Provider First Line Business Practice Location Address: 
3100 BOSTON STREET
    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: 
21298-0001
    Provider Business Practice Location Address Country Code: 
US
    Provider Business Practice Location Address Telephone Number: 
410-995-9055
    Provider Business Practice Location Address Fax Number: 
410-505-0275
    Provider Enumeration Date: 
06/13/2017