MEDICARE: BEACON MEDICAL GROUP, INC.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207RC0000X	Cardiovascular Disease Physician
2	207RI0011X	Interventional Cardiology Physician
3	207Q00000X	Family Medicine Physician	01058339A	IN

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1033161617
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	BEACON MEDICAL GROUP, INC.

Provider Business Mailing Address
First Line	:	3245 HEALTH DR STE 100
Second Line	:
City	:	GRANGER
State	:	IN
Zip	:	46530-1380
Country	:	US
Telephone Number	:	574-647-1840
Fax Number	:

Provider Business Practice Location Address
First Line	:	4630 VISTULA RD
Second Line	:
City	:	MISHAWAKA
State	:	IN
Zip	:	46544-4000
Country	:	US
Telephone Number	:	574-647-1900
Fax Number	:	574-254-7222

Authorized Official
Title or Position	:	VP-CFO
Name	:	JEFFREY COSTELLO
Credential	:
Telephone Number	:	574-647-3549

Provider Enumeration Date	:	05/16/2006
Last Update Date	:	02/13/2025

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Directions to “BEACON MEDICAL GROUP, INC. ” Practice Location

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