Organization
BEACON MEDICAL GROUP, INC.
Active
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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