Beacon Medical Group, Inc.

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 Specialists Plymouth

Practice address

2855 Miller Dr
Suite 121
Plymouth, IN 46563-8091

Phone

(574) 647-1600

Fax

(574) 237-6069

NPI assigned

Nov 23, 2009

Last updated

Aug 30, 2016By the provider in NPPES

Organization subpart

No

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

Addresses

Other names 1

• Beacon Medical Group Specialists Plymouth Doing business as

Medicare fee-for-service enrollment

Enrolled in IN

Enrollment records 1

Locations

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

{
    "created_epoch": "1258934400000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1472515200000",
    "number": "1972831311",
    "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": "2855 MILLER DR",
            "address_2": "SUITE 121",
            "city": "PLYMOUTH",
            "state": "IN",
            "postal_code": "465638091",
            "telephone_number": "574-647-1600",
            "fax_number": "574-237-6069"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "BEACON MEDICAL GROUP, INC.",
        "organizational_subpart": "NO",
        "enumeration_date": "2009-11-23",
        "last_updated": "2016-08-30",
        "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": "193200000X MULTI-SPECIALTY GROUP",
            "desc": "Internal Medicine, Cardiovascular Disease",
            "state": "IN",
            "license": "01045628A",
            "primary": true
        },
        {
            "code": "207RR0500X",
            "taxonomy_group": "193200000X MULTI-SPECIALTY GROUP",
            "desc": "Internal Medicine, Rheumatology",
            "state": "IN",
            "license": "01061323A",
            "primary": false
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": [
        {
            "organization_name": "Beacon Medical Group Specialists Plymouth",
            "code": "3",
            "type": "Doing Business As"
        }
    ]
}

• Janice Ann Baldwin, CNM
• Michael Roy Baldwin, CRNA
• Stephen J Barber, LCSW, LCAC, CADAC II
• Scott Kelley Barger, MSW
• Carlos Bastardo
• Sally Beazlie-Walker, D.O
• Bruce Farrell Becker, DDS
• Kelsey K Bell, O.D.
• Teresa Benefit, NP
• Berger Audiology

• Cardiovascular Disease Physician in Plymouth, IN
• Providers in Plymouth, IN by specialty
• Cardiovascular Disease Physician in Indiana

• NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Aug 30, 2016; 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.