Healthcare Provider Details

I. General information

NPI: 1629164447
Provider Name (Legal Business Name): MICHAEL JOHN SUPERIOR MD, MPH
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/05/2006
Last Update Date: 08/18/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5158 BLACK HAWK RD
ABERDEEN PROVING GROUND MD
21010-5403
US

IV. Provider business mailing address

5158 BLACK HAWK RD
ABERDEEN PROVING GROUND MD
21010-5403
US

V. Phone/Fax

Practice location:
  • Phone: 410-436-5127
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2083P0901X
TaxonomyPublic Health & General Preventive Medicine Physician
License Number62171
License Number StateGA
# 2
Primary TaxonomyN
Taxonomy Code2083P0901X
TaxonomyPublic Health & General Preventive Medicine Physician
License Number25MA09423100
License Number StateNJ
# 3
Primary TaxonomyY
Taxonomy Code2083P0901X
TaxonomyPublic Health & General Preventive Medicine Physician
License NumberC1-0008620
License Number StateDE

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: