1205852365 NPI number — BEACON MEDICAL GROUP, INC.

Table of content: (NPI 1205852365)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1205852365 NPI number — BEACON MEDICAL GROUP, INC.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
BEACON MEDICAL GROUP, INC.
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
BEACON MEDICAL GROUP EDWARDSBURG
Provider Other Organization Name Type Code:
3
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1205852365
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
05/03/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
710 N NILES AVE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
SOUTH BEND
Provider Business Mailing Address State Name:
IN
Provider Business Mailing Address Postal Code:
46617-1924
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
574-647-1610
Provider Business Mailing Address Fax Number:
574-237-6069

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
27082 W MAIN STREET
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
EDWARDSBURG
Provider Business Practice Location Address State Name:
MI
Provider Business Practice Location Address Postal Code:
49112-9334
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
269-663-8288
Provider Business Practice Location Address Fax Number:
269-663-2426
Provider Enumeration Date:
07/14/2006

Additional Information

Authorized Official

Authorized Official Last Name:
COSTELLO
Authorized Official First Name:
JEFF
Authorized Official Middle Name:
P
Authorized Official Title or Position:
CFO
Authorized Official Telephone Number:
574-647-3549

Provider Taxonomy Codes

  • Taxonomy code: 207Q00000X , with the licence number:  06-005017-1 , registered in the state of IN ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 080A410090 , issued by the state of ( MI ) . This identifiers is of the category "MEDICAID".
  • Identifier: 100220310A , issued by the state of ( IN ) . This identifiers is of the category "MEDICAID".




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