Provider Demographics
NPI:1689627812
Name:BEACON MEDICAL GROUP
Entity Type:Organization
Organization Name:BEACON MEDICAL GROUP
Other - Org Name:MEMORIAL CHILDREN'S HOSPITAL NAVARRE PEDIATRICS
Other - Org Type:Doing Business As
Authorized Official - Title/Position:VP-CFO
Authorized Official - Prefix:
Authorized Official - First Name:JEFFREY
Authorized Official - Middle Name:
Authorized Official - Last Name:COSTELLO
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:574-647-3549
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:
Practice Address - Street 1:100 NAVARRE PL
Practice Address - Street 2:SUITE 4400
Practice Address - City:SOUTH BEND
Practice Address - State:IN
Practice Address - Zip Code:46601-1156
Practice Address - Country:US
Practice Address - Phone:574-647-4535
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-18
Last Update Date:2016-03-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01024987A208800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208800000XAllopathic & Osteopathic PhysiciansUrologyGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN15D1038973OtherCLIA NUMBER
IN225380Medicare PIN