All covered health care providers, health plans and health care clearinghouse must use a 10-digit National Provider Identifier(NPI) in their administrative and financial transactions, as required by HIPAA Administrative Simplification regulations.
The information below helps you to identify which NPI(s) you may need and how to obtain those.
Types of NPIs
Type 1 NPI—Individual health care providers who are sole proprietors (not incorporated)
- Individual health care providers must submit claims under their Social Security number, not an employee identification number (EIN) or taxpayer identification number (TIN). If you use a tax ID and/or business name, you are not considered a sole proprietor.
- Note: An incorporated individual is a single health care provider who forms and conducts business under a corporation. A sole proprietor isn’t an incorporated individual because the sole proprietor didn’t form a corporation. If you’re a sole practitioner or solo practitioner, it doesn’t mean you’re a sole proprietor and vice versa.
Type 2 NPI—Organization health care providers who are incorporated (incorporated individuals), group practices, clinics, county health departments and partnerships
- Organization health care providers may have one or thousands of employees.
- If you’re an individual health care provider who has incorporated, you may need to get an NPI for yourself (Type 1) and an NPI for the corporation or LLC (Type 2).
- On claims, the Type 2 NPI identifies the payee and may be submitted in conjunction with a Type 1 NPI to identify the dentist who provided treatment. Example: On a standard ADA dental claim form, the treating dentist’s NPI is entered in addition to the billing entity’s NPI.
Which NPI do you need?
Type 1 NPIs are required on all claims submissions to indicate which provider performed services. To determine whether you need to obtain a Type 2 NPI, ask yourself:
- Who will receive payment? For example, will John Smith, DDS (individual) receive payment for services or will John Smith Dental, PLLC (legal entity)? If John Smith Dental, PLLC will receive payment, a Type 2 NPI is required.
- What TIN was the claim submitted under? If you submitted a claim under the TIN associated with your business, you will need a Type 2. For example, if the TIN that John Smith, DDS submits on his claims is connected to John Smith Dental, PLLC, then a Type 2 NPI is required because the TIN submitted on Dr. Smith’s claims is the legal entity’s TIN.
|Sole proprietor/solo practitioner
||Type 1 only, if claims are transmitted in the dentist’s name and SSN
|Individual dentist at one practice location, but has incorporated (incorporated individual)
||Type 1 for the dentist and Type 2 for the practice, if claims are transmitted in the practice’s name and TIN
|Multiple dentists at one practice location (group practice, partnership)
||Type 1 for each dentist and Type 2 for the practice, if claims are transmitted in the practice’s name and TIN
|Multiple dentists at multiple practices (clinics, dental service organizations, etc.)
||Type 1 for each dentist and Type 2 for each practice, with a separate TIN
Apply for an NPI
There are three options to obtain an NPI:
- Apply through the National Plan and Provider Enumeration System (NPPES) at https://nppes.cms.hhs.gov/#/. Individual providers must create a username and password through the Identity and Access Management System, then log in to NPPES using that username and password.
- Mail a paper application, Form CMS-10114 NPI Application/Update Form, to the NPI Enumerator address listed on the form. To request a hard copy application, call 800-465-3203 or TTY 800-692-2326, or email firstname.lastname@example.org.
- Give permission to an electronic file interchange organization to submit application data through a bulk enumeration process.