BEACON MEDICAL GROUP INC. NPI 1548415474

NPI Information

  • NPI: 1548415474
  • Provider Name: BEACON MEDICAL GROUP, INC.
  • Classification: Pediatrics - 208000000X
  • Entity Type: Organization
  • :
  • CLIA Number: 15D1099816
  • Address: 100 NAVARRE PL STE 5550
    SOUTH BEND, IN
    ZIP 46601
  • Phone: (574) 647-2550

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NPI Details

BEACON MEDICAL GROUP, INC. is a pediatrics in South Bend, IN. The provider is a pediatrician is concerned with the physical, emotional and social health of children from birth to young adulthood. Care encompasses a broad spectrum of health services ranging from preventive healthcare to the diagnosis and treatment of acute and chronic diseases. A pediatrician deals with biological, social and environmental influences on the developing child, and with the impact of disease and dysfunction on development. BEACON MEDICAL GROUP, INC. NPI is 1548415474. The provider is registered as an organization entity type and is a multi-specialty group.
The provider .

The provider's business location address is:

100 NAVARRE PL STE 5550
SOUTH BEND, IN
ZIP 46601-169
Phone: (574) 647-2550
Fax: (574) 647-1129

The provider's authorized official is Jeffrey P Costello .
The authorized official title is Vice President/cfo and has the following contact phone number (574) 647-3549.

The CLIA number assigned to this NPI record is 15D1099816 - physician office with a certificate type of Certificate of Waiver.

The enumeration date for this NPI number is 11/19/2008 and was last updated on 7/21/2025.

Taxonomy Codes

The NPI record includes the healthcare provider taxonomy classification, state license number and state of licensure. The following information regarding the scope of practice of this provider is available:

No. Taxonomy Code Taxonomy Clasification Taxonomy Specialization License Number License State Primary
1103T00000XPsychologistNo
2103TC0700XPsychologistClinicalNo
3133V00000XDietitian, RegisteredNo
42080N0001XPediatricsNeonatal-Perinatal MedicineNo
52080P0214XPediatricsPediatric PulmonologyNo
6363L00000XNurse PractitionerNo
7208000000XPediatrics01065535AINDIANAYes

Other Identifiers

The following information regarding additional identifiers associated to this NPI record includes the other identifier number, identifier type, identifier state and issuer.

No. Other Provider Identifier Other Provider Identifier Type Other Provider Identifier State Other Provider Identifier Issuer
1200928880AMEDICAIDINDIANA
2300069919MEDICAIDINDIANA

What is NPI?

NPI stands for National Provider Identifier. The NPI is a 10-digit identification number that is completely unique. The NPI number by itself does not contain any identifiable information such as a provider’s speciality or location. The NPI is assigned to individuals or organizacions for their lifespan and it is independent of key provider information type updates like a change of practices, location or speciality.

This page was last updated on: 11/21/2025

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