NPIMap

Organization Active NPI

Beacon Medical Group, Inc.

Doing business as Beacon Medical Group Behavioral Health South Bend

  • Psychiatry Physician
  • South Bend, IN
National Provider Identifier
1629376645
Registry record updated Feb 22, 2024
On this page

Key facts

NPPES NPI Registry
Primary specialty
Psychiatry PhysicianTaxonomy code 2084P0800X
License
01052982A Issued in IN
Legal business name
BEACON MEDICAL GROUP, INC.
Doing business as
Beacon Medical Group Behavioral Health South Bend
Practice address
707 N Michigan St Ste 400
South Bend, IN 46601-1071
Phone
(574) 647-8470
Fax
(574) 647-8475
NPI assigned
Mar 1, 2011
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
Jeffrey P Costello
Title
VP/Cfo
Phone
(574) 647-3549

Specialties & licenses 5

Specialty (taxonomy)CodeLicenseStatePrimary
Family Medicine PhysicianGroup: 193200000X MULTI-SPECIALTY GROUP 207Q00000X
Psychiatry PhysicianGroup: 193200000X MULTI-SPECIALTY GROUP 2084P0800X 01052982A IN Primary
Child & Adolescent Psychiatry PhysicianGroup: 193200000X MULTI-SPECIALTY GROUP 2084P0804X 01052982A IN
Geriatric Psychiatry PhysicianGroup: 193200000X MULTI-SPECIALTY GROUP 2084P0805X 01052982A IN
Psychiatric/Mental Health Nurse PractitionerGroup: 193200000X MULTI-SPECIALTY GROUP 363LP0808X

Addresses

Primary practice location

707 N Michigan St Ste 400
South Bend, IN 46601-1071

Mailing address

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

Other names 1

  • Beacon Medical Group Behavioral Health 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
Goshen Family27 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

Member organizations 10

Organizations listed as members of this organization in the National Provider Directory.

Practitioners & affiliated clinicians

Practitioners 26

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 26

NPI Registry JSON

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

{
    "created_epoch": "1298937600000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1708560000000",
    "number": "1629376645",
    "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": "707 N MICHIGAN ST STE 400",
            "city": "SOUTH BEND",
            "state": "IN",
            "postal_code": "466011071",
            "telephone_number": "574-647-8470",
            "fax_number": "574-647-8475"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "BEACON MEDICAL GROUP, INC.",
        "organizational_subpart": "NO",
        "enumeration_date": "2011-03-01",
        "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"
    },
    "taxonomies": [
        {
            "code": "207Q00000X",
            "taxonomy_group": "193200000X MULTI-SPECIALTY GROUP",
            "desc": "Family Medicine",
            "state": null,
            "license": null,
            "primary": false
        },
        {
            "code": "2084P0800X",
            "taxonomy_group": "193200000X MULTI-SPECIALTY GROUP",
            "desc": "Psychiatry & Neurology, Psychiatry",
            "state": "IN",
            "license": "01052982A",
            "primary": true
        },
        {
            "code": "2084P0804X",
            "taxonomy_group": "193200000X MULTI-SPECIALTY GROUP",
            "desc": "Psychiatry & Neurology, Child & Adolescent Psychiatry",
            "state": "IN",
            "license": "01052982A",
            "primary": false
        },
        {
            "code": "2084P0805X",
            "taxonomy_group": "193200000X MULTI-SPECIALTY GROUP",
            "desc": "Psychiatry & Neurology, Geriatric Psychiatry",
            "state": "IN",
            "license": "01052982A",
            "primary": false
        },
        {
            "code": "363LP0808X",
            "taxonomy_group": "193200000X MULTI-SPECIALTY GROUP",
            "desc": "Nurse Practitioner, Psychiatric/Mental Health",
            "state": null,
            "license": null,
            "primary": false
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": [
        {
            "organization_name": "Beacon Medical Group Behavioral Health South Bend",
            "code": "3",
            "type": "Doing Business As"
        },
        {
            "organization_name": "Beacon Medical Group Behavioral Health 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 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.