Beacon Medical Group, Inc.

Primary specialty

Sports Medicine (Family Medicine) PhysicianTaxonomy code 207QS0010X

License

01049328A Issued in IN

Legal business name

BEACON MEDICAL GROUP, INC.

Doing business as

Beacon Medical Group Sports Medicine South Bend

Practice address

111 W Jefferson Blvd
Suite 100
South Bend, IN 46601-1994

Phone

(574) 647-1669

Fax

(574) 239-6461

NPI assigned

May 16, 2006

Last updated

Aug 30, 2016By the provider in NPPES

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 Sports Medicine South Bend 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, and the practitioner matching its NPPES authorized official.

• Kristine Elizabeth Jennings, MD

  • Family Medicine Physician
  • South Bend, IN
  • NPI 1194011775
  NPD
• Emily-Rae Reed Singh, MD

  • Family Medicine Physician
  • South Bend, IN
  • NPI 1457490450
  NPD

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

{
    "created_epoch": "1147737600000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1472515200000",
    "number": "1578515151",
    "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": "111 W JEFFERSON BLVD",
            "address_2": "SUITE 100",
            "city": "SOUTH BEND",
            "state": "IN",
            "postal_code": "466011994",
            "telephone_number": "574-647-1669",
            "fax_number": "574-239-6461"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "BEACON MEDICAL GROUP, INC.",
        "organizational_subpart": "NO",
        "enumeration_date": "2006-05-16",
        "last_updated": "2016-08-30",
        "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": "207QS0010X",
            "taxonomy_group": "193200000X MULTI-SPECIALTY GROUP",
            "desc": "Family Medicine, Sports Medicine",
            "state": "IN",
            "license": "01049328A",
            "primary": true
        }
    ],
    "identifiers": [
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "200302560A",
            "state": "IN"
        }
    ],
    "endpoints": [],
    "other_names": [
        {
            "organization_name": "Beacon Medical Group Sports Medicine South Bend",
            "code": "3",
            "type": "Doing Business As"
        }
    ]
}

• 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 Portage Road)
• 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)
• Beacon Medical Group, Inc. (Beacon Medical Group Maternal Fetal Medicine South Bend)

• Sports Medicine (Family Medicine) Physician in South Bend, IN
• Providers in South Bend, IN by specialty
• Sports Medicine (Family Medicine) Physician in Indiana

• NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Aug 30, 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.