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	208000000X	Pediatrics Physician	01046281A	IN

General Provider Information

NPI Number	:	1447203674
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	BEACON MEDICAL GROUP, INC.

Provider Business Mailing Address
First Line	:	710 N NILES AVE
Second Line	:
City	:	SOUTH BEND
State	:	IN
Zip	:	46617-1924
Country	:	US
Telephone Number	:	574-647-1610
Fax Number	:

Provider Business Practice Location Address
First Line	:	100 NAVARRE PL STE 4440
Second Line	:
City	:	SOUTH BEND
State	:	IN
Zip	:	46601-1171
Country	:	US
Telephone Number	:	574-647-4540
Fax Number	:	574-647-4542

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

Provider Enumeration Date	:	05/18/2006
Last Update Date	:	04/04/2019

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

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