Provider First Line Business Practice Location Address:
5600 YORK 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:
21212-3601
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
240-423-0835
Provider Business Practice Location Address Fax Number:
888-322-4188
Provider Enumeration Date:
10/09/2025