# BEACON MEDICAL GROUP, INC.

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

## Provider details

- **NPI number:** 1639196249
- **Authorized official:** MR. JEFFREY P COSTELLO (CFO)
- **Authorized official phone:** (574) 647-3549

## Contact information

- **Practice address:** 3301 COUNTY ROAD 6 E, ELKHART, IN 46514-7673
- **Practice address phone:** (574) 264-9635
- **Practice address fax:** (574) 262-0398
- **Mailing address:** 3245 HEALTH DR STE 100, GRANGER, IN 46530-1380
- **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 |
| 207R00000X | Internal Medicine Physician | — | NULL | — |
| 207R00000X | Internal Medicine Physician | — | — | — |
| 207RN0300X | Nephrology Physician | — | NULL | — |
| 207RN0300X | Nephrology Physician | — | — | — |
| 207X00000X | Orthopaedic Surgery Physician | — | NULL | — |
| 207X00000X | Orthopaedic Surgery Physician | — | — | — |
| 213ES0103X | Foot & Ankle Surgery Podiatrist | — | NULL | — |
| 213ES0103X | Foot & Ankle Surgery Podiatrist | — | — | — |
| 363LF0000X | Family Nurse Practitioner | — | NULL | — |
| 363LF0000X | Family Nurse Practitioner | — | — | — |

## Other

- **Enumeration date:** 07/17/2006
- **Last updated:** 02/05/2025

## Other identifiers

| Code | Description | Identifier | Issuer | State |
| --- | --- | --- | --- | --- |
| 05 | — | 100114000A | — | IN |
| 01 | — | ANTHEM BCBS | 000000110759 | IN |