NPIMap

Organization Active NPI

Memorial Hospital of South Bend

Doing business as Beacon Granger Hospital, A Memorial Hospital Extension

  • General Acute Care Hospital
  • Granger, IN
National Provider Identifier
1881177756
Registry record updated Dec 1, 2022
On this page

Key facts

NPPES NPI Registry
Primary specialty
General Acute Care HospitalTaxonomy code 282N00000X
Legal business name
MEMORIAL HOSPITAL OF SOUTH BEND
Doing business as
Beacon Granger Hospital, A Memorial Hospital Extension
Practice address
3220 Beacon Parkway
Granger, IN 46530
Phone
(574) 999-8788
Fax
(574) 999-8781
NPI assigned
Sep 7, 2018
Last updated
Dec 1, 2022By the provider in NPPES
Organization subpart
No

NPPES NPI Registry

Updated by the provider on Dec 1, 2022

Registry information is reported by the provider to CMS and is not verified. About this source

Authorized official

Name
Jeffrey Peter Costello
Title
Cfo
Phone
(574) 647-3460

Specialties & licenses 1

Specialty (taxonomy)CodeLicenseStatePrimary
General Acute Care Hospital 282N00000X Primary

Addresses

Primary practice location

3220 Beacon Parkway
Granger, IN 46530

Mailing address

615 N Michigan St
South Bend, IN 46601-1033
Phone (574) 647-1000

Other identifiers 2

IdentifierTypeStateIssuer
300032573MedicaidIN
300031565MedicaidIN

Other names 1

  • Beacon Granger Hospital, A Memorial Hospital Extension Doing business as

Medicare participation

Medicare enrollment files
Medicare fee-for-service enrollment
Enrolled in IN2 enrollments

Enrollment records 2

Enrollment IDStateProvider typePAC IDDetails
O20040506000783 IN Part B Supplier - Clinic/Group Practice 8123017126 Receives reassigned benefits from 17 practitioners
1 other NPI on this enrollment
This NPI is an additional NPI on the enrollment
Practice locations: Granger, IN; South Bend, IN
O20071213000267 IN Part A Provider - Hospital 8123017126 2 other NPIs on this enrollment
This NPI is an additional NPI on the enrollment
Practice locations: South Bend, IN; Granger, IN

NPI to CCN mapping 1

The Medicare certification numbers (CCNs) connected to NPI 1881177756. Details of each certification follow.

Hospital certification: CCN 150058

Legal name
MEMORIAL HOSPITAL OF SOUTH BEND
Doing business as
MEMORIAL HOSPITAL OF SOUTH BEND
Certification status
Active
Provider type (POS)
Hospital – Short-term
Participating since
Jul 1, 1966
Last certification
Nov 19, 2004
Beds
463
Ownership / control type
Private (not for profit)
Organization structure
CorporationNon-profit
Enrollment address
615 N Michigan St
South Bend, IN 46601-1033
Other Hospital Practice Location
Hospital subgroups
Acute care

Facilities connected through Provider of Services related, parent or unit certification numbers.

Other NPIs on the same Medicare enrollment 2

NPIs listed together on one Medicare enrollment, typically parts of the same organization.

Care Compare: Hospital

Medicare Care Compare
Listed as
Memorial Hospital of South BendCCN 150058 · All quality measures
Overall star rating
2 of 5
Type
Acute Care Hospitals
Ownership
Voluntary non-profit - Private
Medicare certification status
ActiveFrom the Provider of Services file
Emergency services
Yes

Laboratory certificates & supplier records

Derived by NPIMap

These CMS records do not include an NPI. They are shown because their name and street address match this provider’s.

CLIA laboratory certificates

CLIA numberLaboratoryCertificateExpires
15D2166315Beacon Granger Hospital3220 Beacon Parkway, Granger, IN 46530AccreditationMar 31, 2028

National Provider Directory

National Provider Directory
Tax ID family
Memorial Hospital of5 organizations share this tax ID, including this one

Other organizations with this tax ID 4

Organizations that report the same tax identification number in the National Provider Directory.

Locations

53990 Carmichael Dr
Ste 150
South Bend, IN 46635

Ownership & related parties

All disclosed owners & managing parties 4

As disclosed on the Medicare enrollment (CMS All Owners files). Individuals include officers, directors and managing employees, who may not hold ownership.

NameRoleSinceShare
Kreg Gruber Individual Corporate OfficerCeo Jan 1, 2018
Beacon Health System Inc Organization, South Bend, IN Corporation Operational/Managerial Control Nov 23, 2011 100%
Larry a Tracy Individual Corporate OfficerHospital President Jun 26, 2016 100%
W-2 Managing EmployeePresident Jun 26, 2016 100%
Jeffrey P Costello Individual Corporate OfficerCfo Oct 1, 1995 100%

Practitioners & affiliated clinicians

Practitioners 3

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.

Affiliated clinicians 787

Clinicians who list this facility as an affiliation in Medicare Care Compare.

View all 787

NPI Registry JSON

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

{
    "created_epoch": "1536278400000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1669852800000",
    "number": "1881177756",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "615 N MICHIGAN ST",
            "city": "SOUTH BEND",
            "state": "IN",
            "postal_code": "466011033",
            "telephone_number": "574-647-1000"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "3220 BEACON PARKWAY",
            "city": "GRANGER",
            "state": "IN",
            "postal_code": "46530",
            "telephone_number": "574-999-8788",
            "fax_number": "574-999-8781"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "MEMORIAL HOSPITAL OF SOUTH BEND",
        "organizational_subpart": "NO",
        "enumeration_date": "2018-09-07",
        "last_updated": "2022-12-01",
        "certification_date": "2022-12-01",
        "status": "A",
        "authorized_official_last_name": "COSTELLO",
        "authorized_official_first_name": "JEFFREY",
        "authorized_official_middle_name": "PETER",
        "authorized_official_title_or_position": "CFO",
        "authorized_official_telephone_number": "574-647-3460"
    },
    "taxonomies": [
        {
            "code": "282N00000X",
            "taxonomy_group": "",
            "desc": "General Acute Care Hospital",
            "state": null,
            "license": null,
            "primary": true
        }
    ],
    "identifiers": [
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "300032573",
            "state": "IN"
        },
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "300031565",
            "state": "IN"
        }
    ],
    "endpoints": [],
    "other_names": [
        {
            "organization_name": "Beacon Granger Hospital, A Memorial Hospital Extension",
            "code": "3",
            "type": "Doing Business As"
        }
    ]
}

Other providers in Granger, IN

Sources for this page

Verify at the official NPI Registry.