Provider Demographics
NPI:1073552097
Name:PROLIANCE SURGEONS INC., P.S.
Entity Type:Organization
Organization Name:PROLIANCE SURGEONS INC., P.S.
Other - Org Name:PROLIANCE PROORTHO ORTHOPEDICS, SPORTS, JOINTS AND SPINE
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 1:12911 120TH AVE NE STE G10
Mailing Address - Street 2:
Mailing Address - City:KIRKLAND
Mailing Address - State:WA
Mailing Address - Zip Code:98034-3048
Mailing Address - Country:US
Mailing Address - Phone:425-823-4000
Mailing Address - Fax:
Practice Address - Street 1:14841 179TH AVE SE STE 330
Practice Address - Street 2:
Practice Address - City:MONROE
Practice Address - State:WA
Practice Address - Zip Code:98272-1127
Practice Address - Country:US
Practice Address - Phone:360-794-3300
Practice Address - Fax:360-794-6610
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-05
Last Update Date:2022-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA601484763207X00000X
207X00000X, 207XS0117X, 261QM1300X, 363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryGroup - Single Specialty
No207XS0117XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryOrthopaedic Surgery of the SpineGroup - Multi-Specialty
No261QM1300XAmbulatory Health Care FacilitiesClinic/CenterMulti-SpecialtyGroup - Multi-Specialty
No363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgicalGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
51292OtherWA LABOR & INDUSTRIES
WA1015791Medicaid