Form CMS-10114, NPI Application/Update Instructions

Enter your first name as it appears on official documents.

Enter your middle name as it appears on official documents. If you do not have a middle name, leave this field blank.

Enter your last name as it appears on official documents.

Enter any suffix associated with your name, such as Jr. or Sr., if applicable.

Enter the applicant's date of birth. Fill only if 'An individual who renders health care' is 'Yes'.

Enter the U.S. state where the applicant was born (use the state's full name or its standard postal abbreviation). Fill only if 'An individual who renders health care' is 'Yes'.

If the applicant was born outside the United States, enter the country of birth; leave blank if born in the U.S. Fill only if 'An individual who renders health care' is 'Yes'.

Check this box if the individual's gender is male. Fill only if 'An individual who renders health care' is 'Yes'.

Check this box if the individual's gender is female. Fill only if 'An individual who renders health care' is 'Yes'.

Provide the applicant's U.S. Social Security Number as issued by the Social Security Administration. Fill only if 'An individual who renders health care' is 'Yes'.

Provide the applicant's IRS Individual Taxpayer Identification Number (ITIN) if one has been assigned. Fill only if 'An individual who renders health care' is 'Yes'.

Enter the street number and street name for the primary business practice location (P.O. Boxes are not acceptable).

Enter secondary address information for the business practice location such as suite, apartment, floor, or other unit designator.

Enter the city or town where the business practice location is located.

Enter the U.S. state or territory (name or postal abbreviation) in which the business practice location is located.

Enter the U.S. ZIP code or the foreign postal code for the business practice location.

If applicable, enter the 4-digit ZIP+4 code extension for the U.S. ZIP code.

Enter the country name if the business practice location is outside the United States; leave blank if within the U.S.

Enter the primary business telephone number including the area code.

Enter the telephone extension for the business phone number if one applies.

Enter the business fax number including the area code, if available.

Enter the date of the individual practitioner's signature in the format mm/dd/yyyy.

Enter the date of the authorized official's signature for the organization in the format mm/dd/yyyy. This is required for Type 2 Organizations only.

Enter the telephone number including the area code.

Enter the prefix (e.g., Mr., Mrs.) of the contact person.

Enter your email address for contact purposes.

Enter your telephone number, including the area code.

Enter the extension number for your telephone, if applicable.

Enter the primary correspondence mailing address (street number and name or P.O. Box).

Enter additional address information such as suite, apartment, unit, or floor number.

Enter the city or town for the correspondence mailing address.

Enter the U.S. state or territory (abbreviation or full name) for the mailing address.

Enter the 5‑digit U.S. ZIP code or the appropriate foreign postal code for the mailing address.

Enter the 4‑digit ZIP+4 code (additional digits to the U.S. ZIP code), if known.

Enter the country name for the correspondence mailing address if the address is outside the United States.

Enter the primary telephone number for correspondence, including area code.

Enter the telephone extension associated with the correspondence phone number, if applicable.

Enter the fax number for correspondence, including area code, if available.

Check this box if the entity applying is an individual health care provider (complete Sections 2A, 3, 4A and 5 only).

Check this box if the individual applicant operates as a sole proprietor. Fill only if 'An individual who renders health care' is 'Yes'.

Check this box if the individual applicant is not a sole proprietor. Fill only if 'An individual who renders health care' is 'Yes'.

Check this box if the entity applying is an organization or business that renders health care (complete Sections 2B, 3, 4B and 5 only).

Check this box if the organization applying is a subpart of a parent organization. Fill only if 'An organization that renders health care' is 'Yes'.

Check this box if the organization applying is not a subpart of another (parent) organization. Fill only if 'An organization that renders health care' is 'Yes'.

Enter the full legal business name of the parent organization (the official name under which the parent entity is registered). Fill only if 'Is the organization a subpart? — Yes' is 'Yes'.

Enter the Taxpayer Identification Number (TIN) of the parent organization as assigned by the IRS. Fill only if 'Is the organization a subpart? — Yes' is 'Yes'.

Enter your professional credential, such as M.D. or D.O.

Enter your current title or position within your organization.

Enter the title or honorific that precedes your name (optional), for example Mr., Mrs., Ms., Dr., etc. Fill only if 'An individual who renders health care' is 'Yes'.

