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Organization
BEACON MEDICAL GROUP, INC.
Active
Organization
BEACON MEDICAL GROUP, INC.
Active
Other names
Beacon Medical Group Cardiothoracic Surgery South Bend
Organization subpart
No
Provider details
NPI number
Authorized official
JEFFREY P COSTELLO (VP/CFO)
(574) 647-3549
Entity
Organization
Contact information
Practice address
610 N MICHIGAN ST STE 306, SOUTH BEND, IN 46601-1079
(574) 647-6500
(574) 647-6518
Mailing address
710 N NILES AVE, SOUTH BEND, IN 46617-1924
(574) 647-1610
Taxonomy
Speciality
Code
Description
License number
State
208G00000X
Thoracic Surgery (Cardiothoracic Vascular Surgery) Physician
Primary
—
NULL
208G00000X
Thoracic Surgery (Cardiothoracic Vascular Surgery) Physician
Primary
—
—
363A00000X
Physician Assistant
—
NULL
363A00000X
Physician Assistant
—
—
363LF0000X
Family Nurse Practitioner
—
NULL
363LF0000X
Family Nurse Practitioner
—
—
Other
Enumeration date
11/09/2011
Last updated
02/22/2024
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