Organization
BSA LLC
Active
Other names
Brevard Surgical Associates TEPAS Healthcare
Organization subpart
No
Provider details
NPI number
Authorized official
EMRAN RIAZ IMAMI M.D. (OWNER PHYSICIAN)
(321) 733-1901
Entity
Organization
Contact information
Practice address
1140 BROADBAND DR, MELBOURNE, FL 32901-2623
(321) 733-1901
(321) 733-0211
Mailing address
PO BOX 33428, INDIALANTIC, FL 32903-0428
(321) 733-1901
(321) 733-0211
Taxonomy
Speciality
Code
Description
License number
State
208600000X
Surgery Physician
Primary
ME56101
FL
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
15274
BLUE CROSS
FL
05
—
370625700
—
FL
Enumeration date
05/18/2006
Last updated
04/11/2012
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