Basic Information
| Provider Information | |||||||||
| NPI: | 1548832017 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | PROLIANCE SURGEONS, INC., P.S. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3801 5TH ST SE STE 110 | ||||||||
| Address2: | |||||||||
| City: | PUYALLUP | ||||||||
| State: | WA | ||||||||
| PostalCode: | 983742106 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2538459585 | ||||||||
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| Practice Location | |||||||||
| Address1: | 3801 5TH ST SE | ||||||||
| Address2: | SUITE 120 | ||||||||
| City: | PUYALLUP | ||||||||
| State: | WA | ||||||||
| PostalCode: | 983742103 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2538644106 | ||||||||
| FaxNumber: | 2538644143 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/14/2021 | ||||||||
| LastUpdateDate: | 07/14/2021 | ||||||||
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| AuthorizedOfficialLastName: | KLEISLE | ||||||||
| AuthorizedOfficialFirstName: | LAURA | ||||||||
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| AuthorizedOfficialTitleorPosition: | CHIEF RISK OFFICER | ||||||||
| AuthorizedOfficialTelephone: | 2068382590 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MRS. | ||||||||
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| NPICertificationDate: | 06/17/2021 | ||||||||
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 | Y | Ambulatory Health Care Facilities | Clinic/Center | Magnetic Resonance Imaging (MRI) |
No ID Information.