MEDICARE: CONNECTICUT GENERAL LIFE INS 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

General Provider Information

NPI Number	:	1689913949
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	CONNECTICUT GENERAL LIFE INS COMPANY (CGLIC)

Provider Business Mailing Address
First Line	:	25500 N NORTERRA DR
Second Line	:
City	:	PHOENIX
State	:	AZ
Zip	:	85085-8200
Country	:	US
Telephone Number	:	877-733-1710
Fax Number	:	623-277-1091

Provider Business Practice Location Address
First Line	:	6700 HOLLISTER ST
Second Line	:
City	:	HOUSTON
State	:	TX
Zip	:	77040-5331
Country	:	US
Telephone Number	:	713-718-1800
Fax Number	:	713-718-1476

Authorized Official
Title or Position	:	VICE PRESIDENT
Name	:	MICHAEL SLICE
Credential	:	RPH
Telephone Number	:	623-277-2351

Provider Enumeration Date	:	02/06/2013
Last Update Date	:	02/06/2013

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