1255500542 NPI number — PROLIANCE SURGEONS, INC., P.S.

Table of content: (NPI 1255500542)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1255500542 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:
Provider Other Organization Name Type Code:
6
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:
1255500542
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/19/2022
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 310
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:
425-454-3938
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1231 116TH AVE NE STE 915
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
BELLEVUE
Provider Business Practice Location Address State Name:
WA
Provider Business Practice Location Address Postal Code:
98004-3822
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
425-454-3938
Provider Business Practice Location Address Fax Number:
425-454-2568
Provider Enumeration Date:
02/21/2008

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: 207Y00000X , 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: 207Y00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 207YX0905X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 231H00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 261QM1300X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

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

  • Identifier: 229378 . This is a "WA LABOR & INDUSTRIES" identifier , issued by the state of ( WA ) . This identifiers is of the category "OTHER".
  • Identifier: 1060221 , issued by the state of ( WA ) . This identifiers is of the category "MEDICAID".




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