Basic Information
| Provider Information | |||||||||
| NPI: | 1437803285 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | BEACON MEDICAL GROUP INC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 710 N NILES AVE | ||||||||
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| City: | SOUTH BEND | ||||||||
| State: | IN | ||||||||
| PostalCode: | 466171924 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5746471610 | ||||||||
| FaxNumber: | 5742376069 | ||||||||
| Practice Location | |||||||||
| Address1: | 600 EAST BLVD | ||||||||
| Address2: | |||||||||
| City: | ELKHART | ||||||||
| State: | IN | ||||||||
| PostalCode: | 465142483 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5745248130 | ||||||||
| FaxNumber: | 5745248138 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/10/2022 | ||||||||
| LastUpdateDate: | 02/10/2022 | ||||||||
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| AuthorizedOfficialLastName: | MAFFETONE | ||||||||
| AuthorizedOfficialFirstName: | IRENE | ||||||||
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| AuthorizedOfficialTitleorPosition: | CONTRACTING SPECIALIST | ||||||||
| AuthorizedOfficialTelephone: | 5746471040 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| NPICertificationDate: | 02/10/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207L00000X | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Anesthesiology |
No ID Information.