MEDICARE: PROLIANCE SURGEONS INC P S

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	208600000X	Surgery Physician	601484763	WA

General Provider Information

NPI Number	:	1164461018
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	PROLIANCE SURGEONS INC P S

Provider Business Mailing Address
First Line	:	805 MADISON ST.
Second Line	:	SUITE 901
City	:	SEATTLE
State	:	WA
Zip	:	98104-1172
Country	:	US
Telephone Number	:	206-264-8100
Fax Number	:	206-264-8689

Provider Business Practice Location Address
First Line	:	3124 SOUTH 19TH ST.
Second Line	:	SUITE 220
City	:	TACOMA
State	:	WA
Zip	:	98405-2433
Country	:	US
Telephone Number	:	253-301-5050
Fax Number	:	253-301-5070

Authorized Official
Title or Position	:	CEO
Name	:	MR. DAVID G. FITZGERALD
Credential	:
Telephone Number	:	206-838-2599

Provider Enumeration Date	:	06/06/2006
Last Update Date	:	11/01/2011

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