Provider Demographics
NPI:1508937236
Name:CIGNA HEALTH CARE OF ARIZONA INC.
Entity Type:Organization
Organization Name:CIGNA HEALTH CARE OF ARIZONA INC.
Other - Org Name:EVERNORTH CARE GROUP SOUTH MOUNTAIN HEALTH CENTER
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 1:8888 E RAINTREE DR FL 3
Mailing Address - Street 2:
Mailing Address - City:SCOTTSDALE
Mailing Address - State:AZ
Mailing Address - Zip Code:85260-3951
Mailing Address - Country:US
Mailing Address - Phone:602-328-8400
Mailing Address - Fax:
Practice Address - Street 1:7236 S CENTRAL AVE
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85042-5425
Practice Address - Country:US
Practice Address - Phone:602-276-5565
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-13
Last Update Date:2023-06-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZOTC 0648261Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ061812Medicaid
AZ061812Medicaid