Provider Demographics
NPI: | 1821222829 |
---|---|
Name: | BEACON MEDICAL GROUP, INC. |
Entity Type: | Organization |
Organization Name: | BEACON MEDICAL GROUP, INC. |
Other - Org Name: | BEACON MEDICAL GROUP HOSPITAL SPECIALTIES |
Other - Org Type: | Doing Business As |
Authorized Official - Title/Position: | VP/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: | 574-647-1069 |
Mailing Address - Fax: | |
Practice Address - Street 1: | 500 ARCADE AVE STE 320 |
Practice Address - Street 2: | |
Practice Address - City: | ELKHART |
Practice Address - State: | IN |
Practice Address - Zip Code: | 46514-2477 |
Practice Address - Country: | US |
Practice Address - Phone: | 574-523-7900 |
Practice Address - Fax: | |
EIN: | <UNAVAIL> |
Is Organization Subpart?: | No |
Parent Organization LBN: | |
Parent Organization TIN: | |
Enumeration Date: | 2009-05-06 |
Last Update Date: | 2024-03-04 |
Deactivation Date: | |
Deactivation Code: | |
Reactivation Date: |
Provider Licenses
State | License ID | Taxonomies |
---|---|---|
207Q00000X, 207RC0000X, 207RC0200X, 207RI0200X, 207RP1001X, 207YX0905X, 208100000X, 208200000X, 2085R0204X, 208600000X, 2086S0129X | ||
IN | 01049858A | 207V00000X, 207VF0040X, 207X00000X, 208M00000X |
Provider Taxonomies
Primary? | Code | Type | Classification | Specialization | Group |
---|---|---|---|---|---|
Yes | 208M00000X | Allopathic & Osteopathic Physicians | Hospitalist | Group - Multi-Specialty | |
No | 207Q00000X | Allopathic & Osteopathic Physicians | Family Medicine | Group - Multi-Specialty | |
No | 207RC0000X | Allopathic & Osteopathic Physicians | Internal Medicine | Cardiovascular Disease | Group - Multi-Specialty |
No | 207RC0200X | Allopathic & Osteopathic Physicians | Internal Medicine | Critical Care Medicine | Group - Multi-Specialty |
No | 207RI0200X | Allopathic & Osteopathic Physicians | Internal Medicine | Infectious Disease | Group - Multi-Specialty |
No | 207RP1001X | Allopathic & Osteopathic Physicians | Internal Medicine | Pulmonary Disease | Group - Multi-Specialty |
No | 207V00000X | Allopathic & Osteopathic Physicians | Obstetrics & Gynecology | Group - Multi-Specialty | |
No | 207VF0040X | Allopathic & Osteopathic Physicians | Obstetrics & Gynecology | Female Pelvic Medicine and Reconstructive Surgery | Group - Multi-Specialty |
No | 207X00000X | Allopathic & Osteopathic Physicians | Orthopaedic Surgery | Group - Multi-Specialty | |
No | 207YX0905X | Allopathic & Osteopathic Physicians | Otolaryngology | Otolaryngology/Facial Plastic Surgery | Group - Multi-Specialty |
No | 208100000X | Allopathic & Osteopathic Physicians | Physical Medicine & Rehabilitation | Group - Multi-Specialty | |
No | 208200000X | Allopathic & Osteopathic Physicians | Plastic Surgery | Group - Multi-Specialty | |
No | 2085R0204X | Allopathic & Osteopathic Physicians | Radiology | Vascular & Interventional Radiology | Group - Multi-Specialty |
No | 208600000X | Allopathic & Osteopathic Physicians | Surgery | Group - Multi-Specialty | |
No | 2086S0129X | Allopathic & Osteopathic Physicians | Surgery | Vascular Surgery | Group - Multi-Specialty |
Provider Identifiers
State | Identifier ID | ID Type | Issuer |
---|---|---|---|
IN | 300070471 | Medicaid | |
IN | 300013260 | Medicaid | |
IN | 300068474 | Medicaid | |
IN | 300013675 | Medicaid | |
IN | 300068062 | Medicaid | |
IN | 300012878 | Medicaid | |
IN | 300013073 | Medicaid |