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

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

# 1
Identifier076550
Identifier TypeOTHER
Identifier StatePA
Identifier IssuerBLUE CARE HMO (FPH)
# 2
Identifier250002212
Identifier TypeOTHER
Identifier StatePA
Identifier IssuerRAILROAD MEDICARE
# 3
Identifier70303-1067
Identifier TypeOTHER
Identifier StatePA
Identifier IssuerGEISINGER
# 4
Identifier20038434
Identifier TypeOTHER
Identifier StatePA
Identifier IssuerAMERIHEALTH
# 5
Identifier251645055
Identifier TypeOTHER
Identifier StatePA
Identifier IssuerUNITEDHEALTH CARE
# 6
Identifier536118
Identifier TypeOTHER
Identifier StatePA
Identifier IssuerAETNA
# 7
Identifier001216964-0002
Identifier TypeMEDICAID
Identifier StatePA
Identifier Issuer
# 8
Identifier476988
Identifier TypeOTHER
Identifier StatePA
Identifier IssuerBLUE CARE

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: