Organization
BEACON MEDICAL GROUP, INC.
Active
Other names
Beacon Medical Group Cardiothoracic Surgery 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
610 N MICHIGAN ST STE 306, SOUTH BEND, IN 46601-1079
(574) 647-6500
(574) 647-6518
Mailing address
710 N NILES AVE, SOUTH BEND, IN 46617-1924
(574) 647-1610
Taxonomy
Speciality
Code
Description
License number
State
208G00000X
Thoracic Surgery (Cardiothoracic Vascular Surgery) Physician
Primary
—
—
363A00000X
Physician Assistant
—
—
363LF0000X
Family Nurse Practitioner
—
—
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
201041690A
—
IN
Enumeration date
11/09/2011
Last updated
02/22/2024
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