Individual
DR. BRAD L SUPRENANT
Active
Sole proprietor
No
Provider details
NPI number
Gender
Man
Credential
DO
Contact information
Practice address
500 N WALL ST, KANKAKEE, IL 60901-2942
(844) 404-4787
(815) 936-3243
Mailing address
500 N WALL ST, KANKAKEE, IL 60901-2942
(844) 404-4787
(815) 936-3243
Taxonomy
Speciality
Code
Description
License number
State
207RC0001X
Clinical Cardiac Electrophysiology Physician
02001098A
IN
207RC0001X
Clinical Cardiac Electrophysiology Physician
Primary
036071427
IL
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
000000095316
ANTHEM PIN
IN
05
—
036071247
—
IL
01
—
060030169
RR MEDICARE
—
Enumeration date
12/07/2005
Last updated
03/29/2021
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