Provider First Line Business Practice Location Address:
4004 ERDMAN AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
BALTIMORE
Provider Business Practice Location Address State Name:
MD
Provider Business Practice Location Address Postal Code:
21213-2042
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
410-498-4643
Provider Business Practice Location Address Fax Number:
410-498-4612
Provider Enumeration Date:
10/31/2026