Enter your given first name exactly as you want it recorded on the application (this field is required). Fill only if 'An individual who renders health care' is 'Yes'.

Enter your middle name or middle initial as you want it recorded; leave blank if you have no middle name. Fill only if 'An individual who renders health care' is 'Yes'.

Enter your family name or surname exactly as it appears on legal documents (this field is required). Fill only if 'An individual who renders health care' is 'Yes'.

Enter any suffix to your last name such as Jr., Sr., II, III, etc., if applicable; leave blank if none. Fill only if 'An individual who renders health care' is 'Yes'.

List professional credentials or academic degrees to appear after your name (for example M.D., D.O., Ph.D., RN); separate multiple entries with commas. Fill only if 'An individual who renders health care' is 'Yes'.

Enter the name prefix or title used with this other name (for example: Mr., Mrs., Ms., Dr.). Fill only if 'An individual who renders health care' is 'Yes'.

Enter the first (given) name that was used in the other name you are reporting. Fill only if 'An individual who renders health care' is 'Yes'.

Enter the middle name or initial that was used with the other name, if applicable. Fill only if 'An individual who renders health care' is 'Yes'.

Enter the last (family or surname) that was used in the other name you are reporting. Fill only if 'An individual who renders health care' is 'Yes'.

Enter any suffix used with the other name (for example: Jr., Sr., III), if applicable. Fill only if 'An individual who renders health care' is 'Yes'.

Enter any professional or academic credentials that were used with the other name (for example: M.D., D.O.), if applicable. Fill only if 'An individual who renders health care' is 'Yes'.

Enter the state where the license was issued if applicable. This helps in verifying the validity of the license.

Check this box if you are removing (deleting) your Medicaid identification number from the form and have provided the identification number and state/territory where it was issued.

Enter the Medicaid identification number assigned to the provider by the state, exactly as issued (include any letters, leading zeros, or punctuation). Fill only if 'Medicaid — Delete' Fill only if Delete is 'Yes'.

Enter the U.S. state or territory that issued the Medicaid identification number (you may use the full name or the two-letter postal abbreviation). Fill only if 'Medicaid — Delete' Fill only if Delete is 'Yes'.

Enter the organization’s full, legal business name as registered with the IRS or state authorities. Fill only if 'An organization that renders health care' is 'Yes'.

Provide the organization's Employer Identification Number assigned by the IRS. Fill only if 'An organization that renders health care' is 'Yes'.

Enter any other name the organization uses (for example, a trade name, doing-business-as name, or previously used legal name). Fill only if 'An organization that renders health care' is 'Yes'.

Check this box if the 'Other Name' you are reporting is a former legal business name previously used by the organization. Fill only if 'An organization that renders health care' is 'Yes'.

Check this box if the 'Other Name' you are reporting is a trade name or DBA (Doing Business As) the organization currently uses. Fill only if 'An organization that renders health care' is 'Yes'.

Check this box if the 'Other Name' you are reporting does not fit the 'Former Legal Business Name' or 'DBA' categories (specify the type of other name). Fill only if 'An organization that renders health care' is 'Yes'.

Enter the name or type of the other non‑Medicare identification (e.g., Medicaid ID type, state program name, or other payer identifier) being reported.

Check this box when you want to delete an Other (Non‑Medicare) provider identification number (and then provide the Identification Number and State/Territory where issued). Fill only if 'Other (Non‑Medicare) – Specify' Fill only if Delete is 'Yes'.

Enter the identification number assigned to the other non‑Medicare identifier specified in the previous field. Fill only if 'Other (Non‑Medicare) – Specify' Fill only if Delete is 'Yes'.

Enter the U.S. state or territory (or country/region if applicable) that issued the identification number entered for the other non‑Medicare identifier.

Enter the prefix (e.g., Mr., Mrs.) of the individual.

Enter the first name of the individual.

Enter the middle name of the individual.

Enter the last name of the individual.

Enter the suffix (e.g., Jr., Sr.) of the individual.

Enter the credential (e.g., M.D., D.O.) of the individual.

Enter the title or position of the individual.

Enter the provider taxonomy code that identifies the provider type/specialty for the primary taxonomy (e.g., a 10-character alphanumeric taxonomy code). Fill only if 'Delete (Provider Taxonomy Row 1)' Fill only if Delete is 'Yes'.

