Provider First Line Business Practice Location Address:
3801 MARKET ST
Provider Second Line Business Practice Location Address:
MEDICAL ARTS BUILDING, SUITE 111
Provider Business Practice Location Address City Name:
PHILADELPHIA
Provider Business Practice Location Address State Name:
PA
Provider Business Practice Location Address Postal Code:
19104-3153
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
215-662-9563
Provider Business Practice Location Address Fax Number:
215-243-4606
Provider Enumeration Date:
01/15/2009