Provider Demographics
NPI:1699225698
Name:EDGEWATER SYSTEMS FOR BALANCED LIVING, INC.
Entity Type:Organization
Organization Name:EDGEWATER SYSTEMS FOR BALANCED LIVING, INC.
Other - Org Name:EDGEWATER PRIMARY CARE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT/CEO
Authorized Official - Prefix:DR
Authorized Official - First Name:DANITA
Authorized Official - Middle Name:
Authorized Official - Last Name:JOHNSON HUGHES
Authorized Official - Suffix:
Authorized Official - Credentials:PHD
Authorized Official - Phone:219-885-4264
Mailing Address - Street 1:1100 W 6TH AVE
Mailing Address - Street 2:
Mailing Address - City:GARY
Mailing Address - State:IN
Mailing Address - Zip Code:46402-1711
Mailing Address - Country:US
Mailing Address - Phone:219-885-4264
Mailing Address - Fax:219-882-0962
Practice Address - Street 1:5495 BROADWAY
Practice Address - Street 2:
Practice Address - City:MERRILLVILLE
Practice Address - State:IN
Practice Address - Zip Code:46410-1647
Practice Address - Country:US
Practice Address - Phone:219-884-4900
Practice Address - Fax:219-980-7585
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:EDGEWATER SYSTEMS FOR BALANCED LIVING, INC.
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2016-10-13
Last Update Date:2023-09-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01033511A207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN200030490AMedicaid
IN223030Medicare UPIN