Organization
BEACON MEDICAL GROUP, INC.
Active
Other names
Memorial Pain Management
Organization subpart
No
Provider details
NPI number
Authorized official
JEFFREY P. COSTELLO (CFO)
(574) 647-3549
Entity
Organization
Contact information
Practice address
621 MEMORIAL DR, SUITE 602, SOUTH BEND, IN 46601-1063
(574) 647-7413
(574) 647-2471
Mailing address
710 N NILES AVE, SOUTH BEND, IN 46617-1924
(574) 647-1610
Taxonomy
Speciality
Code
Description
License number
State
363LA2200X
Adult Health Nurse Practitioner
Primary
71001587A
IN
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
201164630A
—
IN
Enumeration date
05/08/2013
Last updated
08/30/2016
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