Provider Demographics
NPI:1639337405
Name:CHARLES J SUPERNAVAGE, MD, PC
Entity Type:Organization
Organization Name:CHARLES J SUPERNAVAGE, MD, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:MS
Authorized Official - First Name:APRIL
Authorized Official - Middle Name:C
Authorized Official - Last Name:EVANS
Authorized Official - Suffix:
Authorized Official - Credentials:CMM
Authorized Official - Phone:301-739-0400
Mailing Address - Street 1:201 S CLEVELAND AVE
Mailing Address - Street 2:SUITE 403
Mailing Address - City:HAGERSTOWN
Mailing Address - State:MD
Mailing Address - Zip Code:21740-5745
Mailing Address - Country:US
Mailing Address - Phone:301-739-0400
Mailing Address - Fax:301-739-0402
Practice Address - Street 1:201 S CLEVELAND AVE
Practice Address - Street 2:SUITE 403
Practice Address - City:HAGERSTOWN
Practice Address - State:MD
Practice Address - Zip Code:21740-5745
Practice Address - Country:US
Practice Address - Phone:301-739-0400
Practice Address - Fax:301-739-0402
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-05-29
Last Update Date:2008-05-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDD0026440207Y00000X
MD00963231H00000X, 237600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Y00000XAllopathic & Osteopathic PhysiciansOtolaryngologyGroup - Single Specialty
No231H00000XSpeech, Language and Hearing Service ProvidersAudiologistGroup - Single Specialty
No237600000XSpeech, Language and Hearing Service ProvidersAudiologist-Hearing Aid FitterGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD314681200Medicaid
MD8290Medicare PIN
MD314681200Medicaid