Provider First Line Business Practice Location Address:
5743 EDGEPARK RD
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:
21239-3243
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
443-860-9490
Provider Business Practice Location Address Fax Number:
443-860-9512
Provider Enumeration Date:
02/11/2026