Organization
BEACON MEDICAL GROUP, INC.
Active
Other names
Beacon Medical Group Goshen
Organization subpart
No
Provider details
NPI number
Authorized official
MR. JEFFREY P COSTELLO (CFO)
(574) 647-3549
Entity
Organization
Contact information
Practice address
2120 RIETH BLVD STE A, GOSHEN, IN 46526-5858
(574) 875-5126
(574) 875-1874
Mailing address
710 N NILES AVE, SOUTH BEND, IN 46617-1924
(574) 647-1610
(574) 237-6069
Taxonomy
Speciality
Code
Description
License number
State
207N00000X
Dermatology Physician
06-005017-1
IN
207Q00000X
Family Medicine Physician
Primary
06-005017-1
IN
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
000000110758
ANTHEM BCBS
IN
05
—
200116290A
—
IN
Enumeration date
07/17/2006
Last updated
04/24/2023
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