Olympic Online NPI Provider Reference

Important Information Concerning the National Provider Identifier (NPI)


Instructions: Please complete Section A of the form once. If there is only one combination of NPI and legacy numbers fill out Section B once. If there is more than one combination of NPI and legacy numbers, then add and complete an additional Section B to account for each combination.


* Indicates a Required Field
Section A

*Organization Name:

Professional First Name:

Professional Last Name:

*Tax ID:

*Pay To - Address 1:

Pay To - Address 2:

*City:

*State:

*Zip:

*Contact Name:

*Contact Phone Number:


  
Section B

*Medicare Provider ID:

UPIN:

*NPI:

Taxonomy Code:

*Physical Address 1:

Address 2:

*City:

*State:

*Zip:


*Indicates a Required Field