Beacon Medical Group, Inc.

Primary specialty

Family Medicine PhysicianTaxonomy code 207Q00000X

License

01059718A Issued in IN

Legal business name

BEACON MEDICAL GROUP, INC.

Practice address

1708 High St
South Bend, IN 46613-2633

Phone

(574) 647-1400

NPI assigned

May 15, 2006

Organization subpart

No

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

Authorized official

Name

Jeffrey Costello

Title

VP-Cfo

Phone

(574) 647-3549

Specialties & licenses 1

Addresses

Other identifiers 1

Other names 1

• Beacon Medical Group Southeast Neighborhood Health Center Doing business as

Medicare fee-for-service enrollment

Enrolled in IN

Enrollment records 1

Practitioners 2

Individual providers connected to this organization through Medicare benefit reassignment, Care Compare group membership or National Provider Directory roles.

• Marjorie Thermidor Daoud, MD

  • Infectious Disease Physician
  • South Bend, IN
  • NPI 1346276995
  NPD
• Kristin Joy Kile, CNM

  • Advanced Practice Midwife
  • South Bend, IN
  • NPI 1447241179
  NPD

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

{
    "created_epoch": "1147651200000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1472428800000",
    "number": "1437100161",
    "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"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "1708 HIGH ST",
            "city": "SOUTH BEND",
            "state": "IN",
            "postal_code": "466132633",
            "telephone_number": "574-647-1400"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "BEACON MEDICAL GROUP, INC.",
        "organizational_subpart": "NO",
        "enumeration_date": "2006-05-15",
        "last_updated": "2016-08-29",
        "status": "A",
        "authorized_official_last_name": "COSTELLO",
        "authorized_official_first_name": "JEFFREY",
        "authorized_official_title_or_position": "VP-CFO",
        "authorized_official_telephone_number": "574-647-3549"
    },
    "taxonomies": [
        {
            "code": "207Q00000X",
            "taxonomy_group": "193200000X MULTI-SPECIALTY GROUP",
            "desc": "Family Medicine",
            "state": "IN",
            "license": "01059718A",
            "primary": true
        }
    ],
    "identifiers": [
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "200114230A",
            "state": "IN"
        }
    ],
    "endpoints": [],
    "other_names": [
        {
            "organization_name": "Beacon Medical Group Southeast Neighborhood Health Center",
            "code": "3",
            "type": "Doing Business As"
        }
    ]
}

• Beacon Medical Group, Inc.
• Beacon Medical Group, Inc.
• Beacon Medical Group, Inc.
• Beacon Medical Group, Inc.
• Beacon Medical Group, Inc.
• Beacon Medical Group, Inc.
• Beacon Medical Group, Inc.
• Beacon Medical Group, Inc.
• Beacon Medical Group, Inc.
• Beacon Medical Group, Inc.

• All providers in South Bend, IN
• Family Medicine Physician in Indiana

• NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Aug 29, 2016; 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.