Organization
BEACON MEDICAL GROUP, INC.
Active
Other names
Beacon Medical Group Critical Kids
Organization subpart
No
Provider details
NPI number
Authorized official
JEFFREY COSTELLO (CFO)
(574) 647-3549
Entity
Organization
Contact information
Practice address
615 N MICHIGAN ST 5TH FL, SOUTH BEND, IN 46601-1033
(574) 647-7275
(574) 647-3696
Mailing address
710 N NILES AVE, SOUTH BEND, IN 46617-1924
(574) 647-1610
Taxonomy
Speciality
Code
Description
License number
State
2080P0203X
Pediatric Critical Care Medicine Physician
Primary
—
—
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
200235870A
—
IN
Enumeration date
05/25/2006
Last updated
04/24/2023
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