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
1	207Q00000X	Family Medicine Physician	01054535A	IN

Other Identifiers

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

General Provider Information

NPI Number	:	1568413359
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	BEACON MEDICAL GROUP, INC.

Provider Business Mailing Address
First Line	:	53842 GENERATIONS DR
Second Line	:
City	:	SOUTH BEND
State	:	IN
Zip	:	46635-1543
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	3575 PORTAGE AVE
Second Line	:
City	:	SOUTH BEND
State	:	IN
Zip	:	46628-6092
Country	:	US
Telephone Number	:	574-647-4530
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	:	09/27/2013

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

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