Register your National Provider Identifier (NPI) with
LIPA/EHA/TRILLIUM
Please seperate multiple taxonomy numbers with commas.
Office
Name of office:
Contact name:
Phone:
Address:
City:
State:
Zip:
Physician/Provider 1
Last name:
First name:
Middle name:
DOB (mm/dd/yyy):
Address (clinic):
City:
State:
Zip:
Phone:
Fax:
Email:
Tax ID:
Taxonomy:
OMAP ID No.:
NPI:
Medicare ID No.:
Facility 1
Name:
Address:
City:
State:
Zip:
NPI:
Taxonomy:
Medicare ID No.: