MEDICARE: CONNECTICUT GENERAL LIFE INSURANCE COMPANY (CGLIC)

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	261Q00000X	Clinic/Center		TX

General Provider Information

NPI Number	:	1104150721
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	CONNECTICUT GENERAL LIFE INSURANCE COMPANY (CGLIC)

Provider Business Mailing Address
First Line	:	11001 N BLACK CANYON HWY
Second Line	:
City	:	PHOENIX
State	:	AZ
Zip	:	85029-4757
Country	:	US
Telephone Number	:	877-733-1710
Fax Number	:	602-328-8410

Provider Business Practice Location Address
First Line	:	1640 DALLAS PKWY
Second Line	:
City	:	PLANO
State	:	TX
Zip	:	75093-4515
Country	:	US
Telephone Number	:	972-863-4940
Fax Number	:

Authorized Official
Title or Position	:	VICE PRESIDENT
Name	:	MICHAEL SLICE
Credential	:	RPH
Telephone Number	:	602-371-2971

Provider Enumeration Date	:	09/29/2009
Last Update Date	:	09/29/2009

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