Provider First Line Business Practice Location Address: 
1111 PARK AVE STE L104
    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: 
21201-5651
    Provider Business Practice Location Address Country Code: 
US
    Provider Business Practice Location Address Telephone Number: 
410-669-6964
    Provider Business Practice Location Address Fax Number: 
410-486-0891
    Provider Enumeration Date: 
05/23/2008