Provider Demographics
NPI:1578801718
Name:PROLIANCE SURGEONS, INC., P.S.
Entity Type:Organization
Organization Name:PROLIANCE SURGEONS, INC., P.S.
Other - Org Name:PROLIANCE EASTSIDE SURGICAL SPECIALISTS
Other - Org Type:Doing Business As
Authorized Official - Title/Position:DEL CRED & 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 1:1231 116TH AVE NE STE 930
Mailing Address - Street 2:
Mailing Address - City:BELLEVUE
Mailing Address - State:WA
Mailing Address - Zip Code:98004-3804
Mailing Address - Country:US
Mailing Address - Phone:425-668-1916
Mailing Address - Fax:425-688-1901
Practice Address - Street 1:1231 116TH AVE NE STE 930
Practice Address - Street 2:
Practice Address - City:BELLEVUE
Practice Address - State:WA
Practice Address - Zip Code:98004-3804
Practice Address - Country:US
Practice Address - Phone:425-668-1916
Practice Address - Fax:425-688-1901
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-01-23
Last Update Date:2023-08-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
207Y00000X, 208C00000X, 261QM1300X
WA601484763208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208600000XAllopathic & Osteopathic PhysiciansSurgeryGroup - Multi-Specialty
No207Y00000XAllopathic & Osteopathic PhysiciansOtolaryngologyGroup - Multi-Specialty
No208C00000XAllopathic & Osteopathic PhysiciansColon & Rectal SurgeryGroup - Multi-Specialty
No261QM1300XAmbulatory Health Care FacilitiesClinic/CenterMulti-SpecialtyGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA2024876Medicaid
WA307116OtherWA LNI
WA2024876Medicaid