Organization
BEACON MEDICAL GROUP, INC.
Active
Other names
Beacon Medical Group Bristol
Organization subpart
No
Provider details
NPI number
Authorized official
MR. JEFFREY P COSTELLO (CFO)
(574) 647-3549
Entity
Organization
Contact information
Practice address
306 E VISTULA, BRISTOL, IN 46507-9489
(574) 848-4427
(574) 848-4592
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
06-005017-1
IN
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
000000110755
BCBS REMIT
IN
05
—
100114000B
—
IN
Enumeration date
07/12/2006
Last updated
04/24/2023
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