| Entity Name: | ROGER E BASSIN MD PA |
| Jurisdiction: | FLORIDA |
| Filing Type: | Domestic Profit |
| Status: | Active |
| Date Filed: | 22 Jun 2005 (20 years ago) |
| Document Number: | P05000089213 |
| FEI/EIN Number | 202998816 |
| Address: | 1705 BERGLUND LANE, SUITE 103, MELBOURNE, FL, 32940, US |
| Mail Address: | 1705 BERGLUND LANE, SUITE 103, MELBOURNE, FL, 32940, US |
| ZIP code: | 32940 |
| County: | Brevard |
| Place of Formation: | FLORIDA |
| NPI | Enumeration Date | Last Update Date | Mailing Address | Practice Location Address | |||||||||||||||||||||||||||||||||||||||||||||||||
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| 1588849780 | 2008-01-07 | 2024-07-17 | 1705 BERGLUND LN, SUITE 103, VIERA, FL, 329406231, US | 1705 BERGLUND LN, SUITE 103, VIERA, FL, 329406231, US | |||||||||||||||||||||||||||||||||||||||||||||||||
|
|||||||||||||||||||||||||||||||||||||||||||||||||||||
| Phone | +1 321-255-0025 |
| Fax | 3212550027 |
Authorized person
| Name | ROGER E BASSIN |
| Role | OWNER/OPERATOR |
| Phone | 3212550025 |
Taxonomy
| Taxonomy Code | 207W00000X - Ophthalmology Physician |
| License Number | ME85585 |
| State | FL |
| Is Primary | No |
| Taxonomy Code | 208200000X - Plastic Surgery Physician |
| License Number | ME85585 |
| State | FL |
| Is Primary | No |
| Taxonomy Code | 2082S0099X - Plastic Surgery Within the Head and Neck (Plastic Surgery) Physician |
| License Number | ME85585 |
| State | FL |
| Is Primary | Yes |
| Taxonomy Code | 2086S0122X - Plastic and Reconstructive Surgery Physician |
| License Number | ME85585 |
| State | FL |
| Is Primary | No |
Other Provider Identifiers
| Issuer | MEDICARE PTAN |
| Number | AH792 |
| State | FL |
| Name | Role |
|---|---|
| C T CORPORATION SYSTEM | Agent |
| Name | Role | Address |
|---|---|---|
| BASSIN ROGER E | President | 1705 BERGLUND LANE, MELBOURNE, FL, 32940 |
| Registration Number | Fictitious Name | Status | Filed Date | Expiration Date | Cancellation Date | Mailing Address |
|---|---|---|---|---|---|---|
| G16000023037 | OPPENHEIMER PLASTIC SURGERY | EXPIRED | 2016-03-03 | 2021-12-31 | No data | 1705 BERGLUND LANE, SUITE 103, VIERA, FL, 32940 |
| G16000018297 | AQUA LIPO BODY SCULPTING CENTER | ACTIVE | 2016-02-19 | 2026-12-31 | No data | 1705 BERGLUND LANE, SUITE 103, VIERA, FL, 32940 |
| G15000088253 | JACKSONVILLE HAIR RESTORATION CENTER | ACTIVE | 2015-08-26 | 2025-12-31 | No data | 1705 BERGLUND LANE, SUITE 103, VIERA, FL, 32940 |
| G15000088257 | MELBOURNE HAIR RESTORATION CENTER | ACTIVE | 2015-08-26 | 2025-12-31 | No data | 1705 BERGLUND LANE, SUITE 103, VIERA, FL, 32940 |
| G13000002398 | JACKSONVILLE HAIR RESTORATION | EXPIRED | 2013-01-07 | 2018-12-31 | No data | 1705 BERGLUND LANE, SUITE 103, MELBOURNE, FL, 32940 |
| G12000084806 | TAMPA HAIR RESTORATION CENTER | ACTIVE | 2012-08-28 | 2027-12-31 | No data | 1705 BERGLUND LANE, SUITE 103, VIERA, FL, 32940 |
| G12000075308 | ORLANDO HAIR MD | EXPIRED | 2012-07-30 | 2017-12-31 | No data | 1705 BERGLUND LANE, SUITE 103, MELBOURNE, FL, 32940 |
| G12000075302 | ORLANDO HAIR RESTORATION CENTER | ACTIVE | 2012-07-30 | 2027-12-31 | No data | 1705 BERGLUND LANE, SUITE 103, VIERA, FL, 32940 |
| G10000072040 | THE BASSIN CENTER FOR PLASTIC SURGERY | ACTIVE | 2010-08-05 | 2025-12-31 | No data | 1705 BERGLUND LANE, SUITE 103, VIERA, FL, 32940 |
| Event Type | Filed Date | Value | Description |
|---|---|---|---|
| REGISTERED AGENT NAME CHANGED | 2024-08-09 | C T CORPORATION SYSTEM | No data |
| REGISTERED AGENT ADDRESS CHANGED | 2024-08-09 | 1200 SOUTH PINE ISLAND ROAD, PLANTATION, FL 33324 | No data |
| CHANGE OF PRINCIPAL ADDRESS | 2009-04-03 | 1705 BERGLUND LANE, SUITE 103, MELBOURNE, FL 32940 | No data |
| CHANGE OF MAILING ADDRESS | 2009-04-03 | 1705 BERGLUND LANE, SUITE 103, MELBOURNE, FL 32940 | No data |
| Name | Date |
|---|---|
| Reg. Agent Change | 2024-08-09 |
| ANNUAL REPORT | 2024-01-31 |
| ANNUAL REPORT | 2023-01-26 |
| ANNUAL REPORT | 2022-01-25 |
| ANNUAL REPORT | 2021-01-27 |
| ANNUAL REPORT | 2020-06-30 |
| ANNUAL REPORT | 2019-02-07 |
| ANNUAL REPORT | 2018-01-16 |
| ANNUAL REPORT | 2017-01-05 |
| ANNUAL REPORT | 2016-01-24 |
Date of last update: 01 Feb 2025
Sources: Florida Department of State
