Basic Information
| Provider Information | |||||||||
| NPI: | 1578801718 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | PROLIANCE SURGEONS, INC., P.S. | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | PROLIANCE SURGICAL SPECIALISTS AT OVERLAKE | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1231 116TH AVE NE STE 535 | ||||||||
| Address2: | |||||||||
| City: | BELLEVUE | ||||||||
| State: | WA | ||||||||
| PostalCode: | 980043804 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4256681916 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 1231 116TH AVE NE STE 535 | ||||||||
| Address2: | |||||||||
| City: | BELLEVUE | ||||||||
| State: | WA | ||||||||
| PostalCode: | 980043804 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4256681916 | ||||||||
| FaxNumber: | 4256881901 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/23/2013 | ||||||||
| LastUpdateDate: | 11/07/2022 | ||||||||
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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: | 11/07/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208C00000X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Colon & Rectal Surgery | 261QM1300X | N | Ambulatory Health Care Facilities | Clinic/Center | Multi-Specialty | 208600000X | 601484763 | WA | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Surgery |
ID Information
| ID | Type | State | Issuer | Description | 307116 | 01 | WA | WA LNI | OTHER | 2024876 | 05 | WA | MEDICAID |