Provider First Line Business Practice Location Address: 
1250 E MARSHALL STREET
    Provider Second Line Business Practice Location Address: 
EMERGENCY MEDICINE
    Provider Business Practice Location Address City Name: 
RICHMOND
    Provider Business Practice Location Address State Name: 
VA
    Provider Business Practice Location Address Postal Code: 
23298-0510
    Provider Business Practice Location Address Country Code: 
US
    Provider Business Practice Location Address Telephone Number: 
804-828-7738
    Provider Business Practice Location Address Fax Number: 
804-828-4686
    Provider Enumeration Date: 
10/17/2006