Healthcare Provider Details

I. General information

NPI: 1265492748
Provider Name (Legal Business Name): ROBERTO A PENNE-CASANOVA MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/27/2006
Last Update Date: 07/01/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3991 DUTCHMANS LN MEDICAL PLAZA II STE G03
LOUISVILLE KY
40207-4700
US

IV. Provider business mailing address

PO BOX 847
PROSPECT KY
40059
US

V. Phone/Fax

Practice location:
  • Phone: 502-899-6100
  • Fax: 502-899-6108
Mailing address:
  • Phone: 502-386-9415
  • Fax: 502-899-6108

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2083X0100X
TaxonomyOccupational Medicine Physician
License Number37074
License Number StateKY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: