NPIMap

Organization Active NPI

Memorial Hospital of South Bend

  • Psychiatric Hospital Unit
  • South Bend, IN
National Provider Identifier
1376841395
Registry record updated Feb 21, 2022
On this page

Key facts

NPPES NPI Registry
Primary specialty
Psychiatric Hospital UnitTaxonomy code 273R00000X
License
005053 Issued in IN
Legal business name
MEMORIAL HOSPITAL OF SOUTH BEND
Practice address
420 N Niles Ave
South Bend, IN 46617-1918
Phone
(574) 647-8400
Fax
(574) 647-8410
NPI assigned
Mar 1, 2011
Organization subpart
No

NPPES NPI Registry

Updated by the provider on Feb 21, 2022

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

Authorized official

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

Specialties & licenses 1

Specialty (taxonomy)CodeLicenseStatePrimary
Psychiatric Hospital Unit 273R00000X 005053 IN Primary

Addresses

Primary practice location

420 N Niles Ave
South Bend, IN 46617-1918

Mailing address

615 N Michigan St
South Bend, IN 46601-1033
Phone (574) 647-7167

Other identifiers 1

IdentifierTypeStateIssuer
100269890BMedicaidIN

Other names 1

  • Memorial Epworth Center Doing business as

Medicare participation

Medicare enrollment files
Medicare fee-for-service enrollment
Enrolled in IN

Enrollment records 1

Enrollment IDStateProvider typePAC IDDetails
O20071213000267 IN Part A Provider - Hospital 8123017126 2 other NPIs on this enrollment
This NPI is an additional NPI on the enrollment
Practice locations: South Bend, IN; Granger, IN

Hospital certification: CCN 150058

Legal name
MEMORIAL HOSPITAL OF SOUTH BEND
Doing business as
MEMORIAL HOSPITAL OF SOUTH BEND
Certification status
Active
Provider type (POS)
Hospital – Short-term
Participating since
Jul 1, 1966
Last certification
Nov 19, 2004
Beds
463
Ownership / control type
Private (not for profit)
Organization structure
CorporationNon-profit
Enrollment address
615 N Michigan St
South Bend, IN 46601-1033
Other Hospital Practice Location
Hospital subgroups
Acute care

Facilities connected through Provider of Services related, parent or unit certification numbers.

Other NPIs on the same Medicare enrollment 2

NPIs listed together on one Medicare enrollment, typically parts of the same organization.

National Provider Directory

National Provider Directory

Member organizations 1

Organizations listed as members of this organization in the National Provider Directory.

Ownership & related parties

All disclosed owners & managing parties 4

As disclosed on the Medicare enrollment (CMS All Owners files). Individuals include officers, directors and managing employees, who may not hold ownership.

NameRoleSinceShare
Kreg Gruber Individual Corporate OfficerCeo Jan 1, 2018
Beacon Health System Inc Organization, South Bend, IN Corporation Operational/Managerial Control Nov 23, 2011 100%
Larry a Tracy Individual Corporate OfficerHospital President Jun 26, 2016 100%
W-2 Managing EmployeePresident Jun 26, 2016 100%
Jeffrey P Costello Individual Corporate OfficerCfo Oct 1, 1995 100%

Affiliated clinicians 787

Clinicians who list this facility as an affiliation in Medicare Care Compare.

View all 787

Care Compare: Hospital

Medicare Care Compare
Listed as
Memorial Hospital of South BendCCN 150058
Overall star rating
2 of 5
Type
Acute Care Hospitals
Ownership
Voluntary non-profit - Private
Medicare certification status
ActiveFrom the Provider of Services file
Emergency services
Yes

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
15D2046888Memorial Epworth Center420 N Niles Ave, South Bend, IN 46617Certificate of waiverSep 12, 2026
15D2046890Memorial Epworth Ctr Geropsych Inst420 N Niles, South Bend, IN 46617Certificate of waiverSep 12, 2026

NPI Registry JSON

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

{
    "created_epoch": "1298937600000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1645401600000",
    "number": "1376841395",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "615 N MICHIGAN ST",
            "city": "SOUTH BEND",
            "state": "IN",
            "postal_code": "466011033",
            "telephone_number": "574-647-7167"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "420 N NILES AVE",
            "city": "SOUTH BEND",
            "state": "IN",
            "postal_code": "466171918",
            "telephone_number": "574-647-8400",
            "fax_number": "574-647-8410"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "MEMORIAL HOSPITAL OF SOUTH BEND",
        "organizational_subpart": "NO",
        "enumeration_date": "2011-03-01",
        "last_updated": "2022-02-21",
        "certification_date": "2022-02-21",
        "status": "A",
        "authorized_official_last_name": "COSTELLO",
        "authorized_official_first_name": "JEFFREY",
        "authorized_official_middle_name": "P",
        "authorized_official_title_or_position": "VP/CFO",
        "authorized_official_telephone_number": "574-647-3549",
        "authorized_official_name_prefix": "Mr."
    },
    "taxonomies": [
        {
            "code": "273R00000X",
            "taxonomy_group": "",
            "desc": "Psychiatric Unit",
            "state": "IN",
            "license": "005053",
            "primary": true
        }
    ],
    "identifiers": [
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "100269890B",
            "state": "IN"
        }
    ],
    "endpoints": [],
    "other_names": [
        {
            "organization_name": "Memorial Epworth Center",
            "code": "3",
            "type": "Doing Business As"
        },
        {
            "organization_name": "Memorial Epworth Center",
            "code": "3",
            "type": "Doing Business As"
        }
    ]
}

Other providers in South Bend, IN

Sources for this page

Verify at the official NPI Registry.