Provider First Line Business Practice Location Address:
255 SOUTH 17TH STREET
Provider Second Line Business Practice Location Address:
SUITE 1605 MEDICAL TOWER BUILDING
Provider Business Practice Location Address City Name:
PHILADELPHIA
Provider Business Practice Location Address State Name:
PA
Provider Business Practice Location Address Postal Code:
19103
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
215-545-5493
Provider Business Practice Location Address Fax Number:
215-545-5494
Provider Enumeration Date:
05/24/2007