Healthcare Provider Details

I. General information

NPI: 1710939608
Provider Name (Legal Business Name): BEACON MEDICAL GROUP, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/17/2006
Last Update Date: 08/16/2025
Certification Date: 08/16/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

621 MEMORIAL DR STE 403
SOUTH BEND IN
46601-1074
US

IV. Provider business mailing address

3245 HEALTH DR STE 100
GRANGER IN
46530-1380
US

V. Phone/Fax

Practice location:
  • Phone: 574-647-6370
  • Fax: 574-647-6373
Mailing address:
  • Phone: 574-647-3725
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code170300000X
TaxonomyGenetic Counselor (M.S.)
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code207V00000X
TaxonomyObstetrics & Gynecology Physician
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code2086S0102X
TaxonomySurgical Critical Care Physician
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number
License Number State
# 5
Primary TaxonomyY
Taxonomy Code207VM0101X
TaxonomyMaternal & Fetal Medicine Physician
License Number01053966A
License Number StateIN

VIII. Authorized Official

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