US · guidance
CMS Pub. 100-06, ch. 6, § 430.3
Type of Provider
B3-13430.3
The carrier reports provider enrollment application data in the following columns for all lines on
Form 4.
Column (1) - Total - The sum of columns 2-24 for each line.
Column (2) - Physician - Provider applications for specialty codes 1-8, 10-14, 16, 18-20, 22, 24-
26, 28-30, 33-41, 44, 46, 48, 66, 76-79, 81-86, 90-94, 98, and 99.
Column (3) - Group - Provider applications for specialty code 70.
Column (4) - Certified Nurse Midwife - Provider applications for specialty code 42.
Column (5) - Certified Registered Nurse Anesthetist - Provider applications for specialty code 43.
Column (6) - Nurse Practitioner - Provider applications for specialty code 50.
Column (7) - Ambulance Service Supplier - Provider applications for specialty code 59.
Column (8) - Independent Audiologist - Provider applications for specialty code 64.
Column (9) - Independent Physical Therapist - Provider applications for specialty code 65.
Column (10) - Independent Occupational Therapist - Provider applications for specialty code 67.
Column (11) - Clinical Psychologist - Provider applications for specialty code 68.
Column (12) - Licensed Clinical Social Worker - Provider applications for specialty code 80.
Column (13) - Certified Nurse Specialist - Provider applications for specialty code 89.
Column (14) - Independent Physiological Laboratory - Provider applications for specialty code
95.
Column (15) - Physician Assistant - Provider applications for specialty code 97.
Column (16) - Mammography Screening Center - Provider applications for specialty code 45.
Column (17 - Ambulatory Surgical Center - Provider applications for specialty code 49.
Column (18) - Public Health/Welfare Agency - Provider applications for specialty code 60.
Column (19) - Voluntary Health/Charitable Agency - Provider applications for specialty code 61.
Column (20) - Independent Psychologist - Provider applications for specialty code 62.
Column (21) - Portable X-Ray - Provider applications for specialty code 63.
Column (22) - Independent Clinical Laboratory - Provider applications for specialty code 69.
Column (23) - Unknown Supplier/Provider - Provider applications for specialty code 88.
Column (24) - Flu Immunization Biller - Providers applications from individuals identified as
flu immunization billers.
History
(Rev. 6, 08-30-02)
Provenance
- Source
- cms.gov
- Retrieved
- 2026-08-25
- Edition
- iom-2026-08-25
- Content hash
f5c8e7d03502517e865a464beb47ba38fa7a08d200d971db174e49366cbe4fdc
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