MEDICARE: THEODORE F HOLLAND III 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	208800000X	Urology Physician	01026261A	IN

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
2	000000351008	OTHER	IN	ANTHEM PROVIDER NUMBER

General Provider Information

NPI Number	:	1417961103
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	THEODORE F HOLLAND III MD

Provider Business Mailing Address
First Line	:	679 E COUNTY LINE RD
Second Line	:
City	:	GREENWOOD
State	:	IN
Zip	:	46143-1049
Country	:	US
Telephone Number	:	317-890-2000
Fax Number	:	317-859-4269

Provider Business Practice Location Address
First Line	:	8240 NAAB ROAD
Second Line	:	SUITE 200
City	:	INDIANAPOLIS
State	:	IN
Zip	:	46260-1986
Country	:	US
Telephone Number	:	317-876-2330
Fax Number	:	317-876-2320

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

Provider Enumeration Date	:	07/28/2006
Last Update Date	:	03/16/2021

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