Provider Demographics
NPI:1528051091
Name:GENTILEZZA, KENNETH W (MD)
Entity type:Individual
Prefix:
First Name:KENNETH
Middle Name:W
Last Name:GENTILEZZA
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 1:5 MORGAN HWY
Mailing Address - Street 2:SUITE 4
Mailing Address - City:SCRANTON
Mailing Address - State:PA
Mailing Address - Zip Code:18508-2641
Mailing Address - Country:US
Mailing Address - Phone:570-344-3788
Mailing Address - Fax:570-969-9280
Practice Address - Street 1:5 MORGAN HWY
Practice Address - Street 2:SUITE 4
Practice Address - City:SCRANTON
Practice Address - State:PA
Practice Address - Zip Code:18508-2641
Practice Address - Country:US
Practice Address - Phone:570-344-3788
Practice Address - Fax:570-969-9280
Is Sole Proprietor?:No
Enumeration Date:2005-08-30
Last Update Date:2015-02-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD040119L2081P2900X, 208100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & Rehabilitation
No2081P2900XAllopathic & Osteopathic PhysiciansPhysical Medicine & RehabilitationPain Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA076550OtherBLUE CARE HMO (FPH)
PA250002212OtherRAILROAD MEDICARE
PA70303-1067OtherGEISINGER
PA20038434OtherAMERIHEALTH
PA251645055OtherUNITEDHEALTH CARE
PA536118OtherAETNA
PA001216964-0002Medicaid
PA476988OtherBLUE CARE
PA076550OtherBLUE CARE HMO (FPH)
PA536118OtherAETNA