Beacon Medical Group, Inc.
Organization Active NPI Cardiovascular Disease Physician · Plymouth, IN
NPI 1972831311 · NPPES record last updated Aug 30, 2016
Key facts
- NPI
- 1972831311
- Entity type
- Organization (NPI type 2)
- Primary specialty
- Cardiovascular Disease Physician 207RC0000X
- License
- 01045628A (IN)
- Legal business name
- BEACON MEDICAL GROUP, INC.
- Practice address
- 2855 Miller Dr
Suite 121
Plymouth, IN 46563-8091 - Phone
- (574) 647-1600
- Fax
- (574) 237-6069
- NPI assigned
- Nov 23, 2009
- Organization subpart
- No
Authorized official
- Name
- Mr. Jeffrey P Costello
- Title
- VP/Cfo
- Phone
- (574) 647-3549
Medicare participation
- Medicare fee-for-service enrollment
- Enrolled in IN
Medicare enrollment records
| Enrollment ID | State | Provider type | PAC ID | Details |
|---|---|---|---|---|
| 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
Specialties & licenses
| Specialty (taxonomy) | Code | License | State | Primary |
|---|---|---|---|---|
| Cardiovascular Disease Physician |
207RC0000X | 01045628A | IN | Yes |
| Rheumatology Physician |
207RR0500X | 01061323A | IN |
Addresses
Primary practice location
2855 Miller Dr
Suite 121
Plymouth, IN 46563-8091
Mailing address
710 N Niles Ave
South Bend, IN 46617-1924
Phone (574) 647-1610
Other identifiers
| Identifier | Type | State | Issuer |
|---|---|---|---|
| 100092700C | Medicaid | IN |
Other names
- Beacon Medical Group Specialists Plymouth
Other providers in Plymouth, IN
- Janice Ann Baldwin
- Michael Roy Baldwin
- Stephen J Barber
- Scott Kelley Barger
- Carlos Bastardo
- Sally Beazlie-Walker
- Bruce Farrell Becker
- Kelsey K Bell
- Teresa Benefit
- Berger Audiology
All providers in Plymouth, IN · Cardiovascular Disease Physician in Indiana
Sources for this page
- NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Record last updated by the provider on Aug 30, 2016. Information in NPPES is self-reported and not verified by CMS.
- NUCC Health Care Provider Taxonomy: specialty names.
- Medicare Fee-For-Service Public Provider Enrollment (CMS/PECOS): enrollments, PAC IDs and benefit reassignments.
- National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.