Provider Demographics
NPI:1518039833
Name:FLOURTOWN PAIN EVALUATION AND TREATMENT CENTER
Entity Type:Organization
Organization Name:FLOURTOWN PAIN EVALUATION AND TREATMENT CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEDICAL DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:KENNETH
Authorized Official - Middle Name:L
Authorized Official - Last Name:IZZO
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:215-233-1223
Mailing Address - Street 1:1811 BETHLEHEM PIKE
Mailing Address - Street 2:SUITE 221
Mailing Address - City:FLOURTOWN
Mailing Address - State:PA
Mailing Address - Zip Code:19031
Mailing Address - Country:US
Mailing Address - Phone:215-233-1223
Mailing Address - Fax:215-233-1141
Practice Address - Street 1:1811 BETHLEHEM PIKE
Practice Address - Street 2:SUITE 221
Practice Address - City:FLOURTOWN
Practice Address - State:PA
Practice Address - Zip Code:19031
Practice Address - Country:US
Practice Address - Phone:215-233-1223
Practice Address - Fax:215-233-1141
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-14
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD0171012081P2900X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2081P2900XAllopathic & Osteopathic PhysiciansPhysical Medicine & RehabilitationPain MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA12112248OtherVA MEDICARE
PA3503051OtherAETNA HEALTHCARE
0060080000OtherBCBS KEYSTONE EAST
PA01927385Medicaid
0060080000OtherBCBS KEYSTONE EAST
PA112248Medicare ID - Type Unspecified