NPIMap

Organization Active NPI

Beacon Medical Group, Inc.

Doing business as Beacon Medical Group Midwifery Centered Care South Bend

  • Advanced Practice Midwife
  • South Bend, IN
National Provider Identifier
1578862181
Registry record updated Jan 30, 2025
On this page

Key facts

NPPES NPI Registry
Primary specialty
Advanced Practice MidwifeTaxonomy code 367A00000X
Legal business name
BEACON MEDICAL GROUP, INC.
Doing business as
Beacon Medical Group Midwifery Centered Care South Bend
Practice address
100 Navarre PL Ste 4470
South Bend, IN 46601-1168
Phone
(574) 647-1405
Fax
(574) 647-3970
NPI assigned
Mar 22, 2011
Last updated
Jan 30, 2025By the provider in NPPES
Organization subpart
Yes
Parent organization
BEACON HEALTH SYSTEM, INC.As reported in NPPES

NPPES NPI Registry

Updated by the provider on Jan 30, 2025

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

Authorized official

Name
Jeffrey P Costello
Title
VP/Cfo
Phone
(574) 647-3549

Specialties & licenses 3

Specialty (taxonomy)CodeLicenseStatePrimary
Women's Health Nurse Practitioner 363LW0102X NU
Advanced Practice Midwife 367A00000X NU Primary
Obstetrics & Gynecology Physician 207V00000X NU

Addresses

Primary practice location

100 Navarre PL Ste 4470
South Bend, IN 46601-1168

Mailing address

3245 Health Dr Ste 100
Granger, IN 46530-1380

Other practice location 1

621 Memorial Dr Ste 403
South Bend, IN 46601-1074
Phone (574) 647-1405

Other identifiers 1

IdentifierTypeStateIssuer
201020740AMedicaidIN

Other names 1

  • Beacon Medical Group Midwifery Centered Care South Bend 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
Beacon Medical Group 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

Locations

2405 W Lexington Ave
Elkhart, IN 46514
Phone (574) 295-8805

714 N Michigan St
South Bend, IN 46601
Phone (574) 647-7477

Practitioners & affiliated clinicians

Practitioners 10

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": "1300752000000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1738195200000",
    "number": "1578862181",
    "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"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "100 NAVARRE PL STE 4470",
            "city": "SOUTH BEND",
            "state": "IN",
            "postal_code": "466011168",
            "telephone_number": "574-647-1405",
            "fax_number": "574-647-3970"
        }
    ],
    "practiceLocations": [
        {
            "address_1": "621 Memorial Dr Ste 403",
            "address_purpose": "LOCATION",
            "city": "South Bend",
            "state": "IN",
            "postal_code": "466011074",
            "country_code": "US",
            "telephone_number": "574-647-1405",
            "fax_number": "574-647-3970",
            "country_name": "United States",
            "address_type": "DOM"
        }
    ],
    "basic": {
        "organization_name": "BEACON MEDICAL GROUP, INC.",
        "organizational_subpart": "YES",
        "parent_organization_legal_business_name": "BEACON HEALTH SYSTEM, INC.",
        "enumeration_date": "2011-03-22",
        "last_updated": "2025-01-30",
        "certification_date": "2025-01-30",
        "status": "A",
        "authorized_official_last_name": "COSTELLO",
        "authorized_official_first_name": "JEFFREY",
        "authorized_official_middle_name": "P",
        "authorized_official_title_or_position": "VP/CFO",
        "authorized_official_telephone_number": "574-647-3549"
    },
    "taxonomies": [
        {
            "code": "363LW0102X",
            "taxonomy_group": "",
            "desc": "Nurse Practitioner, Women's Health",
            "state": "NU",
            "license": null,
            "primary": false
        },
        {
            "code": "367A00000X",
            "taxonomy_group": "",
            "desc": "Advanced Practice Midwife",
            "state": "NU",
            "license": null,
            "primary": true
        },
        {
            "code": "207V00000X",
            "taxonomy_group": "",
            "desc": "Obstetrics & Gynecology",
            "state": "NU",
            "license": null,
            "primary": false
        }
    ],
    "identifiers": [
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "201020740A",
            "state": "IN"
        }
    ],
    "endpoints": [],
    "other_names": [
        {
            "organization_name": "Beacon Medical Group Midwifery Centered Care South Bend",
            "code": "3",
            "type": "Doing Business As"
        },
        {
            "organization_name": "Beacon Medical Group Midwifery Centered Care South Bend",
            "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 Jan 30, 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.