Organization
BEACON MEDICAL GROUP, INC.
Active
Other names
Beacon Medical Group Wakarusa
Organization subpart
No
Provider details
NPI number
Authorized official
MR. JEFFREY P COSTELLO (CFO)
(574) 647-3549
Entity
Organization
Contact information
Practice address
207 N ELKHART ST, WAKARUSA, IN 46573-9729
(574) 862-2165
(574) 862-4112
Mailing address
710 N NILES AVE, SOUTH BEND, IN 46617-1924
(574) 647-1610
(574) 237-6069
Taxonomy
Speciality
Code
Description
License number
State
207Q00000X
Family Medicine Physician
Primary
—
—
363LF0000X
Family Nurse Practitioner
—
—
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
200019030A
—
IN
01
—
ANTHEM BCBS
000000110760
IN
Enumeration date
07/17/2006
Last updated
03/04/2024
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