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17b. NPI#
NPI#
25. Federal Tax ID Number
Federal Tax ID Number Do not enter hyphens with numbers.
32. Service Facility Location Information
1st Line – Name 2nd Line – Address 3rd Line – City, State and Zip Code. To separate lines, please type a hyphen, which won't be printed. Instructions: Do not use commas, periods, or other punctuation in the address. When entering a 9 digit zip code, include the hyphen.
32a. NPI number.
Enter the NPI number of the service facility location in 32.
32b. Other ID#
Enter the two digit qualifier identifying the non-NPI number followed by the ID number. Do not enter a space, hyphen, or other separator between the qualifier and number.
33. Billing Provider Info & Ph #.
Enter the provider’s or supplier’s billing name, address, zip code, and phone number. Enter the name and address information in the following format: 1st Line – Name 2nd Line – Address 3rd Line – City, State and Zip Code. To separate lines, please type a hyphen, which won't be printed. Instructions: Do not use commas, periods, or other punctuation in the address. Enter a space between town name and state code; do not include a comma. When entering a 9 digit zip code, include the hyphen. Do not use a hyphen or space as a separator within the telephone number.
33a. NPI#
Enter the NPI number of the billing provider in 33.
33b. Other ID#
Enter the two digit qualifier identifying the non-NPI number followed by the ID number. Do not enter a space, hyphen, or other separator between the qualifier and number.
Other comments.
Enter any additional comments or questions here.
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