Healthcare NPI Registry

Healthcare NPI Registry

I. Registry Action

Select action to be taken for the National Provider Identifier record:

New NPI registration
Update existing NPI record
Reassign/Change ownership
Deactivate NPI record

II. Provider Identifiers

Individual (sole practitioner)
Organization / Group practice / Facility

III. Primary Practice Location (Physical)

Mailing address same as primary practice location:

IV. Contact Information

V. Taxonomy / Specialization

Provide taxonomy codes and classifications for this provider record. Mark primary taxonomy that best describes practice.

Primary taxonomy:

Primary taxonomy:

VI. Professional Licenses and Identifiers

List all state licenses, certifications, or registration numbers used for identification in practice.

VII. Authorized Official for Record Changes

Provide the contact information for the person authorized to submit updates to this NPI record.

VIII. Effective Date and Record History

IX. Attestation and Certification

By signing below, the authorized signer certifies that the information provided on this Healthcare NPI Registry form is true, correct, and complete to the best of their knowledge. The signer affirms they are legally authorized to submit this application or update on behalf of the provider identified herein.

The signer acknowledges responsibility to promptly notify the registry of any changes to the information provided, and understands that intentional misrepresentation of identifying information may subject the signer and the provider to civil and criminal penalties under applicable law.

I certify under penalty of perjury that the factual statements made in this form are true and correct. I authorize release and use of this information for registration, verification, and where permitted, public disclosure consistent with registry rules and applicable law.

I acknowledge that I have read and understand the above attestation:

X. Additional Remarks

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