Organization
BEACON MEDICAL GROUP, INC.
Active
Other names
Beacon Medical Group Pediatric Hematology Oncology
Organization subpart
No
Provider details
NPI number
Authorized official
JEFFREY COSTELLO (CFO)
(574) 647-3549
Entity
Organization
Contact information
Practice address
615 N MICHIGAN ST 4TH FL, SOUTH BEND, IN 46601-1033
(574) 647-6892
(574) 647-6895
Mailing address
710 N NILES AVE, SOUTH BEND, IN 46617-1924
(574) 647-1610
Taxonomy
Speciality
Code
Description
License number
State
2080P0207X
Pediatric Hematology & Oncology Physician
Primary
02001713A
IN
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
200510720A
—
IN
Enumeration date
05/15/2006
Last updated
03/04/2024
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