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Organization
BEACON MEDICAL GROUP, INC.
Active
Organization
BEACON MEDICAL GROUP, INC.
Active
Other names
Beacon Medical Group OBGYN River Oaks, Beacon Medical Group OBGYN River Oaks Lawn Aenue, Beacon Medical Group Obstetrics & Gynecology Elkhart
Organization subpart
No
Provider details
NPI number
Authorized official
MR. JEFFREY P COSTELLO (CFO)
(574) 647-3549
Entity
Organization
Contact information
Practice address
1215 LAWN AVE STE 100, ELKHART, IN 46514-2450
(574) 293-2893
(574) 293-1298
Mailing address
710 N NILES AVE, SOUTH BEND, IN 46617-1924
(574) 647-1610
(574) 237-6069
Taxonomy
Speciality
Code
Description
License number
State
207V00000X
Obstetrics & Gynecology Physician
Primary
07-005017-1
IN
363LF0000X
Family Nurse Practitioner
—
NULL
363LF0000X
Family Nurse Practitioner
—
—
367A00000X
Advanced Practice Midwife
—
NULL
367A00000X
Advanced Practice Midwife
—
—
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
000000519823
ANTHEM BCBS
IN
05
—
200853000A
—
IN
Enumeration date
02/26/2007
Last updated
03/04/2024
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