Provider First Line Business Practice Location Address: 
200 E NORTH AVE STE 312
    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: 
21202-4888
    Provider Business Practice Location Address Country Code: 
US
    Provider Business Practice Location Address Telephone Number: 
667-201-3400
    Provider Business Practice Location Address Fax Number: 
    Provider Enumeration Date: 
07/10/2014