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Organization
BEACON MEDICAL GROUP, INC.
Active
Organization
BEACON MEDICAL GROUP, INC.
Active
Other names
Beacon Medical Group E. Blair Warner
Organization subpart
No
Provider details
NPI number
Authorized official
JEFFREY COSTELLO (VP-CFO)
(574) 647-3549
Entity
Organization
Contact information
Practice address
714 N MICHIGAN ST, SOUTH BEND, IN 46601-1035
(574) 647-7477
(574) 647-3655
Mailing address
710 N NILES AVE, SOUTH BEND, IN 46617-1924
(574) 647-1610
Taxonomy
Speciality
Code
Description
License number
State
207Q00000X
Family Medicine Physician
Primary
01034518A
IN
207V00000X
Obstetrics & Gynecology Physician
—
NULL
207V00000X
Obstetrics & Gynecology Physician
—
—
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
100092670B
—
IN
Enumeration date
05/16/2006
Last updated
07/10/2024
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