Provider Demographics
NPI:1588948046
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:WILLIAM
Authorized Official - Middle Name:
Authorized Official - Last Name:NELSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:309-344-2323
Mailing Address - Street 1:310 WYLIE DR
Mailing Address - Street 2:SUITE 464
Mailing Address - City:NORMAL
Mailing Address - State:IL
Mailing Address - Zip Code:61761-5504
Mailing Address - Country:US
Mailing Address - Phone:309-452-2797
Mailing Address - Fax:309-452-9811
Practice Address - Street 1:310 WYLIE DR
Practice Address - Street 2:SUITE 464
Practice Address - City:NORMAL
Practice Address - State:IL
Practice Address - Zip Code:61761-5504
Practice Address - Country:US
Practice Address - Phone:309-452-2797
Practice Address - Fax:309-452-9811
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-10-03
Last Update Date:2019-08-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL04016101Y00000X, 101YM0800X, 101YP2500X, 104100000X, 251S00000X
261QM0801X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)
No101Y00000XBehavioral Health & Social Service ProvidersCounselorGroup - Multi-Specialty
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Multi-Specialty
No101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessionalGroup - Multi-Specialty
No104100000XBehavioral Health & Social Service ProvidersSocial WorkerGroup - Multi-Specialty
No251S00000XAgenciesCommunity/Behavioral Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILAC 217/557-9285OtherMEDICARE CERTIFICATION
IL04016Medicaid
IL04016Medicaid
ILAC 217/557-9285OtherMEDICARE CERTIFICATION
IL655362Medicare UPIN