Provider First Line Business Practice Location Address:
5601 LOCH RAVEN BLVD
Provider Second Line Business Practice Location Address:
SURGICAL PA SERVICE
Provider Business Practice Location Address City Name:
BALTIMORE
Provider Business Practice Location Address State Name:
MD
Provider Business Practice Location Address Postal Code:
21239-2905
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
410-464-5621
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
12/06/2006