NPIMap

Organization Active NPI

Beacon Medical Group, Inc.

  • Orthopaedic Surgery Physician
  • South Bend, IN
National Provider Identifier
1831149525
Registry record updated Oct 12, 2017
On this page

Key facts

NPPES NPI Registry
Primary specialty
Orthopaedic Surgery PhysicianTaxonomy code 207X00000X
License
01055773A Issued in IN
Legal business name
BEACON MEDICAL GROUP, INC.
Practice address
100 Navarre PL Ste 5500
South Bend, IN 46601-1172
Phone
(574) 647-5300
Fax
(574) 647-5305
NPI assigned
May 11, 2006
Last updated
Oct 12, 2017By the provider in NPPES
Organization subpart
No

NPPES NPI Registry

Updated by the provider on Oct 12, 2017

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)CodeLicenseStatePrimary
Orthopaedic Surgery Physician 207X00000X 01055773A IN Primary

Addresses

Primary practice location

100 Navarre PL Ste 5500
South Bend, IN 46601-1172

Mailing address

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

Other identifiers 1

IdentifierTypeStateIssuer
200241180AMedicaidIN

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

Locations

100 Navarre Pl
South Bend, IN 46601
Phone (574) 235-1010

Practitioners & affiliated clinicians

Practitioners 400

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 400

NPI Registry JSON

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

{
    "created_epoch": "1147305600000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1507766400000",
    "number": "1831149525",
    "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 STE 5500",
            "city": "SOUTH BEND",
            "state": "IN",
            "postal_code": "466011172",
            "telephone_number": "574-647-5300",
            "fax_number": "574-647-5305"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "BEACON MEDICAL GROUP, INC.",
        "organizational_subpart": "NO",
        "enumeration_date": "2006-05-11",
        "last_updated": "2017-10-12",
        "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": "207X00000X",
            "taxonomy_group": "",
            "desc": "Orthopaedic Surgery",
            "state": "IN",
            "license": "01055773A",
            "primary": true
        }
    ],
    "identifiers": [
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "200241180A",
            "state": "IN"
        }
    ],
    "endpoints": [],
    "other_names": []
}

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 Oct 12, 2017; 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.