Healthcare Provider Details

I. General information

NPI: 1720680440
Provider Name (Legal Business Name): BRIDGEWAY THERAPEUTICS INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/09/2020
Last Update Date: 11/25/2024
Certification Date: 11/25/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2610 E 32ND ST STE 1
MINNEAPOLIS MN
55406-1905
US

IV. Provider business mailing address

2610 E 32ND ST STE 1
MINNEAPOLIS MN
55406-1905
US

V. Phone/Fax

Practice location:
  • Phone: 612-361-7727
  • Fax: 612-454-2693
Mailing address:
  • Phone: 612-361-7727
  • Fax: 612-454-2693

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QM0850X
TaxonomyAdult Mental Health Clinic/Center
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code324500000X
TaxonomySubstance Abuse Rehabilitation Facility
License Number
License Number State

VIII. Authorized Official

Name: FATMA ABDILLE
Title or Position: CEO
Credential:
Phone: 612-361-7727