Provider Demographics
NPI:1699794057
Name:BEACON MEDICAL GROUP, INC.
Entity type:Organization
Organization Name:BEACON MEDICAL GROUP, INC.
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CFO
Authorized Official - Prefix:MR
Authorized Official - First Name:JEFFREY
Authorized Official - Middle Name:P
Authorized Official - Last Name:COSTELLO
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:574-647-3549
Mailing Address - Street 1:3245 HEALTH DR STE 100
Mailing Address - Street 2:
Mailing Address - City:GRANGER
Mailing Address - State:IN
Mailing Address - Zip Code:46530-1380
Mailing Address - Country:US
Mailing Address - Phone:574-647-1610
Mailing Address - Fax:574-237-6069
Practice Address - Street 1:500 ARCADE AVE STE 300
Practice Address - Street 2:
Practice Address - City:ELKHART
Practice Address - State:IN
Practice Address - Zip Code:46514-2486
Practice Address - Country:US
Practice Address - Phone:574-389-7362
Practice Address - Fax:574-389-5612
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-18
Last Update Date:2024-12-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN06-005017-1207RG0100X
2085R0204X, 208800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterologyGroup - Multi-Specialty
No2085R0204XAllopathic & Osteopathic PhysiciansRadiologyVascular & Interventional RadiologyGroup - Multi-Specialty
No208800000XAllopathic & Osteopathic PhysiciansUrologyGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN300054801Medicaid
IN300042826Medicaid
IN300098369Medicaid
IN300098524Medicaid
INCD5238Medicare PIN
IN181970Medicare PIN
IN236040Medicare PIN