Basic Information
| Provider Information | |||||||||
| NPI: | 1184140477 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | PROLIANCE SURGEONS, INC., P.S. | ||||||||
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| OtherOrganizationName: | PROLIANCE MRI NORTH PUGET SOUND | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 7320 216TH ST SW STE 320 | ||||||||
| Address2: | |||||||||
| City: | EDMONDS | ||||||||
| State: | WA | ||||||||
| PostalCode: | 980268006 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4256733900 | ||||||||
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| Practice Location | |||||||||
| Address1: | 6808 220TH ST SW STE 105 | ||||||||
| Address2: | |||||||||
| City: | MOUNTLAKE TERRACE | ||||||||
| State: | WA | ||||||||
| PostalCode: | 980432187 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4259676490 | ||||||||
| FaxNumber: | 4259676495 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/17/2017 | ||||||||
| 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 | 2085R0202X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology | 2085R0204X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Radiology | Vascular & Interventional Radiology | 2471M1202X | N | 193200000X MULTI-SPECIALTY GROUP | Technologists, Technicians & Other Technical Service Providers | Radiologic Technologist | Magnetic Resonance Imaging | 261QR0200X | N | Ambulatory Health Care Facilities | Clinic/Center | Radiology | 261QM1200X | 601484763 | WA | Y | Ambulatory Health Care Facilities | Clinic/Center | Magnetic Resonance Imaging (MRI) |
ID Information
| ID | Type | State | Issuer | Description | 2155286 | 05 | WA | MEDICAID |