1700022662 NPI number — PROLIANCE SURGEONS, INC., P.S.

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1700022662 NPI number — PROLIANCE SURGEONS, INC., P.S.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
PROLIANCE SURGEONS, INC., P.S.
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
PUGET SOUND ORTHOPAEDICS
Provider Other Organization Name Type Code:
3
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1700022662
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
09/07/2011
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
805 MADISON STREET
Provider Second Line Business Mailing Address:
SUITE 901
Provider Business Mailing Address City Name:
SEATTLE
Provider Business Mailing Address State Name:
WA
Provider Business Mailing Address Postal Code:
98104-1172
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
206-264-8100
Provider Business Mailing Address Fax Number:
206-264-8689

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
350 S. 333RD STREET
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
FEDERAL WAY
Provider Business Practice Location Address State Name:
WA
Provider Business Practice Location Address Postal Code:
98003-6321
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
253-830-5200
Provider Business Practice Location Address Fax Number:
253-874-5386
Provider Enumeration Date:
12/24/2008

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
FITZGERALD
Authorized Official First Name:
DAVID
Authorized Official Middle Name:
G.
Authorized Official Title or Position:
CEO
Authorized Official Telephone Number:
206-838-2599

Provider Taxonomy Codes

  • Taxonomy code: 207X00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)