Organization
BEACON MEDICAL GROUP, INC.
Active
Other names
Beacon Medical Group OBGYN River Oaks, Beacon Medical Group OBGYN River Oaks Lawn Aenue, Beacon Medical Group Obstetrics & Gynecology Elkhart
Organization subpart
No
Provider details
NPI number
Authorized official
MR. JEFFREY P COSTELLO (CFO)
(574) 647-3549
Entity
Organization
Contact information
Practice address
1215 LAWN AVE STE 100, ELKHART, IN 46514-2450
(574) 293-2893
(574) 293-1298
Mailing address
710 N NILES AVE, SOUTH BEND, IN 46617-1924
(574) 647-1610
(574) 237-6069
Taxonomy
Speciality
Code
Description
License number
State
207V00000X
Obstetrics & Gynecology Physician
Primary
07-005017-1
IN
363LF0000X
Family Nurse Practitioner
—
—
367A00000X
Advanced Practice Midwife
—
—
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
000000519823
ANTHEM BCBS
IN
05
—
200853000A
—
IN
Enumeration date
02/26/2007
Last updated
03/04/2024
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