Provider Demographics
NPI:1053707208
Name:CONNECTICUT GENERAL LIFE INSURANCE COMPANY
Entity type:Organization
Organization Name:CONNECTICUT GENERAL LIFE INSURANCE COMPANY
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:MEDICAL SENIOR DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:STACEY
Authorized Official - Middle Name:
Authorized Official - Last Name:POPKO
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:412-747-4128
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 1:8620 SPECTRUM CENTER BLVD
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92123-1406
Practice Address - Country:US
Practice Address - Phone:858-751-3042
Practice Address - Fax:858-751-3044
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-04-14
Last Update Date:2015-05-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center