Healthcare Provider Details

I. General information

NPI: 1528051091
Provider Name (Legal Business Name): KENNETH W. GENTILEZZA M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/30/2005
Last Update Date: 02/16/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5 MORGAN HWY SUITE 4
SCRANTON PA
18508-2641
US

IV. Provider business mailing address

5 MORGAN HWY SUITE 4
SCRANTON PA
18508-2641
US

V. Phone/Fax

Practice location:
  • Phone: 570-344-3788
  • Fax: 570-969-9280
Mailing address:
  • Phone: 570-344-3788
  • Fax: 570-969-9280

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208100000X
TaxonomyPhysical Medicine & Rehabilitation Physician
License NumberMD040119L
License Number StatePA
# 2
Primary TaxonomyN
Taxonomy Code2081P2900X
TaxonomyPain Medicine (Physical Medicine & Rehabilitation) Physician
License NumberMD040119L
License Number StatePA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: