# BEACON MEDICAL GROUP

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- **Entity:** Organization
- **Status:** Active
- **Other names:** Memorial Children's Hospital Navarre Pediatrics
- **Organization subpart:** No

## Provider details

- **NPI number:** 1689627812
- **Authorized official:** JEFFREY COSTELLO (VP-CFO)
- **Authorized official phone:** (574) 647-3549

## Contact information

- **Practice address:** 100 NAVARRE PL, SUITE 4400, SOUTH BEND, IN 46601-1156
- **Practice address phone:** (574) 647-4535
- **Mailing address:** 710 N NILES AVE, SOUTH BEND, IN 46617-1924
- **Mailing address phone:** (574) 647-1610

## Taxonomy

| Code | Description | License number | State | Primary |
| --- | --- | --- | --- | --- |
| 208800000X | Urology Physician | 01024987A | IN | Yes |

## Other

- **Enumeration date:** 05/18/2006
- **Last updated:** 03/09/2016

## Other identifiers

| Code | Description | Identifier | Issuer | State |
| --- | --- | --- | --- | --- |
| 01 | — | 15D1038973 | CLIA NUMBER | IN |