Provider First Line Business Practice Location Address: 
MMG - CO-OP CITY
    Provider Second Line Business Practice Location Address: 
2100 BARTOW AVENUE, STE. 311
    Provider Business Practice Location Address City Name: 
BRONX
    Provider Business Practice Location Address State Name: 
NY
    Provider Business Practice Location Address Postal Code: 
10475
    Provider Business Practice Location Address Country Code: 
US
    Provider Business Practice Location Address Telephone Number: 
718-320-5300
    Provider Business Practice Location Address Fax Number: 
    Provider Enumeration Date: 
10/26/2006