=====================================================
General NPI Number Information
=====================================================
NPI Number | 1063921260
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | LIFT AESTHETIC SURGERY
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/20/2017
-----------------------------------------------------
Last Update Date | 07/21/2022
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 4700 NICOLE CT
-----------------------------------------------------
City | MISSOULA
-----------------------------------------------------
State | MT
-----------------------------------------------------
Zip | 59803-2792
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 215-990-1851
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 4700 NICOLE CT
-----------------------------------------------------
City | MISSOULA
-----------------------------------------------------
State | MT
-----------------------------------------------------
Zip | 59803-2792
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 215-990-1851
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | SURGEON/OWNER
-----------------------------------------------------
Name | DR. RYAN PHILIP MARSHALL
-----------------------------------------------------
Credential | DO
-----------------------------------------------------
Telephone | 215-990-1851
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 208200000X
-----------------------------------------------------
Taxonomy Name | Plastic Surgery Physician
-----------------------------------------------------
License Number | 35293
-----------------------------------------------------
License Number State | MT
-----------------------------------------------------