# BEACON MEDICAL GROUP, INC.

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- **Entity:** Organization
- **Status:** Active
- **Other names:** Beacon Medical Group Bittersweet Commons
- **Organization subpart:** No

## Provider details

- **NPI number:** 1003042318
- **Authorized official:** MR. JEFFREY P COSTELLO (CFO)
- **Authorized official phone:** (574) 647-3549

## Contact information

- **Practice address:** 12340 BITTERSWEET COMMONS BLVD W, GRANGER, IN 46530-6959
- **Practice address phone:** (574) 271-8610
- **Practice address fax:** (574) 271-8620
- **Mailing address:** 710 N NILES AVE, SOUTH BEND, IN 46617-1924
- **Mailing address phone:** (574) 647-1610
- **Mailing address fax:** (574) 237-6069

## Taxonomy

| Code | Description | License number | State | Primary |
| --- | --- | --- | --- | --- |
| 207Q00000X | Family Medicine Physician | — | IN | Yes |

## Other

- **Enumeration date:** 06/02/2009
- **Last updated:** 04/24/2023

## Other identifiers

| Code | Description | Identifier | Issuer | State |
| --- | --- | --- | --- | --- |
| 01 | — | 000000631897 | ANTHEM | IN |
| 05 | — | 100114000F | — | IN |