Check this box if you are removing the taxonomy code listed on this first provider taxonomy row and want it deleted from the record.

Enter the provider's professional license or certification number associated with the taxonomy code, if applicable.

Enter the U.S. state or territory (name or postal abbreviation) that issued the license or where the taxonomy code is registered. Fill only if 'Delete (Provider Taxonomy Row 1)' Fill only if Delete is 'Yes'.

Enter the provider taxonomy code for the primary specialty (the standardized alphanumeric code that identifies the provider type and specialty). Fill only if 'Delete (Provider Taxonomy Row 2)' Fill only if Delete is 'Yes'.

Check this box only if you are removing the provider taxonomy code entered on row 2 (to indicate that the taxonomy code and its related information on this row should be deleted).

Enter the provider's professional license number associated with the taxonomy code if applicable (include any letters or punctuation as shown on the license).

Enter the U.S. state or territory (name or standard postal abbreviation) that issued the license listed in the previous field, if applicable. Fill only if 'Delete (Provider Taxonomy Row 2)' Fill only if Delete is 'Yes'.

Enter the provider taxonomy code for this row (primary taxonomy code listed first) that describes the provider type/specialty. Fill only if 'Delete (Taxonomy row 3)' Fill only if Delete is 'Yes'.

Check this box only if you are removing the provider taxonomy code listed on the third taxonomy row and want that taxonomy entry deleted.

Enter the professional license or certification number associated with the taxonomy code on this row, or leave blank if not applicable.

Enter the U.S. state, territory, or foreign jurisdiction that issued the license or credential associated with this taxonomy code (use the standard postal abbreviation or full name). Fill only if 'Delete (Taxonomy row 3)' Fill only if Delete is 'Yes'.

Enter the provider taxonomy code for this row (primary specialty code) as assigned in the healthcare provider taxonomy set. Fill only if 'Delete (Provider Taxonomy Row 4)' Fill only if Delete is 'Yes'.

Check this box only if you are removing the provider taxonomy code listed on row 4 and want to indicate the code/entry should be deleted.

Enter the state or jurisdiction-issued professional license number associated with the taxonomy code in this row.

Enter the two-letter state or other territory name/abbreviation that issued the license entered for this taxonomy row. Fill only if 'Delete (Provider Taxonomy Row 4)' Fill only if Delete is 'Yes'.

Check this box if you are applying for a new NPI (initial application).

Check this box if you are updating information for an existing NPI (provide the NPI and complete only the sections that are changing).

Enter the National Provider Identifier (NPI) for the provider whose information is being changed. Fill only if 'Change of Information' is 'Yes'.

Check this box if you are requesting that an existing NPI be deactivated (provide the NPI and choose a deactivation reason).

Enter the National Provider Identifier (NPI) for the provider to be deactivated. Fill only if 'Deactivation' is 'Yes'.

Check this box if the provider has died and you are submitting the form to deactivate the NPI for that reason. Fill only if 'Deactivation' is 'Yes'.

Check this box if the business associated with the NPI has been dissolved and you are submitting the form to deactivate the NPI. Fill only if 'Deactivation' is 'Yes'.

Check this box if the reason for deactivation is not listed and you will specify the reason in the space provided. Fill only if 'Deactivation' is 'Yes'.

If you selected 'Other' as the deactivation reason, briefly describe the specific reason for deactivation. Fill only if 'Other, Specify' is 'Yes'.

Check this box if you are requesting reactivation of a previously deactivated NPI (provide the NPI and the reactivation reason).

Enter the National Provider Identifier (NPI) for the provider to be reactivated. Fill only if 'Reactivation' is 'Yes'.

Provide the required reason explaining why the provider should be reactivated. Fill only if 'Reactivation' is 'Yes'.

Check this box if the 'Other Name' you are providing is a former name you previously used (e.g., maiden name or prior legal name). Fill only if 'An individual who renders health care' is 'Yes'.

Check this box if the 'Other Name' you are providing is a professional name you use in your work (e.g., stage name, pen name, or professional alias). Fill only if 'An individual who renders health care' is 'Yes'.

Check this box if the 'Other Name' you are providing does not fit the 'Former Name' or 'Professional Name' categories and is another type of alternate name. Fill only if 'An individual who renders health care' is 'Yes'.