Provider Demographics
NPI:1972296382
Name:BRIDGEWELL LLC
Entity Type:Organization
Organization Name:BRIDGEWELL LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:NURSE PRACTITIONER
Authorized Official - Prefix:
Authorized Official - First Name:ISOKEN
Authorized Official - Middle Name:
Authorized Official - Last Name:OGBOMO
Authorized Official - Suffix:
Authorized Official - Credentials:FNP
Authorized Official - Phone:312-451-6418
Mailing Address - Street 1:402 W BOUGHTON RD STE A
Mailing Address - Street 2:
Mailing Address - City:BOLINGBROOK
Mailing Address - State:IL
Mailing Address - Zip Code:60440-1998
Mailing Address - Country:US
Mailing Address - Phone:312-451-6148
Mailing Address - Fax:
Practice Address - Street 1:402 W BOUGHTON RD STE A
Practice Address - Street 2:
Practice Address - City:BOLINGBROOK
Practice Address - State:IL
Practice Address - Zip Code:60440-1998
Practice Address - Country:US
Practice Address - Phone:312-451-6148
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-05-31
Last Update Date:2023-09-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LG0600XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGerontologyGroup - Single Specialty
No261QC1500XAmbulatory Health Care FacilitiesClinic/CenterCommunity Health
No261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care
Yes363LP2300XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPrimary CareGroup - Single Specialty