Provider Demographics
NPI:1841209020
Name:MEDICINE BEYOND WALLS
Entity Type:Organization
Organization Name:MEDICINE BEYOND WALLS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:ANTONOWSKY
Authorized Official - Middle Name:DEMEL
Authorized Official - Last Name:COLEMAN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:205-296-6464
Mailing Address - Street 1:6291 LETSON FARMS DR
Mailing Address - Street 2:
Mailing Address - City:BESSEMER
Mailing Address - State:AL
Mailing Address - Zip Code:35022-7025
Mailing Address - Country:US
Mailing Address - Phone:205-296-6464
Mailing Address - Fax:205-477-1515
Practice Address - Street 1:6291 LETSON FARMS DR
Practice Address - Street 2:
Practice Address - City:BESSEMER
Practice Address - State:AL
Practice Address - Zip Code:35022-7025
Practice Address - Country:US
Practice Address - Phone:205-296-6464
Practice Address - Fax:205-477-1515
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-05
Last Update Date:2007-09-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL24899173000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes173000000XOther Service ProvidersLegal MedicineGroup - Single Specialty