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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
1207RN0300XNephrology Physician
2207X00000XOrthopaedic Surgery Physician
3207R00000XInternal Medicine Physician
4213ES0103XFoot & Ankle Surgery Podiatrist
5363LF0000XFamily Nurse Practitioner
6207Q00000XFamily Medicine Physician

Other Identifiers

# Provider Identifier Provider Identifier Type Provider Identifier State Provider Identifier Issuer
1MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
2ANTHEM BCBSOTHERIN000000110759

General Provider Information

NPI Number : 1639196249
Entity Type Code : Organization
Provider Name (Legal Business Name) : BEACON MEDICAL GROUP, INC.
Provider Business Mailing Address
First Line : 3245 HEALTH DR STE 100
Second Line :
City : GRANGER
State : IN
Zip : 46530-1380
Country : US
Telephone Number : 574-647-1610
Fax Number : 574-237-6069
Provider Business Practice Location Address
First Line : 3301 COUNTY ROAD 6 E
Second Line :
City : ELKHART
State : IN
Zip : 46514-7673
Country : US
Telephone Number : 574-264-9635
Fax Number : 574-262-0398
Authorized Official
Title or Position : CFO
Name : MR. JEFFREY P COSTELLO
Credential :
Telephone Number : 574-647-3549
Provider Enumeration Date : 07/17/2006
Last Update Date : 02/05/2025

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