MEDICARE: AXIS FORENSIC TOXICOLOGY, INC.

Medicare Provider Information

Scope of Practice

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

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	291U00000X	Clinical Medical Laboratory	9472384	IN

General Provider Information

NPI Number	:	1457804197
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	AXIS FORENSIC TOXICOLOGY, INC.

Provider Business Mailing Address
First Line	:	PO BOX 681513
Second Line	:
City	:	INDIANAPOLIS
State	:	IN
Zip	:	46268-7513
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	2265 EXECUTIVE DR
Second Line	:
City	:	INDIANAPOLIS
State	:	IN
Zip	:	46241-4352
Country	:	US
Telephone Number	:	317-759-4869
Fax Number	:

Authorized Official
Title or Position	:	VP, COO
Name	:	DENISE PURDIE ANDREWS
Credential	:
Telephone Number	:	317-759-4869

Provider Enumeration Date	:	07/29/2016
Last Update Date	:	07/29/2016

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