be completed

Practitioner NPI: The unique 10-digit identification number assigned to each health care providers at this facility

Completed by: Name of the individual completing this form. Individual must be authorized to represent the provider office for enrollment with health insurance payers

Email Address: Email address associated with contact

Phone: Telephone number associated with contact