BEACON MEDICAL GROUP, INC. (NPI# 1518302264) is a health care provider registered in Centers for Medicare & Medicaid Services (CMS), National Plan and Provider Enumeration System (NPPES).
| Nation Provider ID (NPI) | 1518302264 |
| Entity Type | Organization |
| Organization Name | BEACON MEDICAL GROUP, INC. |
| Other Organization Name | MEMORIAL PAIN MANAGEMENT |
| Practice Address |
621 Memorial Dr Suite 602 South Bend IN 46601-1063 |
| Mailing Address |
710 N Niles Ave South Bend IN 46617-1924 |
| Practice Telephone | 5746477413 |
| Practice Fax Number | 5746472471 |
| Mailing Telephone | 5746471610 |
| Enumeration Date | 2013-05-08 |
| Last Update Date | 2016-08-30 |
| Authorized Official Name | JEFFREY P. COSTELLO (CFO) |
| Authorized Official Telephone | 5746473549 |
| Is Organization Subpart | N |
| Primary | Taxonomy Code | Classification | License Number | License State | Taxonomy Group |
|---|---|---|---|---|---|
| Y | 363LA2200X |
Nurse Practitioner Specialization: Adult Health |
71001587A | IN | Physician Assistants & Advanced Practice Nursing Providers |
| State | Issuer | Identifier | Type Code |
|---|---|---|---|
| IN | 201164630A | 05 |
| Other Name | Type Code |
|---|---|
| Memorial Pain Management | Doing Business As Name - Organization |
| NPI | Name | Taxonomy | Address | Enumeration |
|---|---|---|---|---|
| 1487038360 | Beacon Medical Group, Inc. | Radiology | 233 Florence Ave, Granger, IN 46530-8048 | 2015-07-10 |
| 1124423546 | Beacon Medical Group, Inc. | Internal Medicine | 100 Navarre Pl Ste 4400, South Bend, IN 46601-1100 | 2014-10-28 |
| 1487061131 | Beacon Medical Group, Inc. | Internal Medicine | 2400 N Ventura Way, Lagrange, IN 46761-4101 | 2014-07-15 |
| 1437574530 | Beacon Medical Group, Inc. | Otolaryngology | 711 S Health Pkwy Ste 1, Medical Office Building #1, Three Rivers, MI 49093-8354 | 2014-02-26 |
| 1528362647 | Beacon Medical Group, Inc. | Internal Medicine | 500 Arcade Ave., Suite 400, Elkhart, IN 46514 | 2011-01-04 |
| 1699794057 | Beacon Medical Group, Inc. | Internal Medicine | 500 Arcade Ave Ste 300, Elkhart, IN 46514-2486 | 2006-07-18 |
| 1205852365 | Beacon Medical Group, Inc. | Family Medicine | 27082 W. Main Street, Edwardsburg, MI 49112-9334 | 2006-07-14 |
| 1861421141 | Beacon Medical Group, Inc. | Psychiatry & Neurology | 100 Navarre Pl Ste 6600, South Bend, IN 46601 | 2006-06-30 |
| 1467408237 | Beacon Medical Group, Inc. | Pediatrics | 615 N Michigan St Fl 5, South Bend, IN 46601 | 2006-05-25 |
| 1275587149 | Beacon Medical Group, Inc. | Family Medicine | 813 S Michigan St, South Bend, IN 46601 | 2006-05-22 |
| Entity Type | Entity Name | Entity Address |
|---|---|---|
| System for Award Management (SAM) Entities | BEACON MEDICAL GROUP, INC. | 4601 Glendale Court, Savage, MN 55378-2543 |
| Street Address |
621 MEMORIAL DR SUITE 602 |
| City | SOUTH BEND |
| State | IN |
| Zip Code | 46601-1063 |
| NPI | Name | Taxonomy | Address | Enumeration |
|---|---|---|---|---|
| 1003818212 | John L Jenkins | Specialist | 621 Memorial Dr, Ste 502, South Bend, IN 46601-1075 | 2005-06-01 |
| 1447783188 | Khonnah Weithers | Nurse Practitioner | 621 Memorial Dr, Suite 512, South Bend, IN 46601-1063 | 2017-04-10 |
| 1619388717 | Sarah Ann Holewczynski | Registered Nurse | 621 Memorial Dr, Ste 617, South Bend, IN 46601-1063 | 2014-05-12 |
| 1255620985 | David L. Clayton Md Inc | Family Medicine | 621 Memorial Dr, Suite 624, South Bend, IN 46601-1063 | 2011-04-04 |
| 1477873644 | Rebecca M Castro | Nurse Practitioner | 621 Memorial Dr, Ste 502, South Bend, IN 46601-1063 | 2010-06-10 |
| 1508191768 | Allied Physicians of Michiana, LLC | Surgery | 621 Memorial Dr, Suite 302, South Bend, IN 46601-1063 | 2009-10-06 |
| 1841434354 | Kelly Elizabeth Mortell | Radiology | 621 Memorial Dr, Ste 312, South Bend, IN 46601-1063 | 2009-04-28 |
