MEDICARE: TOP FORM INC.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	332B00000X	Durable Medical Equipment & Medical Supplies

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	045X2	OTHER	NC	BLUE CROSS AND BLUE SHIEL

General Provider Information

NPI Number	:	1598750010
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	TOP FORM INC.

Provider Business Mailing Address
First Line	:	PO BOX 1594
Second Line	:
City	:	WILMINGTON
State	:	NC
Zip	:	28402-1594
Country	:	US
Telephone Number	:	910-392-5806
Fax Number	:	910-452-2913

Provider Business Practice Location Address
First Line	:	1731 DAWSON ST
Second Line	:
City	:	WILMINGTON
State	:	NC
Zip	:	28403-2326
Country	:	US
Telephone Number	:	910-392-5806
Fax Number	:	910-452-2913

Authorized Official
Title or Position	:	CEO
Name	:	MR. MARTIN GALLAN
Credential	:
Telephone Number	:	910-392-5806

Provider Enumeration Date	:	09/12/2005
Last Update Date	:	08/22/2020

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Directions to “TOP FORM INC. ” Practice Location

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