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Organization
BEACON MEDICAL GROUP, INC.
Active
Organization
BEACON MEDICAL GROUP, INC.
Active
Other names
Beacon Medical Group Sports Medicine South Bend
Organization subpart
No
Provider details
NPI number
Authorized official
JEFFREY COSTELLO (VP-CFO)
(574) 647-3549
Entity
Organization
Contact information
Practice address
111 W JEFFERSON BLVD, SUITE 100, SOUTH BEND, IN 46601-1994
(574) 647-1669
(574) 239-6461
Mailing address
710 N NILES AVE, SOUTH BEND, IN 46617-1924
(574) 647-1610
Taxonomy
Speciality
Code
Description
License number
State
207QS0010X
Sports Medicine (Family Medicine) Physician
Primary
01049328A
IN
Other
Enumeration date
05/16/2006
Last updated
08/30/2016
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