NPIMap

Individual provider Active NPI

Thomas Larsen, MD

  • Family Medicine Physician
  • South Bend, IN
National Provider Identifier
1285998146
Registry record updated Sep 9, 2015
On this page

Key facts

NPPES NPI Registry
Primary specialty
Family Medicine PhysicianTaxonomy code 207Q00000X
License
01075173A Issued in IN
Practice address
4440 Portage Ave
South Bend, IN 46628-9570
Phone
(574) 204-6200
Fax
(574) 239-1520
NPI assigned
Jun 26, 2012
Sex
Male
Sole proprietor
No

NPPES NPI Registry

Updated by the provider on Sep 9, 2015

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

Specialties & licenses 1

Specialty (taxonomy)CodeLicenseStatePrimary
Family Medicine Physician 207Q00000X 01075173A IN Primary

Addresses

Primary practice location

4440 Portage Ave
South Bend, IN 46628-9570

Mailing address

4440 Portage Ave
South Bend, IN 46628-9570
Phone (574) 204-6200

Other identifiers 1

IdentifierTypeStateIssuer
201112870MedicaidIN

Medicare participation

Medicare enrollment files
Medicare fee-for-service enrollment
Enrolled in IN
Eligible to order & refer
  • Part B services
  • Medical equipment
  • Home health
  • Power mobility devices
  • Hospice
Green means eligible to order or refer.

Enrollment records 1

Enrollment IDStateProvider typePAC IDDetails
I20150611000123 IN Practitioner - Family Practice 1355589284 Reassigns benefits to 2 organizations

Care Compare profile

Medicare Care Compare
Specialty
Family Practice
Education
Other, 2008
Medicare assignment
Accepts the Medicare-approved amount as payment in full
Group practices
The South Bend Clinic LLCGroup PAC ID 3779577937, 171 clinicians
Beacon Medical Group IncGroup PAC ID 1254243306, 575 clinicians

Practice addresses (Care Compare)

211 N Eddy St
South Bend, IN 46617-2808
Phone (574) 234-8161

4440 Portage Rd
South Bend, IN 46628-9570
Phone (574) 204-6200

714 N Michigan St
Beacon Medical Group E Blair Warner
South Bend, IN 46601-1035
Phone (574) 647-7477

Hospital & facility affiliations

Procedures performed for Medicare patients

ProcedureNumber of procedures
Removal of skin lesions1-10

National Provider Directory

National Provider Directory
Medicare enrollment (NPD)
Enrolled
Credentials
Doctor of Medicine

State licenses

LicenseStateTypeSpecialty
01075173AINMDFamily Medicine Physician

Practice roles

OrganizationSpecialtyStatusNew patients
The South Bend Clinic, LLC CurrentSince Aug 1, 2015 Accepting new patients
Beacon Medical Group Inc CurrentSince Jan 1, 2020 Accepting new patients
The South Bend Clinic LLC CurrentSince Aug 1, 2015 Accepting new patients
Beacon Medical Group, Inc. Family Medicine Current Accepting new patients
Beacon Medical Group, Inc. Family Medicine CurrentSince Jan 1, 2020 Accepting new patients
Beacon Medical Group, Inc. Past Accepting new patients

Locations

714 N Michigan St
South Bend, IN 46601
Phone (574) 647-7477

4440 Portage Rd
South Bend, IN 46628
Phone (574) 204-6200

211 N Eddy St
South Bend, IN 46617
Phone (574) 237-9331

Interoperability endpoints

  • Direct secure messaging: tlarsen254062@dulyhealthandcare.direct-ci.com
  • FHIR API: https://epicproxy.et1296.epichosted.com/APIProxyPRD/api/FHIR/R4/

Organizations & group practices 6

Organizations this provider is connected to: Medicare benefit reassignments (the organization bills Medicare for this provider’s services), Care Compare group memberships and National Provider Directory roles.

Hospital & facility affiliations 7

Hospitals and other facilities this clinician is affiliated with according to Medicare Care Compare.

NPI Registry JSON

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

{
    "created_epoch": "1340668800000",
    "enumeration_type": "NPI-1",
    "last_updated_epoch": "1441756800000",
    "number": "1285998146",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "4440 PORTAGE AVE",
            "city": "SOUTH BEND",
            "state": "IN",
            "postal_code": "466289570",
            "telephone_number": "574-204-6200",
            "fax_number": "574-239-1520"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "4440 PORTAGE AVE",
            "city": "SOUTH BEND",
            "state": "IN",
            "postal_code": "466289570",
            "telephone_number": "574-204-6200",
            "fax_number": "574-239-1520"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "last_name": "LARSEN",
        "first_name": "THOMAS",
        "credential": "MD",
        "sole_proprietor": "NO",
        "sex": "M",
        "enumeration_date": "2012-06-26",
        "last_updated": "2015-09-09",
        "status": "A"
    },
    "taxonomies": [
        {
            "code": "207Q00000X",
            "taxonomy_group": "",
            "desc": "Family Medicine",
            "state": "IN",
            "license": "01075173A",
            "primary": true
        }
    ],
    "identifiers": [
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "201112870",
            "state": "IN"
        }
    ],
    "endpoints": [],
    "other_names": []
}

Other providers in South Bend, IN

Sources for this page

Verify at the official NPI Registry.