Provider Demographics
NPI:1821097684
Name:GUARDIAN ANGEL OUTPATIENT REHAB INC
Entity Type:Organization
Organization Name:GUARDIAN ANGEL OUTPATIENT REHAB INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO/OWNER
Authorized Official - Prefix:
Authorized Official - First Name:SAM
Authorized Official - Middle Name:D
Authorized Official - Last Name:KASSAB
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:248-293-2400
Mailing Address - Street 1:1715 NORTHFIELD DR
Mailing Address - Street 2:
Mailing Address - City:ROCHESTER HILLS
Mailing Address - State:MI
Mailing Address - Zip Code:48309-3819
Mailing Address - Country:US
Mailing Address - Phone:248-293-2400
Mailing Address - Fax:248-293-2401
Practice Address - Street 1:34612 DEQUINDRE RD
Practice Address - Street 2:SUITE C
Practice Address - City:STERLING HTS
Practice Address - State:MI
Practice Address - Zip Code:48310-5233
Practice Address - Country:US
Practice Address - Phone:586-983-4101
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-07-14
Last Update Date:2013-01-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI261QP2000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2000XAmbulatory Health Care FacilitiesClinic/CenterPhysical Therapy
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI164198OtherGREAT LAKES HEALTH PLAN
MI30635OtherBCBSM
MI025370OtherMIDWEST HEALTH PLAN
MI1029053OtherMCLAREN HEALTH PLAN
MI236840Medicare Oscar/Certification