Provider First Line Business Practice Location Address: 
200 NORTHERN AVE
    Provider Second Line Business Practice Location Address: 
    Provider Business Practice Location Address City Name: 
HAGERSTOWN
    Provider Business Practice Location Address State Name: 
MD
    Provider Business Practice Location Address Postal Code: 
21742-2920
    Provider Business Practice Location Address Country Code: 
US
    Provider Business Practice Location Address Telephone Number: 
301-733-4445
    Provider Business Practice Location Address Fax Number: 
301-733-3383
    Provider Enumeration Date: 
12/31/2007