Organization
BEACON MEDICAL GROUP, INC.
Active
Other names
Beacon Medical Group Vascular Interventional Radiology
Organization subpart
No
Provider details
NPI number
Authorized official
JEFFREY P. COSTELLO (CFO)
(574) 647-3549
Entity
Organization
Contact information
Practice address
621 MEMORIAL DR STE 312, SOUTH BEND, IN 46601-1073
(574) 647-5200
(574) 647-5210
Mailing address
710 N NILES AVE, SOUTH BEND, IN 46617-1924
(574) 647-1610
Taxonomy
Speciality
Code
Description
License number
State
2085R0204X
Vascular & Interventional Radiology Physician
Primary
—
—
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
201063130A
—
IN
Enumeration date
05/04/2012
Last updated
10/12/2017
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