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General NPI Number Information
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NPI Number | 1710939608
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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 | 05/17/2006
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Last Update Date | 08/16/2025
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Provider Practice Location Address
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Address Line | 621 MEMORIAL DR STE 403
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City | SOUTH BEND
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State | IN
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Zip | 46601-1074
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Country | US
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Telephone | 574-647-6370
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Fax | 574-647-6373
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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 | 574-647-3725
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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 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 | 170300000X
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Taxonomy Name | Genetic Counselor (M.S.)
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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 | 207V00000X
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Taxonomy Name | Obstetrics & Gynecology 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 | 2086S0102X
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Taxonomy Name | Surgical Critical Care Physician
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License Number |
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License Number State |
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Taxonomy #4
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Taxonomy Code | 363LF0000X
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Taxonomy Name | Family Nurse Practitioner
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License Number |
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License Number State |
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Taxonomy #5
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Taxonomy Code | 207VM0101X
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Taxonomy Name | Maternal & Fetal Medicine Physician
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License Number | 01053966A
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License Number State | IN
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