NPIMap

Organization Active NPI

Beacon Medical Group, Inc.

Doing business as Beacon Medical Group Critical Kids

  • Pediatric Critical Care Medicine Physician
  • South Bend, IN
National Provider Identifier
1467408237
Registry record updated Apr 24, 2023
On this page

Key facts

NPPES NPI Registry
Primary specialty
Pediatric Critical Care Medicine PhysicianTaxonomy code 2080P0203X
Legal business name
BEACON MEDICAL GROUP, INC.
Doing business as
Beacon Medical Group Critical Kids
Practice address
615 N Michigan St 5TH FL
South Bend, IN 46601-1033
Phone
(574) 647-7275
Fax
(574) 647-3696
NPI assigned
May 25, 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
Jeffrey Costello
Title
Cfo
Phone
(574) 647-3549

Specialties & licenses 1

Specialty (taxonomy)CodeLicenseStatePrimary
Pediatric Critical Care Medicine PhysicianGroup: 193200000X MULTI-SPECIALTY GROUP 2080P0203X Primary

Addresses

Primary practice location

615 N Michigan St 5TH FL
South Bend, IN 46601-1033

Mailing address

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

Other identifiers 1

IdentifierTypeStateIssuer
200235870AMedicaidIN

Other names 1

  • Beacon Medical Group Critical Kids 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
Memorial Health System 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 13

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 13

NPI Registry JSON

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

{
    "created_epoch": "1148515200000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1682294400000",
    "number": "1467408237",
    "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": "615 N MICHIGAN ST 5TH FL",
            "city": "SOUTH BEND",
            "state": "IN",
            "postal_code": "466011033",
            "telephone_number": "574-647-7275",
            "fax_number": "574-647-3696"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "BEACON MEDICAL GROUP, INC.",
        "organizational_subpart": "NO",
        "enumeration_date": "2006-05-25",
        "last_updated": "2023-04-24",
        "certification_date": "2023-04-24",
        "status": "A",
        "authorized_official_last_name": "COSTELLO",
        "authorized_official_first_name": "JEFFREY",
        "authorized_official_title_or_position": "CFO",
        "authorized_official_telephone_number": "574-647-3549"
    },
    "taxonomies": [
        {
            "code": "2080P0203X",
            "taxonomy_group": "193200000X MULTI-SPECIALTY GROUP",
            "desc": "Pediatrics, Pediatric Critical Care Medicine",
            "state": null,
            "license": null,
            "primary": true
        }
    ],
    "identifiers": [
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "200235870A",
            "state": "IN"
        }
    ],
    "endpoints": [],
    "other_names": [
        {
            "organization_name": "Beacon Medical Group Critical Kids",
            "code": "3",
            "type": "Doing Business As"
        }
    ]
}

Other providers in South Bend, 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.