Basic Information
Provider Information | |||||||||
NPI: | 1184106262 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | PROLIANCE SURGEONS, INC., P.S. | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: | PROLIANCE ORTHOPAEDICS AND SPORTS MEDICINE | ||||||||
OtherOrganizationType: | 3 | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 510 8TH AVE NE STE 320 | ||||||||
Address2: |   | ||||||||
City: | ISSAQUAH | ||||||||
State: | WA | ||||||||
PostalCode: | 980295436 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2065070733 | ||||||||
FaxNumber: | 2062835551 | ||||||||
Practice Location | |||||||||
Address1: | 18100 NE UNION HILL RD STE 330 | ||||||||
Address2: |   | ||||||||
City: | REDMOND | ||||||||
State: | WA | ||||||||
PostalCode: | 980523330 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 4253923030 | ||||||||
FaxNumber: | 4254979084 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 09/05/2018 | ||||||||
LastUpdateDate: | 02/20/2019 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | OVERBEY | ||||||||
AuthorizedOfficialFirstName: | KENNETH | ||||||||
AuthorizedOfficialMiddleName: | G. | ||||||||
AuthorizedOfficialTitleorPosition: | COO | ||||||||
AuthorizedOfficialTelephone: | 2068382583 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: | MR. | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207X00000X | 601484763 | WA | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Orthopaedic Surgery |   | 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 | 261QM1300X | 601484763 | WA | Y |   | Ambulatory Health Care Facilities | Clinic/Center | Multi-Specialty |
ID Information
ID | Type | State | Issuer | Description | 2016746 | 05 | WA |   | MEDICAID | 122274 | 01 | WA | LABOR AND INDUSTRIES | OTHER |