# BEACON MEDICAL GROUP, INC.

> Is this information incorrect? This page shows public data from NPPES. Update your record in NPPES and this page will update automatically within 7 days. [Update your NPPES record](https://nppes.cms.hhs.gov)

- **Entity:** Organization
- **Status:** Active
- **Organization subpart:** No

## Provider details

- **NPI number:** 1275587149
- **Authorized official:** JEFFREY COSTELLO (VP-CFO)
- **Authorized official phone:** (574) 647-3549

## Contact information

- **Practice address:** 813 S MICHIGAN ST, SOUTH BEND, IN 46601
- **Practice address phone:** (574) 647-2400
- **Practice address fax:** (574) 647-4201
- **Mailing address:** 710 N NILES AVE, SOUTH BEND, IN 46617-1924
- **Mailing address phone:** (574) 647-1610

## Taxonomy

| Code | Description | License number | State | Primary |
| --- | --- | --- | --- | --- |
| 207Q00000X | Family Medicine Physician | 01022886A | IN | Yes |

## Other

- **Enumeration date:** 05/22/2006
- **Last updated:** 07/03/2018

## Other identifiers

| Code | Description | Identifier | Issuer | State |
| --- | --- | --- | --- | --- |
| 05 | — | 200191560A | — | IN |
| 05 | — | 200191560B | — | IN |