NPIMap

Organization Active NPI

Edgewater Systems for Balanced Living, Inc.

  • Internal Medicine Physician
  • Merrillville, IN
National Provider Identifier
1699225698
Registry record updated Nov 22, 2024
On this page

Key facts

NPPES NPI Registry
Primary specialty
Internal Medicine PhysicianTaxonomy code 207R00000X
License
01033511A Issued in IN
Legal business name
EDGEWATER SYSTEMS FOR BALANCED LIVING, INC.
Practice address
5495 Broadway
Merrillville, IN 46410-1647
Phone
(219) 884-4900
Fax
(219) 980-7585
NPI assigned
Oct 13, 2016
Organization subpart
Yes
Parent organization
EDGEWATER SYSTEMS FOR BALANCED LIVING, INC.As reported in NPPES

NPPES NPI Registry

Updated by the provider on Nov 22, 2024

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

Authorized official

Name
Dr. Danita Johnson Hughes, PHD.
Title
President/Ceo
Phone
(219) 885-4264

Specialties & licenses 3

Specialty (taxonomy)CodeLicenseStatePrimary
Mental Health CounselorGroup: 193200000X MULTI-SPECIALTY GROUP 101YM0800X
Clinical Social WorkerGroup: 193200000X MULTI-SPECIALTY GROUP 1041C0700X
Internal Medicine PhysicianGroup: 193200000X MULTI-SPECIALTY GROUP 207R00000X 01033511A IN Primary

Addresses

Primary practice location

5495 Broadway
Merrillville, IN 46410-1647

Mailing address

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

Other practice location 1

1212 N Broad St
Griffith, IN 46319-1534
Phone (219) 838-1270

Other practice location 2

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

Other identifiers 1

IdentifierTypeStateIssuer
200030490AMedicaidIN

Other names 1

  • Edgewater Primary Care Doing business as

Medicare participation

Medicare enrollment files
Medicare fee-for-service enrollment
Enrolled in IN

Enrollment records 1

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

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
Part of
Edgewater System for Ba

Practitioners & affiliated clinicians

Practitioners 5

Individual providers connected to this organization through Medicare benefit reassignment, Care Compare group membership or National Provider Directory roles.

NPI Registry JSON

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

{
    "created_epoch": "1476316800000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1732233600000",
    "number": "1699225698",
    "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",
            "fax_number": "219-882-0962"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "5495 BROADWAY",
            "city": "MERRILLVILLE",
            "state": "IN",
            "postal_code": "464101647",
            "telephone_number": "219-884-4900",
            "fax_number": "219-980-7585"
        }
    ],
    "practiceLocations": [
        {
            "address_1": "1212 N Broad St",
            "address_purpose": "LOCATION",
            "city": "Griffith",
            "state": "IN",
            "postal_code": "463191534",
            "country_code": "US",
            "telephone_number": "219-838-1270",
            "country_name": "United States",
            "address_type": "DOM"
        },
        {
            "address_1": "1100 W 6th Ave",
            "address_purpose": "LOCATION",
            "city": "Gary",
            "state": "IN",
            "postal_code": "464021711",
            "country_code": "US",
            "telephone_number": "219-885-4264",
            "country_name": "United States",
            "address_type": "DOM"
        }
    ],
    "basic": {
        "organization_name": "EDGEWATER SYSTEMS FOR BALANCED LIVING, INC.",
        "organizational_subpart": "YES",
        "parent_organization_legal_business_name": "EDGEWATER SYSTEMS FOR BALANCED LIVING, INC.",
        "enumeration_date": "2016-10-13",
        "last_updated": "2024-11-22",
        "certification_date": "2024-11-22",
        "status": "A",
        "authorized_official_last_name": "JOHNSON HUGHES",
        "authorized_official_first_name": "DANITA",
        "authorized_official_title_or_position": "PRESIDENT/CEO",
        "authorized_official_telephone_number": "219-885-4264",
        "authorized_official_name_prefix": "Dr.",
        "authorized_official_credential": "PHD."
    },
    "taxonomies": [
        {
            "code": "101YM0800X",
            "taxonomy_group": "193200000X MULTI-SPECIALTY GROUP",
            "desc": "Counselor, Mental Health",
            "state": null,
            "license": null,
            "primary": false
        },
        {
            "code": "1041C0700X",
            "taxonomy_group": "193200000X MULTI-SPECIALTY GROUP",
            "desc": "Social Worker, Clinical",
            "state": null,
            "license": null,
            "primary": false
        },
        {
            "code": "207R00000X",
            "taxonomy_group": "193200000X MULTI-SPECIALTY GROUP",
            "desc": "Internal Medicine",
            "state": "IN",
            "license": "01033511A",
            "primary": true
        }
    ],
    "identifiers": [
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "200030490A",
            "state": "IN"
        }
    ],
    "endpoints": [],
    "other_names": [
        {
            "organization_name": "Edgewater Primary Care",
            "code": "3",
            "type": "Doing Business As"
        },
        {
            "organization_name": "Edgewater Primary Care",
            "code": "3",
            "type": "Doing Business As"
        }
    ]
}

Other providers in Merrillville, IN

Sources for this page

  • NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Nov 22, 2024; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
  • Medicare enrollment (CMS PECOS): enrollments, PAC IDs and benefit reassignments.
  • National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.