Organization
BEACON MEDICAL GROUP, INC.
Active
Other names
Beacon Medical Group Pediatric Multi-Specialty, Beacon Medical Group Pediatric Specialists
Organization subpart
No
Provider details
NPI number
Authorized official
MR. JEFFREY P COSTELLO (VICE PRESIDENT/CFO)
(574) 647-3549
Entity
Organization
Contact information
Practice address
100 NAVARRE PL STE 5550, SOUTH BEND, IN 46601-1169
(574) 647-2550
(574) 647-1129
Mailing address
3245 HEALTH DR STE 100, GRANGER, IN 46530-1380
(574) 647-1069
Taxonomy
Speciality
Code
Description
License number
State
103T00000X
Psychologist
—
—
103TC0700X
Clinical Psychologist
—
—
133V00000X
Registered Dietitian
—
—
208000000X
Pediatrics Physician
Primary
01065535A
IN
2080N0001X
Neonatal-Perinatal Medicine Physician
—
—
2080P0214X
Pediatric Pulmonology Physician
—
—
363L00000X
Nurse Practitioner
—
—
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
200928880A
—
IN
05
—
300069919
—
IN
Enumeration date
11/19/2008
Last updated
07/21/2025
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