NPIMap

Organization Active NPI

Beacon Medical Group, Inc.

Doing business as Beacon Medical Group Goshen

  • Family Medicine Physician
  • Goshen, IN
National Provider Identifier
1306863915
Registry record updated Apr 24, 2023
On this page

Key facts

NPPES NPI Registry
Primary specialty
Family Medicine PhysicianTaxonomy code 207Q00000X
License
06-005017-1 Issued in IN
Legal business name
BEACON MEDICAL GROUP, INC.
Doing business as
Beacon Medical Group Goshen
Practice address
2120 Rieth Blvd Ste a
Goshen, IN 46526-5858
Phone
(574) 875-5126
Fax
(574) 875-1874
NPI assigned
Jul 17, 2006
Last updated
Apr 24, 2023By the provider in NPPES
Organization subpart
No

NPPES NPI Registry

Updated by the provider on Apr 24, 2023

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

Authorized official

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

Specialties & licenses 2

Specialty (taxonomy)CodeLicenseStatePrimary
Dermatology Physician 207N00000X 06-005017-1 IN
Family Medicine Physician 207Q00000X 06-005017-1 IN Primary

Addresses

Primary practice location

2120 Rieth Blvd Ste a
Goshen, IN 46526-5858

Mailing address

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

Other identifiers 2

IdentifierTypeStateIssuer
000000110758OtherINANTHEM BCBS
200116290AMedicaidIN

Other names 1

  • Beacon Medical Group Goshen 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

National Provider Directory

National Provider Directory
Tax ID family
Beacon Medical Group 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 4

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": "1153094400000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1682294400000",
    "number": "1306863915",
    "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": "2120 RIETH BLVD STE A",
            "city": "GOSHEN",
            "state": "IN",
            "postal_code": "465265858",
            "telephone_number": "574-875-5126",
            "fax_number": "574-875-1874"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "BEACON MEDICAL GROUP, INC.",
        "organizational_subpart": "NO",
        "enumeration_date": "2006-07-17",
        "last_updated": "2023-04-24",
        "certification_date": "2023-04-24",
        "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",
        "authorized_official_name_prefix": "Mr."
    },
    "taxonomies": [
        {
            "code": "207N00000X",
            "taxonomy_group": "",
            "desc": "Dermatology",
            "state": "IN",
            "license": "06-005017-1",
            "primary": false
        },
        {
            "code": "207Q00000X",
            "taxonomy_group": "",
            "desc": "Family Medicine",
            "state": "IN",
            "license": "06-005017-1",
            "primary": true
        }
    ],
    "identifiers": [
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "ANTHEM BCBS",
            "identifier": "000000110758",
            "state": "IN"
        },
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "200116290A",
            "state": "IN"
        }
    ],
    "endpoints": [],
    "other_names": [
        {
            "organization_name": "Beacon Medical Group Goshen",
            "code": "3",
            "type": "Doing Business As"
        },
        {
            "organization_name": "Beacon Medical Group Goshen",
            "code": "3",
            "type": "Doing Business As"
        }
    ]
}

Other providers in Goshen, IN

Sources for this page

  • NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Apr 24, 2023; 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.