Health Providers DB includes the National Plan and Provider Enumeration System (NPPES) NPI Registry database in the Healthcare Provider’s profile.
Per 42 CFR Part §455.436 — Federal database checks, State Medicaid agencies must do all of the following:
(a) Confirm the identity and determine the exclusion status of providers and any person with an ownership or control interest or who is an agent or managing employee of the provider through routine checks of Federal databases.
(b) Check the Social Security Administration’s Death Master File, the National Plan and Provider Enumeration System (NPPES), the List of Excluded Individuals/Entities (LEIE), the System for Award Management (SAM) (formerly the Excluded Parties List System (EPLS)), and any such other databases as the Secretary may prescribe.
(c)(1) Consult appropriate databases to confirm identity upon enrollment and re-enrollment; and
(c)(2) Check the LEIE and SAM (formerly the EPLS) no less frequently than monthly.
Health Providers DB updates the Healthcare Provider Profiles with the NPPES NPI Registry database daily.
About the NPPES NPI Registry
The Centers for Medicare & Medicaid Services (CMS) is the federal agency that developed the National Plan and Provider Enumeration System (NPPES) to assign unique National Provider Identifier (NPI) numbers for healthcare providers and health plans, as mandated by the Administrative Simplification provisions of the Health Insurance Portability and Accountability Act of 1996 (HIPAA).
From a practical standpoint, the issuance of an NPI was instrumental in facilitating the replacement of several legacy provider identifier systems. Pre-NPI provider identifiers replaced by the NPI system include the Unique Physician Identification Number (UPIN), the Personal Identification Number (PIN), the Online Survey Certification & Reporting (OSCAR) system, and the National Supplier Clearinghouse (NSC) number system used in connection with DMERC claims.
Before enrolling in the Medicare program, a healthcare provider or entity is required to have an NPI. There are two types of NPIs:
Type 1 is at the individual practitioner level. For example, physicians, mid-level providers, dentists and sole proprietors fall under this category.
Type 2 is at the organizational level. For example, physician groups, hospitals, nursing and corporations fall under this category.
Individual healthcare providers who desire to incorporate may need to obtain an NPI for himself/herself (Type 1) and an NPI for their corporation or LLC (Type 2).
HIPAA-covered providers must share their NPI with other healthcare providers, health plans, clearinghouses, and other entities that need it for billing purposes.
Issuing an NPI does not mean that Medicare, Medicaid, or any other health plan has credentialed an individual or organization. To participate in a government or private-payer health plan, healthcare providers must still undergo a separate credentialing process.
NPPES NPI Registry Data Collected
The Health Providers DB includes the following details from the NPPES NPI database. Links to the Clinical Trial data are provided for reference and research.
https://download.cms.gov/nppes/NPI_Files.html
| Field Name |
|---|
| NPI |
| Entity Type Code |
| Employer Identification Number (EIN) |
| Provider Organization Name (Legal Business Name) |
| Provider Last Name (Legal Name) |
| Provider First Name |
| Provider Middle Name |
| Provider Name Prefix Text |
| Provider Name Suffix Text |
| Provider Credential Text |
| Provider Other Organization Name |
| Provider Other Organization Name Type Code |
| Provider Other Last Name |
| Provider Other First Name |
| Provider Other Middle Name |
| Provider Other Name Prefix Text |
| Provider Other Name Suffix Text |
| Provider Other Name Credential Text |
| Provider Other Last Name Type Code |
| Provider First Line Business Mailing Address |
| Provider Second Line Business Mailing Address |
| Provider Business Mailing Address City Name |
| Provider Business Mailing Address State Name |
| Provider Business Mailing Address Postal Code |
| Provider Business Mailing Address Country Code (If outside U.S.) |
| Provider Business Mailing Address Telephone Number |
| Provider Business Mailing Address Fax Number |
| Provider First Line Business Location Address |
| Provider Second Line Business Location Address |
| Provider Business Location Address City Name |
| Provider Business Location Address State Name |
| Provider Business Location Address Postal Code |
| Provider Business Location Address Country Code (If outside U.S.) |
| Provider Business Location Address Telephone Number |
| Provider Business Location Address Fax Number |
| Provider Enumeration Date |
| Last Update Date |
| NPI Deactivation Reason Code |
| NPI Deactivation Date |
| NPI Reactivation Date |
| Provider Gender Code |
| Authorized Official Last Name |
| Authorized Official First Name |
| Authorized Official Middle Name |
| Authorized Official Title or Position |
| Authorized Official Telephone Number |
| Healthcare Provider Taxonomy Code |
| Provider License Number |
| Provider License Number State Code |
| Other Provider Identifier |
| Other Provider Identifier Type Code |
| Provider Organization Subpart TIN |
| Authorized Official Name Prefix Text |
| Authorized Official Name Suffix Text |
| Authorized Official Credential Text |
| Healthcare Provider Taxonomy Group |