Beacon Medical Group, Inc.

Primary specialty

Family Medicine PhysicianTaxonomy code 207Q00000X

License

01022886A Issued in IN

Legal business name

BEACON MEDICAL GROUP, INC.

Practice address

813 S Michigan St
South Bend, IN 46601

Phone

(574) 647-2400

Fax

(574) 647-4201

NPI assigned

May 22, 2006

Organization subpart

No

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 1

Addresses

Other identifiers 2

Medicare fee-for-service enrollment

Enrolled in IN

Enrollment records 1

Practitioners 3

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

• Janel L. Charlton, MD

  • Family Medicine Physician
  • South Bend, IN
  • NPI 1770711145

  Family Medicine

  NPD
• Susana Diaz, CNM

  • Advanced Practice Midwife
  • South Bend, IN
  • NPI 1972857704
  NPD
• Laura Theresa Mabry, MSN, CNM

  • Advanced Practice Midwife
  • South Bend, IN
  • NPI 1184952848
  NPD

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

{
    "created_epoch": "1148256000000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1530576000000",
    "number": "1275587149",
    "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": "813 S MICHIGAN ST",
            "city": "SOUTH BEND",
            "state": "IN",
            "postal_code": "46601",
            "telephone_number": "574-647-2400",
            "fax_number": "574-647-4201"
        }
    ],
    "practiceLocations": [
        {
            "address_1": "621 Memorial Dr Ste 402",
            "address_purpose": "LOCATION",
            "city": "South Bend",
            "state": "IN",
            "postal_code": "466011074",
            "country_code": "US",
            "telephone_number": "574-647-2500",
            "fax_number": "574-647-7140",
            "country_name": "United States",
            "address_type": "DOM"
        }
    ],
    "basic": {
        "organization_name": "BEACON MEDICAL GROUP, INC.",
        "organizational_subpart": "NO",
        "enumeration_date": "2006-05-22",
        "last_updated": "2018-07-03",
        "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": "207Q00000X",
            "taxonomy_group": "193200000X MULTI-SPECIALTY GROUP",
            "desc": "Family Medicine",
            "state": "IN",
            "license": "01022886A",
            "primary": true
        }
    ],
    "identifiers": [
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "200191560B",
            "state": "IN"
        },
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "200191560A",
            "state": "IN"
        }
    ],
    "endpoints": [],
    "other_names": []
}

• 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.
• Beacon Medical Group, Inc.
• Beacon Medical Group, Inc.

• All providers in South Bend, IN
• Family Medicine Physician in Indiana

• NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Jul 3, 2018; 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.