Basic Information
| Provider Information | |||||||||
| NPI: | 1538265863 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | BEACON MEDICAL GROUP, INC. | ||||||||
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| OtherOrganizationName: | BEACON MEDICAL GROUP BEHAVIORAL HEALTH ELKHART | ||||||||
| OtherOrganizationType: | 5 | ||||||||
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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: | 1506 OSOLO RD | ||||||||
| Address2: | SUITE A | ||||||||
| City: | ELKHART | ||||||||
| State: | IN | ||||||||
| PostalCode: | 465144122 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5745233347 | ||||||||
| FaxNumber: | 5742069502 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/15/2006 | ||||||||
| 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 | 261QM0801X | 06-005017-1 | IN | Y | Ambulatory Health Care Facilities | Clinic/Center | Mental Health (Including Community Mental Health Center) |
ID Information
| ID | Type | State | Issuer | Description | 000000110756 | 01 | IN | ANTHEM BCBS | OTHER | 000000075060 | 01 | IN | ANTHEM BCBS-MSW | OTHER | 100268350A | 05 | IN | MEDICAID |