1134168180 NPI number — PROLIANCE SURGEONS INC., P.S.

Table of content: (NPI 1134168180)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1134168180 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:
NORTHWEST ORTHOPAEDIC CLINIC
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:
1134168180
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
05/27/2021
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
9730 3RD AVE NE STE 201
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
SEATTLE
Provider Business Mailing Address State Name:
WA
Provider Business Mailing Address Postal Code:
98115-2023
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
206-526-8444
Provider Business Mailing Address Fax Number:
206-526-0521

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
9730 3RD AVE NE STE 201
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
SEATTLE
Provider Business Practice Location Address State Name:
WA
Provider Business Practice Location Address Postal Code:
98115-2023
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
206-526-8444
Provider Business Practice Location Address Fax Number:
206-526-0521
Provider Enumeration Date:
06/05/2006

Additional Information

Authorized Official

Authorized Official Last Name:
KLEISLE
Authorized Official First Name:
LAURA
Authorized Official Middle Name:
Authorized Official Title or Position:
CHIEF RISK OFFICER
Authorized Official Telephone Number:
206-838-2590

Provider Taxonomy Codes

  • Taxonomy code: 207X00000X , with the licence number:  601484763 , registered in the state of WA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207X00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 261QM1300X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 363AS0400X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

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

  • Identifier: 1042992 , issued by the state of ( WA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 49385 . This is a "WA LABOR & INDUSTRIES" identifier , issued by the state of ( WA ) . This identifiers is of the category "OTHER".




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