Healthcare Provider Details

I. General information

NPI: 1639337405
Provider Name (Legal Business Name): CHARLES J SUPERNAVAGE, MD, PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/29/2008
Last Update Date: 05/29/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

201 S CLEVELAND AVE SUITE 403
HAGERSTOWN MD
21740-5745
US

IV. Provider business mailing address

201 S CLEVELAND AVE SUITE 403
HAGERSTOWN MD
21740-5745
US

V. Phone/Fax

Practice location:
  • Phone: 301-739-0400
  • Fax: 301-739-0402
Mailing address:
  • Phone: 301-739-0400
  • Fax: 301-739-0402

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Y00000X
TaxonomyOtolaryngology Physician
License NumberD0026440
License Number StateMD
# 2
Primary TaxonomyN
Taxonomy Code231H00000X
TaxonomyAudiologist
License Number00963
License Number StateMD
# 3
Primary TaxonomyN
Taxonomy Code237600000X
TaxonomyAudiologist-Hearing Aid Fitter
License Number00963
License Number StateMD

VIII. Authorized Official

Name: MS. APRIL C EVANS
Title or Position: OFFICE MANAGER
Credential: CMM
Phone: 301-739-0400