=====================================================
General NPI Number Information
=====================================================
NPI Number | 1356488647
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | BENJAMIN KONG MD
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/30/2007
-----------------------------------------------------
Last Update Date | 04/26/2013
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 80 SEYMOUR STREET
-----------------------------------------------------
City | HARTFORD
-----------------------------------------------------
State | CT
-----------------------------------------------------
Zip | 06106-5539
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 860-545-2117
-----------------------------------------------------
Fax | 860-545-1784
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 99 EAST RIVER DR HARTFORD ANESTHESIOLOGY ASSOCIATES
-----------------------------------------------------
City | EAST HARTFORD
-----------------------------------------------------
State | CT
-----------------------------------------------------
Zip | 06108-7301
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 860-282-4133
-----------------------------------------------------
Fax | 860-289-0742
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207LC0200X
-----------------------------------------------------
Taxonomy Name | Critical Care Medicine (Anesthesiology) Physician
-----------------------------------------------------
License Number | T1796
-----------------------------------------------------
License Number State | MD
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 207L00000X
-----------------------------------------------------
Taxonomy Name | Anesthesiology Physician
-----------------------------------------------------
License Number | 048473
-----------------------------------------------------
License Number State | CT
-----------------------------------------------------