Provider Demographics
NPI:1417990888
Name:PROLIANCE SURGEONS INC., P.S.
Entity Type:Organization
Organization Name:PROLIANCE SURGEONS INC., P.S.
Other - Org Name:STAR SPORTS THERAPY AND ATHLETIC REHABILITATION
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:MR
Authorized Official - First Name:DAVID
Authorized Official - Middle Name:G
Authorized Official - Last Name:FITZGERALD
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:206-838-2599
Mailing Address - Street 1:720 OLIVE WAY
Mailing Address - Street 2:SUITE 1505
Mailing Address - City:SEATTLE
Mailing Address - State:WA
Mailing Address - Zip Code:98101-1878
Mailing Address - Country:US
Mailing Address - Phone:206-838-2590
Mailing Address - Fax:206-264-8689
Practice Address - Street 1:8009 S 180TH ST
Practice Address - Street 2:SUITE 112
Practice Address - City:KENT
Practice Address - State:WA
Practice Address - Zip Code:98032-1042
Practice Address - Country:US
Practice Address - Phone:425-226-7827
Practice Address - Fax:425-251-5757
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:PROLIANCE SURGEONS INC., P.S.
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2006-06-14
Last Update Date:2008-08-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA601484763225100000X, 225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Single Specialty
No225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA0532700006Medicare NSC
WAAB12057Medicare PIN