Provider First Line Business Practice Location Address: 
9 GLENRIDGE DR
    Provider Second Line Business Practice Location Address: 
KENNEBEC INTERNAL MEDICINE ASSOC. PA
    Provider Business Practice Location Address City Name: 
AUGUSTA
    Provider Business Practice Location Address State Name: 
ME
    Provider Business Practice Location Address Postal Code: 
04330
    Provider Business Practice Location Address Country Code: 
US
    Provider Business Practice Location Address Telephone Number: 
207-623-8434
    Provider Business Practice Location Address Fax Number: 
207-621-4370
    Provider Enumeration Date: 
11/19/2013