Healthcare Provider Details

I. General information

NPI: 1811274459
Provider Name (Legal Business Name): PROLIANCE SURGEONS, INC., P.S.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/10/2011
Last Update Date: 12/09/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

875 SWIFT BLVD
RICHLAND WA
99352-3592
US

IV. Provider business mailing address

805 MADISON ST SUITE 901
SEATTLE WA
98104-1172
US

V. Phone/Fax

Practice location:
  • Phone: 509-946-1654
  • Fax: 509-943-5652
Mailing address:
  • Phone: 206-264-8100
  • Fax: 206-264-8689

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207QS0010X
TaxonomySports Medicine (Family Medicine) Physician
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code207X00000X
TaxonomyOrthopaedic Surgery Physician
License Number
License Number State

VIII. Authorized Official

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