1487823597 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 1487823597 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:
1487823597
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
02/22/2008
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1135 116TH AVE NE
Provider Second Line Business Mailing Address:
SUITE 500
Provider Business Mailing Address City Name:
BELLEVUE
Provider Business Mailing Address State Name:
WA
Provider Business Mailing Address Postal Code:
98004-4623
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
425-454-3938
Provider Business Mailing Address Fax Number:
425-454-2568

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
17000 140TH AVE NE
Provider Second Line Business Practice Location Address:
SUITE 205
Provider Business Practice Location Address City Name:
WOODINVILLE
Provider Business Practice Location Address State Name:
WA
Provider Business Practice Location Address Postal Code:
98072-6928
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:
02/22/2008

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:
206-264-8100

Provider Taxonomy Codes

  • Taxonomy code: 207Y00000X , registered in the state of WA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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