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Click ‘Get Form’ to open the NPI application in the editor.
In Section 1, select the reason for submitting the form: Initial Application, Change of Information, Deactivation, or Reactivation. Ensure you check only one box.
Complete Section 2 by providing identifying information. For individuals, include your full legal name and date of birth. For organizations, provide the legal business name and EIN.
Fill out Section 3 with your correspondence mailing address and primary business practice location. Make sure these addresses are accurate for effective communication.
In Section 4, review the certification statement carefully. Sign and date it to confirm that all information is true and complete.
Finally, provide a contact person’s information in Section 5 who can answer any questions regarding your application.
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