Organization
BEACON MEDICAL GROUP, INC.
Active
Other names
Beacon Medical Group LaPorte
Organization subpart
No
Provider details
NPI number
Authorized official
JEFFREY COSTELLO (VP-CFO)
(574) 647-3549
Entity
Organization
Contact information
Practice address
900 I ST, LA PORTE, IN 46350-5533
(219) 324-1700
(219) 324-1710
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
01056419A
IN
207V00000X
Obstetrics & Gynecology Physician
—
—
363L00000X
Nurse Practitioner
—
—
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
100162390A
—
IN
Enumeration date
05/12/2006
Last updated
03/04/2024
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