NPIMap

Organization Active NPI

Beacon Medical Group, Inc.

Doing business as Beacon Medical Group Pediatric Hematology Oncology

  • Pediatric Hematology & Oncology Physician
  • South Bend, IN
National Provider Identifier
1992756696
Registry record updated Mar 4, 2024
On this page

Key facts

NPPES NPI Registry
Primary specialty
Pediatric Hematology & Oncology PhysicianTaxonomy code 2080P0207X
License
02001713A Issued in IN
Legal business name
BEACON MEDICAL GROUP, INC.
Doing business as
Beacon Medical Group Pediatric Hematology Oncology
Practice address
615 N Michigan St 4TH FL
South Bend, IN 46601-1033
Phone
(574) 647-6892
Fax
(574) 647-6895
NPI assigned
May 15, 2006
Last updated
Mar 4, 2024By the provider in NPPES
Organization subpart
No

NPPES NPI Registry

Updated by the provider on Mar 4, 2024

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

Authorized official

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

Specialties & licenses 1

Specialty (taxonomy)CodeLicenseStatePrimary
Pediatric Hematology & Oncology PhysicianGroup: 193200000X MULTI-SPECIALTY GROUP 2080P0207X 02001713A IN Primary

Addresses

Primary practice location

615 N Michigan St 4TH FL
South Bend, IN 46601-1033

Mailing address

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

Other names 1

  • Beacon Medical Group Pediatric Hematology Oncology 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

615 N Michigan St
Fl 4
South Bend, IN 46601
Phone (574) 647-6892

Practitioners & affiliated clinicians

Practitioners 10

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.

NPI Registry JSON

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

{
    "created_epoch": "1147651200000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1709510400000",
    "number": "1992756696",
    "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": "615 N MICHIGAN ST 4TH FL",
            "city": "SOUTH BEND",
            "state": "IN",
            "postal_code": "466011033",
            "telephone_number": "574-647-6892",
            "fax_number": "574-647-6895"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "BEACON MEDICAL GROUP, INC.",
        "organizational_subpart": "NO",
        "enumeration_date": "2006-05-15",
        "last_updated": "2024-03-04",
        "certification_date": "2024-03-04",
        "status": "A",
        "authorized_official_last_name": "COSTELLO",
        "authorized_official_first_name": "JEFFREY",
        "authorized_official_title_or_position": "CFO",
        "authorized_official_telephone_number": "574-647-3549"
    },
    "taxonomies": [
        {
            "code": "2080P0207X",
            "taxonomy_group": "193200000X MULTI-SPECIALTY GROUP",
            "desc": "Pediatrics, Pediatric Hematology-Oncology",
            "state": "IN",
            "license": "02001713A",
            "primary": true
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": [
        {
            "organization_name": "Beacon Medical Group Pediatric Hematology Oncology",
            "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 Mar 4, 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.