NPIMap

Organization Active NPI

Beacon Medical Group, Inc.

  • Radiation Oncology Physician
  • South Bend, IN
National Provider Identifier
1770775009
Registry record updated Apr 28, 2023
On this page

Key facts

NPPES NPI Registry
Primary specialty
Radiation Oncology PhysicianTaxonomy code 2085R0001X
License
01021173A Issued in IN
Legal business name
BEACON MEDICAL GROUP, INC.
Practice address
621 Memorial Dr Ste 100
South Bend, IN 46601-1063
Phone
(574) 647-1100
Fax
(574) 647-5907
NPI assigned
Aug 10, 2007
Organization subpart
No

NPPES NPI Registry

Updated by the provider on Apr 28, 2023

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 2

Specialty (taxonomy)CodeLicenseStatePrimary
Hematology & Oncology PhysicianGroup: 193200000X MULTI-SPECIALTY GROUP 207RH0003X
Radiation Oncology PhysicianGroup: 193200000X MULTI-SPECIALTY GROUP 2085R0001X 01021173A IN Primary

Addresses

Primary practice location

621 Memorial Dr Ste 100
South Bend, IN 46601-1063

Mailing address

710 N Niles Ave
South Bend, IN 46617-1924
Phone (574) 647-1817

Other practice location 1

1215 Lawn Ave Ste 120
Elkhart, IN 46514-2450
Phone (574) 523-2733

Other identifiers 1

IdentifierTypeStateIssuer
300046000MedicaidIN

Other names 2

  • Beacon Medical Group Oncology Elkhart Doing business as
  • Beacon Medical Group Oncology 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

Practitioners & affiliated clinicians

Practitioners 13

Individual providers connected to this organization through Medicare benefit reassignment, Care Compare group membership or National Provider Directory roles.

View all 13

NPI Registry JSON

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

{
    "created_epoch": "1186704000000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1682640000000",
    "number": "1770775009",
    "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": "574-647-1817"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "621 MEMORIAL DR STE 100",
            "city": "SOUTH BEND",
            "state": "IN",
            "postal_code": "466011063",
            "telephone_number": "574-647-1100",
            "fax_number": "574-647-5907"
        }
    ],
    "practiceLocations": [
        {
            "address_1": "1215 Lawn Ave Ste 120",
            "address_purpose": "LOCATION",
            "city": "Elkhart",
            "state": "IN",
            "postal_code": "465142450",
            "country_code": "US",
            "telephone_number": "574-523-2733",
            "fax_number": "574-523-3251",
            "country_name": "United States",
            "address_type": "DOM"
        }
    ],
    "basic": {
        "organization_name": "BEACON MEDICAL GROUP, INC.",
        "organizational_subpart": "NO",
        "enumeration_date": "2007-08-10",
        "last_updated": "2023-04-28",
        "certification_date": "2023-04-28",
        "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": "207RH0003X",
            "taxonomy_group": "193200000X MULTI-SPECIALTY GROUP",
            "desc": "Internal Medicine, Hematology & Oncology",
            "state": null,
            "license": null,
            "primary": false
        },
        {
            "code": "2085R0001X",
            "taxonomy_group": "193200000X MULTI-SPECIALTY GROUP",
            "desc": "Radiology, Radiation Oncology",
            "state": "IN",
            "license": "01021173A",
            "primary": true
        }
    ],
    "identifiers": [
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "300046000",
            "state": "IN"
        }
    ],
    "endpoints": [],
    "other_names": [
        {
            "organization_name": "Beacon Medical Group Oncology Elkhart",
            "code": "3",
            "type": "Doing Business As"
        },
        {
            "organization_name": "Beacon Medical Group Oncology 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 Apr 28, 2023; 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.