Healthcare Provider Details

I. General information

NPI: 1568799278
Provider Name (Legal Business Name): CONNECTICUT GENERAL LIFE INSURANCE COMPANY (CGLIC)
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/17/2009
Last Update Date: 02/24/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

700 WASHINGTON ST
BATH ME
04530-2574
US

IV. Provider business mailing address

11001 N BLACK CANYON HWY
PHOENIX AZ
85029-4757
US

V. Phone/Fax

Practice location:
  • Phone: 207-442-4939
  • Fax:
Mailing address:
  • Phone: 877-733-1710
  • Fax: 602-328-8410

VI. Provider taxonomy

Scope of Practice (Provider specialty)

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

VIII. Authorized Official

Name: MR. MICHAEL SLICE
Title or Position: VICE PRESIDENT
Credential: RPH
Phone: 602-371-2971