Provider First Line Business Practice Location Address:
5601 LOCH RAVEN BLVD SUITE 200
Provider Second Line Business Practice Location Address:
GOOD SAMARITAN PROFESSIONAL BUILDING
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:
443-444-4288
Provider Business Practice Location Address Fax Number:
443-444-4328
Provider Enumeration Date:
07/12/2006