MEDICARE: CONNECTICUT GENERAL LIFE INSURANCE COMPANY

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	:	1851716195
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	CONNECTICUT GENERAL LIFE INSURANCE COMPANY

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	:	1503 ORCHARD HILL RD
Second Line	:
City	:	LAGRANGE
State	:	GA
Zip	:	30240-5709
Country	:	US
Telephone Number	:	706-812-6131
Fax Number	:

Authorized Official
Title or Position	:	MEDICAL SENIOR DIRECTOR
Name	:	STACEY POPKO
Credential	:
Telephone Number	:	412-747-4128

Provider Enumeration Date	:	02/24/2014
Last Update Date	:	02/24/2014

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