NPIMap

Individual provider Active NPI

Jerome Rusceak Skelly, M.D.

  • Geriatric Medicine (Internal Medicine) Physician
  • South Bend, IN
National Provider Identifier
1396729893
Registry record updated Dec 18, 2024
On this page

Key facts

NPPES NPI Registry
Primary specialty
Geriatric Medicine (Internal Medicine) PhysicianTaxonomy code 207RG0300X
License
01049640A Issued in IN
Practice address
1815 E Ireland Rd
South Bend, IN 46614-2845
Phone
(574) 647-1700
Fax
(574) 647-1993
NPI assigned
Nov 30, 2005
Last updated
Dec 18, 2024By the provider in NPPES
Sex
Male
Sole proprietor
No

NPPES NPI Registry

Updated by the provider on Dec 18, 2024

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

Specialties & licenses 2

Specialty (taxonomy)CodeLicenseStatePrimary
Internal Medicine Physician 207R00000X 01049640A IN
Geriatric Medicine (Internal Medicine) Physician 207RG0300X 01049640A IN Primary

Addresses

Primary practice location

1815 E Ireland Rd
South Bend, IN 46614-2845

Mailing address

3245 Health Dr Ste 100
Granger, IN 46530-1380
Phone (574) 647-1610

Other identifiers 1

IdentifierTypeStateIssuer
200203460MedicaidIN

Electronic endpoints 1

TypeEndpointUseAffiliation
Direct Messaging Address SKELLY@mybeacon.cernerdirect.com

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
I20061103000315 IN Practitioner - Internal Medicine 9638176670 Reassigns benefits to 1 organization

Care Compare profile

Medicare Care Compare
Specialty
Internal Medicine
Education
University of Texas Medical Branch at Galveston, 1987
Medicare assignment
Accepts the Medicare-approved amount as payment in full
Group practices
Beacon Medical Group IncGroup PAC ID 1254243306, 575 clinicians

Practice addresses (Care Compare)

1815 E Ireland Rd
Beacon Medical Group Ireland Road
South Bend, IN 46614-2845
Phone (574) 647-1700

Hospital & facility affiliations

National Provider Directory

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

State licenses

LicenseStateTypeSpecialty
01049640AINMDGeriatric Medicine (Internal Medicine) Physician

Practice roles

OrganizationSpecialtyStatusNew patients
Beacon Medical Group, Inc. Current Accepting new patients
Beacon Medical Group, Inc. Internal Medicine CurrentSince Jun 1, 2006 Accepting new patients
Beacon Medical Group Inc CurrentSince Jun 1, 2006 Accepting new patients
Beacon Medical Group, Inc. Past Accepting new patients

Locations

3245 Health Dr
Ste 100
Granger, IN 46530
Phone (574) 647-2129

900 I St
Laporte, IN 46350
Phone (219) 324-1670

100 Navarre Pl
Ste 4400
South Bend, IN 46601
Phone (574) 647-2501

1815 E Ireland Rd
South Bend, IN 46614
Phone (574) 647-1700

707 N Michigan St
Ste 102
South Bend, IN 46601
Phone (574) 367-3800

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

Interoperability endpoints

  • Direct secure messaging: skelly@mybeacon.cernerdirect.com

Organizations & group practices 4

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

Hospital & facility affiliations 9

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": "1133308800000",
    "enumeration_type": "NPI-1",
    "last_updated_epoch": "1734480000000",
    "number": "1396729893",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "3245 HEALTH DR STE 100",
            "city": "GRANGER",
            "state": "IN",
            "postal_code": "465301380",
            "telephone_number": "574-647-1610"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "1815 E IRELAND RD",
            "city": "SOUTH BEND",
            "state": "IN",
            "postal_code": "466142845",
            "telephone_number": "574-647-1700",
            "fax_number": "574-647-1993"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "last_name": "SKELLY",
        "first_name": "JEROME",
        "middle_name": "RUSCEAK",
        "name_prefix": "Dr.",
        "credential": "M.D.",
        "sole_proprietor": "NO",
        "sex": "M",
        "enumeration_date": "2005-11-30",
        "last_updated": "2024-12-18",
        "certification_date": "2024-12-18",
        "status": "A"
    },
    "taxonomies": [
        {
            "code": "207R00000X",
            "taxonomy_group": "",
            "desc": "Internal Medicine",
            "state": "IN",
            "license": "01049640A",
            "primary": false
        },
        {
            "code": "207RG0300X",
            "taxonomy_group": "",
            "desc": "Internal Medicine, Geriatric Medicine",
            "state": "IN",
            "license": "01049640A",
            "primary": true
        }
    ],
    "identifiers": [
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "200203460",
            "state": "IN"
        }
    ],
    "endpoints": [
        {
            "endpointType": "DIRECT",
            "endpointTypeDescription": "Direct Messaging Address",
            "endpoint": "SKELLY@mybeacon.cernerdirect.com",
            "affiliation": "N",
            "address_1": "1815 E Ireland Rd",
            "city": "South Bend",
            "state": "IN",
            "country_code": "US",
            "postal_code": "466142845",
            "country_name": "United States",
            "address_type": "DOM"
        }
    ],
    "other_names": []
}

Other providers in South Bend, IN

Sources for this page

Verify at the official NPI Registry.