Basic Information
| Provider Information | |||||||||
| NPI: | 1487038360 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | BEACON MEDICAL GROUP, INC. | ||||||||
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| OtherOrganizationName: | BEACON MEDICAL GROUP VEIN SPECIALISTS | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 710 E NILES AVE | ||||||||
| Address2: | |||||||||
| City: | SOUTH BEND | ||||||||
| State: | IN | ||||||||
| PostalCode: | 466171924 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5746471610 | ||||||||
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| Practice Location | |||||||||
| Address1: | 233 FLORENCE AVE | ||||||||
| Address2: | |||||||||
| City: | GRANGER | ||||||||
| State: | IN | ||||||||
| PostalCode: | 465308048 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5746473990 | ||||||||
| FaxNumber: | 5746473995 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/10/2015 | ||||||||
| LastUpdateDate: | 10/12/2017 | ||||||||
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| AuthorizedOfficialLastName: | COSTELLO | ||||||||
| AuthorizedOfficialFirstName: | JEFFREY | ||||||||
| AuthorizedOfficialMiddleName: | P. | ||||||||
| AuthorizedOfficialTitleorPosition: | CFO | ||||||||
| AuthorizedOfficialTelephone: | 5746473549 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | BEACON HEALTH SYSTEM, INC. | ||||||||
| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2085R0204X | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Radiology | Vascular & Interventional Radiology |
No ID Information.