Provider Demographics
NPI:1275757692
Name:EDGEWATER PSYCHIATRIC CENTER
Entity Type:Organization
Organization Name:EDGEWATER PSYCHIATRIC CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR OF BUSINESS OPERATIONS
Authorized Official - Prefix:MR
Authorized Official - First Name:NORMAN
Authorized Official - Middle Name:
Authorized Official - Last Name:TILSON
Authorized Official - Suffix:JR
Authorized Official - Credentials:
Authorized Official - Phone:215-836-3131
Mailing Address - Street 1:4391 STURBRIDGE DR
Mailing Address - Street 2:
Mailing Address - City:HARRISBURG
Mailing Address - State:PA
Mailing Address - Zip Code:17110-3673
Mailing Address - Country:US
Mailing Address - Phone:215-836-3131
Mailing Address - Fax:
Practice Address - Street 1:295 STATE DR
Practice Address - Street 2:
Practice Address - City:ELIZABETHVILLE
Practice Address - State:PA
Practice Address - Zip Code:17023-8661
Practice Address - Country:US
Practice Address - Phone:215-836-3131
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-13
Last Update Date:2009-08-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA1007457920011Medicaid
PA1007457920019Medicaid
551745Medicare PIN