Provider Demographics
NPI:1366461410
Name:SUPAN, TERRY J (CPO)
Entity Type:Individual
Prefix:MR
First Name:TERRY
Middle Name:J
Last Name:SUPAN
Suffix:
Gender:M
Credentials:CPO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:355 W CARPENTER STREET
Mailing Address - Street 2:SUITE B
Mailing Address - City:SPRINGFIELD
Mailing Address - State:IL
Mailing Address - Zip Code:62702-4945
Mailing Address - Country:US
Mailing Address - Phone:217-789-1450
Mailing Address - Fax:217-789-1454
Practice Address - Street 1:355 W CARPENTER STREET
Practice Address - Street 2:SUITE B
Practice Address - City:SPRINGFIELD
Practice Address - State:IL
Practice Address - Zip Code:62702-4945
Practice Address - Country:US
Practice Address - Phone:217-789-1450
Practice Address - Fax:217-789-1454
Is Sole Proprietor?:No
Enumeration Date:2006-07-19
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL222Z00000X, 224P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered222Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOrthotist
Not Answered224P00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersProsthetist