Provider Demographics
NPI:1821267543
Name:EDGEWATER PSYCHIATRIC CENTER
Entity Type:Organization
Organization Name:EDGEWATER PSYCHIATRIC CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CORP. SR. DIRECTOR OF BUSINESS OPS.
Authorized Official - Prefix:MR
Authorized Official - First Name:MATTHEW
Authorized Official - Middle Name:
Authorized Official - Last Name:ZABOLOTNY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:717-441-9565
Mailing Address - Street 1:1320 LINGLESTOWN RD
Mailing Address - Street 2:
Mailing Address - City:HARRISBURG
Mailing Address - State:PA
Mailing Address - Zip Code:17110-2822
Mailing Address - Country:US
Mailing Address - Phone:717-441-9565
Mailing Address - Fax:
Practice Address - Street 1:2421 N FRONT ST
Practice Address - Street 2:
Practice Address - City:HARRISBURG
Practice Address - State:PA
Practice Address - Zip Code:17110-1110
Practice Address - Country:US
Practice Address - Phone:717-441-9565
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-02-27
Last Update Date:2008-02-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA1007457920002Medicaid
PA1007457920004Medicaid
PA1007457920005Medicaid