Healthcare Provider Details

I. General information

NPI: 1255380903
Provider Name (Legal Business Name): JON BLAKE CHADWELL M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/09/2006
Last Update Date: 03/07/2023
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6301 UNIVERSITY COMMONS SUITE 360
SOUTH BEND IN
46635-1571
US

IV. Provider business mailing address

6301 UNIVERSITY COMMONS SUITE 360
SOUTH BEND IN
46635-1571
US

V. Phone/Fax

Practice location:
  • Phone: 574-232-4800
  • Fax: 574-280-4810
Mailing address:
  • Phone: 574-232-4800
  • Fax: 574-280-4810

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207YX0905X
TaxonomyOtolaryngology/Facial Plastic Surgery Physician
License Number01061815A
License Number StateIN
# 2
Primary TaxonomyN
Taxonomy Code207YX0905X
TaxonomyOtolaryngology/Facial Plastic Surgery Physician
License Number43615
License Number StateCO
# 3
Primary TaxonomyN
Taxonomy Code207YX0905X
TaxonomyOtolaryngology/Facial Plastic Surgery Physician
License Number35 085143
License Number StateOH
# 4
Primary TaxonomyN
Taxonomy Code207YX0905X
TaxonomyOtolaryngology/Facial Plastic Surgery Physician
License Number39547
License Number StateKY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: