# BEACON MEDICAL GROUP, INC.

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

## Provider details

- **NPI number:** 1306863915
- **Authorized official:** MR. JEFFREY P COSTELLO (CFO)
- **Authorized official phone:** (574) 647-3549

## Contact information

- **Practice address:** 2120 RIETH BLVD STE A, GOSHEN, IN 46526-5858
- **Practice address phone:** (574) 875-5126
- **Practice address fax:** (574) 875-1874
- **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 |
| --- | --- | --- | --- | --- |
| 207N00000X | Dermatology Physician | 06-005017-1 | IN | — |
| 207Q00000X | Family Medicine Physician | 06-005017-1 | IN | Yes |

## Other

- **Enumeration date:** 07/17/2006
- **Last updated:** 04/24/2023

## Other identifiers

| Code | Description | Identifier | Issuer | State |
| --- | --- | --- | --- | --- |
| 01 | — | 000000110758 | ANTHEM BCBS | IN |
| 05 | — | 200116290A | — | IN |