NPIMap

Organization Active NPI

Beacon Medical Group, Inc.

Doing business as Beacon Medical Group Pediatric Multi-Specialty

  • Pediatrics Physician
  • South Bend, IN
National Provider Identifier
1548415474
Registry record updated Jul 21, 2025
On this page

Key facts

NPPES NPI Registry
Primary specialty
Pediatrics PhysicianTaxonomy code 208000000X
License
01065535A Issued in IN
Legal business name
BEACON MEDICAL GROUP, INC.
Doing business as
Beacon Medical Group Pediatric Multi-Specialty
Beacon Medical Group Pediatric Specialists
Practice address
100 Navarre PL Ste 5550
South Bend, IN 46601-1169
Phone
(574) 647-2550
Fax
(574) 647-1129
NPI assigned
Nov 19, 2008
Last updated
Jul 21, 2025By the provider in NPPES
Organization subpart
No

NPPES NPI Registry

Updated by the provider on Jul 21, 2025

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

Authorized official

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

Specialties & licenses 7

Specialty (taxonomy)CodeLicenseStatePrimary
Nurse Practitioner 363L00000X NU
Psychologist 103T00000X NU
Clinical Psychologist 103TC0700X NU
Registered Dietitian 133V00000X NU
Pediatrics Physician 208000000X 01065535A IN Primary
Neonatal-Perinatal Medicine Physician 2080N0001X NU
Pediatric Pulmonology Physician 2080P0214X NU

Addresses

Primary practice location

100 Navarre PL Ste 5550
South Bend, IN 46601-1169

Mailing address

3245 Health Dr Ste 100
Granger, IN 46530-1380
Phone (574) 647-1069

Other practice location 1

100 Navarre Pl Ste 5570
South Bend, IN 46601-1169
Phone (574) 647-8610

Other identifiers 2

IdentifierTypeStateIssuer
200928880AMedicaidIN
300069919MedicaidIN

Other names 2

  • Beacon Medical Group Pediatric Multi-Specialty Doing business as
  • Beacon Medical Group Pediatric Specialists 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

Practitioners & affiliated clinicians

Practitioners 8

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.

NPI Registry JSON

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

{
    "created_epoch": "1227052800000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1753056000000",
    "number": "1548415474",
    "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": "574-647-1069"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "100 NAVARRE PL STE 5550",
            "city": "SOUTH BEND",
            "state": "IN",
            "postal_code": "466011169",
            "telephone_number": "574-647-2550",
            "fax_number": "574-647-1129"
        }
    ],
    "practiceLocations": [
        {
            "address_1": "100 Navarre Pl Ste 5570",
            "address_purpose": "LOCATION",
            "city": "South Bend",
            "state": "IN",
            "postal_code": "466011169",
            "country_code": "US",
            "telephone_number": "574-647-8610",
            "fax_number": "574-647-8615",
            "country_name": "United States",
            "address_type": "DOM"
        }
    ],
    "basic": {
        "organization_name": "BEACON MEDICAL GROUP, INC.",
        "organizational_subpart": "NO",
        "enumeration_date": "2008-11-19",
        "last_updated": "2025-07-21",
        "certification_date": "2025-07-21",
        "status": "A",
        "authorized_official_last_name": "COSTELLO",
        "authorized_official_first_name": "JEFFREY",
        "authorized_official_middle_name": "P",
        "authorized_official_title_or_position": "VICE PRESIDENT/CFO",
        "authorized_official_telephone_number": "574-647-3549",
        "authorized_official_name_prefix": "Mr."
    },
    "taxonomies": [
        {
            "code": "363L00000X",
            "taxonomy_group": "",
            "desc": "Nurse Practitioner",
            "state": "NU",
            "license": null,
            "primary": false
        },
        {
            "code": "103T00000X",
            "taxonomy_group": "",
            "desc": "Psychologist",
            "state": "NU",
            "license": null,
            "primary": false
        },
        {
            "code": "103TC0700X",
            "taxonomy_group": "",
            "desc": "Psychologist, Clinical",
            "state": "NU",
            "license": null,
            "primary": false
        },
        {
            "code": "133V00000X",
            "taxonomy_group": "",
            "desc": "Dietitian, Registered",
            "state": "NU",
            "license": null,
            "primary": false
        },
        {
            "code": "208000000X",
            "taxonomy_group": "",
            "desc": "Pediatrics",
            "state": "IN",
            "license": "01065535A",
            "primary": true
        },
        {
            "code": "2080N0001X",
            "taxonomy_group": "",
            "desc": "Pediatrics, Neonatal-Perinatal Medicine",
            "state": "NU",
            "license": null,
            "primary": false
        },
        {
            "code": "2080P0214X",
            "taxonomy_group": "",
            "desc": "Pediatrics, Pediatric Pulmonology",
            "state": "NU",
            "license": null,
            "primary": false
        }
    ],
    "identifiers": [
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "200928880A",
            "state": "IN"
        },
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "300069919",
            "state": "IN"
        }
    ],
    "endpoints": [],
    "other_names": [
        {
            "organization_name": "Beacon Medical Group Pediatric Multi-Specialty",
            "code": "3",
            "type": "Doing Business As"
        },
        {
            "organization_name": "Beacon Medical Group Pediatric Multi-Specialty",
            "code": "3",
            "type": "Doing Business As"
        },
        {
            "organization_name": "Beacon Medical Group Pediatric Specialists",
            "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 Jul 21, 2025; 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.