Provider Demographics
NPI:1790986073
Name:SUPER, ELIZABETH ANNE (MD)
Entity Type:Individual
Prefix:
First Name:ELIZABETH
Middle Name:ANNE
Last Name:SUPER
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3201 GLEN TER
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28211-3494
Mailing Address - Country:US
Mailing Address - Phone:704-430-8590
Mailing Address - Fax:
Practice Address - Street 1:425 S SHARON AMITY RD STE B
Practice Address - Street 2:
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28211-2841
Practice Address - Country:US
Practice Address - Phone:980-260-0900
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-05-31
Last Update Date:2022-09-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC2010-01552208000000X, 208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC325394Medicaid