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Change of Tax ID Instructions and Forms

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Certified Providers and Certain Other Suppliers

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Clinics/Group Practices

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Sole Owner/Sole Proprietor

This can be completed using the paper form or online using the Internet-based PECOS.

Forward your completed forms to the appropriate National Government Services office.

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Effective Dates When Changing a Tax ID For Clinics/Group Practices

If both the application for the clinic/group practice and the reassignment of benefits applications are submitted together and all enrollment requirements are met, all will have the same effective date.

Any reassignment of benefits application submitted after the clinic/group practice application, the individual provider’s effective date will be based on the date the approved reassignment of benefits application is received per CMS IOM Publication 100-08, Medicare Program Integrity Manual, Chapter 10, Section 10.6.2.

Revised 11/15/2021

Helpful Resources

Check Provider Enrollment Application Status
Log Into PECOS
Pay Application Fee

J6 Mailing Address:

National Government Services, Inc.
P.O. Box 6475
Indianapolis, IN 46206-6475

Interactive Voice Response:

877-908-9499

Contact Enrollment:

877-908-8476

Hours Available:

Monday–Friday
8:00 a.m.–4:00 p.m. CT

Form(s) you'll need:

Enrollment Forms

Helpful Resources

Check Provider Enrollment Application Status
Log Into PECOS
Pay Application Fee

JK Mailing Address:

National Government Services, Inc.
P.O. Box 7149
Indianapolis, IN 46207-7149

Interactive Voice Response:

877-869-6504

Contact Enrollment:

888-379-3807

Hours Available:

Monday–Friday
8:00 a.m.–4:00 p.m. ET

Form(s) you'll need:

Enrollment Forms