Provider Demographics
NPI:1295998714
Name:BRIDGET J KELLER MD LLC
Entity type:Organization
Organization Name:BRIDGET J KELLER MD LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:BRIDGET
Authorized Official - Middle Name:JEAN
Authorized Official - Last Name:KELLER
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:941-201-2261
Mailing Address - Street 1:8374 MARKET ST
Mailing Address - Street 2:# 239
Mailing Address - City:LAKEWOOD RANCH
Mailing Address - State:FL
Mailing Address - Zip Code:34202-5137
Mailing Address - Country:US
Mailing Address - Phone:941-201-2261
Mailing Address - Fax:
Practice Address - Street 1:2401 UNIVERSITY PKWY
Practice Address - Street 2:SUITE 204
Practice Address - City:SARASOTA
Practice Address - State:FL
Practice Address - Zip Code:34243-2893
Practice Address - Country:US
Practice Address - Phone:941-379-8830
Practice Address - Fax:941-360-0557
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-07-03
Last Update Date:2013-07-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME973132084N0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLAW840Medicare PIN