Organization
BEACON MEDICAL GROUP, INC.
Active
Other names
Beacon Medical Group Southeast Neighborhood Health Center
Organization subpart
No
Provider details
NPI number
Authorized official
JEFFREY COSTELLO (VP-CFO)
(574) 647-3549
Entity
Organization
Contact information
Practice address
1708 HIGH ST, SOUTH BEND, IN 46613-2633
(574) 647-1400
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
01059718A
IN
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
200114230A
—
IN
Enumeration date
05/15/2006
Last updated
08/29/2016
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