# BEACON MEDICAL GROUP, INC.

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- **Entity:** Organization
- **Status:** Active
- **Other names:** Beacon Medical Group Southeast Neighborhood Health Center
- **Organization subpart:** No

## Provider details

- **NPI number:** 1437100161
- **Authorized official:** JEFFREY COSTELLO (VP-CFO)
- **Authorized official phone:** (574) 647-3549

## Contact information

- **Practice address:** 1708 HIGH ST, SOUTH BEND, IN 46613-2633
- **Practice address phone:** (574) 647-1400
- **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 | 01059718A | IN | Yes |

## Other

- **Enumeration date:** 05/15/2006
- **Last updated:** 08/29/2016

## Other identifiers

| Code | Description | Identifier | Issuer | State |
| --- | --- | --- | --- | --- |
| 05 | — | 200114230A | — | IN |