Basic Information
| Provider Information | |||||||||
| NPI: | 1760467377 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | SUPRENANT | ||||||||
| FirstName: | BRAD | ||||||||
| MiddleName: | L | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | DO | ||||||||
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| Mailing Information | |||||||||
| Address1: | 500 N WALL ST | ||||||||
| Address2: | |||||||||
| City: | KANKAKEE | ||||||||
| State: | IL | ||||||||
| PostalCode: | 609012942 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8444044787 | ||||||||
| FaxNumber: | 8159363243 | ||||||||
| Practice Location | |||||||||
| Address1: | 500 N WALL ST | ||||||||
| Address2: | |||||||||
| City: | KANKAKEE | ||||||||
| State: | IL | ||||||||
| PostalCode: | 609012942 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8444044787 | ||||||||
| FaxNumber: | 8159363243 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/07/2005 | ||||||||
| LastUpdateDate: | 03/29/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
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| NPICertificationDate: | 03/29/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207RC0001X | 02001098A | IN | N | Allopathic & Osteopathic Physicians | Internal Medicine | Clinical Cardiac Electrophysiology | 207RC0001X | 036071427 | IL | Y | Allopathic & Osteopathic Physicians | Internal Medicine | Clinical Cardiac Electrophysiology |
ID Information
| ID | Type | State | Issuer | Description | 036071247 | 05 | IL | MEDICAID | 060030169 | 01 | RR MEDICARE | OTHER | 000000095316 | 01 | IN | ANTHEM PIN | OTHER |