Provider First Line Business Practice Location Address:
3900 WOODLAND AVE MSO (11-D) RM B624 ATTN: P. LOCKMAN
Provider Second Line Business Practice Location Address:
DEPT OF VA AFFAIRS MEDICAL CENTER
Provider Business Practice Location Address City Name:
PHILADELPHIA
Provider Business Practice Location Address State Name:
PA
Provider Business Practice Location Address Postal Code:
19104-9019
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
215-823-5233
Provider Business Practice Location Address Fax Number:
215-823-4379
Provider Enumeration Date:
04/20/2010