Healthcare Provider Details

I. General information

NPI: 1497904148
Provider Name (Legal Business Name): CONNECTICUT GENERAL LIFE INSURANCE COMPANY (CGLIC)
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/17/2008
Last Update Date: 08/14/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

53 GLENMAURA NATIONAL BLVD
SCRANTON PA
18507-2132
US

IV. Provider business mailing address

11001 N BLACK CANYON HWY
PHOENIX AZ
85029-4757
US

V. Phone/Fax

Practice location:
  • Phone: 570-496-5101
  • 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 StatePA

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

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