MEDICARE: JIE KONG CRNP MSN

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	363LF0000X	Family Nurse Practitioner	R143501	MD

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	5707	OTHER	MD	ELDERHEALTH
2	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
3	783571	OTHER	MD	NATIONAL CAPITAL PPO
4	90192801	OTHER	MD	BLUE CROSS OF MARYLAND
5	293176	OTHER	MD	KAISER
6	1013404	OTHER	MD	COVENTRY
7	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
8	N1510003	OTHER	MD	BLUE CROSS FEDERAL
9	1013404	OTHER	VA	FIRST HEALTH
10	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1215040951
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JIE KONG CRNP MSN

Provider Business Mailing Address
First Line	:	10802 HICKORY RIDGE RD
Second Line	:
City	:	COLUMBIA
State	:	MD
Zip	:	21044-3622
Country	:	US
Telephone Number	:	410-997-1336
Fax Number	:	410-997-1636

Provider Business Practice Location Address
First Line	:	10802 HICKORY RIDGE RD
Second Line	:
City	:	COLUMBIA
State	:	MD
Zip	:	21044-3622
Country	:	US
Telephone Number	:	410-997-1336
Fax Number	:	410-997-1636

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	08/16/2006
Last Update Date	:	01/26/2017

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