Provider Demographics
NPI:1073540894
Name:PROLIANCE SURGEONS INC., P.S.
Entity Type:Organization
Organization Name:PROLIANCE SURGEONS INC., P.S.
Other - Org Name:PROLIANCE SURGICAL SPECIALISTS OF EDMONDS
Other - Org Type:Doing Business As
Authorized Official - Title/Position:MGR PROVIDER RELATIONS & ENROLLMENT
Authorized Official - Prefix:
Authorized Official - First Name:CORI
Authorized Official - Middle Name:M
Authorized Official - Last Name:PLEASANT
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:206-838-2585
Mailing Address - Street 1:7315 212TH ST SW STE 201
Mailing Address - Street 2:
Mailing Address - City:EDMONDS
Mailing Address - State:WA
Mailing Address - Zip Code:98026-7610
Mailing Address - Country:US
Mailing Address - Phone:425-778-8116
Mailing Address - Fax:425-775-9626
Practice Address - Street 1:7315 212TH ST SW
Practice Address - Street 2:SUITE 201
Practice Address - City:EDMONDS
Practice Address - State:WA
Practice Address - Zip Code:98026-7610
Practice Address - Country:US
Practice Address - Phone:425-778-8116
Practice Address - Fax:425-775-9526
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-27
Last Update Date:2023-09-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
2082S0099X, 208600000X, 208C00000X, 261QM1300X, 363AS0400X
WA601484763208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208600000XAllopathic & Osteopathic PhysiciansSurgeryGroup - Single Specialty
No2082S0099XAllopathic & Osteopathic PhysiciansPlastic SurgeryPlastic Surgery Within the Head and NeckGroup - Multi-Specialty
No208C00000XAllopathic & Osteopathic PhysiciansColon & Rectal SurgeryGroup - Multi-Specialty
No261QM1300XAmbulatory Health Care FacilitiesClinic/CenterMulti-SpecialtyGroup - Multi-Specialty
No363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgicalGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA1042735Medicaid
WA156966OtherWA LABOR & INDUSTRIES
WA700164800OtherOWCP