# BEACON MEDICAL GROUP, INC.

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- **Entity:** Organization
- **Status:** 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:** 1316073372
- **Authorized official:** MR. JEFFREY P COSTELLO (CFO)
- **Authorized official phone:** (574) 647-3549

## Contact information

- **Practice address:** 1215 LAWN AVE STE 100, ELKHART, IN 46514-2450
- **Practice address phone:** (574) 293-2893
- **Practice address fax:** (574) 293-1298
- **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 |
| --- | --- | --- | --- | --- |
| 207V00000X | Obstetrics & Gynecology Physician | 07-005017-1 | IN | Yes |
| 363LF0000X | Family Nurse Practitioner | — | NULL | — |
| 363LF0000X | Family Nurse Practitioner | — | — | — |
| 367A00000X | Advanced Practice Midwife | — | NULL | — |
| 367A00000X | Advanced Practice Midwife | — | — | — |

## Other

- **Enumeration date:** 02/26/2007
- **Last updated:** 03/04/2024

## Other identifiers

| Code | Description | Identifier | Issuer | State |
| --- | --- | --- | --- | --- |
| 01 | — | 000000519823 | ANTHEM BCBS | IN |
| 05 | — | 200853000A | — | IN |