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NPI Code Detail

MEDICARE: BEACON MEDICAL GROUP, INC.

MEDICARE: BEACON MEDICAL GROUP, INC.
Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

# Taxonomy Code Taxonomy License Number License Number State
1207Q00000XFamily Medicine Physician01059718AIN

Other Identifiers

# Provider Identifier Provider Identifier Type Provider Identifier State Provider Identifier Issuer
1MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number : 1437100161
Entity Type Code : Organization
Provider Name (Legal Business Name) : BEACON MEDICAL GROUP, INC.
Provider Business Mailing Address
First Line : 710 N NILES AVE
Second Line :
City : SOUTH BEND
State : IN
Zip : 46617-1924
Country : US
Telephone Number : 574-647-1610
Fax Number :
Provider Business Practice Location Address
First Line : 1708 HIGH ST
Second Line :
City : SOUTH BEND
State : IN
Zip : 46613-2633
Country : US
Telephone Number : 574-647-1400
Fax Number :
Authorized Official
Title or Position : VP-CFO
Name : JEFFREY COSTELLO
Credential :
Telephone Number : 574-647-3549
Provider Enumeration Date : 05/15/2006
Last Update Date : 08/29/2016

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Directions to “BEACON MEDICAL GROUP, INC. ” Practice Location

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