Provider NPI Submission - Berkshire Health Partners

Please complete the following form to provide Berkshire Health Partners with your practitioner NPI number and practice NPI numbers (if applicable). Please take the time to fully complete this form. If the form is incomplete we may need to contact you to attempt to gather all of the information that we require to properly match NPI numbers to practitioners and/or practices.

Practitioner Information
	Practitioner Name:
	Practitioner UPIN:
	Practitioner NPI:

Primary Practice Information
	Practice Name:
	Address Line 1:
	Address Line 2:
	City:
	State:
	Zip Code:
	Tax ID:
	Practice NPI:

Other practice locations for this practitioner
	Location 2	Address 1:
		Address 2:
		City: State: Zip:
		Practice NPI:
	Location 3	Address 1:
		Address 2:
		City: State: Zip:
		Practice NPI:
	Location 4	Address 1:
		Address 2:
		City: State: Zip:
		Practice NPI:
	Location 5	Address 1:
		Address 2:
		City: State: Zip:
		Practice NPI:
	Location 6	Address 1:
		Address 2:
		City: State: Zip:
		Practice NPI:
	Location 7	Address 1:
		Address 2:
		City: State: Zip:
		Practice NPI:
	Location 8	Address 1:
		Address 2:
		City: State: Zip:
		Practice NPI:
	Location 9	Address 1:
		Address 2:
		City: State: Zip:
		Practice NPI:
	Location 10	Address 1:
		Address 2:
		City: State: Zip:
		Practice NPI:

This form can be submitted a second time if more than 10 locations are required

Contact Information
Who may we contact if there are any questions about the information submitted?
	Contact Name:
	Phone Number:
	Email Address:

	I hereby certify that, to the best of my knowledge, the information entered above is correct.