NPIMap

Organization Active NPI

Beacon Medical Group, Inc.

Doing business as Beacon Medical Group Advanced Cardiology Specialists South Bend

  • Cardiovascular Disease Physician
  • South Bend, IN
National Provider Identifier
1780859157
Registry record updated Apr 24, 2023
On this page

Key facts

NPPES NPI Registry
Primary specialty
Cardiovascular Disease PhysicianTaxonomy code 207RC0000X
License
01045628A Issued in IN
Legal business name
BEACON MEDICAL GROUP, INC.
Doing business as
Beacon Medical Group Advanced Cardiology Specialists South Bend
Practice address
610 N Michigan St Ste 400
South Bend, IN 46601-1081
Phone
(574) 647-8120
Fax
(574) 647-8111
NPI assigned
Apr 28, 2008
Last updated
Apr 24, 2023By the provider in NPPES
Organization subpart
No

NPPES NPI Registry

Updated by the provider on Apr 24, 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 1

Specialty (taxonomy)CodeLicenseStatePrimary
Cardiovascular Disease Physician 207RC0000X 01045628A IN Primary

Addresses

Primary practice location

610 N Michigan St Ste 400
South Bend, IN 46601-1081

Mailing address

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

Other identifiers 2

IdentifierTypeStateIssuer
200921930DMedicaidIN
200921930AMedicaidIN

Other names 1

  • Beacon Medical Group Advanced Cardiology Specialists 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
Beacon Medical Group Inc27 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

Practitioners & affiliated clinicians

Practitioners 13

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 13

NPI Registry JSON

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

{
    "created_epoch": "1209340800000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1682294400000",
    "number": "1780859157",
    "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": "610 N MICHIGAN ST STE 400",
            "city": "SOUTH BEND",
            "state": "IN",
            "postal_code": "466011081",
            "telephone_number": "574-647-8120",
            "fax_number": "574-647-8111"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "BEACON MEDICAL GROUP, INC.",
        "organizational_subpart": "NO",
        "enumeration_date": "2008-04-28",
        "last_updated": "2023-04-24",
        "certification_date": "2023-04-24",
        "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": "207RC0000X",
            "taxonomy_group": "",
            "desc": "Internal Medicine, Cardiovascular Disease",
            "state": "IN",
            "license": "01045628A",
            "primary": true
        }
    ],
    "identifiers": [
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "200921930D",
            "state": "IN"
        },
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "200921930A",
            "state": "IN"
        }
    ],
    "endpoints": [],
    "other_names": [
        {
            "organization_name": "Beacon Medical Group Advanced Cardiology Specialists South Bend",
            "code": "3",
            "type": "Doing Business As"
        },
        {
            "organization_name": "Beacon Medical Group Advanced Cardiology Specialists 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 24, 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.