HIPAASpace NPI Form Source NPI Lookup NATIONAL PROVIDER IDENTIFIER NPI FORM SECTION - PDF document

(NPPES) to assign these unique identifiers. NPI 1598924763 10-position all-numeric identification numberassigned by the NPS to uniquely identify a healthcare provider. Entity Type Individual Code describing the type of health care provider thatis being assigned an NPI. Codes are:&#xul00;&#xli00; ()&#x/li0;furnishes health care;&#xli00; ()individual human being that furnishes health care(for example, hospital, SNF, hospital subunit,&#x/li0;pharmacy, or HMO).&#x/ul0; Is Sole Proprietor N Indicate whether provider is a sole proprietor.&#xul00;&#xli00; ()of a business that is not incorporated; thatunincorporated business is a sole&#x/li0;proprietorship.&#xli00; owns all of the assets of the business and is solely&#x/li0;liable for all of the debts of the business.&#xli00; proprietorship and a sole proprietor; they are legally&#x/li0;a single entity: an individual.&#xli00; is an Entity type 1 (Individual) and is eligible for onlyone NPI (the sole proprietorship business is not&#x/li0;eligible for its own NPI).&#xli00; be a subpart and cannot have subparts. (See NPI&#x/li0;Final Rule for information about subparts.)&#xli00; &#x/li0;employees.&#xli00; proprietorship in order to protect the soleproprietor's SSN from disclosure in claims or on W-2s. NPPES does not capture a sole proprietorship's&#x/li0;EIN.&#xli00; sole proprietorships (for example, group practices,&#x/li0;pharmacies, home health agencies).&#x/ul0; Provider Last Name(Legal Name) FOSTER The last name of the provider (if an individual). If theprovider is an individual, this is the legal name. Thisname must match the name on file with the SocialSecurity Administration (SSA). In addition, the dateof birth must match that on file with SSA. (First andlast names are required for initial applications.) TheFirst, Middle, Last and Credential(s) fields allow thefollowing special characters: ampersand,apostrophe, colon, comma, forward slash, hyphen,left and right parentheses, period, pound sign,quotation mark, and semi-colon. A field cannotcontain all special characters. Provider First Name CRISTA-GAYE The first name of the provider, if the provider is anindividual. Provider Middle Name NICOLE The middle name of the provider, if the provider isan individual. Provider CredentialText MD The abbreviations for professional degrees orcredentials used or held by the provider, if theprovider is an individual. Examples are MD, DDS,CSW, CNA, AA, NP, RNA, or PSY. These credentialdesignations will not be verified by NPS. Provider First LineBusiness MailingAddress 3998 FAIR RIDGE RD The first line mailing address of the provider beingidentified. This data element may contain the sameinformation as ''Provider first line location address''. Provider Second LineBusiness MailingAddress SUITE 300 The second line mailing address of the providerbeing identified. This data element may contain thesame information as ''Provider second line locationaddress''. Provider BusinessMailing Address CityName FAIRFAIX The City name in the mailing address of the providerbeing identified. This data element may contain thesame information as ''Provider location address Cityname''. Provider BusinessMailing Address StateName VA The State or Province name in the mailing addressof the provider being identified. This data elementmay contain the same information as ''Providerlocation address State name''. Provider BusinessMailing AddressPostal Code 22033-2921 The postal ZIP or zone code in the mailing addressof the provider being identified. NOTE: ZIP codeplus 4-digit extension, if available. This data elementmay contain the same information as ''Providerlocation address postal code''. Provider BusinessMailing AddressCountry Code US The country code in the mailing address of theprovider being identified. This data element maycontain the same information as ''Provider locationaddress country code''. Provider BusinessMailing AddressTelephone Number 703-295-9360 The telephone number associated with mailingaddress of the provider being identified. This dataelement may contain the same information as''Provider location address telephone number''. Provider BusinessMailing Address FaxNumber 703-766-9725 The fax number associated with the mailing addressof the provider being identified. This data elementmay contain the same information as ''Providerlocation address fax number''. Provider First LineBusiness PracticeLocation Address 1650 GRANDCONCOURSE The first line location address of the provider beingidentified. For providers with more than one physicallocation, this is the primary location. This addresscannot include a Post Office box. Provider BusinessPractice LocationAddress City Name BRONX The city name in the location address of the providerbeing identified. Provider BusinessPractice LocationAddress State Name NY The State or Province name in the location addressof the provider being identified. Provider BusinessPractice LocationAddress Postal Code 10457-7606 The postal ZIP or zone code in the location addressof the provider being identified. NOTE: ZIP codeplus 4-digit extension, if available. Provider BusinessPractice LocationAddress Country Code US The country code in the location address of theprovider being identified. Provider BusinessPractice LocationAddress TelephoneNumber 718-466-8152 The telephone number associated with the locationaddress of the provider being identified. Provider EnumerationDate 06/03/2008 The date the provider was assigned a uniqueidentifier (assigned an NPI). Last Update Date 03/20/2015 The date that a record was last updated or changed. Provider Gender Code F The code designating the provider's gender if theprovider is a person. Provider Gender Female The provider's gender if the provider is a person. Healthcare ProviderTaxonomy Code #1 207LP2900X The Health Care Provider Taxonomy code is aunique alphanumeric code, ten characters in length.The code set is structured into three distinct "Levels"including Provider Type, Classification, and Area ofSpecialization. Healthcare ProviderTaxonomy 1 Pain Medicine Healthcare Provider Taxonomy #1 Provider LicenseNumber 1 264978 Certain taxonomy selections will require you to enteryour license number and the state where the licensewas issued. Select Foreign Country in the state dropdown box if the license was issued outside of UnitedStates. The License Number field allows thefollowing special characters: ampersand,apostrophe, colon, comma, forward slash, hyphen,left and right parentheses, period, pound sign,quotation mark, and semi-colon. A field cannotcontain all special characters. DO NOT report theSocial Security Number (SSN), IRS IndividualTaxpayer Identification Number (ITIN) in thissection. Provider LicenseNumber State Code 1 NY Provider License Number State Code #1 Healthcare ProviderPrimary TaxonomySwitch 1 Y Primary Taxonomy:&#xul00;&#xli00; &#x/li0;Answered;&#xli00; &#x/li0;(there can be only one per NPI record);&#xli00; &#x/li0;taxonomy.&#x/ul0; Other ProviderIdentifier 1 03647032 Other Provider Identifier #1 Other ProviderIdentifier Type 1 MEDICAID Other Provider Identifier Type #1 Other ProviderIdentifier State 1 NY Other Provider Identifier State #1 NPPES National Plan & Enumeration System1-800-465-3203 (NPI Toll-Free)1-800-692-2326 (NPI TTY)NPI EnumeratorPO Box 6059Fargo, ND 58108-6059Email: customerservice@npienumerator.com http://www.hipaaspace.com.