Healthcare Provider Details

I. General information

NPI: 1578862181
Provider Name (Legal Business Name): BEACON MEDICAL GROUP, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/22/2011
Last Update Date: 01/30/2025
Certification Date: 01/30/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

100 NAVARRE PL STE 4470
SOUTH BEND IN
46601-1168
US

IV. Provider business mailing address

3245 HEALTH DR STE 100
GRANGER IN
46530-1380
US

V. Phone/Fax

Practice location:
  • Phone: 574-647-1405
  • Fax: 574-647-3970
Mailing address:
  • Phone:
  • 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 Code363LW0102X
TaxonomyWomen's Health Nurse Practitioner
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code367A00000X
TaxonomyAdvanced Practice Midwife
License Number
License Number State

VIII. Authorized Official

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