Organization
BEACON MEDICAL GROUP, INC.
Active
Other names
Beacon Medical Group E. Blair Warner
Organization subpart
No
Provider details
NPI number
Authorized official
JEFFREY COSTELLO (VP-CFO)
(574) 647-3549
Entity
Organization
Contact information
Practice address
714 N MICHIGAN ST, SOUTH BEND, IN 46601-1035
(574) 647-7477
(574) 647-3655
Mailing address
710 N NILES AVE, SOUTH BEND, IN 46617-1924
(574) 647-1610
Taxonomy
Speciality
Code
Description
License number
State
207Q00000X
Family Medicine Physician
Primary
01034518A
IN
207V00000X
Obstetrics & Gynecology Physician
—
—
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
100092670B
—
IN
Enumeration date
05/16/2006
Last updated
07/10/2024
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