Organization
BEACON MEDICAL GROUP, INC.
Active
Other names
Beacon Medical Group Ireland Road
Organization subpart
No
Provider details
NPI number
Authorized official
JEFFREY COSTELLO (VP-CFO)
(574) 647-3549
Entity
Organization
Contact information
Practice address
1815 E IRELAND RD, SOUTH BEND, IN 46614-2845
(574) 647-1700
(574) 291-3351
Mailing address
710 N NILES AVE, SOUTH BEND, IN 46617-1924
(574) 647-1610
Taxonomy
Speciality
Code
Description
License number
State
207Q00000X
Family Medicine Physician
Primary
01043622A
IN
207QS0010X
Sports Medicine (Family Medicine) Physician
—
—
207RR0500X
Rheumatology Physician
—
—
363LF0000X
Family Nurse Practitioner
—
—
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
100224050B
—
IN
Enumeration date
05/12/2006
Last updated
09/30/2024
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