# BEACON MEDICAL GROUP, INC.

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

## Provider details

- **NPI number:** 1114363835
- **Authorized official:** MR. JEFFREY P. COSTELLO (CFO)
- **Authorized official phone:** (574) 647-3549

## Contact information

- **Practice address:** 206 W WARREN ST, MIDDLEBURY, IN 46540-9410
- **Practice address phone:** (574) 825-2146
- **Practice address fax:** (574) 524-7435
- **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 | — | NULL | Yes |
| 207Q00000X | Family Medicine Physician | — | — | Yes |
| 363LF0000X | Family Nurse Practitioner | — | NULL | — |
| 363LF0000X | Family Nurse Practitioner | — | — | — |

## Other

- **Enumeration date:** 05/21/2013
- **Last updated:** 03/04/2024

## Other identifiers

| Code | Description | Identifier | Issuer | State |
| --- | --- | --- | --- | --- |
| 05 | — | 100114000G | — | IN |