MEDICARE: MR. THEODORE DWAYNE GIBSON I CST/CFA

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	246ZS0410X	Surgical Technologist

General Provider Information

NPI Number	:	1639152473
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. THEODORE DWAYNE GIBSON I CST/CFA

Provider Business Mailing Address
First Line	:	1671 RUBY CT
Second Line	:
City	:	HOBART
State	:	IN
Zip	:	46342-6507
Country	:	US
Telephone Number	:	219-945-1572
Fax Number	:	219-945-1572

Provider Business Practice Location Address
First Line	:	1500 S LAKE PARK AVE
Second Line	:
City	:	HOBART
State	:	IN
Zip	:	46342-6638
Country	:	US
Telephone Number	:	219-947-6425
Fax Number	:	219-947-6424

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	11/25/2005
Last Update Date	:	07/08/2007

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