Beacon Medical Group, Inc.
Organization Active NPI Family Medicine Physician · Granger, IN
NPI 1003042318 · NPPES record last updated Apr 24, 2023
Key facts
- NPI
- 1003042318
- Entity type
- Organization (NPI type 2)
- Primary specialty
- Family Medicine Physician 207Q00000X
- Legal business name
- BEACON MEDICAL GROUP, INC.
- Practice address
- 12340 Bittersweet Commons Blvd W
Granger, IN 46530-6959 - Phone
- (574) 271-8610
- Fax
- (574) 271-8620
- NPI assigned
- Jun 2, 2009
- Organization subpart
- No
Authorized official
- Name
- Mr. Jeffrey P Costello
- Title
- Cfo
- Phone
- (574) 647-3549
Practitioners 5
-
Nazmul Huda, MD
-
Shelley A. Morris, D.O.
-
Mary-Kate Oatman, MSN, RN, FNP
-
Mark P Schmeltz, DO
-
Tammy Gene Slott, FNP-BC
Laboratory certificates & supplier records
CLIA laboratory certificates
| CLIA number | Laboratory | Certificate | Expires |
|---|---|---|---|
| 15D1101762 | Beacon Med GRP Bittersweet Commons | Provider-performed microscopy | Jul 5, 2027 |
Medicare participation
- Medicare fee-for-service enrollment
- Enrolled in IN
Medicare enrollment records
| Enrollment ID | State | Provider type | PAC ID | Details |
|---|---|---|---|---|
| O20031105000657 | IN | Part B Supplier - Clinic/Group Practice | 1254243306 |
Receives reassigned benefits from 737 practitioners This NPI is an additional NPI on the enrollment |
National Provider Directory
Specialties & licenses
| Specialty (taxonomy) | Code | License | State | Primary |
|---|---|---|---|---|
| Family Medicine Physician |
207Q00000X | IN | Yes |
Addresses
Primary practice location
12340 Bittersweet Commons Blvd W
Granger, IN 46530-6959
Mailing address
710 N Niles Ave
South Bend, IN 46617-1924
Phone (574) 647-1610
Other identifiers
| Identifier | Type | State | Issuer |
|---|---|---|---|
| 000000631897 | Other | IN | ANTHEM |
| 100114000F | Medicaid | IN |
Other names
- Beacon Medical Group Bittersweet Commons
Other providers in Granger, IN
- Douglas Craig Bateman
- David S Battle
- Jane E Beachy
- Beacon Health, LLC
- Beacon Health, LLC
- Beacon Medical Group, Inc.
- Beacon Medical Group, Inc.
- Beacon Medical Group, Inc.
- Beacon Medical Group, Inc.
- Beacon Medical Group, Inc.
All providers in Granger, IN · Family Medicine Physician in Indiana
Sources for this page
- NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Record last updated by the provider on Apr 24, 2023. Information in NPPES is self-reported and not verified by CMS.
- NUCC Health Care Provider Taxonomy: specialty names.
- Medicare Fee-For-Service Public Provider Enrollment (CMS/PECOS): enrollments, PAC IDs and benefit reassignments.
- Medicare Care Compare provider data (CMS): clinician profile, group practices, facility affiliations, MIPS scores and star ratings.
- National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.