Provider First Line Business Practice Location Address: 
6071 OUTER DR W
    Provider Second Line Business Practice Location Address: 
SINAI-GRACE HOSPITAL/DMC
    Provider Business Practice Location Address City Name: 
DETROIT
    Provider Business Practice Location Address State Name: 
MI
    Provider Business Practice Location Address Postal Code: 
48235
    Provider Business Practice Location Address Country Code: 
US
    Provider Business Practice Location Address Telephone Number: 
484-350-2457
    Provider Business Practice Location Address Fax Number: 
    Provider Enumeration Date: 
04/25/2019