Form CMS-10114, NPI Application/Update Instructions
This form contains 112 fields organized into 22 sections. Below is a complete list of every field, its type, and what information is expected.
| Field Name | Type | Description |
|---|---|---|
| Basic Information | ||
| Parent Organization TIN | Text |
Enter the Taxpayer Identification Number (TIN) of the parent organization, if applicable.
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| 2. First | Text |
Enter your first name as it appears on official documents.
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| 3. Middle | Text |
Enter your middle name as it appears on official documents. If you do not have a middle name, leave this field blank.
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| 4. Last | Text |
Enter your last name as it appears on official documents.
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| 5. Suffix (e.g., Jr., Sr.) | Text |
Enter any suffix associated with your name, such as Jr. or Sr., if applicable.
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| Business Address | ||
| 2. Business Primary Practice Location Address Line 2 (Address Information; e.g., Suite Number) | Text |
Enter the secondary address information for your primary practice location, such as a suite number.
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| 3. Business City | Text |
Enter the city where your primary practice location is situated.
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| 4. Business State | Text |
Enter the state where your primary practice location is situated.
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| 5. ZIP or Foreign Postal Code | Text |
Enter the ZIP code or foreign postal code for your primary practice location.
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| 7. Business Country Name (if outside U.S.) | Text |
Enter the name of the country where your business is located, if it is outside the United States.
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| Business Addresses | ||
| Section 3. Business addresses and other information. A. Correspondence Mailing Address. 1. Correspondence Mailing Address Line 1* (Street Number and Name or P.O. Box) | Text |
Enter the first line of the correspondence mailing address, including street number and name or P.O. Box.
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| 2. Correspondence Mailing Address Line 2 (Address Information; e.g., Suite Number) | Text |
Enter the second line of the correspondence mailing address, such as suite number or additional address information.
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| 3. City/Town | Text |
Enter the city or town for the correspondence mailing address.
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| 4. State | Text |
Enter the state for the correspondence mailing address.
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| 5. ZIP or Foreign Postal Code | Text |
Enter the ZIP code or foreign postal code for the correspondence mailing address.
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| 6. +4 | Text |
Enter the additional four digits for the ZIP code, if applicable.
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| 7. Correspondence Country Name (if outside U.S.) | Text |
Enter the country name for the correspondence mailing address if it is outside the United States.
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| 8. Correspondence Telephone Number (Include Area Code) | Text |
Enter the telephone number for correspondence, including the area code.
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| 9. Extension | Text |
Enter the extension number for the correspondence telephone number, if applicable.
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| 10. Correspondence Fax Number (Include Area Code) | Text |
Enter the fax number for correspondence, including the area code.
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| 1. Business Primary Practice Location Address Line 1* (Street Number and Name – P.O. Boxes Not Acceptable) | Text |
Enter the first line of the business primary practice location address, including street number and name. P.O. Boxes are not acceptable.
|
| Certification Statement | ||
| Section 4. Certification Statement. A. Individual Practitioner's Signature Date* (mm/dd/yyyy) | Text |
Enter the date of the individual practitioner's signature in the format mm/dd/yyyy.
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| B. Authorized Official's Signature for the Organization. Required for Type 2 Organizations only. Signature Date* (mm/dd/yyyy) | Text |
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.
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| Contact Information | ||
| 8. Business Telephone Number* (Include Area Code) | Text |
Enter the telephone number for your business, including the area code.
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| 9. Extension | Text |
Enter the extension number for your business telephone, if applicable.
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| 10. Business Fax Number (Include Area Code) | Text |
Enter the fax number for your business, including the area code.
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| 10. Telephone Number* (Include Area Code) | Text |
Enter the telephone number including the area code.
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| Section 5. Contact Person. 1. Prefix (e.g., Mr., Mrs.) | Text |
Enter the prefix (e.g., Mr., Mrs.) of the contact person.
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| 8. E-Mail Address | Text |
Enter your email address for contact purposes.
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| 9. Telephone Number* (Include Area Code) | Text |
Enter your telephone number, including the area code.
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| 10. Extension | Text |
Enter the extension number for your telephone, if applicable.
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| Deactivation Reason | ||
| Deactiviation Reason. Check only one box. Required. Death | RadioButton |
Select this option if the reason for deactivation is the death of the provider.
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| Business Dissolved | RadioButton |
Select this option if the reason for deactivation is that the business has been dissolved.
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| Other | RadioButton |
Select this option if the reason for deactivation is other than the provided options.
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| Specify other deactivation reason | Text |
Specify the reason for deactivation if 'Other' was selected.
