Provider Demographics
NPI:1275550899
Name:BEACON MEDICAL GROUP, INC.
Entity Type:Organization
Organization Name:BEACON MEDICAL GROUP, INC.
Other - Org Name:BEACON MEDICAL GROUP MISHAWAKA
Other - Org Type:Doing Business As
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:574-647-2129
Mailing Address - Fax:
Practice Address - Street 1:5314 LINCOLNWAY E
Practice Address - Street 2:
Practice Address - City:MISHAWAKA
Practice Address - State:IN
Practice Address - Zip Code:46544-4249
Practice Address - Country:US
Practice Address - Phone:574-584-2812
Practice Address - Fax:574-584-2813
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-17
Last Update Date:2024-03-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
207Q00000X, 363L00000X
IN06-005017-12084P0800X, 2084S0012X, 2081P2900X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2081P2900XAllopathic & Osteopathic PhysiciansPhysical Medicine & RehabilitationPain MedicineGroup - Multi-Specialty
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGroup - Multi-Specialty
No2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatryGroup - Multi-Specialty
No2084S0012XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologySleep MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN100220310AMedicaid
IN000000107132OtherANTHEM BCBS
INCD5238Medicare PIN
IN100220310AMedicaid
IN100220310AMedicaid
INM400029907Medicare PIN