Healthcare Provider Details

I. General information

NPI: 1700187457
Provider Name (Legal Business Name): BEACON MEDICAL GROUP, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/11/2010
Last Update Date: 04/28/2023
Certification Date: 04/28/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

303 S NAPPANEE ST STE A
ELKHART IN
46514-2066
US

IV. Provider business mailing address

710 N NILES AVE
SOUTH BEND IN
46617-1924
US

V. Phone/Fax

Practice location:
  • Phone: 574-296-3338
  • Fax: 574-296-3332
Mailing address:
  • Phone: 574-647-1610
  • Fax: 574-237-6069

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RC0000X
TaxonomyCardiovascular Disease Physician
License Number10-005017-1
License Number StateIN

VIII. Authorized Official

Name: MR. JEFF P COSTELLO
Title or Position: CFO
Credential:
Phone: 574-647-3549