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| Entity Type | ||
| B. Entity type. An individual who renders health care | RadioButton |
Select this option if the entity type is an individual who renders health care.
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| An individual who renders health care | RadioButton |
Select this option if the entity type is an organization that renders health care.
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| Identifying Information | ||
| Section 2. Identifying Information. A. Individuals includes sole proprietorships and incorporated individuals. 1. Prefix (e.g., Mr., Mrs.) | Text |
Select the appropriate prefix for the individual (e.g., Mr., Mrs.).
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| 2. First | Text |
Enter the first name of the individual.
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| 3. Middle | Text |
Enter the middle name of the individual, if applicable.
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| 4. Last | Text |
Enter the last name of the individual.
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| 5. Suffix (e.g., Jr., Sr.) | Text |
Enter the suffix for the individual, if applicable (e.g., Jr., Sr.).
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| 6. Credential (e.g., M.D., D.O.) | Text |
Enter the professional credential of the individual (e.g., M.D., D.O.).
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| 14. Date of Birth* (mm/dd/yyyy) | Text |
Enter the date of birth of the individual in the format mm/dd/yyyy.
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| 15. State of Birth* (U.S. only) | Text |
Enter the state of birth of the individual (U.S. only).
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| 16. Country of Birth* (If other than U.S.) | Text |
Enter the country of birth of the individual if it is other than the U.S.
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| 17. Gender*. Male | RadioButton |
Select this option if the individual is male.
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| Female | RadioButton |
Select this option if the individual is female.
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| 18. Social Security Number (S.S.N.) (See Instructions) | Text |
Enter your Social Security Number (S.S.N.) as instructed. This is used for individual identification purposes.
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| 19. I.R.S. Individual Taxpayer Identification Number (ITIN) (See Instructions) | Text |
Enter your Individual Taxpayer Identification Number (ITIN) as instructed. This is used for tax purposes.
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| 3. Other Name (if applicable see instructions) | Text |
Enter any other name you use or are known by, if applicable. Refer to the instructions for more details.
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| 6. Credential (e.g., M.D., D.O.) | Text |
Enter your professional credential, such as M.D. or D.O.
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| 7. Title/Position | Text |
Enter your current title or position within your organization.
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| License Information | ||
| License Number (If applicable) | Text |
Enter the license number if applicable. This is required for identifying the specific license held by the provider.
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| State where issued (If applicable) | Text |
Enter the state where the license was issued if applicable. This helps in verifying the validity of the license.
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| License Number (If applicable) | Text |
Enter the license number if applicable. This is required for identifying the specific license held by the provider.
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| State where issued (If applicable) | Text |
Enter the state where the license was issued if applicable. This helps in verifying the validity of the license.
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| License Number (If applicable) | Text |
Enter the license number if applicable. This is required for identifying the specific license held by the provider.
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| State where issued (If applicable) | Text |
Enter the state where the license was issued if applicable. This helps in verifying the validity of the license.
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| State where issued (If applicable) | Text |
Enter the state where the license was issued if applicable. This helps in verifying the validity of the license.
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| Medicaid Information | ||
| Delete Medicaid Identification Number | CheckBox |
Check this box if you want to delete your Medicaid Identification Number.
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| Medicaid Identification Number | Text |
Enter your Medicaid Identification Number.
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| Medicaid. State where issued (If applicable) | Text |
Enter the state where your Medicaid Identification Number was issued, if applicable.
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| NPI Information | ||
| N.P.I. required | Text |
Enter the NPI number that is required for this application or update.
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| NPI required | Text |
Enter the NPI number that is required for this application or update.
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| NPI required | Text |
Enter the NPI number that is required for this application or update.
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| Organization Information | ||
| B. Organizations includes groups, corporations and partnerships. Do not report an S.S.N. in the E.I.N field. 1. Name* (Legal Business Name) | Text |
Enter the legal business name of the organization, group, corporation, or partnership. Do not use a Social Security Number in this field.
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| 2. Employer Identification Number* (E.I.N.) | Text |
Enter the Employer Identification Number (E.I.N.) of the organization.
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| 3. Other Name (if applicable see instructions) | Text |
Enter any other name used by the organization, if applicable, as instructed.
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| 4. Type of Other Name. Former Legal Business Name | RadioButton |
Select this option if the other name is a former legal business name.
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| D/B/A Name | RadioButton |
Select this option if the other name is a Doing Business As (D/B/A) name.
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| Other | RadioButton |
Select this option if the other name does not fit into the provided categories.
