Provider First Line Business Practice Location Address:
1601 WALNUT ST
Provider Second Line Business Practice Location Address:
SUITE 1111 MEDICAL ARTS BUILDING
Provider Business Practice Location Address City Name:
PHILADELPHIA
Provider Business Practice Location Address State Name:
PA
Provider Business Practice Location Address Postal Code:
19102
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
215-564-3830
Provider Business Practice Location Address Fax Number:
215-564-1774
Provider Enumeration Date:
10/31/2006