# BEACON MEDICAL GROUP, INC.

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- **Entity:** Organization
- **Status:** Active
- **Other names:** Beacon Medical Group Cleveland Road
- **Organization subpart:** No

## Provider details

- **NPI number:** 1588024624
- **Authorized official:** MR. JEFFREY P COSTELLO (VP-CFO)
- **Authorized official phone:** (574) 647-3549

## Contact information

- **Practice address:** 2235 CLEVELAND RD, SOUTH BEND, IN 46628-3529
- **Practice address phone:** (574) 647-4530
- **Practice address fax:** (574) 647-2285
- **Mailing address:** 710 N NILES AVE, SOUTH BEND, IN 46617-1924
- **Mailing address phone:** (574) 647-1610
- **Mailing address fax:** (574) 237-6069

## Taxonomy

| Code | Description | License number | State | Primary |
| --- | --- | --- | --- | --- |
| 207Q00000X | Family Medicine Physician | — | NULL | Yes |
| 207Q00000X | Family Medicine Physician | — | — | Yes |
| 207RN0300X | Nephrology Physician | — | NULL | — |
| 207RN0300X | Nephrology Physician | — | — | — |
| 213ES0103X | Foot & Ankle Surgery Podiatrist | — | NULL | — |
| 213ES0103X | Foot & Ankle Surgery Podiatrist | — | — | — |
| 363LF0000X | Family Nurse Practitioner | — | NULL | — |
| 363LF0000X | Family Nurse Practitioner | — | — | — |

## Other

- **Enumeration date:** 03/02/2016
- **Last updated:** 02/22/2024