Active NPI
Beacon Medical Group, Inc.
Doing business as Beacon Medical Group Portage Road
- Family Medicine Physician
- South Bend, IN
National Provider Identifier
1568413359
On this page
Key facts
NPPES NPI Registry- Primary specialty
- Family Medicine Physician
- License
- 01054535A
- Legal business name
- BEACON MEDICAL GROUP, INC.
- Doing business as
- Beacon Medical Group Portage Road
- Practice address
- 3575 Portage Ave
South Bend, IN 46628-6092 - Phone
- (574) 647-4530
- NPI assigned
- May 15, 2006
- Last updated
- Sep 27, 2013
- Organization subpart
- No
NPPES NPI Registry
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
| Specialty (taxonomy) | Code | License | State | Primary |
|---|---|---|---|---|
| Family Medicine Physician | 207Q00000X | 01054535A | IN | Primary |
Addresses
Primary practice location
3575 Portage Ave
South Bend, IN 46628-6092
Mailing address
53842 Generations Dr
South Bend, IN 46635-1543
Other identifiers 1
| Identifier | Type | State | Issuer |
|---|---|---|---|
| 100092700B | Medicaid | IN |
Other names 1
- Beacon Medical Group Portage Road
Medicare participation
Medicare enrollment files- Medicare fee-for-service enrollment
- Enrolled in IN
Enrollment records 1
| Enrollment ID | State | Provider type | PAC ID | Details |
|---|---|---|---|---|
| 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 DirectoryNPI Registry JSON
The complete NPPES record for this NPI in the NPI Registry API format.
{
"created_epoch": "1147651200000",
"enumeration_type": "NPI-2",
"last_updated_epoch": "1380240000000",
"number": "1568413359",
"addresses": [
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "MAILING",
"address_type": "DOM",
"address_1": "53842 GENERATIONS DR",
"city": "SOUTH BEND",
"state": "IN",
"postal_code": "466351543"
},
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "LOCATION",
"address_type": "DOM",
"address_1": "3575 PORTAGE AVE",
"city": "SOUTH BEND",
"state": "IN",
"postal_code": "466286092",
"telephone_number": "574-647-4530"
}
],
"practiceLocations": [],
"basic": {
"organization_name": "BEACON MEDICAL GROUP, INC.",
"organizational_subpart": "NO",
"enumeration_date": "2006-05-15",
"last_updated": "2013-09-27",
"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": "",
"desc": "Family Medicine",
"state": "IN",
"license": "01054535A",
"primary": true
}
],
"identifiers": [
{
"code": "05",
"desc": "MEDICAID",
"issuer": null,
"identifier": "100092700B",
"state": "IN"
}
],
"endpoints": [],
"other_names": [
{
"organization_name": "Beacon Medical Group Portage Road",
"code": "3",
"type": "Doing Business As"
}
]
}Other providers in South Bend, IN
- Beacon Medical Group, Inc. (Beacon Medical Group Southeast Neighborhood Health Center)
- Beacon Medical Group, Inc. (Memorial Children's Hospital Navarre Pediatrics)
- Beacon Medical Group, Inc. (Beacon Medical Group Critical Kids)
- Beacon Medical Group, Inc. (Memorial Pain Management)
- Beacon Medical Group, Inc. (Beacon Medical Group Pediatric Multi-Specialty)
- Beacon Medical Group, Inc. (Beacon Medical Group Sports Medicine South Bend)
- Beacon Medical Group, Inc. (Beacon Medical Group Midwifery Centered Care South Bend)
- Beacon Medical Group, Inc. (Beacon Medical Group Cleveland Road)
- Beacon Medical Group, Inc. (Beacon Medical Group E. Blair Warner)
- Beacon Medical Group, Inc. (Beacon Medical Group Behavioral Health South Bend)
Sources for this page
- NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Sep 27, 2013; 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.