1184106262 NPI number — PROLIANCE SURGEONS, INC., P.S.

Table of content: (NPI 1184106262)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1184106262 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:
PROLIANCE ORTHOPAEDICS AND SPORTS MEDICINE
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:
1184106262
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
02/20/2019
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
510 8TH AVE NE STE 320
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
ISSAQUAH
Provider Business Mailing Address State Name:
WA
Provider Business Mailing Address Postal Code:
98029-5436
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
206-507-0733
Provider Business Mailing Address Fax Number:
206-283-5551

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
18100 NE UNION HILL RD STE 330
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
REDMOND
Provider Business Practice Location Address State Name:
WA
Provider Business Practice Location Address Postal Code:
98052-3330
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
425-392-3030
Provider Business Practice Location Address Fax Number:
425-497-9084
Provider Enumeration Date:
09/05/2018

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
OVERBEY
Authorized Official First Name:
KENNETH
Authorized Official Middle Name:
G.
Authorized Official Title or Position:
COO
Authorized Official Telephone Number:
206-838-2583

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: 208100000X , 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: 261QM1300X , with the licence number: 601484763 , registered in the state of WA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 363AS0400X , with the licence number: 601484763 , registered in the state of WA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

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

  • Identifier: 2016746 , issued by the state of ( WA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 122274 . This is a "LABOR AND INDUSTRIES" identifier , issued by the state of ( WA ) . This identifiers is of the category "OTHER".