# BEACON MEDICAL GROUP, INC.

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- **Entity:** Organization
- **Status:** Active
- **Other names:** Beacon Medical Group Pediatrics Main Street, Beacon Medical Group Main Street
- **Organization subpart:** No

## Provider details

- **NPI number:** 1053361543
- **Authorized official:** JEFFREY COSTELLO (VP-CFO)
- **Authorized official phone:** (574) 647-3549

## Contact information

- **Practice address:** 6913 N MAIN ST STE 300, GRANGER, IN 46530-8039
- **Practice address phone:** (574) 647-1500
- **Practice address fax:** (574) 647-2567
- **Mailing address:** 3245 HEALTH DR STE 100, GRANGER, IN 46530-1380

## Taxonomy

| Code | Description | License number | State | Primary |
| --- | --- | --- | --- | --- |
| 133V00000X | Registered Dietitian | — | NULL | — |
| 133V00000X | Registered Dietitian | — | — | — |
| 207Q00000X | Family Medicine Physician | — | NULL | Yes |
| 207Q00000X | Family Medicine Physician | — | — | Yes |
| 207R00000X | Internal Medicine Physician | — | NULL | — |
| 207R00000X | Internal Medicine Physician | — | — | — |
| 207RE0101X | Endocrinology, Diabetes & Metabolism Physician | — | NULL | — |
| 207RE0101X | Endocrinology, Diabetes & Metabolism Physician | — | — | — |
| 207RR0500X | Rheumatology Physician | — | NULL | — |
| 207RR0500X | Rheumatology Physician | — | — | — |
| 208000000X | Pediatrics Physician | — | NULL | — |
| 208000000X | Pediatrics Physician | — | — | — |
| 363LF0000X | Family Nurse Practitioner | — | NULL | — |
| 363LF0000X | Family Nurse Practitioner | — | — | — |

## Other

- **Enumeration date:** 05/12/2006
- **Last updated:** 06/12/2026

## Other identifiers

| Code | Description | Identifier | Issuer | State |
| --- | --- | --- | --- | --- |
| 05 | — | 100224050C | — | IN |
| 05 | — | 300002852 | — | IN |
| 05 | — | 300015362 | — | IN |