# BEACON MEDICAL GROUP INC

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- **Entity:** Organization
- **Status:** Active
- **Other names:** Beacon Medical Group Bremen, Beacon Medical Group Bremen South Street
- **Organization subpart:** No

## Provider details

- **NPI number:** 1942781109
- **Authorized official:** JEFFREY P. COSTELLO (CFO)
- **Authorized official phone:** (574) 647-3460

## Contact information

- **Practice address:** 1144 W PLYMOUTH ST, BREMEN, IN 46506-1842
- **Practice address phone:** (574) 546-5363
- **Practice address fax:** (574) 546-2575
- **Mailing address:** 710 N NILES AVE, SOUTH BEND, IN 46617-1924
- **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 |
| 207VG0400X | Gynecology Physician | — | NULL | — |
| 207VG0400X | Gynecology Physician | — | — | — |
| 363LF0000X | Family Nurse Practitioner | — | NULL | — |
| 363LF0000X | Family Nurse Practitioner | — | — | — |

## Other

- **Enumeration date:** 08/27/2018
- **Last updated:** 02/22/2024