Provider First Line Business Practice Location Address:
400 E PRATT STREET FL 8
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
BALTIMORE
Provider Business Practice Location Address State Name:
MD
Provider Business Practice Location Address Postal Code:
21202-3180
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
301-673-3575
Provider Business Practice Location Address Fax Number:
866-510-5010
Provider Enumeration Date:
11/24/2025