Provider Demographics
NPI:1821591447
Name:KEY BRIDGE GP INC
Entity Type:Organization
Organization Name:KEY BRIDGE GP INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:
Authorized Official - Last Name:ROGERS
Authorized Official - Suffix:
Authorized Official - Credentials:LMHC
Authorized Official - Phone:305-783-3677
Mailing Address - Street 1:1111 12TH ST STE 212
Mailing Address - Street 2:
Mailing Address - City:KEY WEST
Mailing Address - State:FL
Mailing Address - Zip Code:33040-3001
Mailing Address - Country:US
Mailing Address - Phone:305-783-3677
Mailing Address - Fax:
Practice Address - Street 1:1111 12TH ST STE 212
Practice Address - Street 2:
Practice Address - City:KEY WEST
Practice Address - State:FL
Practice Address - Zip Code:33040-3001
Practice Address - Country:US
Practice Address - Phone:305-783-3677
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:KEY BRIDGE, INC.
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2018-03-09
Last Update Date:2022-09-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGroup - Single Specialty
No207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL022807200Medicaid