MEDICARE: BRIDGEWAY CLINICS LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	2084B0040X	Behavioral Neurology & Neuropsychiatry Physician
2	261Q00000X	Clinic/Center

General Provider Information

NPI Number	:	1609510809
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	BRIDGEWAY CLINICS LLC

Provider Business Mailing Address
First Line	:	4429 S RIVER BLVD
Second Line	:
City	:	INDEPENDENCE
State	:	MO
Zip	:	64055-4659
Country	:	US
Telephone Number	:	816-786-4253
Fax Number	:

Provider Business Practice Location Address
First Line	:	4429 S RIVER BLVD
Second Line	:
City	:	INDEPENDENCE
State	:	MO
Zip	:	64055-4659
Country	:	US
Telephone Number	:	816-786-4253
Fax Number	:

Authorized Official
Title or Position	:	DIRECTOR OF FINANCE
Name	:	SHEILA HALE
Credential	:
Telephone Number	:	816-786-4253

Provider Enumeration Date	:	04/24/2022
Last Update Date	:	11/30/2022

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