Healthcare Provider Details

I. General information

NPI: 1689627812
Provider Name (Legal Business Name): BEACON MEDICAL GROUP
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/18/2006
Last Update Date: 03/09/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

100 NAVARRE PL SUITE 4400
SOUTH BEND IN
46601-1156
US

IV. Provider business mailing address

710 N NILES AVE
SOUTH BEND IN
46617-1924
US

V. Phone/Fax

Practice location:
  • Phone: 574-647-4535
  • Fax:
Mailing address:
  • Phone: 574-647-1610
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208800000X
TaxonomyUrology Physician
License Number01024987A
License Number StateIN

VIII. Authorized Official

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