Basic Information
| Provider Information | |||||||||
| NPI: | 1427356211 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | PROLIANCE SURGEONS, INC., P.S. | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | PROLIANCE SURGEONS SKAGIT NORTHWEST ORTHOPEDICS | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1401 S LAVENTURE RD | ||||||||
| Address2: | |||||||||
| City: | MOUNT VERNON | ||||||||
| State: | WA | ||||||||
| PostalCode: | 982746033 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3604247041 | ||||||||
| FaxNumber: | 3604242418 | ||||||||
| Practice Location | |||||||||
| Address1: | 2720 COMMERCIAL AVE | ||||||||
| Address2: | |||||||||
| City: | ANACORTES | ||||||||
| State: | WA | ||||||||
| PostalCode: | 982212734 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3604247041 | ||||||||
| FaxNumber: | 3604242418 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/03/2011 | ||||||||
| 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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| NPICertificationDate: | 08/19/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208100000X | 601484763 | WA | N | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Physical Medicine & Rehabilitation | 225100000X | 601484763 | WA | N | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist | 332B00000X | N | Suppliers | Durable Medical Equipment & Medical Supplies | 207X00000X | 601484763 | WA | N | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Orthopaedic Surgery | 261QM1300X | Y | Ambulatory Health Care Facilities | Clinic/Center | Multi-Specialty |
ID Information
| ID | Type | State | Issuer | Description | 1042545 | 05 | WA | MEDICAID | 121724 | 01 | WA LABOR & INDUSTRIES | OTHER |