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General NPI Number Information
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NPI Number | 1699794057
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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 | 07/18/2006
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Last Update Date | 06/13/2025
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Provider Practice Location Address
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Address Line | 500 ARCADE AVE STE 300
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City | ELKHART
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State | IN
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Zip | 46514-2486
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Country | US
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Telephone | 574-389-7362
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Fax | 574-389-5612
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Provider Business Mailing Address
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Address Line | 3245 HEALTH DR STE 100
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City | GRANGER
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State | IN
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Zip | 46530-1380
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Country | US
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Telephone | 574-647-1610
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Fax | 574-237-6069
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Authorized Official
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Title or Position | CFO
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Name | MR. 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 | 2085R0204X
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Taxonomy Name | Vascular & Interventional Radiology Physician
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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 | 208800000X
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Taxonomy Name | Urology 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 | 207RG0100X
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Taxonomy Name | Gastroenterology Physician
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License Number | 06-005017-1
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License Number State | IN
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