# BEACON MEDICAL GROUP, INC.

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- **Entity:** Organization
- **Status:** Active
- **Other names:** Beacon Medical Group E. Blair Warner
- **Organization subpart:** No

## Provider details

- **NPI number:** 1609828946
- **Authorized official:** JEFFREY COSTELLO (VP-CFO)
- **Authorized official phone:** (574) 647-3549

## Contact information

- **Practice address:** 714 N MICHIGAN ST, SOUTH BEND, IN 46601-1035
- **Practice address phone:** (574) 647-7477
- **Practice address fax:** (574) 647-3655
- **Mailing address:** 710 N NILES AVE, SOUTH BEND, IN 46617-1924
- **Mailing address phone:** (574) 647-1610

## Taxonomy

| Code | Description | License number | State | Primary |
| --- | --- | --- | --- | --- |
| 207Q00000X | Family Medicine Physician | 01034518A | IN | Yes |
| 207V00000X | Obstetrics & Gynecology Physician | — | NULL | — |
| 207V00000X | Obstetrics & Gynecology Physician | — | — | — |

## Other

- **Enumeration date:** 05/16/2006
- **Last updated:** 07/10/2024

## Other identifiers

| Code | Description | Identifier | Issuer | State |
| --- | --- | --- | --- | --- |
| 05 | — | 100092670B | — | IN |