Provider Demographics
NPI:1720080963
Name:SUPERNAVAGE, CHARLES J (MD)
Entity Type:Individual
Prefix:DR
First Name:CHARLES
Middle Name:J
Last Name:SUPERNAVAGE
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 1:1800 DUAL HIGHWAY
Mailing Address - Street 2:SUITE 303
Mailing Address - City:HAGERSTOWN
Mailing Address - State:MD
Mailing Address - Zip Code:21740-6602
Mailing Address - Country:US
Mailing Address - Phone:301-739-0400
Mailing Address - Fax:301-739-0402
Practice Address - Street 1:1800 DUAL HWY 303
Practice Address - Street 2:
Practice Address - City:HAGERSTOWN
Practice Address - State:MD
Practice Address - Zip Code:21740-6648
Practice Address - Country:US
Practice Address - Phone:301-739-0400
Practice Address - Fax:301-739-0402
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-06-01
Last Update Date:2015-08-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDD0026440207Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Y00000XAllopathic & Osteopathic PhysiciansOtolaryngology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD36496001OtherCAREFIRST BLUE SHIELD ID
770413OtherAETNA ID #
MD314681200Medicaid
MD214080OtherMAMSI ID #
MD314681200Medicaid
MD214080OtherMAMSI ID #