Provider Demographics
NPI:1760467377
Name:SUPRENANT, BRAD L (DO)
Entity Type:Individual
Prefix:DR
First Name:BRAD
Middle Name:L
Last Name:SUPRENANT
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:500 N WALL ST
Mailing Address - Street 2:
Mailing Address - City:KANKAKEE
Mailing Address - State:IL
Mailing Address - Zip Code:60901-2942
Mailing Address - Country:US
Mailing Address - Phone:844-404-4787
Mailing Address - Fax:815-936-3243
Practice Address - Street 1:500 N WALL ST
Practice Address - Street 2:
Practice Address - City:KANKAKEE
Practice Address - State:IL
Practice Address - Zip Code:60901-2942
Practice Address - Country:US
Practice Address - Phone:844-404-4787
Practice Address - Fax:815-936-3243
Is Sole Proprietor?:No
Enumeration Date:2005-12-07
Last Update Date:2021-03-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN02001098A207RC0001X
IL036071427207RC0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0001XAllopathic & Osteopathic PhysiciansInternal MedicineClinical Cardiac Electrophysiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036071247Medicaid
060030169OtherRR MEDICARE
IN000000095316OtherANTHEM PIN
IN406310AMedicare PIN
IN406090DMedicare PIN
ILL96244Medicare PIN
060030169OtherRR MEDICARE