NPIMap

Organization Active NPI

Beacon Medical Group, Inc.

  • Thoracic Surgery (Cardiothoracic Vascular Surgery) Physician
  • South Bend, IN
National Provider Identifier
1881971505
Registry record updated Feb 22, 2024
On this page

Key facts

NPPES NPI Registry
Primary specialty
Thoracic Surgery (Cardiothoracic Vascular Surgery) PhysicianTaxonomy code 208G00000X
Legal business name
BEACON MEDICAL GROUP, INC.
Practice address
610 N Michigan St Ste 306
South Bend, IN 46601-1079
Phone
(574) 647-6500
Fax
(574) 647-6518
NPI assigned
Nov 9, 2011
Organization subpart
No

NPPES NPI Registry

Updated by the provider on Feb 22, 2024

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

Authorized official

Name
Jeffrey P Costello
Title
VP/Cfo
Phone
(574) 647-3549

Specialties & licenses 3

Specialty (taxonomy)CodeLicenseStatePrimary
Thoracic Surgery (Cardiothoracic Vascular Surgery) PhysicianGroup: 193200000X MULTI-SPECIALTY GROUP 208G00000X Primary
Physician AssistantGroup: 193200000X MULTI-SPECIALTY GROUP 363A00000X
Family Nurse PractitionerGroup: 193200000X MULTI-SPECIALTY GROUP 363LF0000X

Addresses

Primary practice location

610 N Michigan St Ste 306
South Bend, IN 46601-1079

Mailing address

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

Other identifiers 1

IdentifierTypeStateIssuer
201041690AMedicaidIN

Other names 1

  • Beacon Medical Group Cardiothoracic Surgery 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

Locations

600 East Blvd
Elkhart, IN 46514
Phone (574) 294-2621

500 Arcade Ave
Ste 230
Elkhart, IN 46514
Phone (574) 522-6565

Practitioners & affiliated clinicians

Practitioners 9

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

NPI Registry JSON

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

{
    "created_epoch": "1320796800000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1708560000000",
    "number": "1881971505",
    "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 306",
            "city": "SOUTH BEND",
            "state": "IN",
            "postal_code": "466011079",
            "telephone_number": "574-647-6500",
            "fax_number": "574-647-6518"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "BEACON MEDICAL GROUP, INC.",
        "organizational_subpart": "NO",
        "enumeration_date": "2011-11-09",
        "last_updated": "2024-02-22",
        "certification_date": "2024-02-22",
        "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"
    },
    "taxonomies": [
        {
            "code": "208G00000X",
            "taxonomy_group": "193200000X MULTI-SPECIALTY GROUP",
            "desc": "Thoracic Surgery (Cardiothoracic Vascular Surgery)",
            "state": null,
            "license": null,
            "primary": true
        },
        {
            "code": "363A00000X",
            "taxonomy_group": "193200000X MULTI-SPECIALTY GROUP",
            "desc": "Physician Assistant",
            "state": null,
            "license": null,
            "primary": false
        },
        {
            "code": "363LF0000X",
            "taxonomy_group": "193200000X MULTI-SPECIALTY GROUP",
            "desc": "Nurse Practitioner, Family",
            "state": null,
            "license": null,
            "primary": false
        }
    ],
    "identifiers": [
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "201041690A",
            "state": "IN"
        }
    ],
    "endpoints": [],
    "other_names": [
        {
            "organization_name": "Beacon Medical Group Cardiothoracic Surgery South Bend",
            "code": "3",
            "type": "Doing Business As"
        },
        {
            "organization_name": "Beacon Medical Group Cardiothoracic Surgery 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 Feb 22, 2024; 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.