Healthcare Provider Details

I. General information

NPI: 1508182692
Provider Name (Legal Business Name): QLIANCE MEDICAL GROUP OF WA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/14/2010
Last Update Date: 04/14/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

521 2ND PL N SUITE 103
KENT WA
98032-4537
US

IV. Provider business mailing address

999 3RD AVE SUITE 810
SEATTLE WA
98104-4019
US

V. Phone/Fax

Practice location:
  • Phone: 253-478-4900
  • Fax: 253-478-4810
Mailing address:
  • Phone: 206-381-3030
  • Fax: 206-381-3035

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number
License Number State

VIII. Authorized Official

Name: DR. GARRISON BLISS
Title or Position: CHIEF MEDICAL OFFICER
Credential: MD
Phone: 206-381-3030