Healthcare Provider Details

I. General information

NPI: 1821158544
Provider Name (Legal Business Name): PROLIANCE SURGEONS, INC., P.S.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/11/2006
Last Update Date: 12/27/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

111 S 13TH ST
MOUNT VERNON WA
98274-4105
US

IV. Provider business mailing address

805 MADISON ST SUITE 901
SEATTLE WA
98104-1172
US

V. Phone/Fax

Practice location:
  • Phone: 360-336-2178
  • Fax: 360-588-7840
Mailing address:
  • Phone: 206-264-8100
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QA1903X
TaxonomyAmbulatory Surgical Clinic/Center
License Number601484763
License Number StateWA

VIII. Authorized Official

Name: MR. DAVID G FITZGERALD
Title or Position: CEO
Credential:
Phone: 206-838-2599