National Provider Identifier Information (NPI)--Professional							

The purpose of this spreadsheet is to insure an accurate understanding of your current status and plans for use of NPI.									
Please review the spreadsheet below and provide as much of the information requested as possible. 									
									
"If you have already applied for and received NPI(s) please provide them in the appropriate spot.  If not, please provide an indication of how you are planning to enumerate by entering NPI #1, NPI #2,"									
"NPI #3, etc., in the NPI field.  Please review the instruction sheet that accompanied this mailing for further information. You may insert additional lines as needed."									
									
1) DBA Name or subpart	2) DBA Street Address	3) City/Town	4) State	5) Zip	6) Tax ID Number	7) MassHealth Provider ID	8) NPI	9) Medicare Provider ID A & B	10) Taxonomy Code
									
									
									
									
									
									
									
									
									
									
Please provide contact information for follow up:									
Contact Name: 									
Telephone Number: 									
Email Address: