Provider First Line Business Practice Location Address: 
19401 HUBBARD DR
    Provider Second Line Business Practice Location Address: 
ORTHOPEDICS
    Provider Business Practice Location Address City Name: 
DEARBORN
    Provider Business Practice Location Address State Name: 
MI
    Provider Business Practice Location Address Postal Code: 
48126-2641
    Provider Business Practice Location Address Country Code: 
US
    Provider Business Practice Location Address Telephone Number: 
313-982-8496
    Provider Business Practice Location Address Fax Number: 
313-982-8459
    Provider Enumeration Date: 
10/26/2006