Basic Information
| Provider Information | |||||||||
| NPI: | 1124500293 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | PROLIANCE SURGEONS, INC., P.S. | ||||||||
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| OtherOrganizationName: | PROLIANCE ORTHOPAEDICS AND SPORTS MEDICINE | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 510 8TH AVE NE STE 320 | ||||||||
| Address2: | |||||||||
| City: | ISSAQUAH | ||||||||
| State: | WA | ||||||||
| PostalCode: | 980295436 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4255070733 | ||||||||
| FaxNumber: | 4252835551 | ||||||||
| Practice Location | |||||||||
| Address1: | 510 8TH AVE NE STE 200 | ||||||||
| Address2: | |||||||||
| City: | ISSAQUAH | ||||||||
| State: | WA | ||||||||
| PostalCode: | 980295436 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4253923030 | ||||||||
| FaxNumber: | 4253922564 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/05/2018 | ||||||||
| LastUpdateDate: | 09/05/2018 | ||||||||
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| AuthorizedOfficialLastName: | OVERBEY | ||||||||
| AuthorizedOfficialFirstName: | KENNETH | ||||||||
| AuthorizedOfficialMiddleName: | G. | ||||||||
| AuthorizedOfficialTitleorPosition: | COO | ||||||||
| AuthorizedOfficialTelephone: | 2068382583 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208100000X | 601484763 | WA | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Physical Medicine & Rehabilitation | 363AS0400X | 601484763 | WA | N | 193200000X MULTI-SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | Surgical | 207X00000X | 601484763 | WA | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Orthopaedic Surgery |
ID Information
| ID | Type | State | Issuer | Description | 2016746 | 05 | WA | MEDICAID | 122274 | 01 | WA | LABOR & INDUSTRIES | OTHER |