Basic Information
| Provider Information | |||||||||
| NPI: | 1144362047 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | PROLIANCE SURGEONS INC PS | ||||||||
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| OtherOrganizationName: | EVERGREEN SURGICAL CLINIC | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 720 OLIVE WAY | ||||||||
| Address2: | SUITE 1505 | ||||||||
| City: | SEATTLE | ||||||||
| State: | WA | ||||||||
| PostalCode: | 981011878 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2068382590 | ||||||||
| FaxNumber: | 2062648689 | ||||||||
| Practice Location | |||||||||
| Address1: | 14841 179TH AVE SE | ||||||||
| Address2: | SUITE 220 | ||||||||
| City: | MONROE | ||||||||
| State: | WA | ||||||||
| PostalCode: | 982721127 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3608638141 | ||||||||
| FaxNumber: | 3608059781 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/14/2007 | ||||||||
| LastUpdateDate: | 08/22/2020 | ||||||||
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| AuthorizedOfficialLastName: | FITZGERALD | ||||||||
| AuthorizedOfficialFirstName: | DAVID | ||||||||
| AuthorizedOfficialMiddleName: | G. | ||||||||
| AuthorizedOfficialTitleorPosition: | CEO | ||||||||
| AuthorizedOfficialTelephone: | 2068382590 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208600000X | WA | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Surgery |
No ID Information.