Provider Demographics
NPI:1497046452
Name:TEWELL, CHAD EDWARD
Entity Type:Individual
Prefix:
First Name:CHAD
Middle Name:EDWARD
Last Name:TEWELL
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11455 N MERIDIAN ST
Mailing Address - Street 2:SUITE 200
Mailing Address - City:CARMEL
Mailing Address - State:IN
Mailing Address - Zip Code:46032-1624
Mailing Address - Country:US
Mailing Address - Phone:317-582-8180
Mailing Address - Fax:
Practice Address - Street 1:11455 N MERIDIAN ST
Practice Address - Street 2:SUITE 200
Practice Address - City:CARMEL
Practice Address - State:IN
Practice Address - Zip Code:46032-1624
Practice Address - Country:US
Practice Address - Phone:317-582-8180
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-04-26
Last Update Date:2016-07-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01076697A207RI0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RI0200XAllopathic & Osteopathic PhysiciansInternal MedicineInfectious Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN000001016480OtherBLUE CROSS BLUE SHIELD
IN201362110Medicaid
IN201362110Medicaid