NPIMap

Organization Active NPI

Edgewater Systems for Balanced Living, Inc

Doing business as Edgewater Health: Lake Street Pediatrics

  • Federally Qualified Health Center (FQHC)
  • Gary, IN
National Provider Identifier
1245907344
Registry record updated Aug 26, 2021
On this page

Key facts

NPPES NPI Registry
Primary specialty
Federally Qualified Health Center (FQHC)Taxonomy code 261QF0400X
Legal business name
EDGEWATER SYSTEMS FOR BALANCED LIVING, INC
Doing business as
Edgewater Health: Lake Street Pediatrics
Practice address
426 S Lake St
Gary, IN 46403-2405
Phone
(219) 939-6070
NPI assigned
Aug 26, 2021
Organization subpart
No

NPPES NPI Registry

Updated by the provider on Aug 26, 2021

Registry information is reported by the provider to CMS and is not verified. About this source

Authorized official

Name
Danita Johnson Hughes
Title
Ceo
Phone
(219) 885-4264

Specialties & licenses 1

Specialty (taxonomy)CodeLicenseStatePrimary
Federally Qualified Health Center (FQHC) 261QF0400X Primary

Addresses

Primary practice location

426 S Lake St
Gary, IN 46403-2405

Mailing address

1100 W 6TH Ave
Gary, IN 46402-1711
Phone (219) 885-4264

Other names 1

  • Edgewater Health: Lake Street Pediatrics Doing business as

Medicare participation

Medicare enrollment files
Medicare fee-for-service enrollment
Enrolled in IN2 enrollments

Enrollment records 2

Enrollment IDStateProvider typePAC IDDetails
O20120308000405 IN Part B Supplier - Clinic/Group Practice 9234398397 Receives reassigned benefits from 31 practitioners
9 other NPIs on this enrollment
This NPI is an additional NPI on the enrollment
Practice locations: Gary, IN; Merrillville, IN; Griffith, IN; Cedar Lake, IN
O20210902000571 IN Part A Provider - Federally Qualified Health Center (FQHC) 9234398397 Practice locations: Gary, IN

NPI to CCN mapping 1

The Medicare certification numbers (CCNs) connected to NPI 1245907344. Details of each certification follow.

Federally qualified health center certification: CCN 151119

Legal name
EDGEWATER SYSTEMS FOR BALANCED LIVING INC
Doing business as
EDGEWATER HEALTH LAKE STREET PEDIATRICS
Certification status
Active
Provider type (POS)
Federally qualified health center
Participating since
Sep 1, 2021
Last certification
Sep 1, 2021
Ownership / control type
For profit – corporation
Organization structure
CorporationNon-profit
Incorporated
Oct 7, 1974 in IN
Enrollment address
426 S Lake St
Gary, IN 46403-2405

Other NPIs with the same Medicare PAC ID 8

NPIs whose Medicare enrollments share a PECOS associate control ID (the same enrolled entity).

Other NPIs on the same Medicare enrollment 9

NPIs listed together on one Medicare enrollment, typically parts of the same organization.

National Provider Directory

National Provider Directory

Ownership & related parties

All disclosed owners & managing parties 1

As disclosed on the Medicare enrollment (CMS All Owners files). Individuals include officers, directors and managing employees, who may not hold ownership.

NameRoleSinceShare
Danita Johnson Individual Corporate OfficerCeo Jul 3, 2019
W-2 Managing EmployeeCeo Jul 3, 2019
Operational/Managerial ControlCeo Jul 3, 2019

All facility ownership & control disclosures 1

Facilities whose Medicare enrollment lists this provider’s PECOS associate ID as an owner or managing party.

FacilityTypeRoleSince
Edgewater SystemsGary, IN, CCN 151057 Federally qualified health center 5% Or Greater Direct Ownership Interest (100%) Oct 7, 1974

Owned or controlled facilities with NPI records 2

Facilities whose Medicare enrollment lists this provider as an owner, officer, director or managing party.

Practitioners & affiliated clinicians

Practitioners 1

Individual providers connected to this organization through Medicare benefit reassignment, Care Compare group membership or National Provider Directory roles, and the practitioner matching its NPPES authorized official.

NPI Registry JSON

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1629936000000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1629936000000",
    "number": "1245907344",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "1100 W 6TH AVE",
            "city": "GARY",
            "state": "IN",
            "postal_code": "464021711",
            "telephone_number": "219-885-4264"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "426 S LAKE ST",
            "city": "GARY",
            "state": "IN",
            "postal_code": "464032405",
            "telephone_number": "219-939-6070"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "EDGEWATER SYSTEMS FOR BALANCED LIVING, INC",
        "organizational_subpart": "NO",
        "enumeration_date": "2021-08-26",
        "last_updated": "2021-08-26",
        "certification_date": "2021-08-26",
        "status": "A",
        "authorized_official_last_name": "HUGHES",
        "authorized_official_first_name": "DANITA",
        "authorized_official_middle_name": "JOHNSON",
        "authorized_official_title_or_position": "CEO",
        "authorized_official_telephone_number": "219-885-4264"
    },
    "taxonomies": [
        {
            "code": "261QF0400X",
            "taxonomy_group": "",
            "desc": "Clinic/Center, Federally Qualified Health Center (FQHC)",
            "state": null,
            "license": null,
            "primary": true
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": [
        {
            "organization_name": "Edgewater Health: Lake Street Pediatrics",
            "code": "3",
            "type": "Doing Business As"
        }
    ]
}

Other providers in Gary, IN

Sources for this page

Verify at the official NPI Registry.