Provider First Line Business Practice Location Address: 
2200 GARRISON BLVD STE 200
    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: 
21216-2649
    Provider Business Practice Location Address Country Code: 
US
    Provider Business Practice Location Address Telephone Number: 
410-878-0357
    Provider Business Practice Location Address Fax Number: 
443-835-1469
    Provider Enumeration Date: 
11/13/2014