=====================================================
General NPI Number Information
=====================================================
NPI Number | 1578862181
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | BEACON MEDICAL GROUP, INC.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/22/2011
-----------------------------------------------------
Last Update Date | 01/30/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 100 NAVARRE PL STE 4470
-----------------------------------------------------
City | SOUTH BEND
-----------------------------------------------------
State | IN
-----------------------------------------------------
Zip | 46601-1168
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 574-647-1405
-----------------------------------------------------
Fax | 574-647-3970
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 3245 HEALTH DR STE 100
-----------------------------------------------------
City | GRANGER
-----------------------------------------------------
State | IN
-----------------------------------------------------
Zip | 46530-1380
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | VP/CFO
-----------------------------------------------------
Name | JEFFREY P COSTELLO
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 574-647-3549
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207V00000X
-----------------------------------------------------
Taxonomy Name | Obstetrics & Gynecology Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 363LW0102X
-----------------------------------------------------
Taxonomy Name | Women's Health Nurse Practitioner
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #3
-----------------------------------------------------
Taxonomy Code | 367A00000X
-----------------------------------------------------
Taxonomy Name | Advanced Practice Midwife
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------