1851344063 NPI number — BSA LLC

Table of content: (NPI 1851344063)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1851344063 NPI number — BSA LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
BSA LLC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
BREVARD SURGICAL ASSOCIATES TEPAS HEALTHCARE
Provider Other Organization Name Type Code:
3
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1851344063
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
04/11/2012
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 33428
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
INDIALANTIC
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
32903-0428
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
321-733-1901
Provider Business Mailing Address Fax Number:
321-733-0211

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1140 BROADBAND DR
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
MELBOURNE
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
32901-2623
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
321-733-1901
Provider Business Practice Location Address Fax Number:
321-733-0211
Provider Enumeration Date:
05/18/2006

Additional Information

Authorized Official

Authorized Official Last Name:
IMAMI
Authorized Official First Name:
EMRAN
Authorized Official Middle Name:
RIAZ
Authorized Official Title or Position:
OWNER PHYSICIAN
Authorized Official Telephone Number:
321-733-1901

Provider Taxonomy Codes

  • Taxonomy code: 208600000X , with the licence number:  ME56101 , registered in the state of FL ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 370625700 , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".
  • Identifier: 15274 . This is a "BLUE CROSS" identifier , issued by the state of ( FL ) . This identifiers is of the category "OTHER".




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