NPIMap

Organization Active NPI

Edgewater Systems for Balanced Living, Inc

Doing business as Primary Care-Griffith

  • Federally Qualified Health Center (FQHC)
  • Griffith, IN
National Provider Identifier
1366043457
Registry record updated Nov 4, 2020
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
Primary Care-Griffith
Practice address
1212 N Broad St
Griffith, IN 46319-1534
Phone
(219) 838-1270
NPI assigned
Nov 4, 2020
Last updated
Nov 4, 2020By the provider in NPPES
Organization subpart
No

NPPES NPI Registry

Updated by the provider on Nov 4, 2020

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 NU Primary

Addresses

Primary practice location

1212 N Broad St
Griffith, IN 46319-1534

Mailing address

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

Other names 1

  • Primary Care-Griffith 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
O20201208001698 IN Part A Provider - Federally Qualified Health Center (FQHC) 9234398397 Practice locations: Griffith, IN

NPI to CCN mapping 1

The Medicare certification numbers (CCNs) connected to NPI 1366043457. Details of each certification follow.

Federally qualified health center certification: CCN 151094

Legal name
EDGEWATER SYSTEMS FOR BALANCED LIVING INC
Doing business as
PRIMARY CARE-GRIFFITH
Certification status
Active
Provider type (POS)
Federally qualified health center
Participating since
Jan 13, 2021
Last certification
Jan 13, 2021
Ownership / control type
For profit – corporation
Organization structure
CorporationNon-profit
Enrollment address
1212 N Broad St
Griffith, IN 46319-1534

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
Tax ID family
Edgewater System for Ba11 organizations share this tax ID, including this one

Other organizations with this tax ID 10

Organizations that report the same tax identification number in the 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

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.

NPI Registry JSON

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

{
    "created_epoch": "1604448000000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1604448000000",
    "number": "1366043457",
    "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": "1212 N BROAD ST",
            "city": "GRIFFITH",
            "state": "IN",
            "postal_code": "463191534",
            "telephone_number": "219-838-1270"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "EDGEWATER SYSTEMS FOR BALANCED LIVING, INC",
        "organizational_subpart": "NO",
        "enumeration_date": "2020-11-04",
        "last_updated": "2020-11-04",
        "certification_date": "2020-11-04",
        "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": "NU",
            "license": null,
            "primary": true
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": [
        {
            "organization_name": "Primary Care-Griffith",
            "code": "3",
            "type": "Doing Business As"
        }
    ]
}

Other providers in Griffith, IN

Sources for this page

Verify at the official NPI Registry.