Provider Demographics
NPI:1891776233
Name:PROLIANCE SURGEONS INC PS
Entity Type:Organization
Organization Name:PROLIANCE SURGEONS INC PS
Other - Org Name:MINOR AND JAMES ENDOSCOPY CENTER
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 1:805 MADISON ST
Mailing Address - Street 2:SUITE 901
Mailing Address - City:SEATTLE
Mailing Address - State:WA
Mailing Address - Zip Code:98104-1172
Mailing Address - Country:US
Mailing Address - Phone:206-264-8100
Mailing Address - Fax:
Practice Address - Street 1:515 MINOR AVE
Practice Address - Street 2:SUITE 200
Practice Address - City:SEATTLE
Practice Address - State:WA
Practice Address - Zip Code:98104-2120
Practice Address - Country:US
Practice Address - Phone:206-386-9515
Practice Address - Fax:206-576-3807
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-11-11
Last Update Date:2016-04-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA601484763261QA1903X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QA1903XAmbulatory Health Care FacilitiesClinic/CenterAmbulatory Surgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA490001094OtherPALMETTO RR MEDICARE
WA5891740001OtherDME
WA7027352Medicaid
WAMI4993OtherREGENCE
WA163569OtherLABOR & INDUSTRIES
WA7027352Medicaid
WA490001094OtherPALMETTO RR MEDICARE