National Provider Identifier (NPI) Notification Form

Report your NPI to Wellmark Blue Cross and Blue Shield using the form below. Please contact EC Solutions at 800-407-0267 if you have any questions.

  • If you have submitted your NPI to us already, do not resend.
  • If you have a group NPI, include it below even if you do not have a Wellmark group provider number.
  • Please provide the federal taxpayer identification number (TIN) you use on your claims. If you need to change the TIN Wellmark has on file, please complete the Provider Change Form and mail a completed and signed W-9 form.
  • To verify a previously reported NPI, TIN, or Social Security number, please e-mail providercredentialing@wellmark.com, or call the Network Administration area at 800-708-1342, option 2.
NPI Notification Type
Type of NPI Notification:  New Notification   Change to Existing Notification
Provider Information
Provider's Full Name:
(Facility, group name, or individual's last name, first name, middle initial)
Address:
City/State/Zip:
Phone:
Fax:
E-mail Address:
NPI Numbers
Please provide the information below for each NPI received. To help validate ownership of the assigned NPI, e-mail a copy of the confirmation notice(s) you received from the Enumerator for each NPI to Terry Demaray at demaraytl@wellmark.com
Wellmark Group Number: Group NPI (10 digits): Taxpayer ID Number:
Wellmark Individual Number: Individual NPI (10 digits): Taxpayer ID Number:
Contact Information
Please provide a contact who can provide additional information if we have questions.
Contact Name:
Contact Phone:
Contact E-mail Address:

 

 

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Wellmark Blue Cross and Blue Shield is an Independent Licensee of the Blue Cross and Blue Shield Association doing business in Iowa and South Dakota.
 
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