Provider First Line Business Practice Location Address: 
222 W COLD SPRING LN STE B
    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: 
21210-2800
    Provider Business Practice Location Address Country Code: 
US
    Provider Business Practice Location Address Telephone Number: 
410-929-1596
    Provider Business Practice Location Address Fax Number: 
    Provider Enumeration Date: 
08/10/2011