National Provider Identifier Submission Form Apply for Your NPI Today!

The National Provider Identifier is an administrative simplification mandate of HIPAA that requires every health-care provider to obtain and use a unique 10-digit identifier (National Provider Identifier) by May 23, 2007.  This identifier will replace all current health-care provider numbers used in HIPAA standard transactions.  Please refer to the for additional information or click here to .  Don't forget...After you obtain your NPI from CMS, please come back to http://NPIReg.bjc.org to submit your NPI to BJC. The sooner you submit your NPI, the more chances you have to win.

Submitting Your NPI to BJC

If you refer patients to BJC facilities, we need to know your individual (Type 1) NPI.  We will use this information only for business purposes and to integrate your NPI into our systems to be compliant with this mandate.  To make our systems and processes ready, we need your information NOW.

If you are submitting multiple NPIs for different providers in your practice, please complete one form for each NPI.  Please complete all fields on this form.

* = required field
Section 1 - Basic Identifying Information
Type 1 - An individual who renders health care, e.g., physician, dentist, chiropractor
Prefix
First Name*
If you do not have a middle name, check box:
Middle Name*
Last Name*
Suffix
Credentials*
Use ctrl-shift or ctrl-alt keys for multiple selections
Individual NPI*

Section 2 - Practice Information
Type 2 - An organization that renders health-care services, e.g., hospital, physician group practice, nursing facility
Organization's Legal Name*
Doing Business As Name
Primary Practice Location Address Line*
Primary Practice Location Address Line 2
City*       State*       ZIP Code*   
Phone*  - -
Fax  - -
Organization NPI  

Section 3 - Other Provider Identification Numbers
If you do not have a UPIN, check box:
UPIN*

Section 4 - Provider Taxonomy Code*
(Information on provider taxonomy code is available at www.wpc-edi.com/taxonomy)
*   select  empty
     select  empty
     select  empty
     select  empty

Section 5 - Contact Person*
Check box if you are the same person completing this form.
Name*
Title*
Phone number* - -

Section 6
Copy and paste the e-mail you received from the NPI enumerator in the window below so we can validate this information. Or fax the confirmation letter/e-mail to 314.747.1572 or forward the e-mail confirmation to NPIcollection@bjc.org.
Indicate which method you have chosen to submit this information*

   

Call BJC NPI help line 314.996.DATA for additional questions