Healthcare Provider Details

I. General information

NPI: 1003441783
Provider Name (Legal Business Name): PROLIANCE SURGEONS, INC., P.S.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/03/2020
Last Update Date: 05/26/2021
Certification Date: 05/26/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2409 N 45TH ST
SEATTLE WA
98103-6907
US

IV. Provider business mailing address

2409 N 45TH ST
SEATTLE WA
98103-6907
US

V. Phone/Fax

Practice location:
  • Phone: 206-633-8100
  • Fax: 206-632-1657
Mailing address:
  • Phone: 206-633-8100
  • Fax: 206-632-1657

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code261QM1200X
TaxonomyMagnetic Resonance Imaging (MRI) Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: MRS. LAURA KLEISLE
Title or Position: CHIEF RISK OFFICER
Credential:
Phone: 206-838-2580