1790325710 NPI number — PROLIANCE SURGEONS, INC., P.S.

Table of content: (NPI 1790325710)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1790325710 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 IMAGING CENTER AT FIRST HILL
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:
1790325710
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
09/02/2022
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1101 MADISON ST STE 950
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:
98104-3592
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
206-400-7625
Provider Business Mailing Address Fax Number:
206-274-4881

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1101 MADISON ST STE 580
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:
98104-4305
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
206-400-7625
Provider Business Practice Location Address Fax Number:
206-832-0586
Provider Enumeration Date:
01/07/2020

Additional Information

Authorized Official

Authorized Official Last Name:
PLEASANT
Authorized Official First Name:
CORI
Authorized Official Middle Name:
M.
Authorized Official Title or Position:
MGR PROVIDER RELATIONS/ENROLLMENT
Authorized Official Telephone Number:
206-838-2585

Provider Taxonomy Codes

  • Taxonomy code: 2085R0202X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 2085U0001X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 2471S1302X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 261QR0200X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

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

  • Identifier: 2166571 , issued by the state of ( WA ) . This identifiers is of the category "MEDICAID".




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