1457378069 NPI number — BEACON MEDICAL GROUP, INC.

Table of content: (NPI 1457378069)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1457378069 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:
Provider Other Organization Name Type Code:
6
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:
1457378069
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
04/26/2023
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:
2102 N MAIN ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
NAPPANEE
Provider Business Practice Location Address State Name:
IN
Provider Business Practice Location Address Postal Code:
46550-9310
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
574-862-2165
Provider Business Practice Location Address Fax Number:
574-862-4112
Provider Enumeration Date:
07/17/2006

Additional Information

Authorized Official

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

Provider Taxonomy Codes

  • Taxonomy code: 207Q00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 300054202 , issued by the state of ( IN ) . This identifiers is of the category "MEDICAID".




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