Provider Demographics
NPI:1114096922
Name:PENKAVA, ROBERT RAY (MD)
Entity Type:Individual
Prefix:
First Name:ROBERT
Middle Name:RAY
Last Name:PENKAVA
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2754 SOLUTION CTR
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60677-2007
Mailing Address - Country:US
Mailing Address - Phone:606-408-4000
Mailing Address - Fax:
Practice Address - Street 1:2201 LEXINGTON AVE
Practice Address - Street 2:
Practice Address - City:ASHLAND
Practice Address - State:KY
Practice Address - Zip Code:41101-2843
Practice Address - Country:US
Practice Address - Phone:606-408-4000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-11-07
Last Update Date:2015-09-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY161142085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY64349665Medicaid
OH2541762Medicaid
WV3810001263Medicaid
KY64349665Medicaid
KYK026310Medicare PIN