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General NPI Number Information
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NPI Number | 1437144870
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Entity Type | Individual
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Provider Name | KENNETH G BRIDGES MD
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Gender | Male
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Dates
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Enumeration Date | 09/13/2005
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Last Update Date | 10/26/2009
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Provider Practice Location Address
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Address Line | 2402 FRIST BLVD SUITE 203
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City | FORT PIERCE
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State | FL
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Zip | 34950-4838
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Country | US
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Telephone | 772-462-3939
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Fax |
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Provider Business Mailing Address
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Address Line | 9639 FAIRWOOD CT
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City | PORT SAINT LUCIE
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State | FL
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Zip | 34986-3250
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Country | US
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Telephone | 772-489-0500
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 2086S0129X
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Taxonomy Name | Vascular Surgery Physician
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License Number | ME69634
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License Number State | FL
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