National Provider Identifier (NPI) Registration Form Guide

Reason for Submission (required)

One of the following must be selected:
New Registration: Adds an NPI to a pending Medicaid provider application or to an active provider file.

Change Registration: Updates an existing NPI on a pending Medicaid provider application or on an active provider file.

Cancel Registration: Inactivates an NPI on an active provider file.

Provider Name and Address

Business or Last Name: (required) - as listed on provider’s proof of tax ID.

First Name: (if applicable) - required only if Last Name is furnished in previous field.

Middle Initial: (if applicable)

Jr., Sr., etc.: (if applicable)

Doing Business As Name: (if applicable)

Service Address Line 1: (required)

Service Address 2: (if applicable)

City: (required)

State: (required)

Zip Code: (required)

+4: (if applicable).

Email Address: (required)

Telephone Number: (required)

Provider Identifiers

Tax ID Type: (required)

Select either Social Security Number (SSN) or Federal Employer Identification Number (FEIN).

Tax ID: (required)

• Enter a Social Security Number (SSN) or Federal Employer Identification Number (FEIN).
• An individual can use either an FEIN or an SSN as long as either is registered with the IRS. Groups must use the FEIN as the tax ID.

Medicaid Provider ID: (or Application Tracking Number; required)

• Enter the nine-digit Provider ID if updating an existing provider record.
• Enter the Application Tracking Number (ATN) if an enrollment application is currently pending approval.

NPI Type: (required)

• Select either Individual (IND) or Organization (ORG), which can be obtained on the NPPES website https://nppes.cms.hhs.gov/#/.

Note: A validation will occur to ensure that provider’s NPPES Entity Type matches the Provider Entity Type on their Florida Medicaid Provider Record. Providers enrolled with an SSN, must have a NPPES Entity Type of 1-Individual. Providers enrolled with an FEIN, must have a NPPES Entity Types of 2-Organization.

If the determined Entity Type does not match the NPPES Entity Type, the NPI Registration Form will be rejected.

NPI: (required)

• Enter the 10-digit NPI number, which can be obtained from the NPPES website https://nppes.cms.hhs.gov/#/.

Taxonomy: (required)

• Taxonomy must be valid for the provider specialty.

Zip: (required)

+4: (if applicable)

• This combination of identifiers must be included on all claim submissions in order for them to successfully process.

Signature

Authorized Signature: (required)

• A signature is needed from a valid authorized signer who is listed as an Owner on the Provider record.
• Stamped signatures and electronic signatures are not acceptable. Florida Medicaid ONLY accepts wet signatures.

Printed Name of Authorized Signer: (required)

Signature Date: (required)