Organization
BEACON MEDICAL GROUP, INC.
Active
Organization subpart
No
Provider details
NPI number
Authorized official
JEFFREY COSTELLO (VP-CFO)
(574) 647-3549
Entity
Organization
Contact information
Practice address
100 NAVARRE PL STE 5500, SOUTH BEND, IN 46601-1172
(574) 647-5300
(574) 647-5305
Mailing address
710 N NILES AVE, SOUTH BEND, IN 46617-1924
(574) 647-1610
Taxonomy
Speciality
Code
Description
License number
State
207X00000X
Orthopaedic Surgery Physician
Primary
01055773A
IN
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
200241180A
—
IN
Enumeration date
05/11/2006
Last updated
10/12/2017
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