Provider Demographics
NPI:1073627162
Name:CIGNA HEALTHCARE OF ARIZONA, INC.
Entity Type:Organization
Organization Name:CIGNA HEALTHCARE OF ARIZONA, INC.
Other - Org Name:GILBERT OUT PATIENT SURGERY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CHIEF MEDICAL DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:KEVIN
Authorized Official - Middle Name:
Authorized Official - Last Name:ELLIS
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:623-277-2246
Mailing Address - Street 1:25500 N NORTERRA DR
Mailing Address - Street 2:ATTN: HCFS
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85085-8200
Mailing Address - Country:US
Mailing Address - Phone:602-328-8400
Mailing Address - Fax:
Practice Address - Street 1:4001 E BASELINE RD
Practice Address - Street 2:SUITE 102
Practice Address - City:GILBERT
Practice Address - State:AZ
Practice Address - Zip Code:85234-2726
Practice Address - Country:US
Practice Address - Phone:480-632-4060
Practice Address - Fax:480-632-4092
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-18
Last Update Date:2014-01-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZOSC 3662261QA1903X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QA1903XAmbulatory Health Care FacilitiesClinic/CenterAmbulatory Surgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZZ72599Medicare PIN
AZZ103003Medicare PIN