Provider Demographics
NPI:1992752919
Name:PROLIANCE SURGEONS, INC., P.S.
Entity type:Organization
Organization Name:PROLIANCE SURGEONS, INC., P.S.
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:MR
Authorized Official - First Name:DAVID
Authorized Official - Middle Name:G
Authorized Official - Last Name:FITZGERALD
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:206-838-2599
Mailing Address - Street 1:720 OLIVE WAY
Mailing Address - Street 2:SUITE 1505
Mailing Address - City:SEATTLE
Mailing Address - State:WA
Mailing Address - Zip Code:98101-1878
Mailing Address - Country:US
Mailing Address - Phone:206-838-2590
Mailing Address - Fax:206-264-8689
Practice Address - Street 1:6505 226TH PL SE
Practice Address - Street 2:SUITE 102
Practice Address - City:ISSAQUAH
Practice Address - State:WA
Practice Address - Zip Code:98027-8905
Practice Address - Country:US
Practice Address - Phone:425-313-0776
Practice Address - Fax:425-313-0771
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-27
Last Update Date:2008-02-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA261QA1903X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QA1903XAmbulatory Health Care FacilitiesClinic/CenterAmbulatory Surgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
WAG8802849Medicare PIN