Provider Demographics
NPI:1992000764
Name:BRIDGEWAY HEALTH SOLUTIONS
Entity Type:Organization
Organization Name:BRIDGEWAY HEALTH SOLUTIONS
Other - Org Name:CENTENE CORPORATION
Other - Org Type:Other Name
Authorized Official - Title/Position:COMPLIANCE OFFICER
Authorized Official - Prefix:
Authorized Official - First Name:NICOLE
Authorized Official - Middle Name:
Authorized Official - Last Name:LARSON
Authorized Official - Suffix:
Authorized Official - Credentials:VP,
Authorized Official - Phone:866-475-3129
Mailing Address - Street 1:1501 W FOUNTAINHEAD PKWY
Mailing Address - Street 2:SUITE 201
Mailing Address - City:TEMPE
Mailing Address - State:AZ
Mailing Address - Zip Code:85282-1868
Mailing Address - Country:US
Mailing Address - Phone:866-475-3129
Mailing Address - Fax:866-687-0515
Practice Address - Street 1:1501 W FOUNTAINHEAD PKWY
Practice Address - Street 2:SUITE 201
Practice Address - City:TEMPE
Practice Address - State:AZ
Practice Address - Zip Code:85282-1868
Practice Address - Country:US
Practice Address - Phone:866-475-3129
Practice Address - Fax:866-687-0515
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:CENTENE
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2011-01-25
Last Update Date:2011-01-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ1283207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ231241Medicaid