# BEACON MEDICAL GROUP, INC.

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- **Entity:** Organization
- **Status:** Active
- **Other names:** Beacon Medical Group Cardiothoracic Surgery South Bend
- **Organization subpart:** No

## Provider details

- **NPI number:** 1881971505
- **Authorized official:** JEFFREY P COSTELLO (VP/CFO)
- **Authorized official phone:** (574) 647-3549

## Contact information

- **Practice address:** 610 N MICHIGAN ST STE 306, SOUTH BEND, IN 46601-1079
- **Practice address phone:** (574) 647-6500
- **Practice address fax:** (574) 647-6518
- **Mailing address:** 710 N NILES AVE, SOUTH BEND, IN 46617-1924
- **Mailing address phone:** (574) 647-1610

## Taxonomy

| Code | Description | License number | State | Primary |
| --- | --- | --- | --- | --- |
| 208G00000X | Thoracic Surgery (Cardiothoracic Vascular Surgery) Physician | — | NULL | Yes |
| 208G00000X | Thoracic Surgery (Cardiothoracic Vascular Surgery) Physician | — | — | Yes |
| 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