Provider Demographics
NPI:1275726739
Name:PROLIANCE SURGEONS, INC., P.S.
Entity Type:Organization
Organization Name:PROLIANCE SURGEONS, INC., P.S.
Other - Org Name:PROLIANCE EASTSIDE ENT
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CREDENTIALING & ENROLLMENT MANAGER
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 1:8301 161ST AVE NE STE 200
Mailing Address - Street 2:
Mailing Address - City:REDMOND
Mailing Address - State:WA
Mailing Address - Zip Code:98052-3858
Mailing Address - Country:US
Mailing Address - Phone:425-899-3838
Mailing Address - Fax:425-899-3844
Practice Address - Street 1:1800 116TH AVE NE
Practice Address - Street 2:SUITE 102
Practice Address - City:BELLEVUE
Practice Address - State:WA
Practice Address - Zip Code:98004-3043
Practice Address - Country:US
Practice Address - Phone:425-451-3710
Practice Address - Fax:425-451-2636
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-08-19
Last Update Date:2023-03-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA601484763207Y00000X
207Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Y00000XAllopathic & Osteopathic PhysiciansOtolaryngologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA2001403Medicaid
WA222338OtherWA LABOR & INDUSTRIES