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	261QA1903X	Ambulatory Surgical Clinic/Center	601484763	WA

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	219719	OTHER	WA	WA L&I
2	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1972565745
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	PROLIANCE SURGEONS INC P S

Provider Business Mailing Address
First Line	:	3801 5TH ST SE STE 110
Second Line	:
City	:	PUYALLUP
State	:	WA
Zip	:	98374-2106
Country	:	US
Telephone Number	:	253-845-9585
Fax Number	:

Provider Business Practice Location Address
First Line	:	3801 5TH ST SE STE 210
Second Line	:
City	:	PUYALLUP
State	:	WA
Zip	:	98374-2106
Country	:	US
Telephone Number	:	253-445-4285
Fax Number	:	253-435-4783

Authorized Official
Title or Position	:	DEL CRED & ENROLLMENT MANAGER
Name	:	CORI M. PLEASANT
Credential	:
Telephone Number	:	206-838-2585

Provider Enumeration Date	:	04/05/2006
Last Update Date	:	10/23/2024

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Directions to “PROLIANCE SURGEONS INC P S ” Practice Location

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