Provider Demographics
NPI:1588849780
Name:ROGER E BASSIN MD PA
Entity Type:Organization
Organization Name:ROGER E BASSIN MD PA
Other - Org Name:BASSIN CENTER FOR EYELID AND FACIAL PLASTIC SURGERY
Other - Org Type:Other Name
Authorized Official - Title/Position:OWNER/OPERATOR
Authorized Official - Prefix:
Authorized Official - First Name:ROGER
Authorized Official - Middle Name:E
Authorized Official - Last Name:BASSIN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:321-255-0025
Mailing Address - Street 1:1705 BERGLUND LN
Mailing Address - Street 2:SUITE 103
Mailing Address - City:VIERA
Mailing Address - State:FL
Mailing Address - Zip Code:32940-6231
Mailing Address - Country:US
Mailing Address - Phone:321-255-0025
Mailing Address - Fax:321-255-0027
Practice Address - Street 1:1705 BERGLUND LN
Practice Address - Street 2:SUITE 103
Practice Address - City:VIERA
Practice Address - State:FL
Practice Address - Zip Code:32940-6231
Practice Address - Country:US
Practice Address - Phone:321-255-0025
Practice Address - Fax:321-255-0027
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-01-07
Last Update Date:2010-08-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME85585207W00000X, 208200000X, 2082S0099X, 2086S0122X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2082S0099XAllopathic & Osteopathic PhysiciansPlastic SurgeryPlastic Surgery Within the Head and NeckGroup - Single Specialty
No207W00000XAllopathic & Osteopathic PhysiciansOphthalmologyGroup - Single Specialty
No208200000XAllopathic & Osteopathic PhysiciansPlastic SurgeryGroup - Single Specialty
No2086S0122XAllopathic & Osteopathic PhysiciansSurgeryPlastic and Reconstructive SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLAH792OtherMEDICARE PTAN
FLH20233Medicare UPIN