Provider Demographics
NPI:1578677076
Name:BRIDGEWAY CENTER INC
Entity type:Organization
Organization Name:BRIDGEWAY CENTER INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CHIEF FINANCIAL OFFICER
Authorized Official - Prefix:MR
Authorized Official - First Name:CLAYTON
Authorized Official - Middle Name:RANDALL
Authorized Official - Last Name:MCALLISTER
Authorized Official - Suffix:
Authorized Official - Credentials:MBA
Authorized Official - Phone:850-634-0050
Mailing Address - Street 1:137 HOSPITAL DR NE
Mailing Address - Street 2:
Mailing Address - City:FORT WALTON BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:32548-5063
Mailing Address - Country:US
Mailing Address - Phone:850-833-7500
Mailing Address - Fax:850-833-7443
Practice Address - Street 1:137 HOSPITAL DRIVE
Practice Address - Street 2:
Practice Address - City:FORT WALTON BEACH
Practice Address - State:FL
Practice Address - Zip Code:32548
Practice Address - Country:US
Practice Address - Phone:850-833-7512
Practice Address - Fax:850-833-7434
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-19
Last Update Date:2024-08-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101Y00000X, 208D00000X, 251S00000X
FL26039072238101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes251S00000XAgenciesCommunity/Behavioral Health
No101Y00000XBehavioral Health & Social Service ProvidersCounselorGroup - Multi-Specialty
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Multi-Specialty
No208D00000XAllopathic & Osteopathic PhysiciansGeneral PracticeGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL060398823Medicaid