Practice Profile Sheet 8/31/2016

Completed By: ________________  Date: ____________

Specialty: ___________________ 

Taxonomy Code: _ _ _ _ _ _ _ _ _ _

Provider Name:

Practice Name:

Practice Complete Address:

Practice phone for statement questions:

Contact:

Contact Phone:                 Contact email:

Home Phone:

Cell#:

Inside or back phone line:

___________________________________________________________________

PIN Listing

Attending NPI: _ _ _ _ _ _ _ _ _ _  Corp NPI: _ _ _ _ _ _ _ _ _ _

TAX-ID:  _ _ _ _ _ _ _ _ _          SSN: _ _ _ _ _ _ _ _ _ (if needed)

UPIN:    _ _ _ _ _ _                Sole Practitioner: Y  N

State License: _ _ _ _ _ _ _ _      DEA: _ _ _ _ _ _ _ _ _

____________________________________________________________________

CLIA: _ _ _ _ _ _ _ _ _ _

Facility TAX-ID: _ _ _ _ _ _ _ _ _  ( if any )

Existing Billing Location Code: _ _ _ _ _   ( if any )

Multi Office Locations:  Yes or No: ______