Active NPI
Beacon Medical Group
Doing business as Memorial Children's Hospital Navarre Pediatrics
- Urology Physician
- South Bend, IN
National Provider Identifier
1689627812
On this page
Key facts
NPPES NPI Registry- Primary specialty
- Urology Physician
- License
- 01024987A
- Legal business name
- BEACON MEDICAL GROUP
- Doing business as
- Memorial Children's Hospital Navarre Pediatrics
- Practice address
- 100 Navarre PL
Suite 4400
South Bend, IN 46601-1156 - Phone
- (574) 647-4535
- NPI assigned
- May 18, 2006
- Last updated
- Mar 9, 2016
- 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
- Jeffrey Costello
- Title
- VP-Cfo
- Phone
- (574) 647-3549
Specialties & licenses 1
| Specialty (taxonomy) | Code | License | State | Primary |
|---|---|---|---|---|
| Urology Physician | 208800000X | 01024987A | IN | Primary |
Addresses
Primary practice location
100 Navarre PL
Suite 4400
South Bend, IN 46601-1156
Mailing address
710 N Niles Ave
South Bend, IN 46617-1924
Phone (574) 647-1610
Other names 1
- Memorial Children's Hospital Navarre Pediatrics
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 DirectoryNPI Registry JSON
The complete NPPES record for this NPI in the NPI Registry API format.
{
"created_epoch": "1147910400000",
"enumeration_type": "NPI-2",
"last_updated_epoch": "1457481600000",
"number": "1689627812",
"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": "100 NAVARRE PL",
"address_2": "SUITE 4400",
"city": "SOUTH BEND",
"state": "IN",
"postal_code": "466011156",
"telephone_number": "574-647-4535"
}
],
"practiceLocations": [],
"basic": {
"organization_name": "BEACON MEDICAL GROUP",
"organizational_subpart": "NO",
"enumeration_date": "2006-05-18",
"last_updated": "2016-03-09",
"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": "208800000X",
"taxonomy_group": "193200000X MULTI-SPECIALTY GROUP",
"desc": "Urology",
"state": "IN",
"license": "01024987A",
"primary": true
}
],
"identifiers": [],
"endpoints": [],
"other_names": [
{
"organization_name": "Memorial Children's Hospital Navarre Pediatrics",
"code": "3",
"type": "Doing Business As"
}
]
}Other providers in South Bend, IN
- Beacon Health Ventures Inc (Beacon HC Pharmacy SB)
- Beacon Health Ventures Inc
- Beacon Health Ventures, Inc (Beacon HC Pharm SB)
- Beacon Health Ventures, Inc. (Compassionate Caregivers - ELK)
- Beacon Health Ventures, Inc.
- Beacon Medical Group Inc (Women's Reproductive Medicine)
- Beacon Medical Group Inc (Michiana Arthritis & Osteoporosis Center)
- Beacon Medical Group, Inc. (MedPoint Express)
- Beacon Medical Group, Inc. (Beacon Medical Group Ireland Road)
- Beacon Medical Group, Inc.
Sources for this page
- NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Mar 9, 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.