Provider Demographics
NPI:1114140621
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 1:137 E COLLEGE ST
Mailing Address - Street 2:
Mailing Address - City:KEWANEE
Mailing Address - State:IL
Mailing Address - Zip Code:61443-3703
Mailing Address - Country:US
Mailing Address - Phone:309-852-4331
Mailing Address - Fax:
Practice Address - Street 1:137 E COLLEGE ST
Practice Address - Street 2:
Practice Address - City:KEWANEE
Practice Address - State:IL
Practice Address - Zip Code:61443-3703
Practice Address - Country:US
Practice Address - Phone:309-852-4331
Practice Address - Fax:
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
IL020101YA0400X, 1041C0700X
IL3709841785020101YM0800X
2084P0800X, 2084P0804X
IA251C00000X, 251S00000X
IL261QM0801X, 261QM0801X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)Group - Multi-Specialty
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)Group - Multi-Specialty
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Multi-Specialty
No1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Multi-Specialty
No2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatryGroup - Multi-Specialty
No2084P0804XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyChild & Adolescent PsychiatryGroup - Multi-Specialty
No251C00000XAgenciesDay Training, Developmentally Disabled ServicesGroup - Multi-Specialty
No251S00000XAgenciesCommunity/Behavioral Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL=========OtherBRIDGEWAY, INC
IL=========020Medicaid