Basic Information
| Provider Information | |||||||||
| NPI: | 1134514433 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | PROLIANCE SURGEONS, INC., P.S. | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
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| OtherOrganizationName: | ORTHOPEDIC PHYSICIAN ASSOCIATES | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 601 BROADWAY FL 6 | ||||||||
| Address2: | |||||||||
| City: | SEATTLE | ||||||||
| State: | WA | ||||||||
| PostalCode: | 981225330 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2063862600 | ||||||||
| FaxNumber: | 2066221644 | ||||||||
| Practice Location | |||||||||
| Address1: | 3216 NE 45TH PL STE 304 | ||||||||
| Address2: | |||||||||
| City: | SEATTLE | ||||||||
| State: | WA | ||||||||
| PostalCode: | 981054028 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2063862600 | ||||||||
| FaxNumber: | 2066221644 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/02/2015 | ||||||||
| LastUpdateDate: | 05/27/2021 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | KLEISLE | ||||||||
| AuthorizedOfficialFirstName: | LAURA | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | CHIEF RISK OFFICER | ||||||||
| AuthorizedOfficialTelephone: | 2068382590 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | MRS. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 05/27/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2080S0010X | 601484763 | WA | Y | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Pediatrics | Sports Medicine |
ID Information
| ID | Type | State | Issuer | Description | 49701 | 01 | WA | WA LABOR & INDUSTRIES | OTHER | 2021639 | 05 | WA | MEDICAID |