NPIMap

Organization Active NPI

Beacon Medical Group, Inc.

Doing business as Beacon Medical Group Cleveland Road

  • Family Medicine Physician
  • South Bend, IN
National Provider Identifier
1588024624
Registry record updated Feb 22, 2024
On this page

Key facts

NPPES NPI Registry
Primary specialty
Family Medicine PhysicianTaxonomy code 207Q00000X
Legal business name
BEACON MEDICAL GROUP, INC.
Doing business as
Beacon Medical Group Cleveland Road
Practice address
2235 Cleveland Rd
South Bend, IN 46628-3529
Phone
(574) 647-4530
Fax
(574) 647-2285
NPI assigned
Mar 2, 2016
Last updated
Feb 22, 2024By the provider in NPPES
Organization subpart
No

NPPES NPI Registry

Updated by the provider on Feb 22, 2024

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

Authorized official

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

Specialties & licenses 4

Specialty (taxonomy)CodeLicenseStatePrimary
Family Nurse Practitioner 363LF0000X NU
Family Medicine Physician 207Q00000X NU Primary
Nephrology Physician 207RN0300X NU
Foot & Ankle Surgery Podiatrist 213ES0103X NU

Addresses

Primary practice location

2235 Cleveland Rd
South Bend, IN 46628-3529

Mailing address

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

Other names 1

  • Beacon Medical Group Cleveland Road 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

Locations

6901 N Main St
Granger, IN 46530
Phone (574) 647-2900

Practitioners & affiliated clinicians

Practitioners 31

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 31

NPI Registry JSON

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

{
    "created_epoch": "1456876800000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1708560000000",
    "number": "1588024624",
    "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",
            "fax_number": "574-237-6069"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "2235 CLEVELAND RD",
            "city": "SOUTH BEND",
            "state": "IN",
            "postal_code": "466283529",
            "telephone_number": "574-647-4530",
            "fax_number": "574-647-2285"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "BEACON MEDICAL GROUP, INC.",
        "organizational_subpart": "NO",
        "enumeration_date": "2016-03-02",
        "last_updated": "2024-02-22",
        "certification_date": "2024-02-22",
        "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",
        "authorized_official_name_prefix": "Mr."
    },
    "taxonomies": [
        {
            "code": "363LF0000X",
            "taxonomy_group": "",
            "desc": "Nurse Practitioner, Family",
            "state": "NU",
            "license": null,
            "primary": false
        },
        {
            "code": "207Q00000X",
            "taxonomy_group": "",
            "desc": "Family Medicine",
            "state": "NU",
            "license": null,
            "primary": true
        },
        {
            "code": "207RN0300X",
            "taxonomy_group": "",
            "desc": "Internal Medicine, Nephrology",
            "state": "NU",
            "license": null,
            "primary": false
        },
        {
            "code": "213ES0103X",
            "taxonomy_group": "",
            "desc": "Podiatrist, Foot & Ankle Surgery",
            "state": "NU",
            "license": null,
            "primary": false
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": [
        {
            "organization_name": "Beacon Medical Group Cleveland Road",
            "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 Feb 22, 2024; 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.