Provider First Line Business Practice Location Address: 
3007 BELAIR 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: 
21213-1225
    Provider Business Practice Location Address Country Code: 
US
    Provider Business Practice Location Address Telephone Number: 
410-327-2516
    Provider Business Practice Location Address Fax Number: 
410-558-0434
    Provider Enumeration Date: 
02/20/2007