Medicare Enrollment Application Information

Application Details

Please enter all required information from the enrollment application for which you wish to submit payment.

* § NPI


Expected Format: 10 Digits

* Legal Business Name


* TIN Type
Select TIN Type EIN SSN

* Tax Identification Information (TIN)

Expected Format: 9 digits without special characters included

* Please select the Provider/Supplier Service and Speciality Type:

Part B Supplier Services

Part B Supplier Type Select Part B Supplier Type AMBULANCE SERVICE SUPPLIER AMBULATORY SURGICAL CENTER CENTRALIZED FLU BILLER CLINIC/GROUP PRACTICE HOME INFUSION THERAPY HOSPITAL DEPARTMENT(S) INDEPENDENT CLINICAL LABORATORY INDEPENDENT DIAGNOSTIC TESTING FACILITY (IDTF) INTENSIVE CARDIAC REHABILITATION MAMMOGRAPHY CENTER MASS IMMUNIZATION (ROSTER BILLER ONLY) OPIOID TREATMENT PROGRAM (OTP) OTHER PHARMACY PHYSICAL/OCCUPATIONAL THERAPY GROUP IN PRIVATE PRACTICE PORTABLE X-RAY SUPPLIER RADIATION THERAPY CENTER

DMEPOS Supplier Services

Part B DMEPOS Supplier Type Select Part B DMEPOS Supplier Type AMBULANCE SERVICE SUPPLIER AMBULATORY SURGICAL CENTER CERTIFIED CLINICAL NURSE SPECIALIST CERTIFIED NURSE MIDWIFE CERTIFIED ORTH/PROS/PEDORTHIST CERTIFIED REGISTERED NURSE ANESTHETISTS CLINICAL PSYCHOLOGIST DEPARTMENT STORE GROCERY STORE HOME HEALTH AGENCY HOSPITAL INDEPENDENT PHYSIOLOGICAL LAB INDEPENDENTLY-BILLING AUDIOLOGIST INDEPENDENTLY-BILLING CLINICAL LAB INDEPENDENTLY-BILLING PSYCHOLOGIST INDEPENDENTLY-PRACTICING OCCUPATIONAL THERAPIST INDEPENDENTLY-PRACTICING PHYSICAL THERAPIST INDIAN HEALTH SERVICE OR TRIBAL FACILITY LICENSED CLINICAL SOCIAL WORKER MEDICAL SUPPLY COMPANY MEDICAL SUPPLY COMPANY WITH ORTHOTIC PERSONNEL MEDICAL SUPPLY COMPANY WITH ORTHOTIC-PROSTHETIC MEDICAL SUPPLY COMPANY WITH PEDORTHIC PERSONNEL MEDICAL SUPPLY COMPANY WITH PROSTHETIC PERSONNEL MEDICAL SUPPLY COMPANY WITH REGISTERED PHARMACIST MEDICAL SUPPLY COMPANY WITH RESPIRATORY THERAPIST MULTI-SPECIALTY - PHYSICIAN NURSE PRACTITIONER NURSING FACILITY NURSING FACILITY INTERMEDIATE CARE OCULARIST OPTICIAN ORAL SURGERY - DENTIST ORTHOTIC PERSONNEL OTHER OXYGEN & EQUIPMENT PEDORTHIC PERSONNEL PHARMACY PHYSICIAN - ADDICTION MEDICINE PHYSICIAN - ALLERGY/IMMUNOLOGY PHYSICIAN - ANESTHESIOLOGY PHYSICIAN - CARDIAC SURGERY PHYSICIAN - CARDIOLOGY PHYSICIAN - CHIROPRACTIC PHYSICIAN - COLORECTAL SURGERY (FORMERLY PROCTOLOGY) PHYSICIAN - CRITICAL CARE INTENSIVISTIST PHYSICIAN - DERMATOLOGY PHYSICIAN - DIAGNOSTIC RADIOLOGY PHYSICIAN - EMERGENCY MEDICINE PHYSICIAN - ENDOCRINOLOGY PHYSICIAN - FAMILY PRACTICE PHYSICIAN - GASTROENTEROLOGY PHYSICIAN - GENERAL PRACTICE PHYSICIAN - GENERAL SURGERY PHYSICIAN - GERIATRIC MEDICINE PHYSICIAN - HAND SURGERY PHYSICIAN - HEMATOLOGY PHYSICIAN - HEMATOLOGY/ONCOLOGY PHYSICIAN - INFECTIOUS DISEASE PHYSICIAN - INTERNAL MEDICINE PHYSICIAN - INTERVENTIONAL PAIN MANAGEMENT PHYSICIAN - INTERVENTIONAL RADIOLOGY PHYSICIAN - MAXILLOFACIAL SURGERY PHYSICIAN - MEDICAL ONCOLOGY PHYSICIAN - NEPHROLOGY PHYSICIAN - NEUROLOGY PHYSICIAN - NEUROPSYCHIATRY PHYSICIAN - NEUROSURGERY PHYSICIAN - NUCLEAR MEDICINE PHYSICIAN - OBSTETRICS/GYNECOLOGY PHYSICIAN - OPHTHALMOLOGY PHYSICIAN - OPTOMETRIST PHYSICIAN - ORTHOPEDIC/ORTHOPEDIC SURGERY PHYSICIAN - OSTEOPATHIC MANIPULATIVE MEDICINE PHYSICIAN - OTOLARYNGOLOGY PHYSICIAN - PATHOLOGY PHYSICIAN - PEDIATRIC MEDICINE PHYSICIAN - PERIPHERAL VASCULAR DISEASE PHYSICIAN - PHYSICAL AND REHABILITATION PHYSICIAN - PLASTIC AND RECONSTRUCTIVE SURGERY PHYSICIAN - PODIATRY PHYSICIAN - PREVENTIVE MEDICINE PHYSICIAN - PSYCHIATRY PHYSICIAN - PULMONARY DISEASE PHYSICIAN - RADIATION ONCOLOGY PHYSICIAN - RHEUMATOLOGY PHYSICIAN - SURGICAL ONCOLOGY PHYSICIAN - THORACIC SURGERY PHYSICIAN - UNKNOWN PHYSICIAN SPECIALTY PHYSICIAN - UROLOGY PHYSICIAN - VASCULAR SURGERY PHYSICIAN ASSISTANT PORTABLE X-RAY SUPPLIER PROSTHETIC PERSONNEL PUBLIC HEALTH OR WELFARE AGENCIES REHABILITATION AGENCY SKILLED NURSING FACILITY OTHER SLEEP LABORATORY/MEDICINE SPORTS MEDICINE UNKNOWN SUPPLIER/PROVIDER VOLUNTARY HEALTH OR CHARITABLE AGENCIES

