Basic Information
| Provider Information | |||||||||
| NPI: | 1184641706 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | BEACON MEDICAL GROUP, INC. | ||||||||
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| OtherOrganizationName: | BEACON MEDICAL GROUP WAKARUSA | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 710 N NILES AVE | ||||||||
| Address2: | |||||||||
| City: | SOUTH BEND | ||||||||
| State: | IN | ||||||||
| PostalCode: | 466171924 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5746471610 | ||||||||
| FaxNumber: | 5742376069 | ||||||||
| Practice Location | |||||||||
| Address1: | 207 N ELKHART ST | ||||||||
| Address2: | |||||||||
| City: | WAKARUSA | ||||||||
| State: | IN | ||||||||
| PostalCode: | 465739729 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5748622165 | ||||||||
| FaxNumber: | 5748624112 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/17/2006 | ||||||||
| LastUpdateDate: | 10/27/2016 | ||||||||
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| AuthorizedOfficialLastName: | COSTELLO | ||||||||
| AuthorizedOfficialFirstName: | JEFFREY | ||||||||
| AuthorizedOfficialMiddleName: | P | ||||||||
| AuthorizedOfficialTitleorPosition: | CFO | ||||||||
| AuthorizedOfficialTelephone: | 5746473549 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | 06-005017-1 | IN | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | ANTHEM BCBS | 01 | IN | 000000110760 | OTHER | 200019030A | 05 | IN | MEDICAID |