Active NPI
Beacon Medical Group, Inc.
- Family Medicine Physician
- Elkhart, IN
National Provider Identifier
1639196249
On this page
Key facts
NPPES NPI Registry- Primary specialty
- Family Medicine Physician
- Legal business name
- BEACON MEDICAL GROUP, INC.
- Practice address
- 3301 County Road 6 E
Elkhart, IN 46514-7673 - Phone
- (574) 264-9635
- Fax
- (574) 262-0398
- NPI assigned
- Jul 17, 2006
- 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
- Mr. Jeffrey P Costello
- Title
- Cfo
- Phone
- (574) 647-3549
Specialties & licenses 6
| Specialty (taxonomy) | Code | License | State | Primary |
|---|---|---|---|---|
| Family Medicine Physician | 207Q00000X | Primary | ||
| Internal Medicine Physician | 207R00000X | |||
| Nephrology Physician | 207RN0300X | |||
| Orthopaedic Surgery Physician | 207X00000X | |||
| Foot & Ankle Surgery Podiatrist | 213ES0103X | |||
| Family Nurse Practitioner | 363LF0000X |
Addresses
Primary practice location
3301 County Road 6 E
Elkhart, IN 46514-7673
Mailing address
3245 Health Dr Ste 100
Granger, IN 46530-1380
Phone (574) 647-1610
Other identifiers 2
| Identifier | Type | State | Issuer |
|---|---|---|---|
| 100114000A | Medicaid | IN | |
| ANTHEM BCBS | Other | IN | 000000110759 |
Other names 1
- Beacon Medical Group-Elkhart East
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 DirectoryPractitioners & affiliated clinicians
Practitioners 7
Individual providers connected to this organization through Medicare benefit reassignment, Care Compare group membership or National Provider Directory roles.
-
- Orthopaedic Surgery Physician
- South Bend, IN
- NPI 1427444165
Orthopaedic Surgery
-
- Clinical Social Worker
- South Bend, IN
- NPI 1164935078
-
- Nurse Practitioner
- Cleveland, OH
- NPI 1801665971
NPI Registry JSON
The complete NPPES record for this NPI in the NPI Registry API format.
{
"created_epoch": "1153094400000",
"enumeration_type": "NPI-2",
"last_updated_epoch": "1738713600000",
"number": "1639196249",
"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",
"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": "3301 COUNTY ROAD 6 E",
"city": "ELKHART",
"state": "IN",
"postal_code": "465147673",
"telephone_number": "574-264-9635",
"fax_number": "574-262-0398"
}
],
"practiceLocations": [],
"basic": {
"organization_name": "BEACON MEDICAL GROUP, INC.",
"organizational_subpart": "NO",
"enumeration_date": "2006-07-17",
"last_updated": "2025-02-05",
"certification_date": "2025-02-05",
"status": "A",
"authorized_official_last_name": "COSTELLO",
"authorized_official_first_name": "JEFFREY",
"authorized_official_middle_name": "P",
"authorized_official_title_or_position": "CFO",
"authorized_official_telephone_number": "574-647-3549",
"authorized_official_name_prefix": "Mr."
},
"taxonomies": [
{
"code": "207Q00000X",
"taxonomy_group": "193200000X MULTI-SPECIALTY GROUP",
"desc": "Family Medicine",
"state": null,
"license": null,
"primary": true
},
{
"code": "207R00000X",
"taxonomy_group": "193200000X MULTI-SPECIALTY GROUP",
"desc": "Internal Medicine",
"state": null,
"license": null,
"primary": false
},
{
"code": "207RN0300X",
"taxonomy_group": "193200000X MULTI-SPECIALTY GROUP",
"desc": "Internal Medicine, Nephrology",
"state": null,
"license": null,
"primary": false
},
{
"code": "207X00000X",
"taxonomy_group": "193200000X MULTI-SPECIALTY GROUP",
"desc": "Orthopaedic Surgery",
"state": null,
"license": null,
"primary": false
},
{
"code": "213ES0103X",
"taxonomy_group": "193200000X MULTI-SPECIALTY GROUP",
"desc": "Podiatrist, Foot & Ankle Surgery",
"state": null,
"license": null,
"primary": false
},
{
"code": "363LF0000X",
"taxonomy_group": "193200000X MULTI-SPECIALTY GROUP",
"desc": "Nurse Practitioner, Family",
"state": null,
"license": null,
"primary": false
}
],
"identifiers": [
{
"code": "05",
"desc": "MEDICAID",
"issuer": null,
"identifier": "100114000A",
"state": "IN"
},
{
"code": "01",
"desc": "Other (non-Medicare)",
"issuer": "000000110759",
"identifier": "ANTHEM BCBS",
"state": "IN"
}
],
"endpoints": [],
"other_names": [
{
"organization_name": "Beacon Medical Group-Elkhart East",
"code": "3",
"type": "Doing Business As"
},
{
"organization_name": "Beacon Medical Group-Elkhart East",
"code": "3",
"type": "Doing Business As"
}
]
}Other providers in Elkhart, IN
Sources for this page
- NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Feb 5, 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.