Provider Demographics
NPI:1184621138
Name:SUPERCZYNSKI, CHRISTOPHER J (MD)
Entity type:Individual
Prefix:DR
First Name:CHRISTOPHER
Middle Name:J
Last Name:SUPERCZYNSKI
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:652 GEORGE WASHINGTON HWY UNIT 201
Mailing Address - Street 2:
Mailing Address - City:LINCOLN
Mailing Address - State:RI
Mailing Address - Zip Code:02865-4267
Mailing Address - Country:US
Mailing Address - Phone:401-353-5224
Mailing Address - Fax:401-353-5162
Practice Address - Street 1:652 GEORGE WASHINGTON HWY UNIT 201
Practice Address - Street 2:
Practice Address - City:LINCOLN
Practice Address - State:RI
Practice Address - Zip Code:02865-4267
Practice Address - Country:US
Practice Address - Phone:401-353-5224
Practice Address - Fax:401-353-5162
Is Sole Proprietor?:Yes
Enumeration Date:2005-07-06
Last Update Date:2021-06-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
RIMD1032207R00000X
RIMD10232207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
RI7008326Medicaid
RI007059416Medicare PIN
RIH17338Medicare UPIN