Provider Demographics
NPI:1063921260
Name:LIFT AESTHETIC SURGERY
Entity type:Organization
Organization Name:LIFT AESTHETIC SURGERY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:SURGEON/OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:RYAN
Authorized Official - Middle Name:PHILIP
Authorized Official - Last Name:MARSHALL
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:215-990-1851
Mailing Address - Street 1:4700 NICOLE CT
Mailing Address - Street 2:
Mailing Address - City:MISSOULA
Mailing Address - State:MT
Mailing Address - Zip Code:59803-2792
Mailing Address - Country:US
Mailing Address - Phone:215-990-1851
Mailing Address - Fax:
Practice Address - Street 1:4700 NICOLE CT
Practice Address - Street 2:
Practice Address - City:MISSOULA
Practice Address - State:MT
Practice Address - Zip Code:59803-2792
Practice Address - Country:US
Practice Address - Phone:215-990-1851
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-09-20
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MT35293208200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208200000XAllopathic & Osteopathic PhysiciansPlastic SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MT1982855334Medicaid