Basic Information
| Provider Information | |||||||||
| NPI: | 1386687747 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | PROLIANCE SURGEONS INC., P.S. | ||||||||
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| OtherOrganizationName: | PROLIANCE SURGEONS EDMONDS ORTHOPEDIC CENTER | ||||||||
| 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 | ||||||||
| FaxNumber: | 2066733910 | ||||||||
| Practice Location | |||||||||
| Address1: | 7320 216TH ST SW STE 320 | ||||||||
| Address2: | |||||||||
| City: | EDMONDS | ||||||||
| State: | WA | ||||||||
| PostalCode: | 980268006 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4256733900 | ||||||||
| FaxNumber: | 4256733910 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/14/2006 | ||||||||
| LastUpdateDate: | 08/19/2022 | ||||||||
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| AuthorizedOfficialLastName: | PLEASANT | ||||||||
| AuthorizedOfficialFirstName: | CORI | ||||||||
| AuthorizedOfficialMiddleName: | M. | ||||||||
| AuthorizedOfficialTitleorPosition: | MGR. PROVIDER RELATIONS/ENROLLMENT | ||||||||
| AuthorizedOfficialTelephone: | 2068382585 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 08/19/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207LP2900X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Anesthesiology | Pain Medicine | 207X00000X | 601484763 | WA | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Orthopaedic Surgery | 208VP0014X | 601484763 | WA | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Pain Medicine | Interventional Pain Medicine | 2251X0800X | N | 193200000X MULTI-SPECIALTY GROUP | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist | Orthopedic | 225X00000X | N | 193200000X MULTI-SPECIALTY GROUP | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Occupational Therapist | 332B00000X | N | Suppliers | Durable Medical Equipment & Medical Supplies | 363AM0700X | N | 193200000X MULTI-SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | Medical | 363AS0400X | N | 193200000X MULTI-SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | Surgical | 261QM1300X | Y | Ambulatory Health Care Facilities | Clinic/Center | Multi-Specialty |
ID Information
| ID | Type | State | Issuer | Description | 49391 | 01 | WA | WA L&I | OTHER | 0532700040 | 01 | WA | DME | OTHER | 1043983 | 05 | WA | MEDICAID |