Provider Demographics
NPI:1396192290
Name:CONNECTICUT GENERAL LIFE INSURANCE COMPANY
Entity Type:Organization
Organization Name:CONNECTICUT GENERAL LIFE INSURANCE COMPANY
Other - Org Name:CIGNA ONSITE HEALTH, LLC; JACK ENTERTAINMENT
Other - Org Type:Other Name
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 1:1000 BROADWAY ST
Practice Address - Street 2:
Practice Address - City:CINCINNATI
Practice Address - State:OH
Practice Address - Zip Code:45202-1364
Practice Address - Country:US
Practice Address - Phone:513-250-3405
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-05-20
Last Update Date:2016-05-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center