Beacon Medical Group, Inc.
Organization Active NPI Family Medicine Physician · Lakeville, IN
NPI 1699727545 · NPPES record last updated Aug 29, 2016
Key facts
- NPI
- 1699727545
- Entity type
- Organization (NPI type 2)
- Primary specialty
- Family Medicine Physician 207Q00000X
- License
- 01033081A (IN)
- Legal business name
- BEACON MEDICAL GROUP, INC.
- Practice address
- 601 North Michigan Street
Lakeville, IN 46536 - Phone
- (574) 784-8244
- Fax
- (574) 784-8632
- NPI assigned
- May 17, 2006
- Organization subpart
- No
Authorized official
- Name
- Jeffrey Costello
- Title
- VP-Cfo
- Phone
- (574) 647-3549
Practitioners 7
-
Kenneth Eugene Elek, M.D.
-
Carolyn Christine Klaus, M.D.
-
Keyna Ann Martinez, M.D.
-
Tamara L Riess, NP
-
Ellyn Therese Stecker, M.D.
-
Maria K Klahre, MD
Medicare participation
- Medicare fee-for-service enrollment
- Enrolled in IN
Medicare enrollment records
| 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
Specialties & licenses
| Specialty (taxonomy) | Code | License | State | Primary |
|---|---|---|---|---|
| Family Medicine Physician |
207Q00000X | 01033081A | IN | Yes |
Addresses
Primary practice location
601 North Michigan Street
Lakeville, IN 46536
Mailing address
710 N Niles Ave
South Bend, IN 46617-1924
Phone (574) 647-1610
Other identifiers
| Identifier | Type | State | Issuer |
|---|---|---|---|
| 200188380A | Medicaid | IN |
Other names
- Beacon Medical Group Lakeville
Other providers in Lakeville, IN
All providers in Lakeville, IN · Family Medicine Physician in Indiana
Sources for this page
- NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Record last updated by the provider on Aug 29, 2016. Information in NPPES is self-reported and not verified by CMS.
- NUCC Health Care Provider Taxonomy: specialty names.
- Medicare Fee-For-Service Public Provider Enrollment (CMS/PECOS): enrollments, PAC IDs and benefit reassignments.
- National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.