| 1659543643 | William Hanley | Nurse Practitioner | 621 Memorial Dr, Suite 502, South Bend, IN 46601-1063 | 2008-03-31 |
| 1134262595 | North Central Neurology, LLC | Psychiatry & Neurology | 621 Memorial Dr, Suite 624, South Bend, IN 46601-1063 | 2007-02-15 |
| 1619015534 | Beacon Medical Group, Inc. | Specialist | 621 Memorial Dr, Suite 502, South Bend, IN 46601-1063 | 2007-02-02 |
| Find all providers in the same location | ||||
| NPI | Name | Taxonomy | Address | Enumeration |
|---|---|---|---|---|
| 1447610449 | David Thomas | Hearing Instrument Specialist | 808 S Michigan St., South Bend, IN 46601 | 2016-03-03 |
| 1285072454 | Kevin Francis Cumper | Internal Medicine | 621 Memorial Dr Ste 624, South Bend, IN 46601 | 2013-06-11 |
| 1952605560 | Robert Lusk Bonham | Dentist | 1222 L.w.e., So. Bend, IN 46601 | 2010-12-23 |
| 1649580911 | Daniel Scott Debrule | Psychologist | 211 W. Washington Street, Suite 2311, South Bend, IN 46601 | 2010-10-20 |
| 1528390770 | Luke Alfred White | Internal Medicine | 615 N. Michigan St., Memorial Hospital, C/o Erin Smith, South Bend, IN 46601 | 2010-02-12 |
| 1548497837 | Tmg Home Health Care | Home Health | 108 N Main St #305, South Bend, IN 46601 | 2009-06-15 |
| 1225283039 | Jody L. Hughes | Counselor | 202 S. Michigan Street, Suite 875, South Bend, IN 46601 | 2008-11-20 |
| 1740432574 | Amanda Jayne Quicksall | Social Worker | 611 Lincolnway W, South Bend, IN 46601 | 2008-10-10 |
| 1952565772 | Thomas P Judd | Dentist | 1901 #b Western Avenue, Ihc South Bend, South Bend, IN 46601 | 2008-07-10 |
| 1851590269 | Warren Larry Penrod | Nurse Practitioner | 333 W. Western Ave, South Bend, IN 46601 | 2007-07-16 |
| Find all providers in zip 46601 | ||||
| Taxonomy Code | 363LA2200X |
| Grouping | Physician Assistants & Advanced Practice Nursing Providers |
| Classification | Nurse Practitioner |
| Specialization | Adult Health |
| Definition to come... |
| NPI | Name | Taxonomy | Address | Enumeration |
|---|---|---|---|---|
| 1083262992 | Francesca E Udoh | Nurse Practitioner | 51875 Whitestable Ln, South Bend, IN 46637-1371 | 2019-09-04 |
| 1760721807 | William John Fox | Nurse Practitioner | 333 W Western Ave, South Bend, IN 46601-2215 | 2013-02-09 |
| 1922290790 | Laura Myers Hieronymus | Nurse Practitioner | 1700 Mishawaka Ave, Student Activity Center Rm 130, South Bend, IN 46634-7111 | 2007-08-15 |
| 1740296516 | Freda Ann Black | Nurse Practitioner | 112 W Jefferson Blvd, South Bend, IN 46601-1923 | 2006-07-31 |
| 1447721105 | Daniela M Edson | Nurse Practitioner | 621 Memorial Dr Ste 502, South Bend, IN 46601-1075 | 2018-12-06 |
| 1265810584 | Tara Pousson | Nurse Practitioner | 112 W Jefferson Blvd, Suite 600, South Bend, IN 46601-1923 | 2015-05-07 |
| 1447669304 | Ludmila Pichugena-emerson | Nurse Practitioner | 211 N Eddy St., South Bend, IN 46617-3096 | 2014-08-05 |
| 1033520101 | Oluyinka Grace Osunnuga | Nurse Practitioner | 707 N Michigan St, Suite 400, South Bend, IN 46601-1067 | 2014-05-12 |
| 1972913804 | Toni Brown | Nurse Practitioner | 333 W Western Ave, South Bend, IN 46601-2215 | 2014-04-30 |
| 1023364262 | Gina M. Connolly | Nurse Practitioner | 100 Navarre Pl Ste 6600, South Bend, IN 46601 | 2012-07-25 |
| Find all providers in SOUTH BEND | ||||
| City | SOUTH BEND |
| Zip Code | 46601 |
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| Data Provider | Centers for Medicare & Medicaid Services (CMS), National Plan and Provider Enumeration System (NPPES) |
| Jurisdiction | Medicare & Medicaid |
This dataset includes 5.44 million covered health care providers and all health plans and health care clearinghouses, registered with CMA NPPES. Each provider is registered with National Provider Identifier (NPI), full name, status, address, taxonomy, other identifiers, etc.