Provider First Line Business Practice Location Address: 
55 FRUIT ST
    Provider Second Line Business Practice Location Address: 
CLN 309 ANESTHESIA ASSOCIATES
    Provider Business Practice Location Address City Name: 
BOSTON
    Provider Business Practice Location Address State Name: 
MA
    Provider Business Practice Location Address Postal Code: 
02114-2696
    Provider Business Practice Location Address Country Code: 
US
    Provider Business Practice Location Address Telephone Number: 
617-726-3030
    Provider Business Practice Location Address Fax Number: 
617-724-8500
    Provider Enumeration Date: 
11/02/2005