Healthcare Provider Details

I. General information

NPI: 1639129117
Provider Name (Legal Business Name): BEACON MEDICAL GROUP, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/12/2006
Last Update Date: 03/04/2024
Certification Date: 03/04/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

900 I ST
LA PORTE IN
46350-5533
US

IV. Provider business mailing address

710 N NILES AVE
SOUTH BEND IN
46617-1924
US

V. Phone/Fax

Practice location:
  • Phone: 219-324-1700
  • Fax: 219-324-1710
Mailing address:
  • Phone: 574-647-1610
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207V00000X
TaxonomyObstetrics & Gynecology Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number01056419A
License Number StateIN

VIII. Authorized Official

Name: JEFFREY COSTELLO
Title or Position: VP-CFO
Credential:
Phone: 574-647-3549