1265492748 NPI number — DR. ROBERTO A PENNE-CASANOVA MD

Table of content: DR. ROBERTO A PENNE-CASANOVA MD (NPI 1265492748)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1265492748 NPI number — DR. ROBERTO A PENNE-CASANOVA MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
PENNE-CASANOVA
Provider First Name:
ROBERTO
Provider Middle Name:
A
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
MD
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1265492748
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/01/2010
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 847
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
PROSPECT
Provider Business Mailing Address State Name:
KY
Provider Business Mailing Address Postal Code:
40059
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
502-386-9415
Provider Business Mailing Address Fax Number:
502-899-6108

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
3991 DUTCHMANS LN
Provider Second Line Business Practice Location Address:
MEDICAL PLAZA II STE G03
Provider Business Practice Location Address City Name:
LOUISVILLE
Provider Business Practice Location Address State Name:
KY
Provider Business Practice Location Address Postal Code:
40207-4700
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
502-899-6100
Provider Business Practice Location Address Fax Number:
502-899-6108
Provider Enumeration Date:
03/27/2006

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 2083X0100X , with the licence number:  37074 , registered in the state of KY ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: P00022895 . This is a "RAILROAD MEDICARE" identifier , issued by the state of ( KY ) . This identifiers is of the category "OTHER".
  • Identifier: 64048564 , issued by the state of ( KY ) . This identifiers is of the category "MEDICAID".
  • Identifier: 000000235989 . This is a "ANTHEM BLUE CROSS BLUE SHIELD" identifier , issued by the state of ( KY ) . This identifiers is of the category "OTHER".
  • Identifier: 1170390 . This is a "PASSPORT HEALTH PLAN" identifier , issued by the state of ( KY ) . This identifiers is of the category "OTHER".
  • Identifier: 2440625000 . This is a "PASSPORT ADVANTAGE" identifier , issued by the state of ( KY ) . This identifiers is of the category "OTHER".
  • Identifier: 200386450A , issued by the state of ( IN ) . This identifiers is of the category "MEDICAID".




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