=====================================================
General NPI Number Information
=====================================================
NPI Number | 1245985175
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | PHYSITEAM HEALTH LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/18/2022
-----------------------------------------------------
Last Update Date | 03/07/2022
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2517 RUSSWOOD DR
-----------------------------------------------------
City | FLOWER MOUND
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 75028-2346
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 214-284-8638
-----------------------------------------------------
Fax | 833-606-1315
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2517 RUSSWOOD DR
-----------------------------------------------------
City | FLOWER MOUND
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 75028-2346
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 214-284-8638
-----------------------------------------------------
Fax | 833-606-1315
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER/PHYSICAL THERAPIST
-----------------------------------------------------
Name | MR. JOHN KEEGAN MCCONNELL
-----------------------------------------------------
Credential | PT
-----------------------------------------------------
Telephone | 214-284-8638
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QP2000X
-----------------------------------------------------
Taxonomy Name | Physical Therapy Clinic/Center
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------