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Organization
BEACON MEDICAL GROUP, INC.
Active
Organization
BEACON MEDICAL GROUP, INC.
Active
Other names
Beacon Medical Group Behavioral Health Elkhart
Organization subpart
No
Provider details
NPI number
Authorized official
MR. JEFFREY P COSTELLO (CFO)
(574) 647-3549
Entity
Organization
Contact information
Practice address
1506 OSOLO RD, SUITE A, ELKHART, IN 46514-4122
(574) 523-3347
(574) 206-9502
Mailing address
710 N NILES AVE, SOUTH BEND, IN 46617-1924
(574) 647-1610
(574) 237-6069
Taxonomy
Speciality
Code
Description
License number
State
261QM0801X
Mental Health Clinic/Center (Including Community Mental Health Center)
Primary
06-005017-1
IN
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
000000075060
ANTHEM BCBS-MSW
IN
01
—
000000110756
ANTHEM BCBS
IN
05
—
100268350A
—
IN
Enumeration date
09/15/2006
Last updated
10/27/2016
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