Beacon Medical Group, Inc.
Organization Active NPI Family Medicine Physician · South Bend, IN
NPI 1124079330 · NPPES record last updated Jun 25, 2026
Key facts
- NPI
- 1124079330
- Entity type
- Organization (NPI type 2)
- Primary specialty
- Family Medicine Physician 207Q00000X
- License
- 01043622A (IN)
- Legal business name
- BEACON MEDICAL GROUP, INC.
- Practice address
- 1815 E Ireland Rd
South Bend, IN 46614-2845 - Phone
- (574) 647-1700
- Fax
- (574) 291-3351
- NPI assigned
- May 12, 2006
- Organization subpart
- No
Authorized official
- Name
- Jeffrey Costello
- Title
- VP-Cfo
- Phone
- (574) 647-3549
Practitioners 68
-
David William Amrhein, M.D.
-
Tucker G. Balam, DO
-
Jennifer N Besemer, RD, CDE
-
Kirk Jon Bodach, MD
-
Joseph Michael Caruso, M.D.
-
Lori L. Checkley, M.D.
-
Leah Diane Craft, M.D.
-
Douglas Mayer David, M.D.
-
Gregg M Ebersole, M.D.
-
Jeffrey Hassel Eifler, D.P.M.
-
Kenneth Eugene Elek, M.D.
-
Zhaijun Fan, DO
-
William Norval Farabaugh, M.D.
-
Erinn C Fuller, PA-C
-
Nicole Gauthier, LCSW
-
Arif Goreja, MD
-
Justin Grannell, DO
-
Shanna Verma Kautzmann, M.D.
Laboratory certificates & supplier records
CLIA laboratory certificates
| CLIA number | Laboratory | Certificate | Expires |
|---|---|---|---|
| 15D0357222 | Ireland Road Medical Group | Provider-performed microscopy | May 3, 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
Locations
4630 Vistula Rd
Mishawaka, IN 46544
Phone (219) 254-7200
Specialties & licenses
| Specialty (taxonomy) | Code | License | State | Primary |
|---|---|---|---|---|
| Family Medicine Physician |
207Q00000X | 01043622A | IN | Yes |
| Sports Medicine (Family Medicine) Physician |
207QS0010X | |||
| Internal Medicine Physician |
207R00000X | |||
| Interventional Cardiology Physician |
207RI0011X | |||
| Rheumatology Physician |
207RR0500X | |||
| Neurological Surgery Physician |
207T00000X | |||
| Diagnostic Ultrasound Physician |
2085U0001X | |||
| Physician Assistant |
363A00000X | |||
| Family Nurse Practitioner |
363LF0000X |
Addresses
Primary practice location
1815 E Ireland Rd
South Bend, IN 46614-2845
Mailing address
3245 Health Dr Ste 100
Granger, IN 46530-1380
Phone (574) 647-3725
Other practice location 1
576 N Oak Dr
Plymouth, IN 46563-1664
Phone (574) 647-5170
Other identifiers
| Identifier | Type | State | Issuer |
|---|---|---|---|
| 100224050B | Medicaid | IN | |
| 300132559 | Medicaid | IN |
Other names
- Beacon Medical Group Ireland Road
- Beacon Medical Group Plymouth
Other providers in South Bend, IN
- 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.
- Beacon Medical Group, Inc.
All providers in South Bend, 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 Jun 25, 2026. 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.