Beacon Medical Group, Inc.

Primary specialty

Nurse PractitionerTaxonomy code 363L00000X

License

71000651A Issued in IN

Legal business name

BEACON MEDICAL GROUP, INC.

Practice address

926 Erskine PLZ
South Bend, IN 46614-3244

Phone

(800) 635-5516

Fax

(574) 647-6514

NPI assigned

May 16, 2006

Organization subpart

No

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

Authorized official

Name

Jeffrey P. Costello

Title

VP-Cfo

Phone

(574) 647-3549

Specialties & licenses 1

Addresses

Other identifiers 4

Other names 1

• MedPoint Express Doing business as

Medicare fee-for-service enrollment

Enrolled in IN

Enrollment records 1

Locations

Practitioners 5

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

• Sara Golden

  • Family Nurse Practitioner
  • Granger, IN
  • NPI 1114378635
  NPD
• Kimberlee Lynn Acton, FNP-C

  • Family Nurse Practitioner
  • Goshen, IN
  • NPI 1225510522
  NPD (past)
• Sam Joseph Borrelli, M.D.

  • Family Medicine Physician
  • Goshen, IN
  • NPI 1114028743
  NPD (past)
• Zachary H Dubois, DO

  • Family Medicine Physician
  • Goshen, IN
  • NPI 1134878853
  NPD (past)
• Michelle D Shelly, MD

  • Family Medicine Physician
  • Goshen, IN
  • NPI 1801863618
  NPD (past)

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

{
    "created_epoch": "1147737600000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1472428800000",
    "number": "1083665673",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "710 N NILES AVE",
            "city": "SOUTH BEND",
            "state": "IN",
            "postal_code": "466171924",
            "telephone_number": "574-647-1610"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "926 ERSKINE PLZ",
            "city": "SOUTH BEND",
            "state": "IN",
            "postal_code": "466143244",
            "telephone_number": "800-635-5516",
            "fax_number": "574-647-6514"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "BEACON MEDICAL GROUP, INC.",
        "organizational_subpart": "NO",
        "enumeration_date": "2006-05-16",
        "last_updated": "2016-08-29",
        "status": "A",
        "authorized_official_last_name": "COSTELLO",
        "authorized_official_first_name": "JEFFREY",
        "authorized_official_middle_name": "P.",
        "authorized_official_title_or_position": "VP-CFO",
        "authorized_official_telephone_number": "574-647-3549"
    },
    "taxonomies": [
        {
            "code": "363L00000X",
            "taxonomy_group": "193400000X SINGLE SPECIALTY  GROUP",
            "desc": "Nurse Practitioner",
            "state": "IN",
            "license": "71000651A",
            "primary": true
        }
    ],
    "identifiers": [
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "200130710H",
            "state": "IN"
        },
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "200130710I",
            "state": "IN"
        },
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "200130710J",
            "state": "IN"
        },
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "200130710K",
            "state": "IN"
        }
    ],
    "endpoints": [],
    "other_names": [
        {
            "organization_name": "MedPoint Express",
            "code": "3",
            "type": "Doing Business As"
        }
    ]
}

• Beacon Health Ventures, Inc.
• Beacon Health Ventures, Inc.
• Beacon Medical Group
• Beacon Medical Group Inc
• Beacon Medical Group Inc
• Beacon Medical Group, Inc.
• Beacon Medical Group, Inc.
• Beacon Medical Group, Inc.
• Beacon Medical Group, Inc.
• Beacon Medical Group, Inc.

• All providers in South Bend, IN
• Nurse Practitioner in Indiana

• NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Aug 29, 2016; 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.