Organization
BEACON MEDICAL GROUP, INC.
Active
Other names
Beacon Medical Group Behavioral Health South Bend
Organization subpart
No
Provider details
NPI number
Authorized official
JEFFREY P COSTELLO (VP/CFO)
(574) 647-3549
Entity
Organization
Contact information
Practice address
707 N MICHIGAN ST STE 400, SOUTH BEND, IN 46601-1071
(574) 647-8470
(574) 647-8475
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
—
—
2084P0800X
Psychiatry Physician
Primary
01052982A
IN
2084P0804X
Child & Adolescent Psychiatry Physician
01052982A
IN
2084P0805X
Geriatric Psychiatry Physician
01052982A
IN
363LP0808X
Psychiatric/Mental Health Nurse Practitioner
—
—
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
201013730A
—
IN
Enumeration date
03/01/2011
Last updated
02/22/2024
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