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General NPI Number Information
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NPI Number | 1629376645
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Entity Type | Organization
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Legal Business Name | BEACON MEDICAL GROUP, INC.
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Dates
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Enumeration Date | 03/01/2011
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Last Update Date | 02/22/2024
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Provider Practice Location Address
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Address Line | 707 N MICHIGAN ST STE 400
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City | SOUTH BEND
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State | IN
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Zip | 46601-1071
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Country | US
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Telephone | 574-647-8470
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Fax | 574-647-8475
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Provider Business Mailing Address
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Address Line | 710 N NILES AVE
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City | SOUTH BEND
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State | IN
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Zip | 46617-1924
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Country | US
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Telephone | 574-647-1610
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Fax |
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Authorized Official
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Title or Position | VP/CFO
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Name | JEFFREY P COSTELLO
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Credential |
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Telephone | 574-647-3549
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 363LP0808X
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Taxonomy Name | Psychiatric/Mental Health Nurse Practitioner
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License Number |
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License Number State |
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Taxonomy #2
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Taxonomy Code | 207Q00000X
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Taxonomy Name | Family Medicine Physician
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License Number |
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License Number State |
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Taxonomy #3
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Taxonomy Code | 2084P0804X
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Taxonomy Name | Child & Adolescent Psychiatry Physician
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License Number | 01052982A
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License Number State | IN
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Taxonomy #4
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Taxonomy Code | 2084P0805X
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Taxonomy Name | Geriatric Psychiatry Physician
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License Number | 01052982A
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License Number State | IN
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Taxonomy #5
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Taxonomy Code | 2084P0800X
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Taxonomy Name | Psychiatry Physician
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License Number | 01052982A
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License Number State | IN
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