MDPP Supplier Services

Part B MDPP Supplier Type Select Part B MDPP Supplier Type IN-PERSON MDPP SUPPLIER

Part A Provider Services

Part A Provider Type Select Part A Provider Type COMMUNITY MENTAL HEALTH CENTER COMPREHENSIVE OUTPATIENT REHABILITATION FACILITY CRITICAL ACCESS HOSPITAL END-STAGE RENAL DISEASE FACILITY (ESRD) FEDERALLY QUALIFIED HEALTH CENTER (FQHC) HISTOCOMPATIBILITY LABORATORY HOME HEALTH AGENCY HOSPICE HOSPITAL INDIAN HEALTH SERVICES FACILITY INDIAN HEALTH SERVICES RURAL EMERGENCY HOSPITAL ORGAN PROCUREMENT ORGANIZATION (OPO) OTHER OUTPATIENT PHYSICAL THERAPY/OCCUPATIONAL THERAPY/SPEECH PATHOLOGY SERVICES RELIGIOUS NON-MEDICAL HEALTH CARE INSTITUTION (RNHCI) RURAL EMERGENCY HOSPITAL (REH) RURAL HEALTH CLINIC SKILLED NURSING FACILITY

* Other Type Specification

* State/Territory

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*FFS Contractor


* The answer to 13 + 4 is


§ Note: NPI is Not required for Organ Procurement Organization or Part B CAP Drug Vendor provider/supplier types.