Provider Demographics
NPI:1831181924
Name:ROSS, LISA RENE (MD)
Entity type:Individual
Prefix:
First Name:LISA
Middle Name:RENE
Last Name:ROSS
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:216 14TH AVE SW
Mailing Address - Street 2:
Mailing Address - City:SIDNEY
Mailing Address - State:MT
Mailing Address - Zip Code:59270-3519
Mailing Address - Country:US
Mailing Address - Phone:406-488-2577
Mailing Address - Fax:406-488-2580
Practice Address - Street 1:214 14TH AVE SW
Practice Address - Street 2:
Practice Address - City:SIDNEY
Practice Address - State:MT
Practice Address - Zip Code:59270-3521
Practice Address - Country:US
Practice Address - Phone:406-488-2100
Practice Address - Fax:406-488-2125
Is Sole Proprietor?:No
Enumeration Date:2005-08-16
Last Update Date:2020-11-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA34661207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
WY122154000OtherMDCD PIN
MT000092716OtherBCBS PIN
MT0150917OtherMDCD PIN
MT10978OtherSTATE LICENSE
MT10978OtherSTATE LICENSE
WY122154000OtherMDCD PIN
MTP00332418Medicare PIN
MT000085203Medicare PIN