=====================================================
General NPI Number Information
=====================================================
NPI Number | 1073627162
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | CIGNA HEALTHCARE OF ARIZONA, INC.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/18/2006
-----------------------------------------------------
Last Update Date | 01/28/2014
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 4001 E BASELINE RD SUITE 102
-----------------------------------------------------
City | GILBERT
-----------------------------------------------------
State | AZ
-----------------------------------------------------
Zip | 85234-2726
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 480-632-4060
-----------------------------------------------------
Fax | 480-632-4092
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 25500 N NORTERRA DR ATTN: HCFS
-----------------------------------------------------
City | PHOENIX
-----------------------------------------------------
State | AZ
-----------------------------------------------------
Zip | 85085-8200
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 602-328-8400
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CHIEF MEDICAL DIRECTOR
-----------------------------------------------------
Name | KEVIN ELLIS
-----------------------------------------------------
Credential | D.O
-----------------------------------------------------
Telephone | 623-277-2246
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QA1903X
-----------------------------------------------------
Taxonomy Name | Ambulatory Surgical Clinic/Center
-----------------------------------------------------
License Number | OSC 3662
-----------------------------------------------------
License Number State | AZ
-----------------------------------------------------