Provider Demographics
NPI:1225100787
Name:BEACON HEALTH VENTURES INC
Entity Type:Organization
Organization Name:BEACON HEALTH VENTURES INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:GREGORY
Authorized Official - Middle Name:M
Authorized Official - Last Name:CONRAD
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:574-647-8777
Mailing Address - Street 1:3355 DOUGLAS ROAD
Mailing Address - Street 2:
Mailing Address - City:SOUTH BEND
Mailing Address - State:IN
Mailing Address - Zip Code:46635-1780
Mailing Address - Country:US
Mailing Address - Phone:574-273-2273
Mailing Address - Fax:574-273-5602
Practice Address - Street 1:2602 SOUTH U.S. 35
Practice Address - Street 2:
Practice Address - City:KNOX
Practice Address - State:IN
Practice Address - Zip Code:46534
Practice Address - Country:US
Practice Address - Phone:574-772-4458
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-13
Last Update Date:2017-02-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN69000136A332B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN200253800BMedicaid
IN000000097412OtherANTHEM PROVIDER
IN0369000005Medicare ID - Type UnspecifiedMEDICARE PROVIDER