Basic Information
| Provider Information | |||||||||
| NPI: | 1508893066 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | PROLIANCE SURGEONS INC., P.S. | ||||||||
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| OtherOrganizationName: | PROLIANCE ORTHOPAEDICS AND SPORTS MEDICINE | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 510 8TH AVE NE STE 320 | ||||||||
| Address2: | |||||||||
| City: | ISSAQUAH | ||||||||
| State: | WA | ||||||||
| PostalCode: | 980295436 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4255070733 | ||||||||
| FaxNumber: | 4252835551 | ||||||||
| Practice Location | |||||||||
| Address1: | 1231 116TH AVE NE STE 750 | ||||||||
| Address2: | |||||||||
| City: | BELLEVUE | ||||||||
| State: | WA | ||||||||
| PostalCode: | 980043812 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4254553600 | ||||||||
| FaxNumber: | 4254553920 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/28/2006 | ||||||||
| LastUpdateDate: | 05/27/2021 | ||||||||
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| AuthorizedOfficialLastName: | KLEISLE | ||||||||
| AuthorizedOfficialFirstName: | LAURA | ||||||||
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| AuthorizedOfficialTitleorPosition: | CHIEF RISK OFFICER | ||||||||
| AuthorizedOfficialTelephone: | 2068382590 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MRS. | ||||||||
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| NPICertificationDate: | 05/27/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207XS0106X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Orthopaedic Surgery | Hand Surgery | 207XS0114X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Orthopaedic Surgery | Adult Reconstructive Orthopaedic Surgery | 207XS0117X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Orthopaedic Surgery | Orthopaedic Surgery of the Spine | 207XX0004X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Orthopaedic Surgery | Foot and Ankle Surgery | 207XX0005X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Orthopaedic Surgery | Sports Medicine | 261QM1300X | N | Ambulatory Health Care Facilities | Clinic/Center | Multi-Specialty | 332B00000X | N | Suppliers | Durable Medical Equipment & Medical Supplies | 363AS0400X | N | 193200000X MULTI-SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | Surgical | 207X00000X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Orthopaedic Surgery |
ID Information
| ID | Type | State | Issuer | Description | 0532700042 | 01 | WA | DME | OTHER | 0122274 | 01 | WA | L & I | OTHER | 192649200 | 01 | WA | OWCP | OTHER | 2016746 | 05 | WA | MEDICAID |