NPIMap

Organization Active NPI

Beacon Medical Group, Inc.

  • Nephrology Physician
  • South Bend, IN
National Provider Identifier
1124423546
Registry record updated Oct 12, 2017
On this page

Key facts

NPPES NPI Registry
Primary specialty
Nephrology PhysicianTaxonomy code 207RN0300X
Legal business name
BEACON MEDICAL GROUP, INC.
Practice address
100 Navarre PL Ste 4400
South Bend, IN 46601-1100
Phone
(574) 647-1972
Fax
(574) 647-1974
NPI assigned
Oct 28, 2014
Last updated
Oct 12, 2017By the provider in NPPES
Organization subpart
No

NPPES NPI Registry

Updated by the provider on Oct 12, 2017

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

Authorized official

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

Specialties & licenses 1

Specialty (taxonomy)CodeLicenseStatePrimary
Nephrology Physician 207RN0300X Primary

Addresses

Primary practice location

100 Navarre PL Ste 4400
South Bend, IN 46601-1100

Mailing address

710 N Niles Ave
South Bend, IN 46617-1924
Phone (574) 647-1610

Other practice location 1

100 Navarre Pl Ste 4405
South Bend, IN 46601-1176
Phone (574) 647-1972

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

National Provider Directory

National Provider Directory
Tax ID family
Memorial Health System Inc27 organizations share this tax ID, including this one

Other organizations with this tax ID 26

Organizations that report the same tax identification number in the National Provider Directory.

View all 26

Practitioners & affiliated clinicians

Practitioners 1

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.

NPI Registry JSON

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

{
    "created_epoch": "1414454400000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1507766400000",
    "number": "1124423546",
    "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",
            "fax_number": "574-237-6069"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "100 NAVARRE PL STE 4400",
            "city": "SOUTH BEND",
            "state": "IN",
            "postal_code": "466011100",
            "telephone_number": "574-647-1972",
            "fax_number": "574-647-1974"
        }
    ],
    "practiceLocations": [
        {
            "address_1": "100 Navarre Pl Ste 4405",
            "address_purpose": "LOCATION",
            "city": "South Bend",
            "state": "IN",
            "postal_code": "466011176",
            "country_code": "US",
            "telephone_number": "574-647-1972",
            "fax_number": "574-647-1974",
            "country_name": "United States",
            "address_type": "DOM"
        }
    ],
    "basic": {
        "organization_name": "BEACON MEDICAL GROUP, INC.",
        "organizational_subpart": "NO",
        "enumeration_date": "2014-10-28",
        "last_updated": "2017-10-12",
        "status": "A",
        "authorized_official_last_name": "COSTELLO",
        "authorized_official_first_name": "JEFFREY",
        "authorized_official_middle_name": "P.",
        "authorized_official_title_or_position": "CFO",
        "authorized_official_telephone_number": "574-647-3549"
    },
    "taxonomies": [
        {
            "code": "207RN0300X",
            "taxonomy_group": "",
            "desc": "Internal Medicine, Nephrology",
            "state": null,
            "license": null,
            "primary": true
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": []
}

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 Oct 12, 2017; 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.