NPIMap

Organization Active NPI

Beacon Medical Group, Inc.

Doing business as Beacon Medical Group Ireland Road

  • Family Medicine Physician
  • South Bend, IN
National Provider Identifier
1124079330
Registry record updated Jun 25, 2026
On this page

Key facts

NPPES NPI Registry
Primary specialty
Family Medicine PhysicianTaxonomy code 207Q00000X
License
01043622A Issued in IN
Legal business name
BEACON MEDICAL GROUP, INC.
Doing business as
Beacon Medical Group Ireland Road
Beacon Medical Group Plymouth
Practice address
1815 E Ireland Rd
South Bend, IN 46614-2845
Phone
(574) 647-1700
Fax
(574) 291-3351
NPI assigned
May 12, 2006
Last updated
Jun 25, 2026By the provider in NPPES
Organization subpart
No

NPPES NPI Registry

Updated by the provider on Jun 25, 2026

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

Authorized official

Name
Jeffrey Costello
Title
VP-Cfo
Phone
(574) 647-3549

Specialties & licenses 9

Specialty (taxonomy)CodeLicenseStatePrimary
Physician Assistant 363A00000X
Family Nurse Practitioner 363LF0000X
Family Medicine Physician 207Q00000X 01043622A IN Primary
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

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 2

IdentifierTypeStateIssuer
300132559MedicaidIN
100224050BMedicaidIN

Other names 2

  • Beacon Medical Group Ireland Road Doing business as
  • Beacon Medical Group Plymouth Doing business as

Medicare participation

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

Enrollment records 1

Enrollment IDStateProvider typePAC IDDetails
O20031105000657 IN Part B Supplier - Clinic/Group Practice 1254243306 Receives reassigned benefits from 737 practitioners
This NPI is an additional NPI on the enrollment

Laboratory certificates & supplier records

Derived by NPIMap

These CMS records do not include an NPI. They are shown because their name and street address match this provider’s.

CLIA laboratory certificates

CLIA numberLaboratoryCertificateExpires
15D0357222Ireland Road Medical Group1815 E Ireland Rd, South Bend, IN 46614Provider-performed microscopyMay 3, 2027

National Provider Directory

National Provider Directory

Locations

600 East Blvd
Elkhart, IN 46514
Phone (574) 294-2621

6301 University Commons
Ste 420
South Bend, IN 46635
Phone (574) 968-2832

Practitioners & affiliated clinicians

Practitioners 68

Individual providers connected to this organization through Medicare benefit reassignment, Care Compare group membership or National Provider Directory roles, and the practitioner matching its NPPES authorized official.

View all 68

NPI Registry JSON

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

{
    "created_epoch": "1147392000000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1782345600000",
    "number": "1124079330",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "3245 HEALTH DR STE 100",
            "city": "GRANGER",
            "state": "IN",
            "postal_code": "465301380",
            "telephone_number": "574-647-3725"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "1815 E IRELAND RD",
            "city": "SOUTH BEND",
            "state": "IN",
            "postal_code": "466142845",
            "telephone_number": "574-647-1700",
            "fax_number": "574-291-3351"
        }
    ],
    "practiceLocations": [
        {
            "address_1": "576 N Oak Dr",
            "address_purpose": "LOCATION",
            "city": "Plymouth",
            "state": "IN",
            "postal_code": "465631664",
            "country_code": "US",
            "telephone_number": "574-647-5170",
            "fax_number": "574-647-5183",
            "country_name": "United States",
            "address_type": "DOM"
        }
    ],
    "basic": {
        "organization_name": "BEACON MEDICAL GROUP, INC.",
        "organizational_subpart": "NO",
        "enumeration_date": "2006-05-12",
        "last_updated": "2026-06-25",
        "certification_date": "2026-06-25",
        "status": "A",
        "authorized_official_last_name": "COSTELLO",
        "authorized_official_first_name": "JEFFREY",
        "authorized_official_title_or_position": "VP-CFO",
        "authorized_official_telephone_number": "574-647-3549"
    },
    "taxonomies": [
        {
            "code": "363A00000X",
            "taxonomy_group": "",
            "desc": "Physician Assistant",
            "state": null,
            "license": null,
            "primary": false
        },
        {
            "code": "363LF0000X",
            "taxonomy_group": "",
            "desc": "Nurse Practitioner, Family",
            "state": null,
            "license": null,
            "primary": false
        },
        {
            "code": "207Q00000X",
            "taxonomy_group": "",
            "desc": "Family Medicine",
            "state": "IN",
            "license": "01043622A",
            "primary": true
        },
        {
            "code": "207QS0010X",
            "taxonomy_group": "",
            "desc": "Family Medicine, Sports Medicine",
            "state": null,
            "license": null,
            "primary": false
        },
        {
            "code": "207R00000X",
            "taxonomy_group": "",
            "desc": "Internal Medicine",
            "state": null,
            "license": null,
            "primary": false
        },
        {
            "code": "207RI0011X",
            "taxonomy_group": "",
            "desc": "Internal Medicine, Interventional Cardiology",
            "state": null,
            "license": null,
            "primary": false
        },
        {
            "code": "207RR0500X",
            "taxonomy_group": "",
            "desc": "Internal Medicine, Rheumatology",
            "state": null,
            "license": null,
            "primary": false
        },
        {
            "code": "207T00000X",
            "taxonomy_group": "",
            "desc": "Neurological Surgery",
            "state": null,
            "license": null,
            "primary": false
        },
        {
            "code": "2085U0001X",
            "taxonomy_group": "",
            "desc": "Radiology, Diagnostic Ultrasound",
            "state": null,
            "license": null,
            "primary": false
        }
    ],
    "identifiers": [
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "300132559",
            "state": "IN"
        },
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "100224050B",
            "state": "IN"
        }
    ],
    "endpoints": [],
    "other_names": [
        {
            "organization_name": "Beacon Medical Group Ireland Road",
            "code": "3",
            "type": "Doing Business As"
        },
        {
            "organization_name": "Beacon Medical Group Ireland Road",
            "code": "3",
            "type": "Doing Business As"
        },
        {
            "organization_name": "Beacon Medical Group Plymouth",
            "code": "3",
            "type": "Doing Business As"
        }
    ]
}

Other providers in South Bend, IN

Sources for this page

  • NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Jun 25, 2026; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
  • Medicare enrollment (CMS PECOS): enrollments, PAC IDs and benefit reassignments.
  • Medicare Care Compare (CMS): clinician profile, group practices, facility affiliations, MIPS scores and star ratings.
  • National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.