Provider Demographics
NPI:1134514433
Name:PROLIANCE SURGEONS, INC., P.S.
Entity Type:Organization
Organization Name:PROLIANCE SURGEONS, INC., P.S.
Other - Org Name:ORTHOPEDIC PHYSICIAN ASSOCIATES
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CHIEF RISK OFFICER
Authorized Official - Prefix:MRS
Authorized Official - First Name:LAURA
Authorized Official - Middle Name:
Authorized Official - Last Name:KLEISLE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:206-838-2590
Mailing Address - Street 1:601 BROADWAY FL 6
Mailing Address - Street 2:
Mailing Address - City:SEATTLE
Mailing Address - State:WA
Mailing Address - Zip Code:98122-5330
Mailing Address - Country:US
Mailing Address - Phone:206-386-2600
Mailing Address - Fax:206-622-1644
Practice Address - Street 1:3216 NE 45TH PL STE 304
Practice Address - Street 2:
Practice Address - City:SEATTLE
Practice Address - State:WA
Practice Address - Zip Code:98105-4028
Practice Address - Country:US
Practice Address - Phone:206-386-2600
Practice Address - Fax:206-622-1644
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-04-02
Last Update Date:2021-05-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA6014847632080S0010X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2080S0010XAllopathic & Osteopathic PhysiciansPediatricsSports MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA49701OtherWA LABOR & INDUSTRIES
WA2021639Medicaid