Provider First Line Business Practice Location Address:
7979 STATE RD
Provider Second Line Business Practice Location Address:
BLACK DOCTORS CONSORTIUM - CEDAR BLDG
Provider Business Practice Location Address City Name:
PHILADELPHIA
Provider Business Practice Location Address State Name:
PA
Provider Business Practice Location Address Postal Code:
19136-3407
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
267-501-1627
Provider Business Practice Location Address Fax Number:
267-817-3031
Provider Enumeration Date:
08/09/2005