Provider Demographics
NPI:1316160823
Name:BRIDGEWAY INC
Entity type:Organization
Organization Name:BRIDGEWAY INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:BILL
Authorized Official - Middle Name:
Authorized Official - Last Name:NELSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:309-344-4337
Mailing Address - Street 1:301 INDUSTRIAL PARK RD
Mailing Address - Street 2:
Mailing Address - City:MONMOUTH
Mailing Address - State:IL
Mailing Address - Zip Code:61462-9794
Mailing Address - Country:US
Mailing Address - Phone:309-734-9461
Mailing Address - Fax:309-734-3909
Practice Address - Street 1:301 INDUSTRIAL PARK RD
Practice Address - Street 2:
Practice Address - City:MONMOUTH
Practice Address - State:IL
Practice Address - Zip Code:61462-9794
Practice Address - Country:US
Practice Address - Phone:309-734-9461
Practice Address - Fax:309-734-3909
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-11
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL2084P0800X, 2084P0804X, 261QR0405X
IL003251S00000X
261QM0801X, 261QM0801X
IA251C00000X, 251K00000X, 251S00000X
IL=========003251S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)Group - Multi-Specialty
No2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatryGroup - Multi-Specialty
No2084P0804XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyChild & Adolescent PsychiatryGroup - Multi-Specialty
No251S00000XAgenciesCommunity/Behavioral HealthGroup - Multi-Specialty
No251C00000XAgenciesDay Training, Developmentally Disabled Services
No251K00000XAgenciesPublic Health or Welfare
No261QR0405XAmbulatory Health Care FacilitiesClinic/CenterRehabilitation, Substance Use Disorder
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL=========003Medicaid
IL=========OtherBRIDGEWAY, INC