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Organization
BEACON MEDICAL GROUP, INC.
Active
Organization
BEACON MEDICAL GROUP, INC.
Active
Other names
Beacon Medical Group Portage Road
Organization subpart
No
Provider details
NPI number
Authorized official
JEFFREY COSTELLO (VP-CFO)
(574) 647-3549
Entity
Organization
Contact information
Practice address
3575 PORTAGE AVE, SOUTH BEND, IN 46628-6092
(574) 647-4530
Mailing address
53842 GENERATIONS DR, SOUTH BEND, IN 46635-1543
Taxonomy
Speciality
Code
Description
License number
State
207Q00000X
Family Medicine Physician
Primary
01054535A
IN
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
100092700B
—
IN
Enumeration date
05/15/2006
Last updated
09/27/2013
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