Healthcare Provider Details

I. General information

NPI: 1780856724
Provider Name (Legal Business Name): BEACON MEDICAL GROUP, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/31/2008
Last Update Date: 08/30/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2301 N BENDIX DR SUITE 500
SOUTH BEND IN
46628-3486
US

IV. Provider business mailing address

710 N NILES AVE
SOUTH BEND IN
46617-1924
US

V. Phone/Fax

Practice location:
  • Phone: 574-647-1675
  • Fax: 574-232-5595
Mailing address:
  • Phone: 574-647-1610
  • Fax: 574-647-1825

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number71000502A
License Number StateIN
# 2
Primary TaxonomyY
Taxonomy Code2083A0100X
TaxonomyAerospace Medicine Physician
License Number01047560A
License Number StateIN

VIII. Authorized Official

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