Provider Demographics
NPI:1861776213
Name:BRIDGEWAY INC
Entity type:Organization
Organization Name:BRIDGEWAY INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:BILLING MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:STACI
Authorized Official - Middle Name:
Authorized Official - Last Name:DANNER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:309-344-2323
Mailing Address - Street 1:590 S DEER RD
Mailing Address - Street 2:
Mailing Address - City:MACOMB
Mailing Address - State:IL
Mailing Address - Zip Code:61455-2639
Mailing Address - Country:US
Mailing Address - Phone:309-836-9910
Mailing Address - Fax:309-836-3422
Practice Address - Street 1:590 S DEER RD
Practice Address - Street 2:
Practice Address - City:MACOMB
Practice Address - State:IL
Practice Address - Zip Code:61455-2604
Practice Address - Country:US
Practice Address - Phone:309-837-4876
Practice Address - Fax:309-833-1531
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-10-04
Last Update Date:2011-11-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL04016101Y00000X, 101YM0800X, 101YP2500X, 104100000X, 251S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes251S00000XAgenciesCommunity/Behavioral Health
No101Y00000XBehavioral Health & Social Service ProvidersCounselorGroup - Multi-Specialty
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Multi-Specialty
No101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessionalGroup - Multi-Specialty
No104100000XBehavioral Health & Social Service ProvidersSocial WorkerGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL04016OtherMENTAL HEALTH MEDICAID CERTIFICATE
IL655362Medicare UPIN
IL655360Medicare UPIN
IL655361Medicare UPIN