MEDICARE: AXON COLUMBUS, LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy
1	364SP0808X	Psychiatric/Mental Health Clinical Nurse Specialist
2	1041C0700X	Clinical Social Worker
3	2084P0800X	Psychiatry Physician

General Provider Information

NPI Number	:	1073398186
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	AXON COLUMBUS, LLC

Provider Business Mailing Address
First Line	:	9245 N MERIDIAN ST STE 300
Second Line	:
City	:	INDIANAPOLIS
State	:	IN
Zip	:	46260-1832
Country	:	US
Telephone Number	:	317-818-9000
Fax Number	:	317-818-9009

Provider Business Practice Location Address
First Line	:	2675 FOX POINTE DR STE B
Second Line	:
City	:	COLUMBUS
State	:	IN
Zip	:	47203-3391
Country	:	US
Telephone Number	:	812-665-0181
Fax Number	:	812-605-0183

Authorized Official
Title or Position	:	MEMBER
Name	:	JERAD DALTON
Credential	:	DO
Telephone Number	:	317-402-8992

Provider Enumeration Date	:	08/28/2023
Last Update Date	:	08/28/2023

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Directions to “AXON COLUMBUS, LLC ” Practice Location

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