Basic Information
| Provider Information | |||||||||
| NPI: | 1023170313 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | PROLIANCE SURGEONS, INC., P.S. | ||||||||
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| OtherOrganizationName: | PROLIANCE SURGEONS ORTHOPEDIC SPECIALISTS OF SEATTLE | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2409 N 45TH ST | ||||||||
| Address2: | |||||||||
| City: | SEATTLE | ||||||||
| State: | WA | ||||||||
| PostalCode: | 981036907 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2066338100 | ||||||||
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| Practice Location | |||||||||
| Address1: | 5350 TALLMAN AVE NW STE 500 | ||||||||
| Address2: | |||||||||
| City: | SEATTLE | ||||||||
| State: | WA | ||||||||
| PostalCode: | 981075902 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2067848833 | ||||||||
| FaxNumber: | 2067840676 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/14/2006 | ||||||||
| LastUpdateDate: | 08/22/2022 | ||||||||
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| AuthorizedOfficialLastName: | PLEASANT | ||||||||
| AuthorizedOfficialFirstName: | CORI | ||||||||
| AuthorizedOfficialMiddleName: | M. | ||||||||
| AuthorizedOfficialTitleorPosition: | MGR PROVIDER RELATIONS/ENROLLMENT | ||||||||
| AuthorizedOfficialTelephone: | 2068382585 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| NPICertificationDate: | 08/22/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207X00000X | 601484763 | WA | N | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Orthopaedic Surgery | 261QM1300X | N | Ambulatory Health Care Facilities | Clinic/Center | Multi-Specialty | 363AS0400X | N | 193200000X MULTI-SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | Surgical | 207X00000X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Orthopaedic Surgery |
ID Information
| ID | Type | State | Issuer | Description | 49718 | 01 | WA | WA LABOR & INDUSTRIES | OTHER | 1045421 | 05 | WA | MEDICAID |