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| Other Identification Numbers | ||
| Other (Non-Medicare), Specify | Text |
Specify any other non-Medicare identification number you have.
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| Delete Other (Non-Medicare) Identification Number | CheckBox |
Check this box if you want to delete another non-Medicare identification number.
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| Other (Non-Medicare). Identification Number | Text |
Enter any other non-Medicare identification number you have.
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| Other (Non-Medicare). State where issued (If applicable) | Text |
Enter the state where your other non-Medicare identification number was issued, if applicable.
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| Other Name Information | ||
| Other name information. 1. Prefix (e.g., Mr., Mrs.) | Text |
Select the appropriate prefix for the other name (e.g., Mr., Mrs.).
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| 2. First | Text |
Enter the first name for the other name.
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| 3. Middle | Text |
Enter the middle name for the other name, if applicable.
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| 4. Last | Text |
Enter the last name for the other name.
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| 5. Suffix (e.g., Jr., Sr.) | Text |
Enter the suffix for the other name, if applicable (e.g., Jr., Sr.).
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| 6. Credential (e.g., M.D., D.O.) | Text |
Enter the professional credential for the other name (e.g., M.D., D.O.).
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| 13. Type of Other Name. Former Name | RadioButton |
Select this option if the other name is a former name.
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| Professional Name | RadioButton |
Select this option if the other name is a professional name.
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| Other | RadioButton |
Select this option if the other name is of another type not listed.
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| Parent Organization | ||
| Parent Organization L.B.N | Text |
Enter the Legal Business Name (LBN) of the parent organization.
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| Personal Information | ||
| 3. Prefix (e.g., Mr., Mrs.) | Text |
Enter the prefix (e.g., Mr., Mrs.) of the individual.
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| 4. First | Text |
Enter the first name of the individual.
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| 5. Middle | Text |
Enter the middle name of the individual.
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| 6. Last | Text |
Enter the last name of the individual.
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| 7. Suffix (e.g., Jr., Sr.) | Text |
Enter the suffix (e.g., Jr., Sr.) of the individual.
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| 8. Credential (e.g., M.D., D.O.) | Text |
Enter the credential (e.g., M.D., D.O.) of the individual.
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| 9. Title/Position | Text |
Enter the title or position of the individual.
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| Provider Taxonomy | ||
| D. Provider Taxonomy Code (Provider type/speciality) and License Number Information. Taxonomy Code. List primary first | Text |
Enter your provider taxonomy code, listing the primary code first. This code identifies your provider type or specialty.
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| Delete Taxonomy Code | CheckBox |
Check this box if you want to delete a taxonomy code.
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| License Number (If applicable) | Text |
Enter your license number, if applicable.
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| State where issued (If applicable) | Text |
Enter the state where your license number was issued, if applicable.
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| Taxonomy Code 2 | Text |
Enter a secondary provider taxonomy code, if applicable.
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| Delete Taxonomy Code | CheckBox |
Check this box if you want to delete a secondary taxonomy code.
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| Reactivation Reason | ||
| Reactivation reason required | Text |
Provide the reason for reactivation of the NPI.
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| Reason for Submittal | ||
| A. Reason for Submittal of this Form. Initial Application | RadioButton |
Select this option if you are submitting this form for an initial application for an NPI.
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| Change of Information | RadioButton |
Select this option if you are submitting this form to update or change existing information.
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| Deactivation | RadioButton |
Select this option if you are submitting this form to deactivate an existing NPI.
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| Reactivation | RadioButton |
Select this option if you are submitting this form to reactivate a previously deactivated NPI.
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| Sole Proprietor | ||
| Is the individual a sole proprietor? Yes | RadioButton |
Select 'Yes' if the individual is a sole proprietor.
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| No | RadioButton |
Select 'No' if the individual is not a sole proprietor.
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| Subpart Information | ||
| Is the organization a subpart? Yes | RadioButton |
Select 'Yes' if the organization is a subpart.
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| Is the organization a subpart? Yes | RadioButton |
Select 'No' if the organization is not a subpart.
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| Taxonomy Codes | ||
| Taxonomy Code 3 | Text |
Enter the third taxonomy code that classifies the provider's type, classification, and specialization.
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| Delete Taxonomy Code | CheckBox |
Check this box if you want to delete the specified taxonomy code.
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| Taxonomy Code 4 | Text |
Enter the fourth taxonomy code that classifies the provider's type, classification, and specialization.
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| Delete Taxonomy Code | CheckBox |
Check this box if you want to delete the specified taxonomy code.
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