Provider Demographics
NPI:1437803285
Name:BEACON MEDICAL GROUP INC
Entity Type:Organization
Organization Name:BEACON MEDICAL GROUP INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CONTRACTING SPECIALIST
Authorized Official - Prefix:
Authorized Official - First Name:IRENE
Authorized Official - Middle Name:
Authorized Official - Last Name:MAFFETONE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:574-647-1040
Mailing Address - Street 1:710 N NILES AVE
Mailing Address - Street 2:
Mailing Address - City:SOUTH BEND
Mailing Address - State:IN
Mailing Address - Zip Code:46617-1924
Mailing Address - Country:US
Mailing Address - Phone:574-647-1610
Mailing Address - Fax:574-237-6069
Practice Address - Street 1:600 EAST BLVD
Practice Address - Street 2:
Practice Address - City:ELKHART
Practice Address - State:IN
Practice Address - Zip Code:46514-2483
Practice Address - Country:US
Practice Address - Phone:574-524-8130
Practice Address - Fax:574-524-8138
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-02-10
Last Update Date:2022-02-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiologyGroup - Single Specialty