Healthcare Provider Details

I. General information

NPI: 1669922324
Provider Name (Legal Business Name): CONNECTICUT GENERAL LIFE INSURANCE COMPANY
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/06/2016
Last Update Date: 12/06/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

25500 N NORTERRA DR
PHOENIX AZ
85085-8200
US

IV. Provider business mailing address

25500 N NORTERRA DR
PHOENIX AZ
85085-8200
US

V. Phone/Fax

Practice location:
  • Phone: 877-733-1710
  • Fax: 623-277-1091
Mailing address:
  • Phone: 877-733-1710
  • Fax: 623-277-1091

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261Q00000X
TaxonomyClinic/Center
License Number
License Number State

VIII. Authorized Official

Name: DIRK WALES
Title or Position: CEO
Credential: MD
Phone: 623-277-1170