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 CMS web site for additional information or click here to Apply Online for an NPI.  After you obtain your NPI from CMS, please come back here to submit 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	Dr. Ms. Miss Mr. Mrs.
First Name*
If you do not have a middle name, check box:
Middle Name*
Last Name*
Suffix	Sr. Jr. I II III IV V VI VII IX X
Credentials*
Use ctrl-shift or ctrl-alt keys for multiple selections M.D. - Medical Doctor  MD, PHD - M.D. & Doctor of Philosophy  D.O. - Doctor Of Osteopathic Medicine  DC - Doctor Of Chiropractic Medicine  ACNP - Acute Care Nurse Practitioner  ACSW - Academy Of Certified Social Workers  ADNP - Adult Nurse Practitioner  ANP - Advanced Practice Nurse  AUD - Audiologist  BSN - Bach. Science in Nursing  CCA - Certified Clinical Audiologist  CCS - Certified Cardiopulmonary Specialist  CDC - Chemical Dependency Counselor  CNIM - Certified Neurophysiologic Interoperative Mon  CNM  - Certified Nurse Midwife  CNS - Clinical Nurse Specialist  CO - Certified Orthotist  COA - Certified Ophthalmic Assistant  COMSA - Certified Oral Maxillofacial Surgery Assistant  COT - Certified Ophthalmology Therapst  CP - Certified Cardiovascular Perfusionist  CPNP - Certified Pediatric Nurse Practitioner  CPO - Certified Prosthetist Orthotist  CPR - Certified Prosthetist  CRNA - Certified Registered Nurse Anesthetist  CRNFA - Certified Registered Nurse First Assisant  CST - Certified Surgical Technician  D.D.S. - Doctor of Dental Surgery  D.M.D. - Doctor Of Dental Medicine  D.P.M. - Doctor Of Podiatric Medicine  DA - Dental Assistant  DDS - Doctor Of Dental Surgery  DI - Dietician  DMD - Doctor Of Dental Medicine  DO - Doctor Of Osteopathic Medicine  DPM - Doctor Of Podiatric Medicine  DPT - Doctor in Physical Therapy  ET - Enterostomal Therapist  F.N.P. - F.N.P.  FACC - Fellow American College of Cardiology  FACEP - American College of Emergency Physicians  FACIM - Fellow American College of Internal Medicine  FACOEP - FACOEP  FACP - FACP  FACS - Fellow American College of Surgery  FNP - Family Nurse Practitioner  FSCAI - Fellow in Society for Angiogrpahy & Interventions  GCNS - Gerontological Clinical Nurse Specialist  GNP - Gerontolocial Nurse Practitioner  GRNA - Graduate Registerd Nurse Anesthetist  LCSW - Licensed Clinical Social Worker  LPC - Licensed Professional Counselor  LPN - Licensed Practical Nurse  M.A - Masters of Arts  MA - Medical Assistant  MALCPC - M.A. Licensed Clinical Professional Counselor  MBA - Masters of Business Administration  MD - Medical Doctor  MD,FACE - Medical Doctor & F.A.C.E  MD,PHD - MD,PHD  MHS - Master in Health Science  MP - Master of Psychology  MPH - Master Public Health  MPT - Master in Physical Therapy  MS - Master of Science  MSN - Master of Science Nursing  MSPT - Master of Science in Physical Therapy  MSW - Master Social Worker  NP - Nurse Practitioner  O.T. - Occupational Therapist  OCCUMED - Occupational Medicine Specialty Group  OCS - Orthpedic Certified Specialist  OD - Optomotists  OGNP - OG Nurse Practitioner  P.A. - Physician Assistant  P.A.-C. - Physician Assistant-Certified  P.A.C. - Physician Assistant Certitifed  PA-C - Physician Assistant Certified  PAT - Pathology Assistant  PERF - Perfusionist  PH.D - Doctor Of Philosophy  PHD - PHD PHD, MD - M.D. & Doctor of Philosophy  PNP - Pediatric Nurse Practitioner  PSY.D. - Doctor of Psychology  PT - Physicial Therapist  R.N. - R.N.  RADTEC - Radiology Technician  RN - Registered Nurse  RNC - Registered Nurse Certified  RNFA - Registered Nurse First Assistant  RPH - Doctor of Pharmacy  RPT - Registered Physical Therapist  RT - Respiratory Therapist  SA - Surgical Assistant  SP - Speech Pathologist  WHNP - Women`s Health Care Nurse Practitioner
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*    AK AL AR AZ CA CO CT DC DE FL GA HI IA ID IL IN KS KY LA MA MD ME MI MN MO MS MT NC ND NE NH NJ NM NV NY OH OK OR PA RI SC SD TN TX UT VA VT WA WI WV WY     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*

pasted in the box below forwarded e-mail to NPIcollection@bjc.org faxed to 314.747.1572