Provider Demographics
NPI:1851344063
Name:BSA LLC
Entity Type:Organization
Organization Name:BSA LLC
Other - Org Name:BREVARD SURGICAL ASSOCIATES TEPAS HEALTHCARE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER PHYSICIAN
Authorized Official - Prefix:
Authorized Official - First Name:EMRAN
Authorized Official - Middle Name:RIAZ
Authorized Official - Last Name:IMAMI
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:321-733-1901
Mailing Address - Street 1:PO BOX 33428
Mailing Address - Street 2:
Mailing Address - City:INDIALANTIC
Mailing Address - State:FL
Mailing Address - Zip Code:32903-0428
Mailing Address - Country:US
Mailing Address - Phone:321-733-1901
Mailing Address - Fax:321-733-0211
Practice Address - Street 1:1140 BROADBAND DR
Practice Address - Street 2:
Practice Address - City:MELBOURNE
Practice Address - State:FL
Practice Address - Zip Code:32901-2623
Practice Address - Country:US
Practice Address - Phone:321-733-1901
Practice Address - Fax:321-733-0211
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-18
Last Update Date:2012-04-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME56101208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208600000XAllopathic & Osteopathic PhysiciansSurgeryGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL370625700Medicaid
FL15274OtherBLUE CROSS
FL15274OtherBLUE CROSS
FL370625700Medicaid