# BEACON MEDICAL GROUP, INC.

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

## Provider details

- **NPI number:** 1639129117
- **Authorized official:** JEFFREY COSTELLO (VP-CFO)
- **Authorized official phone:** (574) 647-3549

## Contact information

- **Practice address:** 900 I ST, LA PORTE, IN 46350-5533
- **Practice address phone:** (219) 324-1700
- **Practice address fax:** (219) 324-1710
- **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 | 01056419A | IN | Yes |
| 207V00000X | Obstetrics & Gynecology Physician | — | NULL | — |
| 207V00000X | Obstetrics & Gynecology Physician | — | — | — |
| 363L00000X | Nurse Practitioner | — | NULL | — |
| 363L00000X | Nurse Practitioner | — | — | — |

## Other

- **Enumeration date:** 05/12/2006
- **Last updated:** 03/04/2024

## Other identifiers

| Code | Description | Identifier | Issuer | State |
| --- | --- | --- | --- | --- |
| 05 | — | 100162390A | — | IN |