Organization
BEACON MEDICAL GROUP, INC.
Active
Organization
BEACON MEDICAL GROUP, INC.
Active
Other names
Beacon Medical Group Specialists Plymouth
Organization subpart
No
Provider details
NPI number
Authorized official
MR. JEFFREY P COSTELLO (VP/CFO)
(574) 647-3549
Entity
Organization
Contact information
Practice address
2855 MILLER DR, SUITE 121, PLYMOUTH, IN 46563-8091
(574) 647-1600
(574) 237-6069
Mailing address
710 N NILES AVE, SOUTH BEND, IN 46617-1924
(574) 647-1610
Taxonomy
Speciality
Code
Description
License number
State
207RC0000X
Cardiovascular Disease Physician
Primary
01045628A
IN
207RR0500X
Rheumatology Physician
01061323A
IN
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
100092700C
—
IN
Enumeration date
11/23/2009
Last updated
08/30/2016
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