Provider Demographics
NPI:1730622747
Name:GUARDIAN NETWORK
Entity type:Organization
Organization Name:GUARDIAN NETWORK
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PATHOLOGIST
Authorized Official - Prefix:DR
Authorized Official - First Name:THOMAS
Authorized Official - Middle Name:ANDRE DUANE
Authorized Official - Last Name:GIBSON
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:301-278-7470
Mailing Address - Street 1:2020 BROOKS DR APT 218
Mailing Address - Street 2:
Mailing Address - City:DISTRICT HEIGHTS
Mailing Address - State:MD
Mailing Address - Zip Code:20747-1047
Mailing Address - Country:US
Mailing Address - Phone:301-278-7470
Mailing Address - Fax:
Practice Address - Street 1:2020 BROOKS DR APT 218
Practice Address - Street 2:
Practice Address - City:DISTRICT HEIGHTS
Practice Address - State:MD
Practice Address - Zip Code:20747-1047
Practice Address - Country:US
Practice Address - Phone:301-278-7470
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-11-22
Last Update Date:2016-11-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA001282NC0060X, 225XP0019X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225XP0019XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistPhysical RehabilitationGroup - Multi-Specialty
No282NC0060XHospitalsGeneral Acute Care HospitalCritical AccessGroup - Multi-Specialty