Provider Demographics
NPI:1699102046
Name:BEACON HEALTH VENTURES, INC
Entity type:Organization
Organization Name:BEACON HEALTH VENTURES, INC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:VICE PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:GREG
Authorized Official - Middle Name:
Authorized Official - Last Name:CONRAD
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:574-647-8777
Mailing Address - Street 1:3355 DOUGLAS RD
Mailing Address - Street 2:SUITE 400
Mailing Address - City:SOUTH BEND
Mailing Address - State:IN
Mailing Address - Zip Code:46635-1781
Mailing Address - Country:US
Mailing Address - Phone:574-647-2273
Mailing Address - Fax:574-647-8764
Practice Address - Street 1:3355 DOUGLAS RD
Practice Address - Street 2:
Practice Address - City:SOUTH BEND
Practice Address - State:IN
Practice Address - Zip Code:46635
Practice Address - Country:US
Practice Address - Phone:574-647-2273
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-10-01
Last Update Date:2016-06-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
332B00000X
IN3336C0004X
IN60004143A3336H0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336H0001XSuppliersPharmacyHome Infusion Therapy Pharmacy
No332B00000XSuppliersDurable Medical Equipment & Medical Supplies
No3336C0004XSuppliersPharmacyCompounding Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
000000097412OtherANTHEM
IN100301140AMedicaid
0369000001Medicare NSC