Healthcare Provider Details

I. General information

NPI: 1790325710
Provider Name (Legal Business Name): PROLIANCE SURGEONS, INC., P.S.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/07/2020
Last Update Date: 09/02/2022
Certification Date: 09/02/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1101 MADISON ST STE 580
SEATTLE WA
98104-4305
US

IV. Provider business mailing address

1101 MADISON ST STE 950
SEATTLE WA
98104-3592
US

V. Phone/Fax

Practice location:
  • Phone: 206-400-7625
  • Fax: 206-832-0586
Mailing address:
  • Phone: 206-400-7625
  • Fax: 206-274-4881

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code2471S1302X
TaxonomySonography Radiologic Technologist
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code261QR0200X
TaxonomyRadiology Clinic/Center
License Number
License Number State
# 4
Primary TaxonomyY
Taxonomy Code2085U0001X
TaxonomyDiagnostic Ultrasound Physician
License Number
License Number State

VIII. Authorized Official

Name: CORI M. PLEASANT
Title or Position: MGR PROVIDER RELATIONS/ENROLLMENT
Credential:
Phone: 206-838-2585