MEDICARE: DR. THEODOR ASGEIRSSON MD

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	208600000X	Surgery Physician	217561	MA
2	208C00000X	Colon & Rectal Surgery Physician	A112879	CA

General Provider Information

NPI Number	:	1255480067
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. THEODOR ASGEIRSSON MD

Provider Business Mailing Address
First Line	:	421 S BALDWIN ST
Second Line	:
City	:	GREENVILLE
State	:	MI
Zip	:	48838-2102
Country	:	US
Telephone Number	:	616-225-8667
Fax Number	:

Provider Business Practice Location Address
First Line	:	421 S BALDWIN ST
Second Line	:
City	:	GREENVILLE
State	:	MI
Zip	:	48838-2102
Country	:	US
Telephone Number	:	616-225-8667
Fax Number	:

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

Provider Enumeration Date	:	01/10/2007
Last Update Date	:	09/19/2012

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