Healthcare Provider Details

I. General information

NPI: 1518185925
Provider Name (Legal Business Name): BRIDGEWAY INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/23/2007
Last Update Date: 07/21/2022
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

900 S DEER RD
MACOMB IL
61455-2639
US

IV. Provider business mailing address

900 S DEER RD
MACOMB IL
61455-2639
US

V. Phone/Fax

Practice location:
  • Phone: 309-837-4876
  • Fax:
Mailing address:
  • Phone: 309-837-4876
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number
License Number StateIL
# 2
Primary TaxonomyN
Taxonomy Code2084P0804X
TaxonomyChild & Adolescent Psychiatry Physician
License Number
License Number StateIL
# 3
Primary TaxonomyN
Taxonomy Code251B00000X
TaxonomyCase Management Agency
License Number
License Number StateIL
# 4
Primary TaxonomyN
Taxonomy Code251C00000X
TaxonomyDevelopmentally Disabled Services Day Training Agency
License Number011
License Number StateIL
# 5
Primary TaxonomyN
Taxonomy Code251C00000X
TaxonomyDevelopmentally Disabled Services Day Training Agency
License Number
License Number StateIA
# 6
Primary TaxonomyN
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number
License Number StateIL
# 7
Primary TaxonomyY
Taxonomy Code261QM0801X
TaxonomyMental Health Clinic/Center (Including Community Mental Health Center)
License Number
License Number StateIL

VIII. Authorized Official

Name: BILL NELSON
Title or Position: CEO
Credential:
Phone: 309-344-4337