Provider Demographics
NPI:1174950307
Name:CONNECTICUT GENERAL LIFE INSURANCE COMPANY (CGLIC)
Entity type:Organization
Organization Name:CONNECTICUT GENERAL LIFE INSURANCE COMPANY (CGLIC)
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CHIEF MEDICAL DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:JAMES
Authorized Official - Middle Name:
Authorized Official - Last Name:BURRELL
Authorized Official - Suffix:III
Authorized Official - Credentials:MD
Authorized Official - Phone:623-277-2351
Mailing Address - Street 1:25500 N NORTERRA DR
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85085-8200
Mailing Address - Country:US
Mailing Address - Phone:877-733-1710
Mailing Address - Fax:623-277-1091
Practice Address - Street 1:7101 METRO BLVD
Practice Address - Street 2:
Practice Address - City:MINNEAPOLIS
Practice Address - State:MN
Practice Address - Zip Code:55439-2117
Practice Address - Country:US
Practice Address - Phone:952-806-1276
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-10-02
Last Update Date:2014-05-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center