Provider First Line Business Practice Location Address:
MEDICAL ARTS BUILDING, 3801 MARKET STREET
Provider Second Line Business Practice Location Address:
SUITE 111
Provider Business Practice Location Address City Name:
PHILADELPHIA
Provider Business Practice Location Address State Name:
PA
Provider Business Practice Location Address Postal Code:
19104-3153
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
215-662-9563
Provider Business Practice Location Address Fax Number:
215-243-4604
Provider Enumeration Date:
12/01/2011