| Beacon Medical Group, Inc. | |
|
813 S Michigan St South Bend IN 46601 | |
| (574) 647-2400 | |
| (574) 647-4201 |
| Full Name | Beacon Medical Group, Inc. |
|---|---|
| Speciality | Family Medicine |
| Location | 813 S Michigan St, South Bend, Indiana |
| Authorized Official Name and Position | Jeffrey Costello (VP-CFO) |
| Authorized Official Contact | 5746473549 |
| Accepts Medicare Insurance | This clinic does not participate in Medicare Program. |
| Mailing Address | Practice Location Address |
|---|---|
| Beacon Medical Group, Inc. 710 N Niles Ave South Bend IN 46617-1924 Ph: (574) 647-1610 | Beacon Medical Group, Inc. 813 S Michigan St South Bend IN 46601 Ph: (574) 647-2400 |
| NPI Number | 1275587149 |
|---|---|
| Provider Enumeration Date | 05/22/2006 |
| Last Update Date | 07/03/2018 |
| Identifier | Type | State | Issuer |
|---|---|---|---|
| 1275587149 | NPI | - | NPPES |
| 200191560B | Medicaid | IN | |
| 200191560A | Medicaid | IN |
| Taxonomy | Type | License (State) | Status |
|---|---|---|---|
| 207Q00000X | Family Medicine | 01022886A (Indiana) | Primary |
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