1780807081 NPI number — PROLIANCE SURGEONS, INC., P.S.

Table of content: (NPI 1780807081)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1780807081 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:
THE EYE SURGEONS GROUP AMBULATORY SURGERY CENTER
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:
1780807081
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
07/21/2022
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
805 MADISON ST STE 901
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:
98104-1172
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
206-264-8100
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
502 S M ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
TACOMA
Provider Business Practice Location Address State Name:
WA
Provider Business Practice Location Address Postal Code:
98405-3728
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
253-301-4953
Provider Business Practice Location Address Fax Number:
253-301-4845
Provider Enumeration Date:
04/11/2007

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:
206-838-2599

Provider Taxonomy Codes

  • Taxonomy code: 261QA1903X , with the licence number:  601484763 , 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)

  • Identifier: 0375352 . This is a "WA STATE L & I" identifier , issued by the state of ( WA ) . This identifiers is of the category "OTHER".
  • Identifier: 7037880 , issued by the state of ( WA ) . This identifiers is of the category "MEDICAID".




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