NPIMap

Organization Active NPI

Beacon Medical Group, Inc.

Doing business as Beacon Medical Group OBGYN River Oaks

  • Obstetrics & Gynecology Physician
  • Elkhart, IN
National Provider Identifier
1316073372
Registry record updated Mar 4, 2024
On this page

Key facts

NPPES NPI Registry
Primary specialty
Obstetrics & Gynecology PhysicianTaxonomy code 207V00000X
License
07-005017-1 Issued in IN
Legal business name
BEACON MEDICAL GROUP, INC.
Doing business as
Beacon Medical Group OBGYN River Oaks
Beacon Medical Group OBGYN River Oaks Lawn Aenue
Beacon Medical Group Obstetrics & Gynecology Elkhart
Practice address
1215 Lawn Ave Ste 100
Elkhart, IN 46514-2450
Phone
(574) 293-2893
Fax
(574) 293-1298
NPI assigned
Feb 26, 2007
Last updated
Mar 4, 2024By the provider in NPPES
Organization subpart
No

NPPES NPI Registry

Updated by the provider on Mar 4, 2024

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 3

Specialty (taxonomy)CodeLicenseStatePrimary
Family Nurse Practitioner 363LF0000X NU
Advanced Practice Midwife 367A00000X NU
Obstetrics & Gynecology Physician 207V00000X 07-005017-1 IN Primary

Addresses

Primary practice location

1215 Lawn Ave Ste 100
Elkhart, IN 46514-2450

Mailing address

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

Other practice location 1

2405 W Lexington Ave
Elkhart, IN 46514-1417
Phone (574) 524-7575

Other practice location 2

1215 Lawn Ave Ste 110
Elkhart, IN 46514-2493
Phone (574) 524-7570

Other identifiers 2

IdentifierTypeStateIssuer
000000519823OtherINANTHEM BCBS
200853000AMedicaidIN

Other names 3

  • Beacon Medical Group OBGYN River Oaks Doing business as
  • Beacon Medical Group OBGYN River Oaks Lawn Aenue Doing business as
  • Beacon Medical Group Obstetrics & Gynecology Elkhart 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
15D2274982Beacon Medical Group OBGYN River Oaks2405 West Lexington Avenue, Elkhart, IN 46514Certificate of waiverJan 12, 2027

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

Locations

2222 Rieth Blvd
Ste 104
Goshen, IN 46526
Phone (574) 875-1082

Practitioners & affiliated clinicians

Practitioners 35

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 35

NPI Registry JSON

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

{
    "created_epoch": "1172448000000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1709510400000",
    "number": "1316073372",
    "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": "1215 LAWN AVE STE 100",
            "city": "ELKHART",
            "state": "IN",
            "postal_code": "465142450",
            "telephone_number": "574-293-2893",
            "fax_number": "574-293-1298"
        }
    ],
    "practiceLocations": [
        {
            "address_1": "2405 W Lexington Ave",
            "address_purpose": "LOCATION",
            "city": "Elkhart",
            "state": "IN",
            "postal_code": "465141417",
            "country_code": "US",
            "telephone_number": "574-524-7575",
            "fax_number": "574-524-7576",
            "country_name": "United States",
            "address_type": "DOM"
        },
        {
            "address_1": "1215 Lawn Ave Ste 110",
            "address_purpose": "LOCATION",
            "city": "Elkhart",
            "state": "IN",
            "postal_code": "465142493",
            "country_code": "US",
            "telephone_number": "574-524-7570",
            "fax_number": "574-524-7571",
            "country_name": "United States",
            "address_type": "DOM"
        }
    ],
    "basic": {
        "organization_name": "BEACON MEDICAL GROUP, INC.",
        "organizational_subpart": "NO",
        "enumeration_date": "2007-02-26",
        "last_updated": "2024-03-04",
        "certification_date": "2024-03-04",
        "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": "363LF0000X",
            "taxonomy_group": "",
            "desc": "Nurse Practitioner, Family",
            "state": "NU",
            "license": null,
            "primary": false
        },
        {
            "code": "367A00000X",
            "taxonomy_group": "",
            "desc": "Advanced Practice Midwife",
            "state": "NU",
            "license": null,
            "primary": false
        },
        {
            "code": "207V00000X",
            "taxonomy_group": "",
            "desc": "Obstetrics & Gynecology",
            "state": "IN",
            "license": "07-005017-1",
            "primary": true
        }
    ],
    "identifiers": [
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "ANTHEM BCBS",
            "identifier": "000000519823",
            "state": "IN"
        },
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "200853000A",
            "state": "IN"
        }
    ],
    "endpoints": [],
    "other_names": [
        {
            "organization_name": "Beacon Medical Group OBGYN River Oaks",
            "code": "3",
            "type": "Doing Business As"
        },
        {
            "organization_name": "Beacon Medical Group OBGYN River Oaks Lawn Aenue",
            "code": "3",
            "type": "Doing Business As"
        },
        {
            "organization_name": "Beacon Medical Group Obstetrics & Gynecology Elkhart",
            "code": "3",
            "type": "Doing Business As"
        }
    ]
}

Other providers in Elkhart, IN

Sources for this page

  • NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Mar 4, 2024; 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.