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Organization
BEACON MEDICAL GROUP, INC.
Active
Organization
BEACON MEDICAL GROUP, INC.
Active
Other names
Beacon Medical Group Southeast Neighborhood Health Center
Organization subpart
No
Provider details
NPI number
Authorized official
JEFFREY COSTELLO (VP-CFO)
(574) 647-3549
Entity
Organization
Contact information
Practice address
1708 HIGH ST, SOUTH BEND, IN 46613-2633
(574) 647-1400
Mailing address
710 N NILES AVE, SOUTH BEND, IN 46617-1924
(574) 647-1610
Taxonomy
Speciality
Code
Description
License number
State
207Q00000X
Family Medicine Physician
Primary
01059718A
IN
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
200114230A
—
IN
Enumeration date
05/15/2006
Last updated
08/29/2016
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