Basic Information
| Provider Information | |||||||||
| NPI: | 1699225698 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | EDGEWATER SYSTEMS FOR BALANCED LIVING, INC. | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | |||||||||
| OtherOrganizationName: | EDGEWATER PRIMARY CARE | ||||||||
| OtherOrganizationType: | 3 | ||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | 1100 W 6TH AVE | ||||||||
| Address2: | |||||||||
| City: | GARY | ||||||||
| State: | IN | ||||||||
| PostalCode: | 464021711 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2198854264 | ||||||||
| FaxNumber: | 2198820962 | ||||||||
| Practice Location | |||||||||
| Address1: | 3535 BROADWAY | ||||||||
| Address2: | |||||||||
| City: | GARY | ||||||||
| State: | IN | ||||||||
| PostalCode: | 464091316 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2198844900 | ||||||||
| FaxNumber: | 2199807585 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/13/2016 | ||||||||
| LastUpdateDate: | 10/25/2016 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | JOHNSON HUGHES | ||||||||
| AuthorizedOfficialFirstName: | DANITA | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT/CEO | ||||||||
| AuthorizedOfficialTelephone: | 2198854264 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | EDGEWATER SYSTEMS FOR BALANCED LIVING, INC. | ||||||||
| AuthorizedOfficialNamePrefix: | DR. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | PHD. | ||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | 01033511A | IN | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine |
ID Information
| ID | Type | State | Issuer | Description | 200030490A | 05 | IN | MEDICAID |