=====================================================
General NPI Number Information
=====================================================
NPI Number | 1740476985
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | FLOWER MOUND MEDICAL CENTER, LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/21/2007
-----------------------------------------------------
Last Update Date | 04/19/2013
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2261 OLYMPIA DR
-----------------------------------------------------
City | FLOWER MOUND
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 75028-1857
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 972-691-8585
-----------------------------------------------------
Fax | 972-691-8686
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2261 OLYMPIA DR SUITE 100
-----------------------------------------------------
City | FLOWER MOUND
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 75028-1857
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 972-691-8585
-----------------------------------------------------
Fax | 972-691-8686
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PHYSICIAN
-----------------------------------------------------
Name | DR. ROYA SEYSAN
-----------------------------------------------------
Credential | M.D.
-----------------------------------------------------
Telephone | 972-691-8585
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 174400000X
-----------------------------------------------------
Taxonomy Name | Specialist
-----------------------------------------------------
License Number | J5896
-----------------------------------------------------
License Number State | TX
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 207Q00000X
-----------------------------------------------------
Taxonomy Name | Family Medicine Physician
-----------------------------------------------------
License Number | J5896
-----------------------------------------------------
License Number State | TX
-----------------------------------------------------