Provider First Line Business Practice Location Address: 
12 NEWPORT DR
    Provider Second Line Business Practice Location Address: 
SUITE C
    Provider Business Practice Location Address City Name: 
FOREST HILL
    Provider Business Practice Location Address State Name: 
MD
    Provider Business Practice Location Address Postal Code: 
21050-1758
    Provider Business Practice Location Address Country Code: 
US
    Provider Business Practice Location Address Telephone Number: 
410-838-2200
    Provider Business Practice Location Address Fax Number: 
410-838-3300
    Provider Enumeration Date: 
06/06/2011